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, 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.

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.

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?

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

Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).

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

Case Study: 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. 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.. 

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:

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

Decision Choice Chosen: Begin Exelon (rivastigmine) 1.5 mg orally BID with an           

                                      increase to 3 mg orally BID in 2 weeks

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

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

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

Increase Exelon to 4.5 mg orally BID

Increase Exelon to 6 mg orally BID

Discontinue Exelon and begin Namenda (memantine) 10 mg orally BID

Decision Choice Chosen: Increase Exelon to 4.5 mg orally BID

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

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

Choices for Decision 3: Select what the PMHNP should do:

Increase Exelon to 6 mg orally BID

Maintain current dose of Exelon

Add Namenda (memantine) 5 mg orally per day

Decision Choice Chosen: Increase Exelon to 6 mg orally BID

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

Outcome: Guidance to Student
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. The PMHNP needs 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, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP 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 the PMHNP 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.

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. 

***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 References. Please 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 please make sure when looking at the ethical consideration for this assignment that you look at how the Caucasian (male) ethnicity and pain medications interact.***

Please use the following format when formulating the paragraphs for each section. Don’t forget the intext citations. Remember to use at least 7 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

Conclusion

References

CHECK OUT THE ATTACHMENT FOR MORE INFORMATION