Treatment of Neurologic And Musculoskeletal Disorders Assignment

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.” Treatment of Neurologic And Musculoskeletal Disorders Assignment

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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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 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. Treatment of Neurologic And Musculoskeletal Disorders Assignment

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.

Begin Aricept (donepezil) 5 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
The client is accompanied by his son who reports that his father is “no better” from this medication
He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall

Decision Point Two

Increase Aricept to 10 mg orally at BEDTIME
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better
He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious Treatment of Neurologic And Musculoskeletal Disorders Assignment

Decision Point Three

Continue Aricept 10 mg orally at BEDTIME
Guidance to Student
At this point, it would be prudent to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that you should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.

Please include the 3 decisions I made to treat the patient in this paper Treatment of Neurologic And Musculoskeletal Disorders Assignment

Students will:

Evaluate patients for treatment of neurologic and musculoskeletal disorders
Analyze decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders
Justify decisions made throughout the diagnosis and treatment of patients with neurologic and musculoskeletal disorders

To Prepare
Review the interactive media piece assigned by your Instructor.
Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
By Day 7 of Week 8
Write a 1- to 2-page summary paper that addresses the following:

Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples. Treatment of Neurologic And Musculoskeletal Disorders Assignment

Case Summary
The case study is about Mr. Akkad, a 76-year-old Iranian who was brought into the office by his son with complaints of having “strange behavior.” The family physician’s investigations showed normal laboratory and diagnostic imaging tests. However, the son reports worsening his strange behavior and has lost interest in religious activities. The MMSE score of 18 out of 30 suggests that he has moderate dementia. From his mental status exam, a diagnosis of major neurocognitive disorder due to Alzheimer’s disease is made.
From his diagnosis, a decision is made to start Aricept (donepezil) 5 mg orally at bedtime. Donepezil is chosen as the first medication for the client since it falls under the cholinesterase inhibitors and therefore improves brain function by alleviating the symptoms of dementia (Adlimoghaddam et al., 2018). Donepezil medication is effective in controlling symptoms of dementia, and an increase in dosage is recommended after 4 to 6 weeks. After four weeks of starting the medication, the son reports that the client’s symptoms have not improved. The client’s MMSE sore is still 18 out of 30, which proves that the medication has not controlled the client’s symptoms.

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The second decision is, therefore, to increase the donepezil medication dosage to 10mg orally. The decision is taken since an increased dosage of donepezil is recommended to control the symptoms of dementia. The medication is dose-dependent, meaning a higher dosage is more effective than a lower dose (Calhoun et al., 2018). After increasing medication, the son reports that the father is tolerating the medication well. The father is still easily amused, but an improvement in the symptoms is noted by the son reporting that he is attending religious services. So the third decision is to continue with the donepezil medication of 10mg since it might take several months to achieve stabilization. Moreover, there is no evidence that a dosage of over 10mg of donepezil improves symptoms, has better outcomes, and might be accompanied by many adverse effects (Zhang et al., 2019). No presenting symptoms or adverse effects suggest donepezil should be discontinued. After deciding to continue the medication, the client’s MMSE score should be checked monthly to monitor progress. Treatment of Neurologic And Musculoskeletal Disorders Assignment

References
Adlimoghaddam, A., Neuendorff, M., Roy, B., & Albensi, B. C. (2018). A review of clinical treatment considerations of donepezil in severe Alzheimer’s disease. CNS Neuroscience & Therapeutics, 24(10), 876-888. https://doi.org/10.1111/cns.13035
Calhoun, A., King, C., Khoury, R., & Grossberg, G. T. (2018). An evaluation of memantine ER + donepezil for the treatment of Alzheimer’s disease. Expert Opinion on Pharmacotherapy, 19(15), 1711-1717. https://doi.org/10.1080/14656566.2018.1519022
Zhang, H., Zhao, Y., Yu, M., Zhao, Z., Liu, P., Cheng, H., Ji, Y., Jin, Y., Sun, B., Zhou, J., & Ding, Y. (2019). Reassembly of native components with donepezil to execute dual-missions in Alzheimer’s disease therapy. Journal of Controlled Release, 296, 14-28. Treatment of Neurologic And Musculoskeletal Disorders Assignment