CASE STUDY 1

Ms. M, Ms. J, Ms. A, and Ms. C are four women, all older than 50 years of age, who reside in a group home setting. All of the women participate in a sheltered workshop during the week and are active participants in a variety of activities offered to the residents in their group home. Two of the women, Ms. J and Ms. C, have family who live in the area, and they often spend weekends and holidays at a family member's home. Their primary care physician sees all four women for yearly physicals, and they receive mammograms and Pap tests on a yearly basis. All four women receive supplemental calcium with vitamin D (600 mg twice daily). This year during their physicals, their physician refers all four women for a bone density study. Based on the results of the studies, both Ms. M and Ms. C are placed on raloxifene (Evista), 60 mg daily. The reports of the studies are forwarded to the nurse consultant. Ms. M's report shows mild osteopenia in her spinal column. Ms. C's report shows significant osteoporosis in both hips and femur. It also shows osteopenia in the spinal column, indicating a significant risk for fracture.

Ms. C is 60 years of age, with cerebral palsy. She ambulates with a wheeled walker. She requires a rocker knife and fork to feed herself but does remain substantially independent in her group home setting. After reading the report, the nurse consultant advises Ms. C's case manager of the findings and recommends discussing the results with Ms. C's sister, who is her advocate, and alerting the direct care staff members to the fall risk. The multidisciplinary team also decides, with Ms. C and her sister's agreement, to place half side rails on Ms. C's bed. Until this time, Ms. C has been very slowly walking the block between the workshop and her home twice a day. This is becoming increasingly difficult for her, and she frequently cries with pain, complaining of feeling too tired for activities after returning home. It is decided to transport her via wheelchair to and from the workshop, with her continuing to use her walker for all other ambulation. She is included in a weekly yoga group and a daily stretching exercise group at the workshop to help increase her agility and muscle strength.

CASE STUDY 2

Mr. M is 42 years of age and resides in a group home, where he attends a sheltered workshop. He has been diagnosed with a moderate developmental disorder. Other diagnoses include seizure disorder, hypothyroidism, and hypercholesterolemia. He enjoys a variety of activities, including simple puzzles, baseball games, and going out to eat. His seizures are fairly well controlled with valproic acid 1,000 mg twice daily and topiramate 100 mg twice daily. He seizures at five- to six-week intervals and is often confused after seizures. Generally, he is cooperative with staff members' requests, but in the past two months, he has had five incidents of swearing and striking out at other residents. On two occasions, he has been physically aggressive with staff members.

After a meeting with the case manager, Mr. M's mother, the workshop supervisor, the nurse consultant, and Mr. M, it is decided to ask all staff members to observe Mr. M closely over the next two weeks to attempt to identify the source of his aggression. At the meeting, his mother reports that she has observed Mr. M talking to images on his television. When the group meets again two weeks later, the case manager has collected behavior observation sheets that indicate the activities Mr. M was engaging in at half-hour intervals. It is apparent that he is spending more time in his room. He has been observed on six occasions swearing at the television. There were also four incidents of physical aggression toward staff members and other residents. His mother reports that he seems very focused on characters on a reality show and talks about them as if he knows them. She also reports that he becomes quite angry while talking about the characters. It is decided that a psychiatric consult was necessary.

The psychiatrist evaluates Mr. M. When asked about the television programs, he is reticent to discuss them and reports to the psychiatrist, "They'll come after me." The psychiatrist concludes that Mr. M is experiencing thought insertion and delusions associated with his inability to correctly interpret reality television. This is leading to paranoia and physical aggression. The psychiatrist recommends quetiapine 50 mg twice daily and limiting television watching.

The case manager seeks approval from the facility's human rights committee for the medication and for a right restriction to limit television viewing. The committee, which includes Mr. M's mother, agrees, and the quetiapine is started. Mr. M's behavior plan is amended to identify efforts by the staff members to engage him in other activities and to encourage television watching in the day area. Fortunately, baseball season is starting, and it is possible to engage Mr. M and several other residents in watching baseball games.

After three weeks, Mr. M is spending more time with his peers, and there have been no further incidence of aggression. He appears to be tolerating the quetiapine well, and there has been no increase in seizures. After two months, the quetiapine is reduced to 50 mg at bedtime, and Mr. M continues to do well.

CASE STUDY 3

Ms. J is a woman with mild developmental disability, diagnosed with type 2 diabetes, recurrent major depression, and PTSD. She lives in a residential facility. Her diabetes is treated with some success with oral agents, although she is noncompliant with diet restrictions. Her recurrent depression and PTSD are treated with an antidepressant and a mood stabilizer. Ms. J's weight remains around 185 lbs, and she has fat folds below her breasts and in the groin area. Direct care staff members report that Ms. J does not shower daily and often goes five to six days without a shower. The nursing staff notes when doing weekly skin audits that Ms. J has excoriated areas in the fat folds and she is complaining of discomfort. The nursing staff has explained to Ms. J the need to shower and dry the area well each day and that topical medication will then be applied to heal the area. Ms. J continues to refuse to shower regularly, and it is determined that it is a necessity for her own well-being that she do so. The case manager discusses this with Ms. J and sets up a program in which she will receive a portion of her weekly allowance on a daily basis, but only after she has showered for the day and allowed the nurse to apply the medication. Ms. J and her advocate agree to this arrangement, and the information is shared with the facilities human rights committee to obtain permission for a rights restriction. After a few weeks, the skin areas begin to heal, and Ms. J is complying with showers on most days. It is determined by the multidisciplinary team to continue the behavior modification strategy with a review on a quarterly basis by the human rights committee.