NURS 6521N Advanced Pharmacology Week 6 Alzheimers Disease
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.
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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 you perform 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 you 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)
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Advanced Pharmacology Nurs 6521
The case study focuses on Mr. Akkad a 76-year-old Iranian man who was diagnosed with major neurocognitive disorder due to Alzheimer’s disease (presumptive). The MMSE score for the client was 18/30 indicating moderate dementia. This paper, therefore, aims to make three decisions on the mediations to prescribe to the client. In addition, the ethical considerations likely to affect communication and the treatment plan for the client will be discussed.
Decision Point One
The first pharmacological agent that was selected for the client is to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks. The rationale for selecting rivastigmine is due to the medication’s efficacy in treating dementia and Alzheimer’s Disease. According to Su et al (2015), pathological changes associated with dementia of Alzheimer type include deficits in cholinergic neuronal pathways. Accordingly, the rivastigmine works by enhancing the cholinergic function by stopping the breakdown of acetylcholine. This improves the synaptic transmissions within the brain and thus improves memory as well as other cognitive functions (Kandiah et al, 2017). Because the client has dementia of Alzheimer type, he has low quantities of acetylcholine in the brain and thus rivastigmine will improve the symptoms the client is manifesting. Additionally, Birks et al (2015) explain that FDA recommended that the initial dose should be 1.5 mg BID and if the client does not experience significant side effects and tolerates the initial dose well after taking rivastigmine for two weeks, the dose should be increased to 3 mg BID.
Selection of this decision expected that the cognitive performance, behavior, function, as well as the ability to conduct activities of daily living for the client, would improve. This is because the efficacy of Exelon (rivastigmine) in treating has been demonstrated in several studies (Kandiah et al, 2017).
However, the expected outcome and the actual outcome of the first decision were different. This is because there was no symptom improvement as the son reported and also there was no change in the MMSE score. The lack of symptom improvement can be attributed to the low dose of rivastigmine prescribed to the client. The low dose of rivastigmine did not avail adequate levels of acetylcholine in the brain that could have led to symptom improvement (Kandiah et al, 2017).
Decision Point Two
The second decision that was selected is to have the rivastigmine dose increased to 4.5 mg orally BID. The reason for increasing the dose is because evidence indicates that an increased dose of rivastigmine has higher efficacy for people with Alzheimer’s Disease (Stahl, 2014). Evidence has shown that the efficacy of rivastigmine is dose-dependent when it comes to symptoms such as activities of daily living, cognitive functions, and global functioning. Therefore, it is expected that an increased dose will be more effective (Su et al, 2015).
The decision to increase the dose to 4.5 mg orally BID hoped that the cognitive function and other symptoms for this client would improve. It was also expected that the client would tolerate the higher dose well (Birks et al, 2016).
The actual outcome of the selected decision and the expected outcome were relatively similar. This is because the client manifested slight symptom improvement as evidenced by his attendance to religious service with the family. This shows that the increased dose of rivastigmine led to symptom improvement for the client, however slight (Kandiah et al, 2017). Moreover, as anticipated, the client tolerated the increased dose well as he did not report any side effect with the higher dose.
Decision Point Three
The last decision was to have the rivastigmine dose increased to 6 mg orally BID. As aforementioned, higher dose of rivastigmine increases the amount of acetylcholine within the brain and thus increases the efficacy of the medication (Sadowsky et al, 2015).
The decision to increase the dose to 6 mg orally BID hoped that there will be notable symptom improvement for the client, especially with the cognitive functioning and the capacity to carry out activities of the daily living. A study performed by Su et al (2015) showed that the administration of higher doses of rivastigmine to people with Alzheimer’s disease led to better symptom improvement especially symptoms such as cognitive functioning and the capacity to carry out activities of daily living. Since cholinesterase inhibitors like rivastigmine can only improve symptoms and not reverse the generative process, it will be important to educate the client and the son as well about how the medication works (Stahl, 2014).
Another expectation was that the client would still tolerate the increased dose of rivastigmine and thus will not experience significant side effects.
Ethical considerations applicable to this client involve capacity determination, the ability of the client to make treatment decisions, and informed consent as well. In regard to capacity determination and the ability to make treatment decisions, symptoms of Alzheimer’s disease and dementia such as impairment in the cognitive functioning may hamper the ability of the client to understand and make treatment decisions (Fields & Calvert, 2015). In addition, it will be important for the PMHNP to explain to the client and the son about all the available treatment choices in order to enable them to make an informed decision (Fields & Calvert, 2015).
The initial medication that was selected is Exelon (rivastigmine) 1.5 mg. This is because the medication works by improving the cholinergic function and thus improves symptoms like cognitive functioning. With this decision, the client did not report any symptom improvement. Therefore, the second decision was to increase the dose of rivastigmine to 4.5 mg and the client showed some symptom improvement as he started attending religious functions with the family. The last decision was also to increase the dose to 6 mg orally BID. The increased dose aimed to increase the efficacy of the medication because higher-doses of rivastigmine are associated with increased efficacy. The ethical considerations applicable to this client encompass capacity determination, the ability of the client to make treatment decisions, and the informed consent.
Birks J, Chong L & Grimley J. (2015). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. 9(2).
Farlow M, Grossberg G, Sadowsky C, Meng X & Somogyi M. (2013). A 24-Week, Randomized, Controlled Trial of Rivastigmine Patch 13.3 mg/24 h Versus 4.6 mg/24 h in Severe Alzheimer’s Dementia. CNS Neurosci Ther. 19(10): 745–752.
Fields L & Calvert J. (2015). Informed consent procedures with cognitively impaired patients: A review of ethics and best practices. Psychiatry and Clinical Neurosciences. 1(69): 462–471.
Kandiah N, Pai M, Looi I, Ampil E, Park K, Karanam A & Christopher S. (2017). Rivastigmine: the advantages of dual inhibition of acetylcholinesterase and butyrylcholinesterase and its role in subcortical vascular dementia and Parkinson’s disease dementia. Clin Interv Aging. 1(12), pp: 697–707.
Sadowsky C, Micca J, Grossberg G & Velting D. (2014). Rivastigmine From Capsules to Patch: Therapeutic Advances in the Management of Alzheimer’s Disease and Parkinson’s Disease Dementia. Prim Care Companion CNS Disord. 16(5).
Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Su J, Liu Y, Liu Y & Ren L. (2015). Long-term effectiveness of rivastigmine patch or capsule for mild-to-severe Alzheimer’s disease: a meta-analysis. Expert Rev Neurother.