What is the priority list for a 77-year-old female patient with vascular dementia, worsening dementia, and hair loss, presenting with a medical history of osteoarthritis, asthma, mood disorder, colorectal cancer screening positive using Cologuard (Colon Cancer Screening Test), vitamin D deficiency, and a history of stroke, among other conditions?

From the Guidelines

The highest priority for this 77-year-old female patient with vascular dementia, worsening cognition, and hair loss should be evaluating her worsening dementia and recent fall, as these pose immediate safety risks, and a thorough neurological assessment is needed to determine if her cognitive decline represents progression of vascular dementia or a new process like delirium from infection or medication effects, as suggested by the American Heart Association/American Stroke Association 1. The patient's medical history, including stroke, right arm weakness, and positive Cologuard test, should be addressed promptly to prevent further complications. Key considerations include:

• Evaluating the patient's cognitive decline and fall risk
• Ensuring optimal secondary prevention for her stroke history with antiplatelet and statin therapy
• Addressing her positive Cologuard test with urgent colonoscopy
• Managing her multiple pain conditions with a multimodal approach
• Optimizing her respiratory conditions with appropriate inhaler therapy
• Providing mental health support for her mood disorder and anxiety The ESPEN guidelines on nutrition in dementia 1 emphasize the importance of screening for malnutrition, monitoring body weight, and providing individualized nutritional support, but these are secondary to addressing the patient's immediate safety risks and medical needs. Given the complexity of her condition, a comprehensive approach that prioritizes her safety, medical needs, and quality of life is essential, and regular follow-up and reassessment will be necessary to adjust her care plan as needed.

From the Research

Patient Priority List

To create a step-by-step priority list for the 77-year-old female patient with vascular dementia and multiple comorbidities, we need to consider the following factors:

• The patient's life expectancy and quality of life
• The severity and impact of each comorbidity on the patient's health
• The potential benefits and risks of each treatment or intervention

Step 1: Addressing Life-Threatening Conditions

• Colorectal cancer screening: The patient has a positive colorectal cancer screening using Cologuard test 2. Given the patient's age and comorbidities, it is essential to weigh the benefits and risks of further screening and potential treatment.
• Stroke and right arm weakness: The patient has a history of stroke and right arm weakness, which requires ongoing management and rehabilitation to prevent further complications.

Step 2: Managing Chronic Conditions

• Vascular dementia: The patient's worsening dementia requires ongoing management and support to maintain her quality of life.
• Osteoarthritis and osteopenia: The patient's arthritis and osteopenia require management to prevent further bone loss and fractures.
• Mixed hyperlipidemia: The patient's high cholesterol requires management to reduce the risk of further cardiovascular events.

Step 3: Addressing Symptomatic Conditions

• Dry eye syndrome and squamous blepharitis: The patient's eye conditions require treatment to alleviate symptoms and prevent further complications.
• Esophageal reflux and mild intermittent asthma: The patient's gastrointestinal and respiratory symptoms require management to improve her quality of life.
• Calf cramp and neck pain: The patient's musculoskeletal symptoms require treatment to alleviate pain and improve mobility.

Step 4: Preventing Further Complications

• Vitamin D deficiency: The patient's vitamin D deficiency requires supplementation to prevent further bone loss and potential colorectal cancer risk 3.
• Fall prevention: The patient's history of falls requires ongoing assessment and intervention to prevent further injuries.

Considerations for Patients with Dementia

• The decision to perform colonoscopy in patients with dementia should be multifactorial, considering the patient's history, comorbidities, and potential benefits and risks 4.
• Interventions for complex conditions in older people, including dementia, should include self-management, patient education, assessment with follow-up care procedures, and structured care processes or pathways 5.