Still Alice by Lisa Genova: Case Management Review

 

Still Alice by Lisa GHenova: Case Management Review

Introduction

            Management of the client’s psychological needs is a critical practice that should be adequately addressed to achieve desired mental health. However, therapy needs amongst the clients accompanied by a host of socioeconomic factors could constrain service delivery. In this case, caregivers are caught in the epicenter of which ideal practice should be employed to guarantee their clients quality services. The book Still Alice by Lisa Genova lends itself to the topic as a compelling case to review in the appraisal of processes involved in managing diverse client situations. The book presents Alice's case, the main female character who suffers from early-onset Alzheimer's disease, and the family struggles to provide the support that should be best sufficed with family-centered intervention.

Issues to Review

The causes

           Researchers have not yet agreed on the real causes of early-onset Alzheimer's. It is only suspected that two proteins get damaged, killing the nerve cells in the end. One of the damaged proteins develops into plagues while the other forms tangle (Kandimalla et al., 2016). These two features are noticeable almost in every person at the aging stage. In the beginning, plagues and tangles damage memory areas that are within the brain. In the long-run, the entire brain is attacked. 

Etiology

           On-set Alzheimer's is caused by old age and hereditary factors. Aging people are vulnerable to memory lapse and are most likely to suffer from on-set Alzheimer’s. In other cases, hereditary factors could be the cause of the condition. In this case, it can be noticeable in people aged as early as 30 (Bird, 2018). 

Interventions that have tried and failed

           On-set Alzheimer's is a condition that affects the health well-being of the patient. To combat the disease, doctors have tried to use pharmacological interventions such as Aricept, razadyne, Exelon, and namenda (Hung & Fu, 2017). However, these drugs are only meant to slow down the rate of memory lapses. In addition, psychotherapy interventions are deemed the best strategy to deal with related mental conditions, have been employed, but failed. The psychotherapy approach has been unable to correct the on-set Alzheimer's disease Alice is experiencing. The failure in psychotherapy is to manage adequately the condition due to the absence of widely defined guidelines for nurse psychotherapists.

The role of the family in providing care

           Family members play a critical role in helping the patient cope with any health-related issue, particularly mental condition. For instance, as inferred to the case, Alice's family members are concerned about on-set Alzheimer's disease she is experiencing (Genova, n.d). However, whether they are doing all it takes to offer Alice full support alongside nurse psychotherapy remains unclear. As such, nurse psychotherapists should explain to Alice's members that they are responsible for helping their mother manage the condition.

Initial Assessment

Alzheimer's condition can be assessed in many ways. Observation and interview approaches are regarded as the appropriate approach. For instance, as revealed in the case, Alice has on-set Alzheimer's signs. These signs can be seen as she appears to carry out her daily activities and forgets about herself. Interviewing Alice by asking her simple questions, struggles to find appropriate answers. A nurse psychiatrist should structure these two approaches before commencing on a treatment plan action to help Alice manage the condition. 

CM theory, models, how do these fit with your client?

       The psychological health needs of patients are varying and complicated. Because of this reason, a nurse psychiatrist should tactically approach the case. A tactical approach will need a case manager to use a scientific case management framework and concepts. While referring to Genova case management, she explained in a structure that encompasses nine steps that should be used by case managers to guarantee quality psychological services (n.d). The effective psychiatric process's nine steps include screening, assessing, stratifying risk, planning, implementing, following-up, transitioning, communicating post-transition, and evaluating (Genova, n.d). Whichever the condition a client could be diagnosed with, the nine steps framework approach is deemed ideal. However, while these steps are suitable for psychiatrists, there are notable gaps in knowledge execution and delivery of services amongst case managers. These gaps in service delivery are attributable to the use of different concepts. For example, a psychosocial concept comprises knowledge touching on cultures, clients, social networks, and support teams play to enhance the client's health (Emery et. al, 2019).

On the other hand, rehabilitation concepts are comprised of knowledge that touches on the client's occupational and physical health functioning (Frankel, Gelman & Pastor, 2018). As such, a case manager who uses either of these concepts will reveal an alteration in knowledge service delivery. Whichever way, the tactical approach case management, which requires a case manager to use scientific framework and concepts are ideal. For instance, the scientific framework provided steps for a high-level case management process ideal for managing related mental conditions such as Alice Alzheimer's case. It is worth noting that psychosocial and rehabilitation concepts provided many options for a case manager to choose from to develop an ideal treatment plan. In particular, major depression requires a treatment plan that has a combination of both the two concepts postulated in this paper. 

Signs of onset Alzheimer’s

           Signs of onset Alzheimer's vary depending on the psychological response of the patient. For instance, in Alice's case review, she presents the following symptoms; foremost, she loses her memory and cannot remember simple things about her life. Also, she cannot trace her home, located a few meters away from where she lectures. Loss of appetite is also another sign and is evidenced in Alice when she loses weight.  

Guideline Questions

      A nurse psychiatrist must ask his/her client questions to gather information, which should be used to implement a treatment plan. Some of the most probable questions include; how often have you felt depressed, down, or hopeless in the past two weeks? A client who expresses to having felt down for more than half the days or daily for over the past two weeks is a clear indication of onset Alzheimer's. Have you had suicidal thoughts? How is your sleep? How is your energy? Do you opt to stay at home or prefer to go out to do new things? Do you have any relatives who had been diagnosed with onset Alzheimer's? Do you have a family? How many children do you have?

Conclusion

      In conclusion, this paper sought to review Still Alice, where Alice is the main female character. The book reveals that she has early-onset Alzheimer's disease and whom the family struggles to provide the support that should be best sufficed with family-centered intervention. In this regard, Genova advised that a nurse psychiatrist should employ a nine-step framework to guide a client through the treatment plan (n.d). However, the fact that nurse psychiatrists have employed the nine-step framework has some noticeable changes that constrain their service delivery. These changes have been mainly attributable to the use of psychosocial and rehabilitation concepts strategies. These two concepts provided many options for case managers to choose from to develop an ideal treatment plan. As a result, some nurse psychiatrists do not adequately stick to the two concepts' guidelines, thus compromising service delivery. Therefore, nurse psychiatrists should adhere to the framework and concept guidelines to enhance their service delivery. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Bird, T. D. (2018). Alzheimer disease overview. In GeneReviews®[Internet]. University of Washington, Seattle.

            https://www.ncbi.nlm.nih.gov/books/NBK1161/

Emery Trindade, P. G., Santos, R. L., Lacerda, I. B., Johannessen, A., & Nascimento Dourado, M. C. (2019). Awareness of disease in Alzheimer’s disease: what do patients realize about their own condition?. Aging & mental health, 23(10), 1292-1299.

https://www.tandfonline.com/doi/abs/10.1080/13607863.2018.1488945

Frankel, A. J., Gelman, S. R., & Pastor, D. K. (2018). Case management: An introduction to concepts and skills. Oxford University Press.

http://www.amazon.com › Case-Management-Third-Introduction-Concepts

Genova., L. (n.d). Still Alice: Case management review. Retrieved on 7^th, august, 2020 from < https://cmbodyofknowledge.com/content/introduction-case-management-body-knowledge>

Hung, S. Y., & Fu, W. M. (2017). Drug candidates in clinical trials for Alzheimer’s disease. Journal of biomedical science, 24(1), 47.

            https://link.springer.com/article/10.1186/s12929-017-0355-7

Kandimalla, R., Manczak, M., Fry, D., Suneetha, Y., Sesaki, H., & Reddy, P. H. (2016). Reduced dynamin-related protein 1 protects against phosphorylated Tau-induced mitochondrial dysfunction and synaptic damage in Alzheimer’s disease. Human molecular genetics, 25(22), 4881-4897.

            https://academic.oup.com/hmg/article/25/22/4881/2525916

 

Elimination Reactions

GC Analysis of Butene Isomers

Student’s Name

Institutional Affiliation

Table of Contents

Purpose. 3

Introduction. 3

Observations. 4

E1 Mechanism of Butyl Alcohol (Dehydration). 6

E2 Mechanism of Butyl bromide (Dehydrobromination). 7

Discussion and Analysis. 8

GC analysis. 9

Conclusion. 10

References. 11

GC Analysis of Butene Isomers

Purpose

The main objective of this laboratory experiment was to prepare butene isomers from dehydration of 1- and 2-butanols using heat and concentrated sulphuric (VI) acid and from the dehydrobromination of organic molecules of 1- and 2-bromobutane using potassium hydroxide solution, ethanol with heating. By performing this experiment, we also aimed to understand the elimination reaction involving E1 and E2 mechanisms and comprehend the GC analysis of the products for the documentation of the quantity of the major and minor butene isomer from after elimination reaction. The will help in understanding the analysis of GC and its industrial applications of the experiment.

Introduction

Elimination reaction is important in the manufacture of butene isomers. The reaction is either dehydrohalogenation or dehydration. In dehydrobromination, bromobutane in presence of concentrated ethanol and potassium or sodium hydroxides are heated to produce gaseous by-products of butene isomers. On the other hand, dehydration of 1- or 2-butane in the presence of concentrated sulphuric (VI) acid or concentrated phosphoric (V) acid produces gaseous byproducts of butene. Because of the less density compared to water, and slightly soluble in water, the gaseous components are collected in the “over-the-water” method through bubbling the gases in an inverted test-tube or boiling tube corked with a rubber septum. The gaseous products are then analyzed using the conventional method, GC after injection of the gaseous mixture into the GC capillary tube. Using the inert gas (mobile phase) and silica coatings of the stationary phase, the isomers butene are eluted corresponding to the boiling points of each isomer as they reach the flame ionization detector (FID). Retention time (t_R) in minutes is the time an eluent takes to elute from the GC (Mohrig et al., 2014). In the detector, signals are displaced as peaks in the picoAmp form a chromatogram if plotted against t_R (Mohrig et al., 2014, p. 292). The GC computer software represents peak areas of each isomer corresponding to each amount of the products (Mohrig et al., 2014). Hence, the number of by-products of a reaction can be identified and each given in percentage ratios.

Observations

After the GC analysis of the products of 1- and 2-butanol under strong acidic environment (Concentrated Sulphuric (VI) acid) with heating through (Dehydration reaction), the three products are formed and are displayed on the GC monitor.

Table 1: GC analysis of butene isomers from dehydration reaction of 1-butanol and Concentrated Sulphuric (VI) acid with heat.

1-butanol byproducts	Retention time(Rt) (Min)	Area pA	Height	Area %
1 Isomer	1.55300	1392.58179	1440.54150	9.56754
2-Isomer	1.59700	8666.57031	9033.75586	59.54249
3-Isomer	1.64000	4496.11914	4240.09961	30.88997

Table 2: GC analysis of butene isomers from elimination reaction of 2-butanol using Concentrated Sulphuric (VI) acid and heat (Dehydration reaction)

2-butanol byproducts	Retention time(Rt) in Minutes	Area pA	Height	Area %
1 Isomer	1.550	315.03412	361.17862	6.66155
2 Isomer	1.595	2933.59448	3172.76782	62.03230
3 Isomer	1.637	1480.51160	1466.69922	31.30615

Table 3: Results of GC analysis of products of elimination reaction of 1-bromobutane using strong base, Potassium hydroxide, ethanol with heating (Dehydrobromination reaction)

2-bromobutane	Retention time (Rt) in Minutes	Area pA	Height	Area %
I Isomer	1.552	2433.96606	2622.00122	27.27015
2 Isomer	1.597	5022.93555	5419.86230	56.27696
3 Isomer	1.639	1468.48389	1395.07690	16.45289

Table 4: GC analysis of butene isomers of elimination reaction of 1-bromobutane using strong base, Potassium hydroxide, ethanol with heating (Dehydrobromination reaction)

1-bromobutane	Retention time (Rt) in Minutes	Area pA	Height	Area %
1-butene	1.564	1.31881e4	1.25790e4	1.000e2

Table 5: Physical Properties of isomers of butene

Physical Properties	1-butene	Trans-butene	Cis-butene
Physical state	Gaseous	Gaseous	Gaseous
Boiling Point (0C)	-6.3	0.8	3.7
Collection Method	Over-Water	Over-Water	Over-Water

(Hayes et al., 2016, p. 3-78)

E1 Mechanism of Butyl Alcohol (Dehydration)

Elimination Reaction of Butyl alcohol such as 2-methyl-2-propanol produces a C-C pi bond in the E1 elimination reaction following dehydration (unimolecular elimination) (Mondal, 2018). The systematic reaction commences by protonation of the tert-alcohol group found on the structure of 2-methyl-2-propanol by the strong acid (Sulphuric (VI) acid to form a hydroxonium ion bond. Subsequently, the bond leaves the group to form a tert-carbocation. The beta hydrogen found on one carbon over is then confronted by Sulphuric (VI) acid to form a pi bond, thus leading to satisfaction of the carbocation (Ashenhurst, 2020). This reaction is only possible in the presence of acidic conditions and increased temperatures (Heat) in the absence of a base. The figure 1 below shows systematic mechanisms

Step 1: Protonation of oxygen on hydroxide group

Figure 1

Step 2: Breaking C-O bond allow release of water molecule (H₂O) resulting in carbocation intermediate.

Figure 2

Step 3: Deprotonation by Water molecule (H2O) from carbon adjacent to the carbocation center occasioning the creation of carbon-carbon double bond.

Figure 3

E2 Mechanism of Butyl bromide (Dehydrobromination)

Elimination of Butyl bromides such as 2-bromo-2-methylpropane using a strong base such as potassium hydroxide to produce 1-butene and 2-butene follow E2 mechanism through dehydrobromination. In this case, the electrons located on the oxygen atom found on the structure of potassium hydroxide attacks the beta proton found at a carbon away from where the bromide group is located, resulting in the repulsion of the electrons to the C-C bonds hence the formation of pi bonds (Carrascosa et al.,2017). This leads to the bromide group leaving the alkyl group and the alkyl group occuring in an anti periplanar geometry (Mondal, 2018). Besides, E2 elimination for the base-induced reaction is a one-step reaction compared to E1 elimination. The systematic step for the formation of butene isomers is shown below.

Figure 4: E2 elimination reaction of butyl bromide using a strong base, potassium hydroxide.

Figure 4

Step 1: Breaking of the C-Br bond allows bromide ion to leave resulting in carbocation intermediate

R=H, CH3CH2-

Figure 5

Step 2: Deprotonation by base-induced elimination from the carbon atom adjacent to the carbocation leads to the creation of pi bond.

R=H, CH₃CH₂- Figure 6

Discussion and Analysis

In the elimination reactions above, dehydrobromination of 1- bromobutane is a byproduct of 1-butene. The electrons on the hydroxide molecule of strong base attack the carbon bound away from the carbon close to where bromide is bonded resulting in bromide ion leaving the group, thus creating an anti periplanar to the beta hydrogen to form butene (Carrascosa et al., 2017). The result is a “Zaitsev product” having the position of the butene at the most substituted position.

From the elimination reactions illustrated above, the hypotheses of the experiment are that majority of products will be the Zaitsev products because of the application of unhindered base (KOH) in E2 reaction and sulphuric (VI) acid (Strong acid) and the hydrogen as the periplanar in the E1 reaction. Nevertheless, if a bulky basic compound that is mostly sterically hindered were to be used with no periplanar hydrogen molecule, then Hoffman products would have been expected to be the major products in E2 and E1 respectively. The best method to verify the formation of stable products of Zaitsev is GC based on the hypotheses of formation of 2-butene for both E1 and E2 elimination being major. This is done by observing the peaks, the calculation of peak areas, and the number of peaks formed as illustrated in the results below.

GC Analysis

From table 1-3 above; and based on the hypotheses, Isomer 1 had the shortest retention time (t_R), followed by Isomer 2 and then 3. In comparison with the boiling points, 1-butene should elute first because it is highly volatile and has a lesser boiling point as shown in Table 5 compared to 2-butene isomers. Following closely is the elution of Trans-butene and finally Cis-butene. The first Isomer is 1-butene, the second Isomer is Trans-butene, and the third isomer is a Cis-butene.

Moreover, the pA areas that are equivalent to the amount of each isomer was identified using the GC analysis. In this case, the elution time and percentage peak areas show that the major isomer of butene was under E1 and E2 elimination. In the dehydration reaction of 1-butanol, 1-butene had a relative amount equivalent to 9.56754%, Trans-butene relative amount was 59.54249%, and Cis-butene amount was indicated as 30.88997%. For 2-butanol undergoing dehydration reaction, 1-butene showed to have a relative amount of 6.66155%, Trans-butene with 62.03230%, and Cis-butene indicating a relative amount of 31.30615%. In the dehydrobromination of 1-bromobutane, only a single product was produced with a relative amount of 1.000e2%. However, the dehydrobromination of 2-bromobutane produced three isomers with relative amounts of 27.27015% representing 1-butene, Trans-butene relative amount was 56.27696%, with Cis-butene having the relative amount of 16.45289%. 

Conclusion

In conclusion, in terms of purity of the byproducts, the E1 elimination reaction showed a pure form reaction mechanism as compared to the E2 reaction. For instance, as illustrated from the percentage areas and elution time (t_R), the elution was early with a small area of 6.66155%. In comparison, 1-butene produced in E2 elimination reaction of dehydrobromination of 2-bromobutane resulted in early elution of 1-butene but with a larger area of 27.27015%. Therefore, a one-step formation of products in the E1 reaction is recommended for use compared to the multi-step E2 elimination reaction. However, the GC of E2 elimination suggested that the products of the elimination reactions were separated efficiently based on the boing points. As indicated, the results produced by the GC showed a coherent association with the elimination mechanism of base-induced dehydrohalogenation of alkyl halides such as butyl bromides and acid-stimulated dehydration of organic alcohols such as butyl alcohols.

References

Ashenhurst, J. (2020). The E1 reaction and its mechanism – Master organic chemistry. Master Organic Chemistry. Retrieved from https://www.masterorganicchemistry.com/2012/09/19/the-e1-reaction/

Carrascosa, E., Meyer, J., Zhang, J., Stei, M., Michaelsen, T., Hase, W. L., Yang, L., & Wester, R. (2017). Imaging dynamic fingerprints of competing E2 and SN2 reactions. Nature Communications, 8(1). doi:10.1038/s41467-017-00065-x

Haynes, W. M., Lide, D. R., & Bruno, T. J. (2016). CRC handbook of chemistry and physics: a ready-reference book of chemical and physical data. (97th ed.). Boca Raton, Florida: CRC Press.

Mohrig, J., Alberg, D., Hofmeister, G., Schatz, P. & Hammond, C. (2014). Laboratory techniques in organic chemistry. (4th ed.). New York: W.H. Freeman.

Mondal, S. (2018). UNIT-III: E1 and E2 reactions Dr. Sumanta Mondal __Pharmaceutical organic chemistry-II (BP 202t) _pharm-ii sem characteristics of e 1-reaction characteristics of e 2 reaction. Lecture Notes. doi:10.13140/RG.2.2.15516.80000.

Venton, B. J. (2017). Gas chromatography (GC) with flame-ionization detection. JoVE | Peer Reviewed Scientific Video Journal - Methods and Protocols. Retrieved June 15, 2020, from https://www.jove.com/science-education/10187