Major Neurocognitive Disorder Due to Alzheimer’s Disease

Student’s Name
Institutional Affiliation
Professor’s Name
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.

Learning Objectives
Students will:
• Assess client factors and history to develop personalized therapy plans for clients with dementia
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for dementia
• Evaluate efficacy of treatment plans
• Analyze ethical and legal implications related to prescribing therapy for clients with dementia

Alzheimer’s Disease
76-year-old Iranian Male

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.

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.

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:

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks Click to see options it will take you to decision point two and three

: Begin Aricept (donepezil) 5 mg orally at BEDTIME Click to see options it will take you to decision point two and three

Begin Razadyne (galantamine) 4 mg orally BID Click to see options it will take you to decision point two and three

All references require creditable sources, nothing less than 5 years. References require doi or http. Please add conclusion.
Tips: – Always use the choices given- Continuation of psych meds may be needed before switching as they take time.
Staying the course (more time) or increasing for the second decision is a good choice
– A 61% reduction is within the proper response limits therefore not changing for the third decision is proper.
– Remember to not be quick to switch any psych meds as many take a long time to start working.

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:

o Decision #1
 Which decision did you select?
 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 #1 and the results of the decision. Why were they different?
o 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.
 Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
o 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?
• Also include how ethical considerations might impact your treatment plan and communication with clients.

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

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

Alzheimer’s Client
Alzheimer’s disease is “the most common form of dementia” with nearly five million people suffering from the disease as of 2014 and projected to grow to more than fourteen million by the year 2060 (Centers for Disease Control and Prevention (CDC), 2018). What is Alzheimer’s disease though? According to the Alzheimer’s Association (2018), this is a disease that is not part of a normal aging process in which progressive memory loss occurs over time due to plaques and tangles accumulating in the brain. This disease has a usual life expectancy of approximately eight years after symptoms become apparent to those around the individual (Alzheimer’s Association, 2018). Cure is not possible at this point; however, there are medications that are available to slow down the progression of the disease. The purpose of this paper is to show that progression can be slowed temporarily, and symptoms improved utilizing Aricept which can improve quality of life for the client and the caregiver.
Decision One
According to the Mayo Clinic (2018), there are three drugs to help medically manage the symptom progression of early to moderate Alzheimer’s disease. This category of drugs called cholinesterase inhibitors helps to manage symptoms and includes the medications Aricept, Exelon, and Razadyne. During Alzheimer’s progression, the neurotransmitter acetylcholine is reduced causing a decrease in memory, thought, and judgement (Mayo Clinic, 2018). Cholinesterase inhibitors help to boost acetylcholine in the brain by blocking the enzyme acetylcholinesterase (AChE) (Stahl, 2013). However, these medications usually loose efficacy in later stages of the disorder due to the complete destruction of the neuron’s postsynaptic cholinergic targets (Stahl, 2013).
The Iranian client in this scenario was diagnosed with moderate dementia presumptive to be related to Alzheimer’s disease. Given the nature of the client’s symptoms of memory loss, personality changes, and impaired insight and judgement, the decision was made to start Aricept 5mg daily at bedtime. This decision was partially made due to the correct suggestion of once daily starting dose of 5mg at bedtime which could help with maintaining compliance with treatment (Stahl, 2014b). Another reason for choosing this medication includes the selective inhibition of AChE, to treat all stages of Alzheimer’s through a greater affinity for this enzyme within the central nervous system (CNS), which is responsible for destroying acetylcholine. By selectively inhibiting AChE, the bioavailability of acetylcholine (ACh) is improved and the decline of loss of memory is slowed (Physician Desk Reference (PDR), 2018). This action is achieved by Aricept binding to AChE via hydrogen bonding making the inhibition action at the receptor sites short, thus reversible (PDR, 2018). However, the longer half-life makes the medication available to the receptors for a longer period with a steady plasma state reached within fifteen days (PDR, 2018). With the oral dosing, 100% bioavailability of the drug is present and can be taken without regard to food (PDR, 2018). Furthermore, this medication has 23 possible severe and moderate adverse reactions (PDR, 2018) According to Iodine (2017) Aricept is more cost effective than Exelon.
While Exelon would be an adequate choice as well with the given starting dose of 1.5mg increasing to 3 mg in 2 weeks, there is an increased chance of developing a greater number of adverse effects from this medication as compared to Aricept which is possibly due to the medication being a potent but selective inhibitor of AChE and butyryl cholinesterase (BChE) (PDR, 2018). There are 60 severe and moderate adverse reactions that can be experienced by those who take Exelon including liver issues, bleeding issues and cardiac implications such as heart failure, myocardial infarction, or Q-T prolongation (PDR, 2018). This drug would probably been optimal had it been offered as the transdermal route of administration as this route reduces side effects by decreasing peak drug concentrations and making the drug delivery optimal (Stahl, 2013).
Razadyne offered at the 4mg orally twice daily dosing was not chosen due to the incidence of discontinuation of the medication related to adverse reactions ranges from 2.4-to 21.1% as compared to Aricept 2.5 to 14.6% and Exelon 3.1 to 40% (Winslow, Onysko, Stob, & Hazelwood, 2011). This is potentially due to the actions on not only ACh, but also the allosteric modulator ACh nicotinic receptors which make a considerable contribution to the reduction in the central cholinergic neurotransmission in Alzheimer’s clients (Stahl, 2013). The client must also be adequately hydrated when taking this medication and must be administered with food to help increase tolerance of the drug; however, this also delays absorption of the medication, but not the extent of absorption (PDR, 2018). Furthermore, there is not any human data to prove that the nicotinic receptor activity results in better clinical benefit versus the other cholinesterase inhibitors (CI) (PDR, 2018). This medication is rapidly adsorbed after oral administration with peak concentrations occurring in approximately one hour with a bioavailability of approximately 90% (PDR, 2018).

Goals and Outcomes
While the goal is to slow down memory loss, this is not a guarantee (Stahl, 2014b). Reversal of Alzheimer’s symptoms are not usually seen with utilization of any CI, and one must allow adequate time for the full efficacy of the medication to be seen (Stahl, 2014b). Furthermore, behavioral problems, long term care placement, and decrease in activities of daily living can all be delayed while caregiver strain can be reduced (Stahl, 2014b). Unfortunately, with the first decision of initial dosing of Aricept, these goals are not met. This is still an expected outcome as most clients require 10mg of Aricept to see benefit with a slower titration to reduce side effects after six weeks of starting dose (Stahl, 2014b).
Decision Two
Due to the knowledge that there may be minimal response to the Aricept treatment, starting slow and titrating up is imperative to minimize side effects. Furthermore, Stahl (2014b) states that the client may require the highest tolerated dosing within the normal dosing range. Since the normal dosing range for Aricept is 10mg daily orally, this decision was made to increase the dose to 10mg at bedtime (Stahl, 2014b). There was not any evidence to support changing the CI to Razadyne at this point. Namenda is utilized as augmentation with Aricept but is not indicated as a monotherapy until late stages of Alzheimer’s (Stahl, 2014b).
Goals and Outcomes
At this follow up visit, the client has shown slight response to the medication by returning to participating with family in religious services which indicates that the medication is providing some effect. This was the desired goal of increasing the medication at bedtime. The son still shows some concern due to the client not being “better.” It is very important to educate that this disease is not reversible. The treatment plan is only to slow the progression, but the medication is being tolerated well without side effects which is the goal with slow titration (Stahl, 2014b).
Decision Three
Since the client has shown response to the last dose increase, the decision was made to continue the same dose of Aricept. Dosing above 10mg has not shown any effectiveness, but the client would be at a higher risk for developing severe adverse reactions such as heart conduction issues should the dose be increased (Stahl, 2014b). Once again, there is no indication to stop the current therapy as some improvement has been noted with the current treatment plan. Ensuring to continue to review mini mental status exams over months not weeks will help indicate whether changes need to be made to the treatment plan. Namenda can be used as an augmenting medication with Aricept, but nothing suggests stopping the client’s Aricept at this point.
Goals and Outcomes
Allowing time for the medication to work was the goal of the changes made to the treatment plan’s dosage increase. There have not been any reports of adverse reactions that warrant changes to Aricept treatment plan as noted by Stahl (2014b). Furthermore, according to Stahl (2014b), discontinuation of the Aricept could lead to memory decline which may not be regained when new medication is started, or Aricept is restarted. It is important to continue the medication to keep the neuron’s receptor targets alive if possible as a prolonging tactic to keep the client’s quality of life from declining.
Ethical Implications
One of the biggest ethical implications when dealing with a client such as this is the lack of judgment and insight. This makes providing informed consent nearly impossible. As noted by Stahl (2014b), the provider must treat the client, but check with the caregivers regarding efficacy of the treatment plan.
Furthermore, understanding the Iranian culture and how Alzheimer’s disease is viewed will help the provider to prevent and treat the client with better strategies and approaches. The Iranian culture views Alzheimer’s disease as being caused by a brain distemperement (Saifadini et al, 2016). This distemperement is caused from coldness and/or dryness of the brain (Saifadini,et al, 2016).
Alzheimer’s disease is a non-curable progressive disease with limited treatment options. Treatment is aimed at providing a slowing of the progression to allow the client a better quality of life and to assist caregivers in the care of the client. This can be achieved with CIs such as Aricept. However, to achieve compliance with treatment, one must keep in mind potential cultural barriers, cost of medications, dosing compliance issues such as number of times per day, and potential side effects from medications prescribed.

—free essay sample

Major Neurocognitive Disorder Due to Alzheimer’s Disease
Alzheimer’s disease is a progressive disorder that causes brain cells to waste away or die. The disorder is one of the most common causes of dementia. Some of the symptoms of the condition include a decline in social, behavior, and thinking capabilities thus undermining the ability of a person to think or function independently. The condition causes progressive memory loss due to plaques in the brain. Research shows that the condition has a life expectancy of eight years (Silva et al., 2019). In the United States, over 5.5 million people across all age brackets suffer from Alzheimer’s disease. Over 5.3 million of the affected patients are 65 years and older. The number of affected patients may rise to 14 million in 40 years according to the Centers for Disease Control and Prevention (Silva et al., 2019). Although there is no cure for the condition, medication is available to reduce the severity of the symptoms and slow down the progression of the disease. The purpose of the essay is to demonstrate that prescription of medication such as Aricept can slow down the progression of the disease and improve the quality of life of a patient.
Decision #1
The first decision is to prescribe Aricept 5mg orally at bedtime.
The patient is in the early stages of developing Alzheimer and thus some of the best medications are cholinesterase inhibitors. They include a group of medications necessary to hinder the normal breakdown of acetylcholine in the brain (Herman et al., 2017). All the three options of drugs are effective in preventing the death of acetylcholine. However, the process of selecting the best medication also involves other factors such as considering the side effects of the medication.
The purpose of selecting Aricept 5mg orally at bedtime is because it is approved to treat all stages of the condition (Herman et al., 2017). According to the son of the patient, the condition has been ongoing for almost two years. Therefore, the medication will be appropriate to suppress the negative outcomes. Research also shows that it has significant positive results for elderly patients (Herman et al., 2017). Aricept works to increase acetylcholine in the brain thus hindering a breakdown and promoting communication between healthy nerves. The improvement provides temporary relief to dementia and its associated symptoms. It also improves cognition which enhances the ability to carry out normal tasks (Lanctôt et al., 2017). For example, after taking the medication, the patient should demonstrate an improvement in thinking, memory, reasoning, and language capabilities.
The decision also involved discarding the other options such as Exelon 1.5mg orally BID and Razadyne 4mg orally BID. One of the reasons for not prescribing the medications is because polypharmacy is exercised with caution in the treatment of mental conditions (Jevtic et al., 2017). Prescribing several medications can trigger adverse effects and it will be hard to determine which medication is reacting negatively. Additionally, it is essential to state that a drug such as Exelon is not effective in treating patients with Alzheimer’s disease since it does not stop the progression of the condition (Jevtic et al., 2017). Exelon can also cause several side effects that can undermine the quality of life of a patient. Clinicians are also careful to ensure they do not prescribe medication that can affect a patient adversely since they can lower their quality of life. For instance, Razadyne can cause weight loss, stomach pain, dizziness, and loss of appetite (Folch et al., 2018). The medication is thus not effective for the 76-year old patient, whose health can be at risk if he experiences a loss of weight.
Exelon 1.5mg was also not selected since it causes adverse reactions in the body. Some of the negative reactions include bleeding, liver issues, heart failure, myocardial infarction, as well as Q-T prolongation. One of the ways of administering Exelon in an attempt to reduce the side effects is the transdermal route (Stahl, 2013). However, the researcher shows that the transdermal patches are not effective in boosting the quality of life of a patient including thought, judgment, and memory (Folch et al., 2018). Additionally, prescribing Exelon 1.5mg means the drug will be increased after four weeks. If the drug is increased, the patient may develop complications.
Razadyne was not a preferred drug since taking the drug twice a day would increase the risk of non-compliance. This is due to the action of allosteric modulator ACh nicotinic receptors which significantly reduce central cholinergic neurotransmission in Alzheimer’s clients (Stahl, 2013). Taking Razadyne also requires the patient to remain hydrated and ensure he takes healthy meals to ensure the drug does not affect his body (Folch et al., 2018). Therefore, it is safe to start with a medication that is friendly to the patient.
Expected Outcomes
One of the expected outcomes is to slow down memory loss since the patient is in the early stages of Alzheimer’s. However, evident results may take time. Research shows that the prescription of Aricept may take time before the results are evident (Hwang et al., 2018). For example, cognition may time including judgment, memory, and thinking.
It is essential to educate the son about the drugs and the expected outcomes. The information will ensure the son will encourage the patient to take the medication even if they do not show results instantly. It is also critical to inform the client about the side effects of the drug (Hwang et al., 2018). Educating patients to ensure that they comply with the medication.

Expected Outcomes vs. Results
The expected results according to research and arguments by Stahl (2013). Aricept do not generate the results instantly thus patients should continue taking the medication. The patient reports back to the clinic after four weeks. The purpose of examining a patient after four weeks is to ensure any side effects are evaluated and determined (Li et al., 2018). However, in the second decision, the client can report back to the clinic after six weeks. The client skills are confused about why they came to the office. According to a mental examination report, the patient still scores 18 out of 30. The condition was expected, especially due to the knowledge that Aricept can take time.
The son also reports that the father is still exhibiting symptoms such as losing track of a conversation. He is also less interested and critical of activities or events such as religious activities which he previously held in high regard. The son also reports that the father has been taking the medication consistently.
Decision #2
The second decision is to prescribe Aricept 10mg orally bedtime.
The purpose of prescribing Aricept 10mg bedtime is to increase the therapeutic ability of the drug. The drug was also increased since, after the four weeks, the patient did not report any adverse reactions. If any adverse reactions were noted, it would be important to change the drug or reduce the dosage (Costa et al., 2018). Prescribing the medication during bedtime is still a way of increasing compliance. Patients of Alzheimer’s can forget to take medication consistently and thus taking once a day has a lower risk (Costa et al., 2018). Research shows that non-compliance can increase the risk of relapse which can undermine the goals of the treatment.
It is not important to change the drug to the other available options such as Razadyne. One of the reasons is to minimize the risk of complications. Stahl (2013) shows that changing the medication after several weeks affect a patient negatively. The negative impact on a patient can undermine their health and increase deterioration (Costa et al., 2018). Psych drugs should also not be changed abruptly as some of them such as Aricept can take time before they start working. It is also not essential to add another drug to trigger the expected results (Silva et al., 2019). It is crucial to consider the precautions of psych medications such as changing or increasing the dosage without a compelling reason.
Namenda is an essential augmentation of Aricept but it cannot be prescribed until a later stage (Silva et al., 2019). The purpose is to observe how the patient responds to the treatment of Aricept before prescribing another medication.
Expected Outcomes
The patient should take the Aricept 10mg for another 6 weeks before returning to the clinic. One of the expectations is that the patient will improve cognitive abilities such as holding a conversation. Aricept increases the ability of the brain to perform various activities. It is also expected that the patient should be less critical about events (Silva et al., 2019). For example, the patient should attend religious masses as he did before. The improvements are essential to ensure the patient is still improving. It is also expected that the patient will have taken all medications as outlined in the prescriptions (Silva et al., 2019). The client should also not experience the side effects of Aricept 10mg orally bedtime.

Expected Outcomes vs. Results
The expected outcomes were similar to the expectations since the patient had started participating in family religious activities. Participation is a great step towards improving the patient’s condition. The commented that his condition was improving gradually. However, he was still concerned that the progress was slow and his father was not the same person he was used to before he fell sick.
While reporting such a situation, it is important to educate the son that disease is irreversible. The son should understand that the purpose of the medication is not to restore the father to normal but to slow down the deterioration of the condition (Silva et al., 2019).
However, some of the expected outcomes were not realized since the patient was still losing track of conversations. He was also having memory problems. With time the condition can improve gradually.
Decision #3
The decision is to continue with the current medication Aricept 10mg orally bedtime.
The purpose of maintaining the drugs is because it has demonstrated positive results in the past. One of the major improvements is when the patient started joining the family in religious activities. There is no need to change the medication since it has no negative results. It is also not appropriate to increase the dose since a dose higher than 10mg can cause adverse reactions (Lanctôt et al., 2017). It is important to consider the age of the patient and the reaction to drugs. Elderly patients may be overwhelmed by drugs since their absorption, distribution, metabolism, and excretion is significantly reduced.

Expected Outcomes
The expected outcomes after taking medication for another 6 weeks is to increase the quality of life of the patient. One of the major expectations is that the patient will continue to participate in religious activities. It is also expected his memory will improve gradually and avoid losing conversation. Aricept is essential for adult patients since it improves their cognitive abilities (Lanctôt et al., 2017). The patient should also continue taking the medication to prevent to avoid cases of relapse.
Ethical and Legal Issues in Healthcare
Treating patients with mental conditions requires clinicians to provide relevant information to the patient or guardian. Educating the patient about the condition and medications available is also necessary (Jevtic et al., 2017). Ethical issues in treatment involve providing patient-centered care. The care should involve the consent of a patient or guardian. If the patient or guardian does not consent to the treatment, it would be illegal to offer help. Medical practitioners and healthcare facilities have been prosecuted for providing treatment to the patient against their consent (Jevtic et al., 2017). For example, in the current case study, it is important to explain to the son that the medication will not provide full recovery. They should also know how to live with their father in the current condition.
Clinicians should make decisions that do not harm patients. The ‘do no harm’ principle is applicable as an ethical issue. Healthcare workers should strive to offer the best treatment that will not affect a patient negatively (Folch et al., 2018). For example, the selection of drugs involves finding the best suitable option. Aricept is a drug that has been used for decades by practitioners who have found it is safe (Folch et al., 2018). Additionally, clinicians should ensure they do not give in to the patient’s demands. For instance, some patients can demand a specific drug that can work against their health. It is also important to note that increasing the dose should be done cautiously to prevent adverse effects.
The patient is from Iranian culture which can affect the understanding of the patient or family members about the disease. For example, they can view the disease as a curse or a bad omen in the life of the father. It is important to educate the son or any other family member about the causes of the disease (Stahl, 2013). Other facts about Alzheimer’s will be important. Patients or family members should also avoid mixing the medication with herbal drugs or any other form of treatment. They should ensure they protect the welfare of the patient by adhering to the prescribed treatment.
Providing treatment to patients with Alzheimer’s disease requires great caution. One of the reasons is because the elderly patient reacts differently to drugs. The medication may also overwhelm their aging body systems. For example, clinicians should consider issues such as liver disease. The patient in the case study shows that the Iranian patient has a presumptive major neurocognitive disorder due to Alzheimer’s disease. The best medication for the condition is Aricept 5mg orally bedtime. It is also important to increase the dose to 10mg to enhance the therapeutic ability. During the treatment, it is important to advise the patient to ensure they comply with the medication. While treating such an old-Iranian patient, there is a need to take some precautions due to ethical issues. Treatment of Alzheimer’s disease can take a long time but an effective assessment is essential to reduce side effects and promote recovery.

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