The Impact of Cognitive And Behavioural Change Assignment

Running head: ALZHEIMER’S DISEASE

1 ALZHEIMER’S DISEASE 5

Case Study- Alzheimer’s Disease (AD) Chantal Beard

Walden University

NURS 6521

2 Week 8, Assignment 1

Advanced Pharmacology

July 21, 2022

3 Introduction Major Neurocognitive Disorder due to Alzheimer’s Disease is a mental condition associated with loss of cognitive function in the affected patient. This progressive loss of cognitive functions is due to attacks on the nerves associated with cholinergic receptors. Eramudugolla et al. (2017), according to DSM V, aging is associated with memory loss and reduced cognitive abilities. Patients with Major Neurocognitive Disorder have an increased dependence due to extensive loss of cognitive function.

4 Summary of the Case Study

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The patient is a 76-year-old Iranian male presented by his son with a complaint of strange behavior. 5 Due to his presentation, a diagnosis of Alzheimer’s disease is made. 4 His son reports that he has shown strange thoughts and behavior for the past two years. His family physician has ruled out any organic causes of his behavioral changes, and diagnostic studies done have also ruled out any organic basis for his condition. 4 The behavioral changes noted were changes in personality, apathy, and memory loss with difficulty locating the right words during conversations. These changes are reported to have been getting worse with time. He first started losing interest in religious activity, which he used to perform together with the family. Instead, he became critical of everyone and now sees serious things as a source of amusement and ridicule. 4 During the interview, confabulation is noted and the patient reports euthymic mood. In addition, the patient demonstrates judgement impairment with lack of impulse control and insight. He has no suicidal thoughts leading to the diagnosis of Alzheimer’s disease, a neurocognitive disorder. The Impact of Cognitive And Behavioural Change Assignment

Decision point one- Start Aricept (donepezil) 5 mg orally, BEDTIME

Reason for the decision and expected outcome: Donepezil is an acetylcholinesterase inhibitor that inhibits the breakdown of acetylcholine hence increasing its level in the brain. This improves the function of cholinergic neurons. Studies show that this improves behavior, cognition, and functional abilities in Alzheimer’s patients (Birks & Harvey, 2018). This will improve memory, the thinking process, and the ability to conduct the daily activities of living. 4 This would improve the patient’s quality of life, although it would take some time before showing improvement. 3 Donepezil is approved by the FDA for the treatment of dementia associated with Alzheimer’s.

The other drug, Exelon is also an Acetylcholinesterase inhibitor with a similar mechanism of action as Donepezil. However, it has a different pharmacokinetics and would require twice daily dosing. This would be a problem in compliance especially for a patient with cognitive dysfunction like this patient.

Expected Outcome

After treatment with the medication, it is expected that the patient will show improvement in his memory process and be able to participate in religious activities and engage in conversations, and developing interest in things he used to take seriously. 3 We also expect minimal to no changes in mini-mental state examination (MMSE).

4 Difference between expected and Actual outcome: The patient comes back after a few weeks with no change with the medication. He however reports no adverse effects like nausea, vomiting, or diarrhea from the medication.

Decision Point Two- Increase Aricept to 10mg orally at BEDTIME

Reason for selection and expected outcome: Since the patient tolerated the initial treatment and had no side effects, it can be safe to increase the dose a little to achieve better results (Birks & Harvey, 2018). However, it is probably a good time to explain to the son that the medications will not bring results immediately and that their father will not get better as before. He should understand that this treatment is only targeted at behavioral improvement, and cognitive behavioral therapy can also be suggested (Burke et al., 2018). 3 Increasing the dose of Aricept to 15-20mg may have more adverse effects that may cause discomfort for the patient.

Expected Outcome

4 The expected outcome is behavioral improvement that will allow the patient to interact better with his relatives and have a better quality of life. The Impact of Cognitive And Behavioural Change Assignment

Difference between expected and actual outcome: The outcome of the treatment is as expected as the patient come back again having tolerated the medication well and is now less critical. The son reports that he is now attending religious services with the family, but is still easily amused by serious things.

Decision point Three- Continue Aricept 10mg orally at BEDTIME

Reasons for selection and expected outcome: Since the patient is responding well to the therapy, at this point, continuing therapy is the best option. Currently, no study has shown that higher doses of Aricept yields more results, whereas higher doses can cause side effects like vomiting and loose stools.

Difference between expected and actual outcome: The patient is still tolerating the drugs well and is showing some behavioral improvement. There are no drug side effects seen. 4 It would be important at this point to address the son’s concern for lack of improvement by assuring him that the drugs take longer for treatment to take effect (Burke et al., 2018). The patient has only been on treatment for four weeks. 4 They should be advised to also explore other treatment modalities like cognitive behavioral therapy in combination with the medication treatment (Smith et al., 2017).

Conclusion

The pharmacological agents used in the management of Alzheimer’s disease do not alter the disease’s progress (Korabecny et al., 2019). 4 They are just used for behavioral modification to improve the patient’s quality of life and to help them cope better with family members. The patient’s caregivers should be informed that the condition is progressive, and thus, cognitive function may continue to deteriorate despite pharmacological treatment. They should also know that therapeutic interventions given do not treat the condition but only tries to improve symptoms of cognitive loss, and this may take a while to be effective. The Impact of Cognitive And Behavioural Change Assignment

References

Birks, J. 4 S., & Harvey, R. J. (2018). 4 Donepezil for dementia due to Alzheimer’s disease. Cochrane Database of Systematic Reviews, 2018(6). https://doi.org/10.1002/14651858.cd001190.pub3

Burke, T., Galvin, M., Maguire, S., Pender, N., & Hardiman, O. (2018). 4 The impact of cognitive and behavioral change on the quality of life of caregivers and patients with ALS and other neurological conditions. Oxford Medicine Online. https://doi.org/10.1093/med/9780198757726.003.0009

3 Eramudugolla, R., Mortby, M. E., Sachdev, P., Meslin, C., Kumar, R., & Anstey, K. J. (2017). 3 Evaluation of a research diagnostic algorithm for DSM-5 neurocognitive disorders in a population-based cohort of older adults. Alzheimer’s research & therapy, 9(1), 1-12

4 Korabecny, J., Spilovska, K., Mezeiova, E., Benek, O., Juza, R., Kaping, D., & Soukup, O. (2019). 4 A systematic review on donepezil-based derivatives as potential cholinesterase inhibitors for Alzheimer’s disease. Current Medicinal Chemistry, 26(30), 5625-5648. https://doi.org/10.2174/0929867325666180517094023

Smith, D., Lovell, J., Weller, C., Kennedy, B., Winbolt, M., Young, C., & Ibrahim, J. (2017). 4 A systematic review of medication non-adherence in persons with dementia or cognitive impairment. PLOS ONE, 12(2), e0170651. https://doi.org/10.1371/journal.pone.0170651

Introduction

Alzheimer’s disease is a progressive neurodegenerative disorder that may be caused by an abnormal build-up of proteins in the brain (amyloidosis). This causes injury and subsequent death of the brain neurons, and finally the brain atrophies. The result is impairment of cognitive and behavioral functions like memory, language, attention, judgement, and reasoning (Khan et al., 2020). In this paper, the author analyzes a case of Alzheimer’s disease pharmacologic management and patient response to treatment by looking at three decision points as possible regimens for the patient.

Case Study Summary

A 76-year-old Iranian male, Mr. A, is brought to the office with complaints of strange behavior. His family physician ruled out organic brain disease as cause of this strange behavior, and all diagnostic studies and laboratory tests are normal. The son reports that his father’s symptoms started two years ago and have been getting worse. It first began with him losing interest in certain things he loved before such as participating in religious events with the family. He has also become forgetful and finds making conversations difficult because he forgets simple words. Mr. A scored 18 out of 30 on the mini mental status exam as he has deficits in orientation, attention, calculation, and recall. He is also not oriented to time, place and events.

During the mental status examination, the patient shows impairment in judgement and insight. He also has impaired impulse control as seen when he stands up and walks towards the door during the interview. With this, we make a diagnosis of major neurocognitive disorder from Alzheimer’s disease (Kumar et al., 2020). The Impact of Cognitive And Behavioural Change Assignment

Decision Point One: Begin Exelon (rivastigmine) 1.5 mg orally BID, increase to 3mg orally BID in two weeks.

Reason for decision selection and the expected outcome: Rivastigmine is an acetylcholinesterase inhibitor, which blocks the actions of acetylcholinesterase enzyme. This prevents the breakdown of neurotransmitter acetylcholine. This increases its levels and improves brain activity. It is recommended as one of the drugs to be used in first line management of Alzheimer’s disease by improving cognition. (Patel & Gupta, 2022). The drug is essentially well tolerated and effective. The expectation of this decision is that the patient would show some improvement in brain function to allow participation in religious activities and eliminate the strange behaviors. We also expect that the patient will start showing memory improvement and be able to participate in conversations after a few weeks of treatment.

Difference between expected and Actual outcome: The patient is brought back into the office after four weeks and the son reports no improvement in his symptoms as he still shows disinterest in religious activities. The strange behaviors are still there and he has not shown improvement in his MMSE. As we had expected improvement in his outcome through better memory performance and behavior change, the actual outcomes are significantly different from the expectations.

Decision Point Two: Increase Exelon to 4.5mg orally BID

Reason for decision selection and the expected outcome: Studies show that the efficacy of rivastigmime is dose dependent, with the maximum dose having the most significant improvement in cognitive function (Patel & Gupta, 2022). This dose-dependent effect means that for the patient to show more improvement, the dose should be increased slowly until the maximum tolerated dose is achieved. We this decision, we expect that the patient will begin to show some improvement while still tolerating the drug well. The patient should start showing some improvement in memory and behavior in a few weeks, but the son should know that the drug takes time to have effect. The Impact of Cognitive And Behavioural Change Assignment

Difference between expected and actual outcome: After another four weeks, the son returns with his father to the clinic and report that he is now attending religious activities. The family is happy with this improvement but they still have some concerns. They feel that he is still not better because he still finds amusement in serious things as before. Contrary to our expectation, the patient still exhibits strange behaviors by laughing at serious things. This shows lack of inhibition as observed in the initial assessment. However, at this point, the patient is still tolerating the drug dosage well and has shown improvement. Therefore, titrating the dose of the drug is still possible for more cognitive improvement (Khan et al., 2020).

Decision Point Three: increase Exelon to 6mg orally BID

Reasons for decision selection and the expected outcome: As noted earlier, the patient is tolerating the dose increment well with no side effects like nausea and vomiting. A higher dose of rivastigmine is required in mild to moderate Alzheimer’s for improvement in cognitive function (Bunt, 2017). The client is now participating in important activities that the family was concerned about. At this point, the nurse needs to explain to the son that Alzheimer’s disease is a neurodegenerative condition that causes irreversible brain damage. Therefore, the father will probably never fully recover and some symptoms such as disinhibition may never go away completely.  They should also inform the family that the drug may take months for the patient to show significant improvement and so they should not take the slow response as treatment failure. The Impact of Cognitive And Behavioural Change Assignment

Difference between the expected and the actual outcome: The expected outcome with the decision was a more significant improvement in the patient’s cognitive function. The son reports that his father is still participating in religious activities and is showing some improvement. He is also tolerating the drug well and is not experiencing any side effects. To address the family’s concerns, the nurse should now assure them that the patient will show further improvements with time as the drug takes more effect. The nurse can also suggest other non-pharmacological interventions such as orientation and memory exercises, music therapy, and art therapy (Quail et al., 2020). Family and caregiver counselling on caring for the patient and ways of interacting with them should also be provided.

The nurse should schedule the patient’s next visit after four weeks to reassess the drug effects and action and see how the patient is doing.

Conclusion

Alzheimers’s disease is a mental condition resulting from irreversible changes in brain function leading to memory loss and confusion. It can result from various factors such as genetics, aging, lifestyle, and environmental causes (Khan et al., 2020). The management principles revolve around improving neuronal functions in the brain to improve symptoms. There is no cure for the disease. Other than providing pharmacological treatment to improve their symptoms, the nurse should also provide reassurance to the patient and their family (Gibson et al., 2021). This can help improve the patient’s quality of life and make it better for the family to care for the patient. The Impact of Cognitive And Behavioural Change Assignment

References

Bunt, C. (2017). What are the benefits and harms of rivastigmine for Alzheimer’s disease? Cochrane Clinical Answers. https://doi.org/10.1002/cca.794

Gibson, C., Goeman, D., Hutchinson, A., Yates, M., & Pond, D. (2021). The provision of dementia care in general practice: Practice nurse perceptions of their role. BMC Family Practice, 22(1). https://doi.org/10.1186/s12875-021-01467-z

Khan, S., Barve, K. H., & Kumar, M. S. (2020). Recent advancements in pathogenesis, diagnostics and treatment of Alzheimer’s disease. Current Neuropharmacology, 18(11), 1106-1125. https://doi.org/10.2174/1570159×18666200528142429

Kumar A., Sidhu J., Goyal A., Tsao, J. W., & Doerr C. (2020). Alzheimer Disease (Nursing). NCBI BOOKSHELF. https://www.ncbi.nlm.nih.gov/books/NBK568805/

Patel, P. H., & Gupta V. (2022). Rivastigmine. StatPearls-NCBI. https://www.ncbi.nlm.nih.gov/books/NBK557438/#:~:text=Oral%20capsule%20dosing%20by%20indication,two%20weeks%20per%20patient%20tolerated

Quail, Z., Carter, M. M., Wei, A., & Li, X. (2020). Management of cognitive decline in Alzheimer’s disease using a non-pharmacological intervention program. Medicine, 99(21), e20128. https://doi.org/10.1097/md.0000000000020128 The Impact of Cognitive And Behavioural Change Assignment

Alzheimer’s Disease
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 difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation. The Impact of Cognitive And Behavioural Change Assignment

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 a 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. The self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes were 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 toward the door. When you 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) The Impact of Cognitive And Behavioural Change Assignment

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RESOURCES
§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.

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 3- to 4-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.
You will submit this Assignment in Week 8. The Impact of Cognitive And Behavioural Change Assignment