Week 8 Assignment: Practicum: Decision Tree

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Examine Case 3: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment. Psychiatric-Mental Health Nurse Practitioner Role II Paper

At each Decision Point, stop to complete the following:

Decision #1: Differential Diagnosis
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: Treatment Plan for Psychotherapy
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: Treatment Plan for Psychopharmacology
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?
Also include how ethical considerations might impact your treatment plan and communication with clients and their family.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

 PRAC 6670: Psychiatric-Mental Health Nurse Practitioner Role II

Mr. Wingate, a 76-year-old male presented for mental assessment. The reported serious memory problems that impaired his ability to perform activities of daily living. The client also reported poor sleep accompanied by vivid nightmares. Additionally, he experiences fluctuating concentration and energy levels, and anhedonia. He manifests coordination problems, abnormal movement, and resting tremors in two hands. According to the MSE, the client has impaired insight, attention and concentration, and constricted affect. The MMSE score is 17, with significant deficits in calculation, memory, and orientation; indicating that his cognition is severely impaired. This paper will discuss three options for the diagnosis and treatment choices for this client, and conclude by discussing any ethical aspects likely to affect his treatment plan.

Decision Point One

The diagnosis for Mr. Wingate is major neurocognitive disorder with Lewy bodies (MNDLB). This diagnosis was chosen since the client manifests symptoms of this neurocognitive disorder. For example, he manifested rapid eye movement sleep behavior disorder (RBD) is characterized by vivid dreams that involve screaming and kicking legs during sleep (McKeith et al, 2017). Additional symptoms indicating RBD include rest tremor, progressive decline of cognition, and slowing movement (McKeith et al, 2017). All these symptoms interfere with the ability of Mr. Wingate to carry out activities of daily living. Moreover, Mr. Wingate reported resting tremor, impaired insight, attention, and concentration. According to the DSM-5 criteria, all these symptoms suggest MNDLB. The essential diagnostic tests to confirm the diagnosis in this client include CT/MRI scan or PET imaging (DAT uptake) (McKeith et al, 2017). The other two options (major neurocognitive disorder due to Alzheimer’s disease and FTNCD) were not selected because these neurocognitive disorders are not characterized by rapid eye movement sleep behavior disorder (REM sleep disorder).

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Decision Point Two

The first treatment option is for the client to begin Rivastigmine 1.5 mg orally two times a day. Rivastigmine was selected because the medication is a cholinesterase inhibitor and thus increases the level of acetylcholine in the brain and thus improves aspects such as judgment, memory, and thought. Cholinesterase inhibitors have been demonstrated to be effective in improving neuropsychiatric and cognitive symptoms (Boot, 2015). Rivastigmine had the widest evidence base on its efficacy in improving symptoms of MNDLB. The other options (olanzapine and Ramelteon) were not selected because they are not first-line treatment choices for this neurocognitive disorder.  Psychiatric-Mental Health Nurse Practitioner Role II Paper

Selecting Rivastigmine hoped that both neuropsychiatric and cognitive symptoms for this client would improve. This is due to the efficacy of the medication in improving the symptoms (Boot, 2015). It was also expected that the client would tolerate the medication. However, even though Mr. Wingate tolerated the medication, there was no noticeable symptom improvement. Moreover, it was reported that the REM sleep disorder worsened as the client had increased acting out during dreaming and more nightmares. The lack of symptom improvement is attributable to the inability of Rivastigmine to reverse the existing cognitive deficits because the medication only slows the progression of the disease (Boot, 2015).

Decision Point Three

The second medication is for the client to begin Clonazepam 0.5 mg at bedtime. Clonazepam was chosen to improve the REM sleep disorder, and the consequent injuries for this client (Chan et al, 2018). Clonazepam has been demonstrated to be very effective in treating REM sleep disorder and it is well tolerated. The other options were not selected because they cannot address REM sleep disorder which seems to be worsening for this client. The PMHNP should educate the client and the son about the medication’s side effect as a long-acting benzodiazepine (Batalini et al, 2016). Selecting Clonazepam hoped that the symptoms of REM sleep disorder would improve.

Ethical Considerations

The PMHNP should seek informed consent from the client and the son by explaining to them about all the available treatment choices, including the side effects. This will ensure that they make an informed decision regarding any treatment choice. Moreover, since the client’s cognitive skills are impaired, he may not be able to make his treatment decisions. Therefore, a family member may be involved to make the treatment decisions (Smebye et al, 2016). Moreover, if the client has the cognitive ability to decide about his treatment, his autonomy should be respected.

Conclusion

The diagnosis for this client is MNDLB due to REM sleep disorder and the cognitive and neuropsychiatric symptoms the client manifests. The selected first treatment choice is for the client to start Rivastigmine because the medication improves both neuropsychiatric and cognitive symptoms. The last decision is for the client to begin Clonazepam to treat the worsening symptoms of REM sleep disorder. The relevant ethical aspects during the treatment of this client include informed consent and the ability to make treatment decisions.

References

Batalini F, Alon A, Moseley B & Ringman J. (2016). Improvement of dream enactment behavior associated with levetiracetam treatment in dementia with Lewy Bodies. Alzheimer Dis Assoc Disord, 30(2), 175–177.

Boot B. (2015). Comprehensive treatment of dementia with Lewy bodies. Alzheimer’s Research & Therapy,7(45).

Chan P, Lee H, Hong C, Hu C & Wu D. (2018). REM Sleep Behavior Disorder (RBD) in Dementia with Lewy Bodies (DLB). Behavioral Neurology, 1(10).

McKeith I, Boeye B, Dockson D & Halliday G. (2017). Diagnosis and management of dementia with Lewy bodies: Fourth consensus report of the DLB Consortium. Neurology,89(1), 88–100. doi:  10.1212/WNL.0000000000004058

Smebye K, Kirkevold M & Knut E. (2016). Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study. BMC Health Serv Res, 16(21).

Psychiatric-Mental Health Nurse Practitioner Role II Paper