COUC 546 Week 6 Case Study 2 Example

Case Study 2: A Widowed Retired Teacher, Two Years of Forgetting and the Question of Dementia Versus Depression

Case Summary

Margaret, a 76-year-old retired elementary teacher, was brought to counseling by her daughter, Lisa. Margaret's husband of fifty years died eighteen months ago. Lisa reports that her mother began repeating questions and misplacing items about two years ago, before his death, and that the problems have gradually worsened: Margaret has missed several bills, left the stove on twice and got lost driving to the church she has attended for forty years. Since the death, Margaret has become quieter, stopped attending her Bible study and says she is "just tired." In session, Margaret was pleasant and well groomed, could not recall the month, and laughed off her memory lapses as "old age." She denied thoughts of suicide. Her primary care physician recently noted a low score on a brief cognitive screen and has not yet ordered further testing.

Key Issues

Five issues require attention. First, safety: driving, cooking and finances present immediate risks. Second, Margaret needs a full medical evaluation to identify any reversible causes of cognitive decline. Third, the differential between a neurocognitive disorder and depression or grief must be clarified. Fourth, Lisa is becoming a caregiver and needs support. Fifth, Margaret's withdrawal from church has cut her off from a lifelong source of meaning and community. Underneath all five is a question of dignity: Margaret has spent her life caring for children and her husband, and she is likely to resist being cared for. Any plan must protect her safety while preserving as much of her independence and choice as possible.

Diagnostic Impressions

Provisional impression: major neurocognitive disorder due to possible Alzheimer's disease, mild, without behavioral disturbance (American Psychiatric Association, 2013), pending medical and neuropsychological evaluation. The history shows a gradual decline in memory and learning over two years that now interferes with independence in complex activities such as managing bills and driving, which is the level of impairment that distinguishes a major from a mild neurocognitive disorder. The insidious onset and steady progression without another evident cause fit possible Alzheimer's disease, though the cause must be determined by a physician.

Several alternatives were considered. Delirium is unlikely, because the onset was gradual rather than acute and attention appears relatively preserved. Depression must be assessed seriously: Margaret's withdrawal, fatigue and loss of interest followed a major loss, and Kring et al. (2016) note that depression in older adults can include cognitive complaints. However, her memory problems began before her husband's death, and she minimizes them rather than emphasizing them, a pattern more typical of neurocognitive decline. A depressive disorder should therefore be evaluated as a possible co-occurring condition. Grief is also part of the picture; the manual places a persistent complex bereavement disorder among conditions for further study rather than as an official diagnosis.

Treatment Recommendations

Biological

Margaret should be referred, with consent, to her physician and a neurologist for a full workup, including laboratory tests and a review of medications that can affect cognition. Any decision about medication for cognition or mood belongs to the physician. Livingston et al. (2020) estimated that around 40% of dementias worldwide are attributable to 12 modifiable risk factors, including hearing loss, hypertension, physical inactivity and social isolation, so her hearing, blood pressure and activity should also be addressed. Even after symptoms begin, treating hearing loss and reducing isolation may help her stay engaged, and an annual review of her medications can prevent avoidable confusion.

Psychological

Counseling should provide grief support adapted to her memory, using shorter sessions, written summaries and familiar routines. Reminiscence about her teaching career and her marriage can support both grief work and her sense of identity, and photographs or letters can anchor sessions when recall is difficult. If depression is confirmed, behavioral activation built around pleasant activities she can still enjoy is appropriate. Kales et al. (2015) recommend nonpharmacological approaches as the first line for behavioral and psychological symptoms of dementia, with the strongest evidence for interventions that support family caregivers.

Social

Lisa is the second client in this case: her ability to cope will shape Margaret's safety, mood and ability to stay at home. Brodaty and Donkin (2009) describe family caregivers as the invisible second patients and report that psychosocial interventions reduce caregiver burden and depression and can delay nursing home admission. Lisa should be connected with the Alzheimer's Association and a caregiver support group, and offered a few counseling sessions of her own to address her stress and her grief for her father. The family should arrange help with finances, a driving evaluation and legal planning, such as powers of attorney, while Margaret can still participate in decisions.

Spiritual

Margaret's faith remains a resource. Familiar hymns, Scripture and prayer often stay meaningful even as memory declines. With her permission, her pastor could visit, and a church member could drive her to Bible study, which would restore both fellowship and routine. The psalmist's plea that God not cast him off in old age or forsake him when his strength fails (English Standard Version Bible, 2001/2016, Psalm 71:9) may give words to her fears and her hope.

Collaboration

With signed releases, the counselor would coordinate with the physician and neurologist, share observations of mood and functioning, meet with Lisa regularly and help the church provide practical support. The team should plan ahead for changes in care, so that decisions about in-home help or assisted living are made calmly rather than in a crisis.

Conclusion

Margaret's case illustrates how grief, depression and cognitive decline can overlap in late life. The counselor's role is not to determine the cause of her memory loss but to make sure it is evaluated, to treat her grief and possible depression, to support her daughter and to keep her connected to the people and faith that sustain her for as long as the illness allows.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Brodaty, H., & Donkin, M. (2009). Family caregivers of people with dementia. Dialogues in Clinical Neuroscience, 11(2), 217-228. https://doi.org/10.31887/DCNS.2009.11.2/hbrodaty

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Kales, H. C., Gitlin, L. N., & Lyketsos, C. G. (2015). Assessment and management of behavioral and psychological symptoms of dementia. BMJ, 350, Article h369. https://doi.org/10.1136/bmj.h369

Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2016). Abnormal psychology: The science and treatment of psychological disorders (13th ed.). Wiley.

Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Ogunniyi, A., ... Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), 413-446. https://doi.org/10.1016/S0140-6736(20)30367-6