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. Assessing and Treating Clients with Dementia Essay Paper

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.

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

Below is a simple of how the paper will look, the needs an introduction, background of the case study, and a conclusion. All 3 medication is discussed in all 3 decisions, the reason why a medication is selected and a reason why they are not selected.

Assessing and Treating Clients with Dementia

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Introduction

The focus of this assignment is on a client whose diagnosis is major neurocognitive disorder due to Alzheimer’s disease (presumptive). Major Neurocognitive disorder due to Alzheimer’s disease is diagnosed to a person manifesting cognitive deficits linked to the onset and progression of Alzheimer’s Dementia. In major neurocognitive disorder due to Alzheimer’s disease, a person has progressive cognitive dysfunction. Symptoms associated with major neurocognitive disorder due to Alzheimer’s disease, include cognitive decline manifested by complex attention where an individual is inattentive and take longer time in processing information; impaired of executive function manifested by inability to plan, impaired decision-making and inability to hold information; memory and learning problems; language problems manifested by loss of the speaking ability or aphasia; impaired perceptual-motor; social cognition exhibited by inability to identify emotions of other people; social withdrawal; as well as emotional distress (Apostolova, 2016). Therefore, this assignment will involve making three decisions about the client’s medication.Assessing and Treating Clients with Dementia Essay Paper

Background of the Case Study

This case study is on Mr. Akkad, a 76-year-old Iranian male who presented to the office accompanied by the son. The son reported that the client was exhibiting “strange behavior” manifested by changed personality and behavior. The client has lost interest in religious activities and was overly critical with everyone.  Other symptoms included forgetfulness, language problems, among other impaired cognitive functions. The client’s MMSE score was 18 out of 30 with major deficits in attention, calculation, memory, orientation, and registration indicating moderate dementia. On assessment, the client’s eye contact was poor, confused, restricted affect, euthymic mood, and impaired impulse control. His insight and judgment are also impaired, and he is also disoriented to event and time.

Decision Point One

The selected decision point one is to have the client begin Exelon (rivastigmine) 1.5 mg orally BID. The reason for selecting this medication is because rivastigmine is effective in treating Alzheimer’s disease and dementia. Symptoms in major neurocognitive disorder due to Alzheimer’s disease are as a result of pathological changes in cholinergic neuronal pathways. Therefore, rivastigmine is an appropriate choice because the medical works by improving cholinergic function; rivastigmine halts the process of acetylcholine breakdown and therefore increases the availability of acetylcholine in the brain improving, synaptic transmissions; this is what improves memory and other cognitive functions in individuals with major neurocognitive disorder and Alzheimer’s disease (Khoury et al, 2018). In addition, rivastigmine reduces the progress of the disease when the brain has fewer cells to make acetylcholine (Yoon-Sang et al, 2015).

The decision to start Aricept (donepezil) 5 mg orally at BEDTIME was not chosen because donepezil is associated with several side effects such as vomiting, loss of appetite, dizziness, diarrhea, shakiness as well as muscle cramps (Chen et al, 2017). In addition, administrating Aricept (donepezil) at bedtime is allied to sleep disturbances another reason the medication was not selected for the client (Carmen et al, 2014).

Selection of this decision hoped to improve the client’s symptoms which will be manifested by improved cognitive function. This is because the selected medication is effective in improving cognitive functions and other symptoms associated with the major neurocognitive disorder and Alzheimer’s disease (Yoon-Sang et al, 2015).

The actual outcome and the expected outcome were different because the son reported that the client’s symptoms did not improve and his MMSE score was still at 18 out of 30 with orientation, attention and memory deficits. Assessing and Treating Clients with Dementia Essay Paper

Decision Point Two

The selected decision point two is for the client’s rivastigmine dose to be increased to 4.5 mg orally BID. The reason for increasing the current dose of rivastigmine is because evidence indicates that higher dose of rivastigmine have higher efficacy because the medication’s efficacy is dose-dependent (Yoon-Sang et al, 2015). Therefore, a higher dose of rivastigmine for the client is expected to be more effective in improving cognitive functions and other behavioral symptoms for the client. This is because the increased dose of rivastigmine increases concentration acetylcholine within the brain and therefore increasing the medication’s efficacy (Yoon-Sang et al, 2015).

The reason for not selecting the decision to increase Exelon to 6 mg is because increasing the dose from 1.5 mg to 6 mg suddenly would result to a sudden increase of the drug levels within the bloodstream which may increase the possibility of the client having adverse and side effects. According to Nour et al (2016), a dosage increase for rivastigmine should be steady in order to ensure tolerability of the medication. The reason for not selecting the decision to discontinue Exelon and start Namenda is because there is no need to discontinue Exelon because the medication normally takes some time to stabilize symptoms in people with presumptive Alzheimer’s disease and therefore given time the client might start manifesting symptom improvement (Mahoney et al, 2014).

The decision to increase rivastigmine dose to 4.5 mg hoped to stabilize and improve the client’s symptoms of presumptive Alzheimer’s disease which will be manifested by improved cognitive function and the client’s ability to perform activities of daily living. It was also hoped that the client will tolerate the dose and therefore experience minimal side effects from the increased dose. This is because evidence shows that the efficacy of Exelon is dose-dependent and therefore increased dose is likely to be more effective for the client (Khoury et al, 2018). In addition, the steady increase in medication dose ensures a steady increase of the medication within the bloodstream and therefore minimal side effects for the individuals.

Generally, there was no difference between what was expected and the outcome of the selected decision. The outcome of the decision was that the client’s symptoms started improving as manifested by the client starting to take part in religious services with the family. The client also tolerated the medication well because he did not manifest any side effect with the increased dose.

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Decision Point Three

The selected third decision is to increase the Exelon dose to 6 mg. The reason for selecting this decision is because the efficacy of Exelon is dose-dependent because an increased dose increases the level of acetylcholine in the brain and hence increasing the medication efficacy (Mahoney et al, 2014). Therefore, it is expected that with the increased level of acetylcholine, cognitive function and other behavioral symptoms for the client will improve.

The decision to maintain the current Exelon dose was not selected because the efficacy of Exelon is dose dependent and therefore it is important to increase the dose in order to increase the efficacy and hence improve the client’s symptoms (Mahoney et al, 2014). The decision to add Namenda 5 mg was not selected because it is recommended to maximize the dose of Exelon as a cholinesterase inhibitor prior to augmenting the Exelon medication.

Selection of the decision to increase Exelon dose to 6 mg was expected to have symptoms continue improving for the client; this would be manifested by improved cognitive functioning as well as the improved ability of the client to perform activities of daily living. According to Nour et al (2016), higher dosages of Exelon are effective in improving cognitive function and behavioral symptoms. It was also expected that the client would tolerate the increased dose and this will be manifested by no or minimal side effects. Assessing and Treating Clients with Dementia Essay Paper

Ethical Considerations

Capacity determination, informed consent, and decision-making ability are the ethical aspects that may affect the client’s treatment plan. This is because the client is manifesting cognitive impairment as a symptom of     Alzheimer’s disease and this may interfere with his ability to understand the treatment options (Dunn et al, 2015).

Conclusion

The selected first decision is to have the client start Exelon 1.5 mg. The reason for choosing this decision is because Exelon has been shown to be effective in treating cognitive function for people with Alzheimer’s disease due to the improved cholinergic function. The results of the selected decision indicated no improvement which can be attributed to the fact that cholinesterase inhibitors take time to improve symptoms. The second decision was to increase the dose to 4.5 mg while the third decision was to increase the dose to 6mg orally. The reason for selecting decisions to increase Exelon dose was because the medication is dose-dependent where higher doses are more effective in treating symptoms for people with Alzheimer’s disease. The results of increased dose in the second and third decisions were that the client manifested improved disease symptoms since he was able to take part in religious activities with the family. Lastly, ethical issues that may affect the treatment plan for the client include informed consent, capacity determination, and decision-making ability because the client’s cognitive function is impaired.

References

Apostolova L. (2016). Alzheimer Disease. Continuum (Minneap Minn). 22(2): 419–434.

Carmen A, Soheyla, Angela S, Patty G, Angela H & Ragan S. (2014) Impact of nighttime donepezil administration on sleep in the older adult population: A retrospective study. Mental Health Clinician. 4(5), 257-259.

Chen R, Chan P, Chu H, Lin Y, Chang P, Chen C & Chou K. (2017). Treatment effects between monotherapy of donepezil versus combination with memantine for Alzheimer disease: A meta-analysis. PLoS One. 12(8), e0183586.

Dunn L, Alici Y & Wiss L. (2015). Ethical Challenges in the Treatment of Cognitive Impairment in Aging. Current Behavioral Neuroscience Reports. 2(4), 226-233.

Khoury R, Jayashree R & Grossberg G. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Ther Adv Drug Saf. 9(3), 171–178.

Mahoney J, Ari K, Verrico C, Arnoudse N, Shapiro B & Garza R. (2014). Preliminary findings of the effects of rivastigmine, an acetylcholinesterase inhibitor, on working memory in cocaine-dependent volunteers. Prog Neuropsychopharmacol Biol Psychiatry. 3(50): 137–142.

Nour J, Chouliaras L & Hickey L. (2016). High dose rivastigmine in the symptom management of Lewy body dementia Case Reports. 2016(2016):bcr2016217240.

Yoon-Sang O, Kim J & Lee P. (2015). Effect of Rivastigmine on Behavioral and Psychiatric Symptoms of Parkinson’s Disease Dementia. J Mov Disord. 8(2), 98–102. Assessing and Treating Clients with Dementia Essay Paper