Note: This case study will serve as the foundation for this Assignment.
To prepare for this Assignment:
To prepare for this Assignment:
- Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for dementia.
ACTUAL ASSIGNMENT
PLEASE Addressed each of the following bullets with a subtopic, include references; in-text citation in each paragraph. Please use my articles and any additional one should come from USA and must be within last five years only that is from 2014 to 2018. Please do not begin a paragraph with author name(s) (PLEASE USE parenthetical/in-text citations) Thanks
The Assignment
Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
- At each decision point stop to complete the following:
- Decision #1
- Which decision did you select?
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
- Decision #2
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
- Decision #1
- Also include how ethical considerations might impact your treatment plan and communication with clients.
BACKGROUND BACKGROUND
Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.
SUBJECTIVE
During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so the PMHNP performs a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.
MENTAL STATUS EXAM
Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When the PMHNP asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.
Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)
RESOURCES
§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.
Decisions Made and Outcomes (Needed to formulate the paper)
Choices for Decision 1: Select what the PMHNP should do:
Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
: Begin Aricept (donepezil) 5 mg orally at BEDTIME
Begin Razadyne (galantamine) 4 mg orally BID
My decision: Begin Aricept (donepezil) 5mg orally at bedtime
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- The client is accompanied by his son who reports that his father is “no better” from this medication
- He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
- You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall
Choices for Decision 2:
Select what the PMHNP should do next:
Increase Aricept to 10 mg orally at BEDTIME
Discontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily
Discontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily
My decision: Increase Aricept to 10mg orally at Bedtime
Outcome: RESULTS OF DECISION POINT TWO:
- Client returns to clinic in four weeks
- Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
- He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious
Choices for Decision 3:
Select what the PMHNP should do next:
Continue Aricept 10 mg orally at BEDTIME
Increase Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME
Discontinue Aricept and begin Namenda 5 mg orally daily
My decision: Continue Aricept 10mg orally at bedtime
Guidance to Student
At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.
There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.
There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.
Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.
References/Resources
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
- Chapter 13, “Dementia and Its Treatment”
Expert Solution Preview
Introduction
Assessing and treating clients with dementia can be challenging due to the complexity of the condition and the individualized needs of each patient. In this assignment, we will examine a case study of an elderly Iranian man with Alzheimer’s disease and make three decisions concerning the medication to prescribe to this client. The paper will also discuss how ethical considerations can impact the treatment plan and communication with clients.
Decision #1
I selected to begin Aricept (donepezil) 5mg orally at bedtime for Mr. Akkad. Aricept is FDA-approved for the treatment of Alzheimer’s disease and has been shown to improve cognition, global function, and behavioral symptoms (Birks, 2006). Aricept works by inhibiting acetylcholinesterase, increasing the concentration of acetylcholine in the brain, which is essential for learning and memory (Salloway et al., 2004). My aim was to improve Mr. Akkad’s cognitive and behavioral symptoms as there is evidence that Aricept is effective in treating Alzheimer’s disease symptoms.
The expected outcome of this decision was to improve Mr. Akkad’s cognitive, behavioral, and functional status. However, the client returned to the clinic in four weeks, and his son reported that his father was “no better” from this medication. He continued to exhibit disinhibited behaviors, and there was no improvement in his orientation, registration, attention, and calculation.
Decision #2
I decided to increase Aricept to 10mg orally at bedtime for Mr. Akkad. Aricept has a dose-dependent effect, and increasing the dose may lead to improved efficacy (Birks, 2006). My aim was to improve Mr. Akkad’s cognitive and behavioral symptoms by increasing the dose of Aricept.
The expected outcome of this decision was to improve Mr. Akkad’s cognitive and behavioral symptoms. The client returned to the clinic in four weeks, and his son reported that the client was tolerating the medication well, but he was concerned that his father was no better. Although Mr. Akkad was attending religious services with the family, there was no significant improvement in his overall mental status.
Decision #3
I selected to continue Aricept 10mg orally at bedtime for Mr. Akkad. Although it may be appropriate to add Namenda (memantine) to the current drug profile, there is no need to discontinue Aricept. NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease (Schneider et al., 2011). Slow titration of both medications is recommended to minimize negative side effects.
The expected outcome of this decision was to maintain Mr. Akkad’s cognitive and behavioral status with minimal side effects. It is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.
Ethical Considerations
When treating clients with dementia, ethical considerations should be weighed against medical decisions. In Mr. Akkad’s case, it is imperative to prioritize patient autonomy and informed consent when making medical decisions (Sachs et al., 2020). The PMHNP should make efforts to communicate effectively with the patient and meet cultural preferences to respect his autonomy.
Conclusion
Assessing and treating clients with dementia requires a tailored approach to meet each individual’s needs. By carefully considering the patient’s symptoms, medication options, and ethical considerations, healthcare providers can develop a treatment plan that holistically addresses the patient’s needs. In Mr. Akkad’s case, a combination of Aricept and potentially Namenda could improve his symptoms in the long-term. However, it is important to seek informed consent and respect cultural preferences when making medical decisions for the patient.
