Episode 1 - Cognition

A physical therapist employed in a skilled nursing facility treats an 82-year-old patient rehabilitating from a fractured tibia. The patient’s daughter mentions that she is concerned that her mother may be developing Alzheimer’s since upon arriving yesterday morning the mother has been extremely confused and at first did not even recognize her. The daughter indicates that the mother seems equally confused today, which according to the daughter is very atypical. Which medical condition could BEST explain the described behavior?

1. Urinary tract infection
2. Mild neurocognitive disorder
3. Sundown syndrome
4. Depression

Welcome to the Scorebuilders’ Q and A Podcast! 

This podcast provides members of the Scorebuilders Team with the opportunity to explore challenging multiple choice examination questions with students actively preparing for the licensing examination.

My name is Scott Giles and I will be your host for today’s journey.

A physical therapist employed in a skilled nursing facility treats an 82-year-old patient rehabilitating from a fractured tibia. The patient’s daughter mentions that she is concerned that her mother may be developing Alzheimer’s since upon arriving yesterday morning the mother has been extremely confused and at first did not even recognize her. The daughter indicates that the mother seems equally confused today, which according to the daughter is very atypical. Which medical condition could BEST explain the described behavior?

1.    Urinary tract infection
2.    Mild neurocognitive disorder
3.    Sundown syndrome
4.    Depression

Any type of obvious cognitive change in a geriatric population can be incredibly concerning for family members. Alzheimer’s disease is often a primary concern since most lay people are very aware of this common disease affecting cognition.

Alzheimer’s Disease
Alzheimer’s disease is a progressive neurodegenerative disorder that results in deterioration and irreversible damage within the cerebral cortex and subcortical areas of the brain. Neurons that are normally involved with acetylcholine transmission deteriorate within the cerebral cortex. Development of amyloid plaques and neurofibrillary tangles result in further damage to the nervous system.

Signs and Symptoms
Alzheimer’s disease is initially noted by a change in higher cortical functions such as difficulty with new learning and subtle changes in memory and concentration. Progression includes a loss of orientation, word finding difficulties, depression, poor judgment, rigidity, bradykinesia, shuffling gait, and impaired ability to perform self-care skills. End-stage disease includes severe intellectual and physical destruction, incontinence, functional dependence, and an inability to speak. 

Despite the discussion about Alzheimer’s disease, the question is simply asking which medical condition could BEST explain the described behavior (that is to say, confusion and difficulty initially recognizing her daughter).

Let’s explore each of the options:

Option 1 - Urinary tract infection
UTIs are very common and occur within the general population. However, there is a higher incidence in women and the geriatric population. UTIs occur when bacteria infiltrate the urethra or further into the bladder itself.

Signs and Symptoms
UTIs are initially noted by an increased frequency of urination, pain and/or burning with urination, cloudy urine, pressure above the pubic bone in women, shakiness, fever, back pain, and fatigue.

UTI Confirmation
Urinalysis and urine culture are most commonly used to diagnose a UTI. Urinalysis details the urine’s physical (for example, color, clarity, odor), microscopic (for example, white blood cell, red blood cell, and bacterial counts), and chemical (for example, acidity, concentration, glucose level) characteristics with comparison to established norms. A urine culture is used to identify the specific organism causing the infection so that the treatment intervention may be targeted accordingly.

Increasing age makes the brain more susceptible to the effects of circulating inflammatory particles, which may result from inflammatory conditions or infections like UTIs. The patient’s current environment (that is to say, skilled nursing facility), advanced age (that is to say, 82) and the acute mental status change provide strong support for the possibility of a UTI.

Option 2 - Mild neurocognitive disorder
A mild neurocognitive disorder is not typically associated with acute confusion. In this particular question, the daughter indicated that her mother did not even recognize her at first. In addition, the change in cognitive behavior was fast and too overt to be characteristic of a mild neurocognitive disorder.

Option 3 - Sundown syndrome
Sundowning is a term used to describe disorientation, agitation or general worsening of mental symptoms that occur specifically at dusk or nightfall. Sundowning is extremely common among individuals with dementia. It is thought to be associated with impaired circadian rhythm, environmental factors, stress, and impaired cognition.

In this particular question, the daughter indicated that the confusion was first observed upon arriving yesterday morning. As mentioned earlier, sundowning as the name implies, typically occurs at dusk or nightfall.

Option 4 – Depression
A mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.

Signs and Symptoms
Depression is characterized by feelings of sadness or loss of interest. The condition can lead to a range of behavioral and physical symptoms that include changes in sleep, appetite, energy level, concentration, and self-esteem. Depression can mimic symptoms of a more chronic neurocognitive disorder, but not typically an acute mental status change of this duration. 

The correct answer is Option 1

Let’s explore the all student data:

64% of students selected Option 1, Urinary tract infection, the correct response
20% of students selected Option 2, Mild neurocognitive disorder
7% of students selected Option 3, Sundown syndrome
9% of students selected Option 4, Depression

System Classification
This question is an Other Systems question which represents approximately 21% of all exam items.

Content Outline Classification
This question is a Foundations for Evaluation, Differential Diagnosis, and Prognosis question which represents approximately 33% of all exam items.

Level Classification
This question is a Level 3 question since the question requires candidates to systematically analyze and often interpret information to determine an appropriate course of action. The questions tend to have some degree of subjectivity and candidates are required to assign varying degrees of importance to different variables. Remediation of Level 3 questions occurs by continuing to refine decision making processes when answering examination questions and differentiating between good, better, and best options.

Academic Focus Area
Looking to review related academic content? Pages 559 and 666 from our review book PTEXAM: The Complete Study Guide.

Thanks for joining us on the Scorebuilders Q and A podcast! See you in two weeks! 

Watch the video version of this Q&A episode on YouTube - https://youtu.be/wBB0Jtr2VSA?si=ebHwTXiEn3OPTs1o.