Assessing and Treating Clients with Dementia case study decision tree example

Assessing and Treating Clients with Dementia case study decision tree example

Assessing and Treating Clients with Dementia

The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life” (Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assessing and Treating Clients with Dementia case study decision tree example Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia.

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Examine Case Study: An Elderly Iranian Man w/ Alzheimer’s Disease

You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point there will be three decisions. I will choose one out of the three and give the outcome. At each decision point these are the thoughts to ponder:

Decision #1

Which decision did you select?

Why did you select this decision? Support your response with evidence and references to the Learning Resources. Assessing and Treating Clients with Dementia case study decision tree example.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Assessing and Treating Clients with Dementia case study decision tree example.

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? Assessing and Treating Clients with Dementia case study decision tree example.

***Also include how ethical considerations might impact your treatment plan and communication with clients. ***

NB:  Write paper addressing all section listed based on the decision tree.

 

Case Study: An Elderly Iranian Man with 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. Assessing and Treating Clients with Dementia case study decision tree example. 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.

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. Assessing and Treating Clients with Dementia case study decision tree example.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

 

Decisions Made and Outcomes (Needed to formulate the paper) (Must use and formulate paper based off of the chosen decision. Then tell why the other two decision were not a good choice with in-text citations noted for each.)

 

Choices for Decision 1: Select what the PMHNP should do:

  1. Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
  2. Begin Aricept (donepezil) 5 mg orally at BEDTIME
  3. Begin Razadyne (galantamine) 4 mg orally BID

 

Decision Choice Chosen: Begin Aricept (donepezil) 5 mg orally at BEDTIME

***Explain why other two choice were rejected (not adequate choices)***

Outcome: 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 Assessing and Treating Clients with Dementia case study decision tree example

 

Choices for Decision 2: Select what the PMHNP should do:

  1. Increase Aricept to 10 mg orally at BEDTIME
  2. Discontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily
  3. Discontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

 

Decision Choice Chosen: Increase Aricept to 10 mg orally at BEDTIME

***Explain why other two choice were rejected (not adequate choices)***

Outcome: 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 Assessing and Treating Clients with Dementia case study decision tree example.
  • 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

Choices for Decision 3: Decision Point Three Select what the PMHNP should do next:

  1. Continue Aricept 10 mg orally at BEDTIME
  2. Increase Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME
  3. Discontinue Aricept and begin Namenda 5 mg orally daily

 

Decision Choice Chosen: Continue Aricept 10 mg orally at BEDTIME

***Explain why other two choice were rejected (not adequate choices)***

Outcome: Guidance to Student

RESULT FROM CHOOSING TO MAINTAIN CURRENT DOSE OF ARICEPT 10 mg ORALLY AT BEDTIME

Guidance to Student

At this point, it would be prudent for the PMHNP 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 Assessing and Treating Clients with Dementia case study decision tree example. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP 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. Assessing and Treating Clients with Dementia case study decision tree example.

 

***Write on each decision. Make sure that in each decision choice that you explain why the other two decisions were not good choices. Use cited sources to validate points. Make sure that this paper has at least 7 ReferencesPlease use in-text citations for each section of each decision. Don’t forget the ethical considerations for this assignment. Make it a section by itself.***

  • *** Also include how ethical considerations might impact your treatment plan and communication with clients.

 

 Please use the following format when formulating the paragraphs for each section. Don’t forget the intext citations. Remember to use at least 6 references.

Introduction

Decision #1

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Decision #2

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Decision #3

Reasons for Choosing the Decision (Why is it the best choice out of the 3 choices)

Anticipated Results (of Chosen Decision)

Difference in Results (Anticipated VS Actual)

Ethical Considerations

References

Assessing and Treating Dementia

Dementia is one of the most chronic ailments that affect human beings. It is typically defined as a clinical syndrome of decline in cognitive functionalities. Basically, victims suffering from the disease experience memory loss. Dementia effects lead to substantial interferences with a victim’s occupational and social functionality. Regular clinical inferences state that dementia is accompanied with personality and diverse behavioral alterations. In fact, the sickness has been linked to cause Alzheimer’s disease in later stages of development. Despite these important scientific deliberations Chertkow, Feldman, Jacova and Massoud (2013) posit that dementia remains a mere clinical diagnosis. Precisely, researchers are yet to offer concrete and clinically proven diagnostic frameworks for the disease. Based on this aspect, dementia does not have an elaborate treatment scientifically proven. Despite these setbacks, clinical professionals have made considerable strides in deriving dependable medications that can help alleviate dementia, based on a keen assessment of the patient’s conditions.

Case Study Overview

Mr. Akkad is a 76-year old Iranian with normal CT-scans from the family physician. However, his elder son reports that Akkad exhibits abnormal behaviors. Particularly, he experience strange thoughts, with his personality getting worse each year. He loses interest in religious matters and criticizes all members of his family. Notably, he ridicules aspects he deemed important in his life when he was healthy. Assessing and Treating Clients with Dementia case study decision tree example. Besides, he is forgetful and finds difficulties talking the right words during conversations.

On conduction of a clinical interview, Akkad is cooperative and speaks pleasantly. However, he exhibits hitches with his mental ability, and performs fair in a Mini-mental exam administered by the Psychiatric Mental Health Nurse Practitioner (PMHNP). The scores suggest moderate dementia. Akkad displays a clear speech but poor eye contact in the next clinical visit. Besides, he exhibits unusual motor movements and denies auditory hallucinations. Akkad’s mood is euthymic and is not delusional. However, he is disoriented at times and exhibits poor judgment. Akkad is presumptively diagnosed with a neurocognitive condition associated with Alzheimer’s disease.

Decision One

Akkad displayed various symptoms that depicted a person suffering from a psychological ailment. Notably, Chertkow et al. (2013) state defections in motor skills and problems with speech may be a sign of a neurologic disorder. However, it is imperative to ascertain the exact ailment to warrant precise medication.  In the light of this aspect, administration of Aricept (donepezil) 5 mg tablets to be taken orally during bed time would be the best option for Akkad.

Notably, dementia is a disease that entails impairment of memory functionality and attention deficits amongst the victims. The aspect arises due to diminished levels of the compound acetylcholine. In fact, the acetylcholine is broken down by butyryl-cholinesterase and acetyl-cholinesterase enzymes, leading to reduced memory functionality. Based on this factor, administration of donepezil would be the best option. Donepezil inhibits the actions and viability of acetyl-cholinesterase enzyme. Assessing and Treating Clients with Dementia case study decision tree example In the long run, Kalisch Ellett, Pratt, Ramsay,Barratt and Roughead (2014) postulate that it minimizes the breakdown of the compound acetylcholine in the brain, leading to mental stability. Albeit there are various options for antipsychotic drugs, donepezil is easily tolerated in the victim’s body, warranting speedy recovery.

Administration of galantamie would not be effective since it causes complications with victims suffering from renal predicaments. According to Coresh et al., (2014), older people are susceptible to urinary problems and problems related to kidneys. Since Akkad was 76 years, administration of galantamine would cause further complications, derailing the recovery process. Besides, administration of Exelon (rivastigmine) would cause adverse side effects which include nausea and diarrhea (Birks, Chong and Grimley Evans, 2015). The symptoms would affect the ability of the patient to respond positively to the medication.

Decision Two

Upon returning for the second visit, the client was reportedly unresponsive to Donepezil. In fact, his son explained that Akkad retained his disinhibited behaviors. At this point, continuation of an increased dose of donepezil orally after bedtime was the best option. Notably, Tan et al., (2014) state that donepezil acts optimally when taken after meals. Besides, it is imperative to note that the dementia victims and their families ought to maintain patience in terms of achieving full recovery. Tan et al., (2014) underscore the fact that donepezil treatment results are achieved after 6-9 months, and in some cases, 1-3 years. Additionally, discontinuing administration of donepezil would lead to dissipation of its clinical effects after only 6 weeks. Based on this factor, it would not be a precise clinical decision to administer Razadyne (galantamine) and Exelon (rivastigmine). Further, the PMHNP ought to increase the quantity of Aricept (donepezil) from 5mg to 10 mg, to be taken orally after meals. The aspect would warrant further inhibition of enzyme acetyl-cholinesterase from breaking down, an aspect that would warrant better cognition of Akkad. Assessing and Treating Clients with Dementia case study decision tree example.

Decision Three

Akkad displayed impressive signs on the following visit. Particularly, he was positively responding to medication and he had started attending religious events. The aspect made his family happy. However, he still found amusement in serious matters. Based on these deliberations, it is evident that donepezil was functioning effectively. In fact, it had reduced the comorbidity of the enzymes butyryl-cholinesterase and acetyl-cholinesterase in breaking down the acetyl-cholinesterase compound in the brain. Based on this fact, continuation of Aricept 10 mg to be taken orally would be the best option. Since the results after the previous dosage were impressive, the clinician has no reason to titrate Aricept 10 mg in an upward manner. In fact, Torniainen et al. (2014) state that excessive administration of antipsychotics may cause detrimental effects to the neurotransmission system of a victim, derailing the recovery process. Besides, it would not be effective to administer Namenda (memantine), since it is most effective when ingested with other anti-psychotics especially donepezil, and therefore would not act meritoriously. In fact, Ellison states that memantine is used to taper cholinesterase inhibitors when attempting to stop administration of particular anti-psychotics. Besides, Exelon (rivastigmine) would not be relevant at this stage, since the clinical effects of donepezil were already dominant.

Conclusion

Dementia is one of the most chronic mental ailments, without a precise known cure. However, administration of relevant anti-psychotics helps alleviate a patient’s situation. Akkad is a 76-year-old Iranian who displayed cognitive and motor-deficiencies. He was prescribed of donepezil, 5 mg to be ingested during bed time. PMHNPs increased the medication to 10mg after the second visit, an aspect that led to impressive results. During the third visit, it was recommended for him to continue with the same dosage to warrant impressive results. Assessing and Treating Clients with Dementia case study decision tree example.

References

Birks, J. S., Chong, L. Y., & Grimley Evans, J. (2015). Rivastigmine for Alzheimer’s disease. The Cochrane Library.

Chertkow, H., Feldman, H. H., Jacova, C., & Massoud, F. (2013). Definitions of dementia and predementia states in Alzheimer’s disease and vascular cognitive impairment: consensus from the Canadian conference on diagnosis of dementia. Alzheimer’s research & therapy, 5(1), S2. https://doi.org/10.1186/alzrt198

Coresh, J., Turin, T. C., Matsushita, K., Sang, Y., Ballew, S. H., Appel, L. J., … & Green, J. A. (2014). Decline in estimated glomerular filtration rate and subsequent risk of end-stage renal disease and mortality. Jama, 311(24), 2518-2531. doi:10.1001/jama.2014.6634

Ellison, M,J. Do Alzheimer’s Medications Really Help? Bright Focus Foundation. Retrieved from https://www.brightfocus.org/alzheimers/article/do-alzheimers-medications-really-help Assessing and Treating Clients with Dementia case study decision tree example.

Kalisch Ellett, L. M., Pratt, N. L., Ramsay, E. N., Barratt, J. D., & Roughead, E. E. (2014). Multiple anticholinergic medication use and risk of hospital admission for confusion or dementia. Journal of the American Geriatrics Society, 62(10), 1916-1922. https://doi.org/10.1111/jgs.13054 Assessing and Treating Clients with Dementia case study decision tree example.

Tan, C. C., Yu, J. T., Wang, H. F., Tan, M. S., Meng, X. F., Wang, C., … & Tan, L. (2014). Efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease: a systematic review and meta-analysis. Journal of Alzheimer’s Disease, 41(2), 615-631. doi: 10.3233/JAD-132690

Torniainen, M., Mittendorfer-Rutz, E., Tanskanen, A., Björkenstam, C., Suvisaari, J., Alexanderson, K., & Tiihonen, J. (2014). Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin, 41(3), 656-663. https://doi.org/10.1093/schbul/sbv181 Assessing and Treating Clients with Dementia case study decision tree example.

Assignment: Assessing and Treating Clients With Dementia

The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life” (Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia. Assessing and Treating Clients with Dementia case study decision tree example.

Reference: Alzheimer’s Association. (2016). What is dementia? Retrieved from http://www.alz.org/what-is-dementia.asp

To prepare for this Assignment:

· Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for dementia.

The Assignment

Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. At each decision point stop to complete the following:

Introduction regarding disease state

High-level summary of patient case

Purpose of the essay statement

Decision #1

What options were listed?

Which decision did you select?

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

Why didn’t you select the other two options?

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

What options were listed?

What option did you choose?

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

Why didn’t you select the other two options?

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

What options were listed?

What option did you choose?

Why did you select this decision? Support your response with evidence and references to the Learning Resources.

Why didn’t you select the other two options?

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

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.

Note : Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

References

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. Assessing and Treating Clients with Dementia case study decision tree example.

To access the following chapter, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

· Chapter 13, “Dementia and Its Treatment”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For insomnia

· donepezil

· galantamine

· memantine

· rivastigmine

Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia. American Family Physician, 85(1), 20–22. Retrieved from http://www.aafp.org/journals/afp.html

Note: Retrieved from from the Walden Library databases. Assessing and Treating Clients with Dementia case study decision tree example.

Meltzer, H. Y., Mills, R., Revell, S., Williams, H., Johnson, A., Bahr, D., & Friedman, J. H. (2010). Pimavanserin, a serotonin receptor inverse agonist for the treatment of Parkinson’s disease psychosis. Neuropsychopharmacology, 35, 881–891. Retrieved from http://www.nature.com/npp/journal/v35/n4/pdf/npp2009176a.pdf

Required Media

Laureate Education. (2016h). Case study: An elderly Iranian man with Alzheimer’s disease [Interactive media file]. Baltimore, MD: Author.

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 case study decision tree example.

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:

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngBegin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.png Begin Aricept (donepezil) 5 mg orally at BEDTIME

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-yellow.pngBegin Razadyne (galantamine) 4 mg orally BID Assessing and Treating Clients with Dementia case study decision tree example

Decision Point One

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.pngBegin 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. Assessing and Treating Clients with Dementia case study decision tree example.

· 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 the PMHNP should do next:

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngIncrease Aricept to 10 mg orally at BEDTIME

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.pngDiscontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-yellow.pngDiscontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

Decision Point Two https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngIncrease 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

Decision Point Three

Select what the PMHNP should do next:

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngContinue Aricept 10 mg orally at BEDTIME

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-blue.pngIncrease Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-yellow.pngDiscontinue Aricept and begin Namenda 5 mg orally daily

Decision Point Three

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/10/mm/alzheimers_disease/img/pill-red.pngContinue Aricept 10 mg orally at BEDTIME Assessing and Treating Clients with Dementia case study decision tree example

Guidance to Student

At this point, it would be prudent for the PMHNP 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 the PMHNP 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. Assessing and Treating Clients with Dementia case study decision tree example.

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