Week 10: Therapy for Clients with Dementia.
Week 10: Therapy for Clients with Dementia Link to full case study: https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/index.html 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.Week 10: Therapy for Clients with Dementia. 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.Week 10: Therapy for Clients with Dementia. Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive) Decision Point One 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 Decision Point Two 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 Decision Point Three 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 dai With each decision answer the following: Which decision did you select? Why did you select this decision? Support your response with evidence and references to the Learning Resources. Week 10: Therapy for Clients with Dementia.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? Also include how ethical considerations might impact your treatment plan and communication with clients. References: Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia. American Family Physician, 85(1), 20–22. Retrieved from http://www.aafp.org/journals/afp.html Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources. https://www.nature.com/articles/npp2009176.pdf Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
Therapy for Clients with Dementia
The client is a 76-year-old man with a diagnosis of major neurocognitive disorder due to Alzheimer’s disease (presumptive). The client’s MMSE score is 18/30, indicating moderate dementia. This paper will discuss three decision points about the treatment plan for the client and discuss the ethical considerations likely to influence his treatment plan.Week 10: Therapy for Clients with Dementia.
Decision Point One
The option that was chosen is for the client to start Exelon (rivastigmine) 1.5 mg and increase the dosage appropriately. Rivastigmine was chosen because Alzheimer’s disease/dementia affects the cholinergic pathways and the medication improves the cholinergic function and thus effective in improving the symptoms (Kandiah et al., 2017).The medicationraises the amount of acetylcholine within the brain by inhibiting its breakdown; this improves the brain’s synaptic transmissions, leading to improvement in memory, as well as other cognitive functions (Birks et al, 2015). The other options were not selected because the medications are associated with more side effects when compared to Exelon.
It is expected that Exelon (rivastigmine) would improve the symptoms, such as functioning, cognitive performance, behavior, and the ability to do daily living activities. This is due to the medication’s effectiveness in improving the symptoms by increasing the amount of acetylcholine in the brain (Birks et al, 2015). It is also hoped that he would tolerate the medication.Week 10: Therapy for Clients with Dementia.
However, after four weeks the client did not indicate any symptom improvement as expected. This could be attributable to the low dose administered to the client.
Decision Point Two
Increasing the the rivastigmine dose to 4.5 mg is the selected option. Dose increment was selected because the efficacy of the medication is dose-dependence where higher doses manifest increased efficacy (Su et al., 2015). As Su et al (2015) indicate, the efficacy of rivastigmine is dose-dependent in improving activities of daily living, cognitive functions, and global functioning. Increasingthe dose to 6 mg was not selected because dose-increment should be gradual. the option to stop Exelon and start Namenda was not selected because the highest dose of Exelon should be administered first, before considering changing the dose. The client seems to be tolerating the Exelon and thus there is no clinical reason to discontinue the medication.Week 10: Therapy for Clients with Dementia.
Increasing the Exelon dose to 4.5 mg expected that the client would start manifesting symptom improvement, for instance through improved cognitive performance. Secondly, it is hoped that he would tolerate the higher dose. Higher doses of the medication are associated with better symptom improvement such as improved cognitive functioning (Birks et al., 2016).
After four weeks, the client manifested slight symptom improvement as demonstrated by the client beginning to attend religious services with his family members. The improvement shows that the increased Exelon dose exhibited better efficacy. There were no reported side effects and thus he is tolerating the higher dose. Week 10: Therapy for Clients with Dementia.
Decision Point Three
The chosen option is to increase the rivastigmine dose to 6 mg. This option was chosen because Exelon’s is dose-dependent.Higher dose elevates the amount of acetylcholine within the brain, leading to increased efficacy (Sadowsky et al., 2015).Maintaining the dose of 4.5 mg was not chosen sincea higher dose is expected to lead to increased efficacy (Su et al., 2015).The decision to augment the Exelon dose with Namenda was not chosen since the dose of cholinesterase inhibitors like Exelon should be maximized before the addition of augmenting agents.
Selecting the option to increase the rivastigmine dose to 6 mg expects that the symptom for this client would continue improving as indicated by better cognitive function and improved ability to perform activities of daily living. This is due to the increased efficacy of rivastigmine, with increased dose(Su et al., 2015).
Capacity determination and informed consent are the relevant ethical aspects during the treatment of this client. PMHNP needs to provide to the client and the son all the information about the available treatment options, including the side effects associated with the treatments. This will allow the client/son to make an informed treatment decision. Secondly, symptoms of Alzheimer’s disease may impair his cognitive ability and this may hinder his ability to comprehend his treatment plan (Fields & Calvert, 2015).Week 10: Therapy for Clients with Dementia.
The selected option for the first decision is for the client to start Exelon 1.5 mg orally. The option was chosen because the medication is well tolerated and it is effective in improving cholinergic function, and thus leading to symptom improvement in Alzheimer’s disease. The client did not show any symptom improvement and thus the option for the second decision was increasing the dose to 4.5 mg orally, while the option for the third decision was increasing the Exelon dose to 6 mg. The relevant ethical considerations during the treatment of this client include decision-making ability and informed consent.Week 10: Therapy for Clients with Dementia.
Birks J, Chong L & Grimley J. (2015). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews, 9(2).
Birks J, Chong L & Grimley J. (2016). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. Cochrane Dementia and Cognitive Improvement Group.
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. (2015). 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).
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 RevNeurothe, 15(9),1093–1103.
Week 10: Therapy for Clients with Dementia.