Summary of The Patients With Alzheimer Disease Case Study

NURS_6521_Week8_Assignment_Rubric

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The client, M. A, is a 76yo Iranian male whose son accompanies the office. During the clinical interview, the son reports strange behavior. The son reports that all diagnostic tests conducted by the family physician were normal. The son reveals that his dad has been portraying some strange behaviors and thoughts, which have persisted for the past two years. He adds that the client’s symptoms are worsening. His son reports that the family noticed a change in the client’s personality some years ago. The client started losing interest in religious activities. Additionally, the client started being amused with the things that he used to take seriously. The further reports that the client has been forgetting things in the last two years. He also experiences difficulty finding the right words while holding a conversation and changes the topic of the conversation completely.

Opinion regarding Decisions Recommended for the Patient in the Case Study

Based on the medical history provided during clinical assessment, the client is diagnosed with Alzheimer’s. Consequently, three treatment decisions are recommended to manage the client’s decision. The first treatment intervention involves beginning Exelon (rivastigmine) 1.5 mg orally BID, which would be titrated upwards to 3 mg orally BID after two weeks. This decision is the most appropriate for this client due to the efficacy of Rivastigmine in managing symptoms of Alzheimer’s disease in elderly adults (Nguyen et al., 2021). Additionally, it is recommended to increase the client’s dosage to 3 mg orally BID after two weeks since the efficacy of Rivastigmine in treating the symptoms of Alzheimer’s disease increase with dosage (Haake et al., 2020). The second treatment decision involves increasing Exelon to 4.5 mg orally BID. This decision is recommendable since the first dosage, 3 mg orally daily, was ineffective in improving the client’s condition. Furthermore, a higher dose of Exelon is more effective in treating Alzheimer’s disease in elderly adults (Haake et al., 2020). The third treatment intervention entails adding Namenda (memantine) 5 mg orally daily. This decision is recommendable since Exelon to 4.5 mg orally BID only partially improved the client’s symptoms. Furthermore, studies show that memantine is effective in treating symptoms of Alzheimer’s disease (Matsunaga et al., 2018).

Expected Results with the Recommended Decision

            First, by beginning Exelon (rivastigmine) 1.5 mg orally BID, which would be titrated upwards to 3 mg orally BID after two weeks, the healthcare provider intended to achieve partial improvement in the client’s symptoms due to the efficacy of Exelon in managing symptoms of Alzheimer’s disease in elderly adults (Nguyen et al., 2021). Secondly, the healthcare provider aimed to further improve the client’s symptoms by increasing Exelon to 4.5 mg orally BID. These results would be achieved since higher doses of Exelon are more effective in treating Alzheimer’s disease than low doses (Cummings et al., 2018). Lastly, by adding Namenda (memantine) 5 mg orally daily, the clinician aimed to remit the client’s symptoms entirely due to the efficacy of memantine in managing symptoms of Alzheimer’s disease in elderly adults (Matsunaga et al., 2018). Summary of The Patients With Alzheimer Disease Case Study

Differences between Expected Results and Actual Outcomes

First, no differences exist between the expected results and actual outcomes following the administration of the first treatment regimen, Exelon (rivastigmine) 1.5 mg orally BID and increasing to 3 mg after 2 weeks. This intervention was expected to achieve partial improvement in the client’s symptoms. Upon returning to the clinic after four weeks, the client’s MMSE score is 18 out of 30, indicating a partial response. However, the client is disinterested in religious activities. Secondly, there is no difference between the expected results and actual outcomes after the second treatment regimen, increasing Exelon to 4.5 mg orally BID. This intervention aimed at improving the client’s symptoms further. Upon returning to the clinic after four weeks, the son reports that the client tolerates the current dosage and is attending religious services. However, the client is still amused by things he used to consider serious. Lastly, no difference between the expected results and actual outcomes after the third treatment regimen, adding Namenda (memantine) 5 mg orally daily. This intervention is expected to remit the client’s symptoms fully. It is expected that the son would report that the client is participating in religious activities and serious things no longer amuse him.  Summary of The Patients With Alzheimer Disease Case Study

References

Cummings, J., Froelich, L., Black, S. E., Bakchine, S., Bellelli, G., Molinuevo, J. L., … & Strohmaier, C. (2018). Randomized, double-blind, parallel-group, 48-week study for efficacy and safety of a higher-dose rivastigmine patch (15 vs. 10 cm2) in Alzheimer’s disease. Dementia and geriatric cognitive disorders, 33(5), 341-353.

Haake, A., Nguyen, K., Friedman, L., Chakkamparambil, B., & Grossberg, G. T. (2020). An update on the utility and safety of cholinesterase inhibitors for the treatment of Alzheimer’s disease. Expert opinion on drug safety, 19(2), 147-157.

Matsunaga, S., Kishi, T., Nomura, I., Sakuma, K., Okuya, M., Ikuta, T., & Iwata, N. (2018). The efficacy and safety of memantine for the treatment of Alzheimer’s disease. Expert Opinion on Drug Safety, 17(10), 1053-1061.

Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48.

This week, you will evaluate patients for the treatment of neurologic and musculoskeletal disorders by focusing on specific patient case studies through a decision tree exercise. You will analyze the decisions you will make in the decision tree exercise.

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. Summary of The Patients With Alzheimer Disease Case Study
• 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.

Alzheimer’s Disease
76-year-old Iranian Male

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. Summary of The Patients With Alzheimer Disease Case Study
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. Summary of The Patients With Alzheimer Disease Case Study
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

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
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
Select what you should do next:
Increase Exelon to 4.5 mg orally BID
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 Summary of The Patients With Alzheimer Disease Case Study

Decision Point Three

Add Namenda (memantine) 5 mg orally per day
Guidance to Student

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At this point, the client is reporting no side effects and is participating in an important part of family life (religious services). This could speak to the fact that the medication may have improved some symptoms. You need to counsel the client’s son on the trajectory of presumptive Alzheimer’s disease in that it is irreversible, and while cholinesterase inhibitors can stabilize symptoms, this process can take months. Also, these medications are incapable of reversing the degenerative process. Some improvements in problematic behaviors (such as disinhibition) may be seen, but not in all clients.
At this point, you could maintain the current dose until the next visit in 4 weeks, or you could increase it to 6 mg orally BID and see how the client is doing in 4 more weeks. Augmentation with Namenda is another possibility, but you should maximize the dose of the cholinesterase inhibitor before adding augmenting agents. However, some experts argue that combination therapy should be used from the onset of treatment. Summary of The Patients With Alzheimer Disease Case Study
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 read the assignment rubric

You can click on this link to access the case study with the decision point three: http://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_10/index.html Summary of The Patients With Alzheimer Disease Case Study