Alzheimerâ€™s Disease76-year-old Iranian Male
Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for â€œstrange behavior.â€ Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkadâ€™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 clientâ€™s son, the family noticed that Mr. Akkadâ€™s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more â€œcriticalâ€ of everyone. They also noticed that things he used to take seriously had become a source of â€œamusementâ€ and â€œridicule.â€
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 â€œfinding the right wordsâ€ 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 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 todayâ€™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 â€œwound up hereâ€- 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. Akkadâ€™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.
Diagnosis: Major neurocognitive disorder due to Alzheimerâ€™s disease (presumptive)
Â§ 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 you should do:
Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
: Begin Aricept (donepezil) 5 mg orally at BEDTIME
Begin Razadyne (galantamine) 4 mg orally BID
The case study is on a 76-year-old Iranian male patient that is suspected to have Alzheimerâ€™s disease. The conclusion is based on the reports provided by his eldest son and there were no organic disease processes that were identified during the examination. The behavioral changes started two years ago, and included personality changes, apathy, which was followed by memory loss and challenges in finding the appropriate words during conversation. Confabulation is also noticed during the clinical interview, speech, and self-reported euthymic mood. The patient also has an impairment in his judgment and insight as well as absence of impulse control. There is no suicide ideation reported and the patient is diagnosed with neurocognitive disorder as a result of Alzheimerâ€™s disease.
The first approach that will be taken will include Donepezil 5mg at bedtime. The use of donepezil among patients that have Alzheimerâ€™s disease has been examined for decades. The medication is an acetylcholinesterase inhibitor, which increases the acetylcholine levels in the brain and compensates the reduced function of cholinergic neurons (Birks and Harvey, 2018). An assessment of randomized clinical trials analyzed the impact that donepezil has on patients with Alzheimerâ€™s using randomized control trials. The findings showed that there is strong evidence that donepezil is effective in three major areas in the management of this condition, which include behavior, functional ability, and cognition (Li et al., 2018). These are the major areas that were affected in the patient and the goal was to limit their impact on his quality of life. As indicated in the case, he had significant personality changes that negatively impacted his engagement in activities of interest. However, there is a need to state that the National Institute of Aging has noted that there is still a poor comparison between different agents that are used as the first line of treatment for the patient (NIH, 2020).
The outcomes from donepezil differ as there can be development of complications along with limited clinical benefits. The patient complained of side effects such as loss of weight and appetite, vomiting, nausea, and diarrhea, which have been reported among patients using this medication (Kumar and Sharma, 2019).
The second decision was the use of cognitive behavioral treatment, which has been found studies to have a positive impact among patients with early stages of Alzheimerâ€™s disease. Evidence supporting psychosocial interventions for patients with dementia has been identified in isolated cases (Forstmeier et al., 2015). However, there is still limited empirical data on these approaches. Some scholars have labelled behavioral interventions as appropriate among patients that have neuropsychiatric symptoms. Therefore, these will be used on the patient to improve behavior, and particularly targeted at reducing apathy and improving the self-control by the patient. Improvement of mood will positively impact the quality of life and the ability for the patient to engage in activities that will improve his cognitive status.
The third decision will be to include family members in the therapeutic process as this will help reinforce behaviors that will assist the patient. Studies illustrate that there is a high lack of adherence to care among elderly patients (Smith et al., 2017). This reduces the ability to evaluate the effectiveness of the interventions, as outcomes may be due to poor drug use. The goal is to increase the support system of the patient, and daily interactions as this has been found to positively impact the cognitive and emotional well-being of patients with dementia.
Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimerâ€™s
disease. Cochrane Database of systematic reviews, (6).
Forstmeier, S., Maercker, A., Savaskan, E., & Roth, T. (2015). Cognitive behavioural
treatment for mild Alzheimerâ€™s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials, 16(1), 526.
How is Alzheimerâ€™s Disease Treated? (2020). NIH
Kumar, A., & Sharma, S. (2019). Donepezil. In StatPearls [Internet]. StatPearls Publishing.
Li, Q., He, S., Chen, Y., Feng, F., Qu, W., & Sun, H. (2018). Donepezil-based multi
functional cholinesterase inhibitors for treatment of Alzheimerâ€™s disease. European journal of medicinal chemistry, 158, 463-477.
Smith, D., Lovell, J., Weller, C., Kennedy, B., Winbolt, M., Young, C., & Ibrahim, J. (2017).
A systematic review of medication non-adherence in persons with dementia or cognitive impairment. PloS one, 12(2).
Assignment: Decision Tree for Neurological and Musculoskeletal Disorders
For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this moduleâ€™s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.
Photo Credit: Getty Images/Science Photo Library RF
- Review the interactive media piece assigned by your Instructor.
- Reflect on the patientâ€™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 patientâ€™s diagnosis and treatment.
By Day 7 of Week 8
Write a 1- to 2-page summary paper that addresses the following:
- Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
- Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
- What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
- Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.