For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat adult and older adult clients presenting symptoms of a mental health disorder.
The Assignment:
You will:
• Evaluate clients for treatment of mental health disorders
• Analyze decisions made throughout diagnosis and treatment of clients with mental health disorders
Examine Case 3(see attachment): You will be asked to make three decisions concerning the diagnosis and treatment for this client (decisions already made see attachment). Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.  Neurocognitive Disorders For Diagnosis Essay Case Study

At each Decision Point, stop to complete the following:
• Decision #1: Differential Diagnosis
o Which Decision did you select?
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o 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
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o 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
o Why did you select this Decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this Decision? Support your response with evidence and references to the Learning Resources.
o 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.

Introduction

Neurocognitive disorders include a group of conditions that result in impairment of mental function. Symptoms that characterize neurocognitive disorders include memory problems, a problem in carrying out activities of daily living; behavior changes; and language difficulties.  The client in this case study presented with symptoms of neurocognitive disorder. The first decision will be on the diagnosis for the client, while the other two decisions will be about the treatment choices for the client. The paper will conclude by discussing the ethical aspects that can affect the client’s treatment plan.

Decision #1: Differential Diagnosis

The diagnosis for this client is major neurocognitive disorder with Lewy bodies (MNDLB). This diagnosis was chosen since the symptoms manifested by the client meet the diagnostic criteria for MNDLB. MNDLB involves the constant decline of cognitive functions that interrupts the ability of the person to perform activities of daily living and also impairs an individuals functioning (Donaghy & McKeith, 2014). The condition is also characterized by memory impairment that is a symptom of cognitive decline. Additionally, there are deficits of the executive and attention functions and other clinical features like rest tremor, inconsistent cognition, REM sleep behavior disorder, and intermittent visual hallucinations (McKeith et al, 2017). The client manifests progressive cognitive decline and memory impairment that significantly affects his ability to perform activities of daily living and normal social functioning as well. For instance, while driving he got lost, performs errors and forgets to pay bills, leaves doors without closing, and he once forgot the food when cooking. It was also reported that the client screams and kicks during sleep indicating REM sleep behavior disorder. the client’s attention, insight, and attention are also impaired further confirming the diagnosis of MNDLB.

The selection of this decision hoped that it was the precise diagnosis and hence would facilitate the correct treatment plan for the client.

Decision Point Two

The second decision is for the client to begin Ramelteon 8 mg at bedtime. The reason why Ramelteon was selected is that the efficacy of the medication in treating MNDLB has been demonstrated. Specifically, Ramelteon has been shown to reduce neuropsychiatric symptoms and sleep disturbances, without major adverse effects (Stinton et al., 2015). Major neurocognitive disorder with Lewy bodies is characterized by disturbed sleep/wake rhythms and hence Ramelteon which is a melatonin agonist can help in treating sleep-wake and rhythm disturbances (Stinton et al., 2015).

By selecting Ramelteon for this client, it was hoped that the symptoms of MNDLB for the client would reduce or his condition would not deteriorate. For example, it was expected that the decline of cognitive function for the client would stoop and that his ability to perform activities of daily living would improve. This is because Ramelteon has been shown to reduce neuropsychiatric symptoms and sleep disturbances. It was also expected that the client would not experience side effects because the majority of individuals taking the mediation do not report major adverse effects (Stinton et al., 2015).

However, the outcomes of the decision that was selected were different from the expected outcomes. When the client reported for review, he reported oversleeping, experiencing falls, lack of energy, and headache morning hours. It was also reported that the client was still experiencing REM sleep behavior disorder. These adverse symptoms are attributable to the side effects of Ramelteon that include sedation, drowsiness during daytime, fatigue, and dizziness.

Decision Point Three

The third decision was for the client to begin Clonazepam 0.5 mg orally during bedtime. The reason why the decision was selected is that the client is still experiencing REM sleep behavior disorder. Clonazepam has been shown to lower the rate of injuries associated with REM sleep behavior disorder (Hogi & Stefani, 2017). The medication has also been shown to be effective in relieving symptoms associated with REM sleep behavior disorder (Aurora et al, 2015). In addition, the client was experiencing many side effects with Ramelteon.

Selection of Clonazepam for the client hoped that symptoms of REM sleep behavior disorder such as nightmares and screaming would improve for the client. This is due to the efficacy of Clonazepam in improving symptoms of REM sleep behavior disorder (Aurora et al, 2015).

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Treatment Plan for Psychotherapy

The client to start using memory aids. The rationale of selecting use of memory aids for the client is to help him to remember things and find his way around because he is experiencing memory loss as indicating by aspects such as the client getting lost while driving, performs errors and forgets to pay bills, leaves doors without closing, and he also once forgot the food when cooking. Therefore, the use of memory aids will help the client with recollection and improve his safety as well (Chester et al., 2018).

By selecting the use of memory aids for the client, it is expected that this will help him in remembering things and hence help him around and improve his safety as well. This is because memory aids help individuals with memory loss and manifesting forgetfulness with recollection and to remember activities and things they should be doing (Chester et al., 2018).

Ethical Considerations

Treating clients with cognitive impairments like the client in the case study is associated with ethical aspects like decision-making ability, informed consent, and autonomy in order to ensure that their rights are respected (Dunn et al, 2015). For instance, the declined cognitive functioning may hinder the ability of the client to understand treatment choices and thus he may be unable to make treatment decisions. Moreover, the client along with the son should be actively involved in the whole treatment plan and ensure that they are fully informed regarding the available treatment choices to ensure that the informed consent is obtained prior to starting treatment (Dunn et al, 2015).  Neurocognitive Disorders For Diagnosis Essay Case Study

Conclusion

The first decision was that the client’s diagnosis was major neurocognitive disorder with Lewy bodies since the symptoms manifested by the client meet the diagnostic criteria for MNDLB. The second decision was for the client to begin Ramelteon 8 mg at bedtime because the efficacy of the medication in treating MNDLB has been demonstrated. However, the client did not show any improvement for REM sleep behavior disorder and he also experienced many serious side effects. Therefore, the third decision was to start Clonazepam because the medication has been shown to be effective in relieving symptoms associated with REM sleep behavior disorder. Ethical issues that may affect the treatment of the client include decision-making ability, informed consent, and autonomy.

BACKGROUND
Mr. Charles Wingate is a 76-year-old Caucasian male who presents to your office for an initial psychiatric evaluation. He is accompanied by his eldest son, Mark, who lives with Mr. Wingate. Mr. Wingate was referred to you by his primary care provider who has performed an extensive diagnostic workup to rule out an organic basis for his changes in cognition. Mr. Wingate’s son Mark has verbalized a concern that Mr. Wingate may have Alzheimer’s disease. When questioned, Mr. Wingate states that he is unaware of anyone in his family ever having been diagnosed with Alzheimer’s disease.

SUBJECTIVE
Mr. Wingate states that he has always been “a little bit forgetful,” but he noticed that in his 60s and 70s, it got worse. Mark states that “for the past 2 years, it has been getting worse. He doesn’t even notice how bad his memory has become.” On at least two occasions, Mr. Wingate has gotten lost when he was driving to the grocery store. Mr. Wingate protested his disagreement with this accusation stating, “but they were doing road construction, anyone could have gotten mixed up!” While his son conceded to this, he pointed out that Mr. Wingate’s memory has caused some other problems, such as errors with paying his monthly utility bills (at one point, the electric company threatened to shut off his electricity due to his nonpayment of the bill).
His son Mark also pointed out that the family is concerned for Mr. Wingate’s safety as he twice left his keys hanging in the door and just two evenings ago, put food in oven and forgot about it until the smoke detector in the kitchen began to alarm.
Mr. Wingate also has had a few issues with managing his medications. Specifically, he took too many Norvasc tablets a few months ago, which resulted in hypotension and a fall. Since that time, Mark’s wife has been setting up Mr. Wingate’s pills in pill boxes, but recently, multiple “missed doses” have been noted.
Mr. Wingate states: “but those are my night pills that I miss—I’m always better at remembering things in the morning.” Mark agrees, stating that Mr. Wingate’s cognition does vary throughout the course of the day and appears to worsen in the evening. He also reports that his father seems much less alert in the evenings, and more alert in the mornings.
Mr. Wingate reports that he has had poor sleep for “a long time now.” He does report that over the past few months, he has been having what he describes as “very vivid nightmares.” His son states that sometimes he is awakened by his father’s yelling during nightmares, and enters his father’s room, and sees his father swinging or kicking in his sleep.
He reports that his appetite is “alright” and that his energy levels do fluctuate throughout the course of the day. He states: “sometimes, I can concentrate really well; other times I can’t … it is very frustrating!” Specific to substance use, Mr. Wingate notes that he used to enjoy a glass of wine or two with dinner, but states that it just doesn’t interest him, anymore. Plus, he stated that he notices that when he does drink, he develops slow muscle contractions.
Mr. Wingate’s son also shares a concern about his father’s abnormal movements. He states that for about the last 6 months, his father has had problems with coordination. He states that he raised these concerns with the family doctor who suggested it may be “late onset Parkinson’s disease.” However, he was not treated because the symptoms were “not that bad.”

OBJECTIVE
Mr. Wingate was overall calm and pleasant during the clinical interview. Throughout the clinical interview, you notice that Mr. Wingate is not really involved in the discussion. He seems somewhat indifferent to the assessment and does not seem very concerned with what is being discussed. He only protested when discussing how he got lost on his way to the supermarket and his evening medication dose.
Review of systems and screening physical assessment were unremarkable, with the exception of fine resting tremors noted in both of Mr. Wingate’s hands. The psychiatric/mental health nurse practitioner (PMHNP) also reviewed laboratory studies that were sent from Mr. Wingate’s primary care provider; they were within normal limits with the exception of a serum sodium level of 130 mEq/L.

MENTAL STATUS EXAM
Mr. Wingate is alert. He is oriented to person, place, and partially oriented to time (he knows that it is morning, but cannot tell the hour). His speech is clear, coherent, goal directed, and spontaneous. Mr. Wingate’s self-reported mood is “ok.” Affect is somewhat constricted. His eye contact is fleeting throughout the clinical interview. He denies visual or auditory hallucinations, no overt delusional or paranoid thought processes appreciated. Judgment seems well preserved, but insight appears impaired as he is having trouble understanding why his son brought him to this appointment. Concentration and attention also appear impaired, which prompts the PMHNP to perform a mini-mental status exam (MMSE) on Mr. Wingate.  Neurocognitive Disorders For Diagnosis Essay Case Study

RESULTS OF MMSE
Score of 17, with primary deficits in orientation; calculation; recall (he was unable to recall any of the three items presented after 5 minutes); and he was unable to perform serial 7’s or spell the word “WORD” in reverse, despite the fact that he is a high school graduate and attended 1 year of college. He also needed prompting with the three-step command. His score suggests severe cognitive impairment.
At this point, please discuss any additional diagnostic tests you would perform on Mr. Wingate.
Decision Point One

Major neurocognitive disorder with Lewy bodies
Decision Point Two

Begin Ramelteon 8 mg at bedtime

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RESULTS OF DECISION POINT TWO
• Client returns to clinic in four weeks
• Mr. Wingate’s son reports that Mr. Wingate takes the medication at bedtime, but instead of getting up at his usual time in the morning (around 7 or 8 am), he has been sleeping past 9:30 am. He also reports that his father has had two falls in the middle of the night when he woke up to go to the bathroom. As a result, Mr. Wingate’s son has been encouraging Mr. Wingate to consume less fluids in the evening (so that he will not have to get up and use the bathroom in the middle of the night).
• Mr. Wingate tells you that he often gets headaches in the morning, and feels like he has no energy until the afternoon.
• Mr. Wingate also reports that he is still having “those horrible dreams” and his son confirms that he is still “acting out” his dreams despite using the medication as prescribed.
Decision Point Three

Begin Clonazepam 0.25 mg orally at bedtime

Guidance to Student

In the case of Mr. Wingate, he meets the diagnostic criteria for major neurocognitive disorder as evidenced by a decline from a previous level of performance in more than one cognitive domain—in this case, complex attention and executive function. The decline is based on a knowledgeable informant, as well as a clinician (the patient’s primary care provider) who referred him to you, as well as substantial impairment in another quantified clinical assessment (the MMSE). Cognitive deficits that Mr. Wingate demonstrates interfere with independence in everyday activities and he requires help with complex IADLs such as medication management and paying bills.
Nothing in the scenario suggests that delirium could be responsible for the cognitive decline, nor is anything in the scenario suggestive of another mental disorder.
While one may be initially inclined to consider major neurocognitive disorder due to Alzheimer’s disease, probable Alzheimer’s would require evidence of a causative genetic mutation either from family history or genetic testing, and/or decline in memory and learning and at least one other cognitive domain; steadily progressive, gradual decline in cognition without extended plateaus; and no evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to the cognitive decline). Similarly, while there is some evidence of mild apathy, and decline in executive abilities, there is insufficient evidence of three or more behavioral symptoms that would be needed to make a diagnosis of major frontotemporal neurocognitive disorder (e.g., behavioral disinhibition, loss of sympathy or empathy, perseverative, stereotyped or compulsive/ritualistic behavior, hyperorality and dietary changes, or prominent decline in social cognition and/or executive abilities) nor is there evidence of prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension that would suggest major frontotemporal neurocognitive disorder. Neurocognitive Disorders For Diagnosis Essay Case Study

In Mr. Wingate’s case, there is clear evidence of fluctuating cognition, and spontaneous features of Parkinsonism, which had their onset subsequent to the development of cognitive decline. These symptoms, coupled with the presence of a rapid eye movement sleep behavior disorder, are suggestive of MNDLB. Diagnostic testing should focus on determining the presence of a synucleinopathy.
Mr. Wingate’s symptoms of sedation, dizziness (with resultant falls), coupled with complaints of headache and fatigue, represent the most common side effects associated with Ramelteon. Although this drug is generally considered safe for healthy individuals (as there have been no reports yet of dependence or abuse), it is clear that the side effects that Mr. Wingate is experiencing outweigh the benefits. Falls in an elderly person should be a major concern as the potential for fracture and resultant cascade iatrogenesis is great. Also, restriction of fluid intake to avoid having to use the bathroom in the middle of the night is also a bad idea as this could lead to dehydration, which could further increase dizziness and risk of falls with injury. It is also interesting to note that despite all of these side effects, neither Mr. Wingate nor his son report any decrease in the frequency/intensity of his REM sleep disorder symptoms.
The decision to use Ambien may carry similar side effects as Ramelteon, with no documented evidence of efficacy in REM sleep disorders. Similarly, changing to over-the-counter Melatonin would probably not be helpful either—recall that Ramelteon is also a melatonin 1 and 2 receptor agonist. Over-the-counter Melatonin may have the same side effects, again, with no documented efficacy in the treatment of REM sleep disorders.
Changing to low-dose Clonazepam (0.25 or even 0.125 mg) may be considered as a treatment for REM sleep disorders in individuals with MNDLB, as it has been demonstrated to have some clinical efficacy. Since Clonazepam has a long half-life, the PMHNP should begin at a low dose, and slowly titrate upward, being mindful to educate the client and family about potential side effects and therapeutic end-goals. Remember that safety is always the first priority with prescribing.

References

Aurora R, Zak R, Maganti R, Auerbach S, Casey K, Chowdhuri S, Karippot A, Ramar K, Kristo D & Morgenthaler T. (2015). Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 6(1):85-95.

Chester, H., Clarkson, P., Davies, L., et al. (2018). Cognitive aids for people with early-stage dementia versus treatment as usual (Dementia Early Stage Cognitive Aids New Trial (DESCANT)): study protocol for a randomized controlled trial. Trials, 19(546).

Donaghy P & McKeith I. (2014). The clinical characteristics of dementia with Lewy bodies and consideration of prodromal diagnosis. Alzheimers Res Ther. 6(4): 46.

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

Hogi B & Stefani A. (2017). REM sleep behavior disorder (RBD). Somnologie (Berl). 21(1): 1–8.

McKeith I, Boeve B et al. (2017). Diagnosis and management of dementia with Lewy bodies. Neurology. 89(1): 88–100.

Stinton, C., McKeith, I., Taylor, J-P., Lafortune, L., Mioshi, E., Mak, E., … O’Brien, J. T. (2015). Pharmacological management of Lewy body dementia: a systematic review and meta-analysis. American Journal of Psychiatry, 172(8), 731-742.  Neurocognitive Disorders For Diagnosis Essay Case Study