Assessing And Treating Clients With Dementia And Alzheimer's

Assessing And Treating Clients With Dementiaalzheimers Disease

Assessing And Treating Clients With Dementiaalzheimers Disease

Assessing and Treating Clients With Dementia Alzheimer’s Disease

Evaluate the case of Mr. Akkad, a 76-year-old Iranian male showing signs of moderate dementia likely due to Alzheimer's disease. The therapeutic decision-making process involves selecting appropriate pharmacologic treatments based on his clinical presentation, disease progression, and evidence-based guidelines. The core task is to decide among different medication options at each decision point, justify these choices with current literature, and anticipate their impact relative to initial expectations.

Paper For Above instruction

Alzheimer’s disease (AD) is a progressive neurodegenerative disorder characterized by cognitive decline, memory impairment, and behavioral changes. Management of AD primarily involves pharmacologic agents aimed at symptom mitigation and, potentially, disease progression deceleration. In Mr. Akkad’s case, the diagnosis of major neurocognitive disorder due to Alzheimer’s disease guides treatment options. The decision-making process revolves around choosing among cholinesterase inhibitors and NMDA receptor antagonists, considering their efficacy and tolerability.

Decision #1: Initiating Pharmacotherapy

The first decision involves initiating pharmacological treatment to address cognitive symptoms. The options include:

  • 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

I selected Aricept (donepezil) 5 mg orally at bedtime because it is one of the most well-studied and tolerated cholinesterase inhibitors for moderate AD. Donepezil has demonstrated efficacy in improving cognition and activities of daily living, with a relatively favorable side-effect profile (Winblad et al., 2006). Moreover, its once-daily dosing enhances compliance, and it has been extensively endorsed by treatment guidelines (Alzheimer's Association, 2023). Starting at a low dose allows for titration based on tolerability. The goal at this stage is to stabilize cognitive decline and improve behavioral symptoms where possible.

I hoped to slow the progression of cognitive impairment and stabilize behavioral symptoms by initiating donepezil. The expectation was to observe some cognitive stabilization within a few months; however, individual responses vary (Birks, 2006). Starting with a well-tolerated agent like donepezil aligns with best practices and evidence-based protocols for moderate AD management (Liu et al., 2018).

The actual outcome might differ due to individual variability, side effects, or progression of the disease despite treatment. If no significant improvement or adverse effects occur, a treatment reassessment is necessary.

Decision #2: Adjusting Pharmacotherapy

The second decision involves either increasing existing medication dosages or switching medications based on patient response and tolerability. The options include:

  • Increase Aricept to 10 mg orally at bedtime
  • Discontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily
  • Discontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

The chosen approach is to increase Aricept to 10 mg at bedtime, considering the initial positive response and tolerability. Evidence suggests that titrating donepezil to higher therapeutic doses can provide additional cognitive benefits in moderate AD (Lilius et al., 2020). This step aims to optimize cholinergic neurotransmission, which is compromised in AD.

The rationale for not switching to galantamine or memantine at this point is to maximize the benefits from the current medication while monitoring for efficacy and side effects. This incremental approach aligns with clinical guidelines recommending dose escalation before considering medications with different mechanisms (Howard et al., 2012).

I anticipated increased cognitive stabilization and behavioral improvements with higher doses of donepezil based on existing literature (Birks & Harvey, 2018). The assumption was that maintaining consistency with medication class would minimize adverse effects and optimize outcomes. However, individual responses remain variable, and side effects such as gastrointestinal upset or bradycardia must be monitored.

Decision #3: Further Treatment Optimization

The third decision explores further dose escalation or switching to NMDA receptor antagonists. The options are:

  • Continue Aricept 10 mg orally at bedtime
  • Increase Aricept to 15 mg orally at bedtime for 6 weeks, then increase to 20 mg orally at bedtime
  • Discontinue Aricept and begin Namenda 5 mg orally daily

I selected continue Aricept at 10 mg at bedtime for the subsequent period, with plans for dose escalation if tolerated, guided by evidence suggesting potential additional benefits at higher doses in moderate AD (Howard et al., 2012). Since Mr. Akkad is showing mild to moderate decline and no significant adverse effects yet, maintaining the current dose allows for ongoing assessment of efficacy and tolerability.

The alternative options of higher doses aim to maximize symptomatic benefits but risk increased adverse effects, particularly cholinergic-related. Switching to memantine, a non-competitive NMDA receptor antagonist, would be appropriate if cholinesterase inhibitors are contraindicated or ineffective, as evidence supports its use in moderate to severe AD (Wilkinson et al., 2019).

My initial expectation was that dose escalation of donepezil could further stabilize cognition; however, the actual results depend on individual pharmacodynamics and tolerability. The decision balances potential benefits with safety considerations, especially in elder patients with comorbidities.

Conclusion

Management of Alzheimer’s disease requires a nuanced, evidence-based approach tailored to individual responses. Initiating with donepezil aligns with current guidelines and evidence supporting cognitive benefits. Progressive titration aims to optimize efficacy while monitoring adverse effects. Should treatment plateau or adverse effects emerge, switching to agents like memantine offers an alternative pathway. Overall, careful monitoring, patient-centered adjustments, and ongoing assessment are crucial in improving quality of life for patients like Mr. Akkad.

References

  • Birks, J. (2006). Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database of Systematic Reviews, (1), CD005593.
  • Birks, J., & Harvey, R. J. (2018). Donepezil for mild and moderate Alzheimer’s disease. Cochrane Database of Systematic Reviews, (6), CD001190.
  • Howard, R., McShane, R., Lindesay, J., et al. (2012). Donepezil and Memantine for moderate-to-severe Alzheimer’s disease. New England Journal of Medicine, 366(10), 893-903.
  • Lilius, T., Kähkönen, S., & Soininen, H. (2020). Dose escalation of donepezil in patients with moderate Alzheimer’s disease. Journal of Alzheimer’s Disease, 78(4), 1343-1350.
  • Liu, B., Li, J., & Zeng, F. (2018). Pharmacological treatment of Alzheimer’s disease: a review of current options. CNS Drugs, 32(2), 109-124.
  • Winblad, B., Amouyel, P., Andrieu, S., et al. (2006). Donepezil in mild to moderate Alzheimer’s disease: A meta-analysis. The Lancet Neurology, 5(9), 716-723.
  • Wilkinson, D., Mead, G. E., & Spector, A. (2019). Memantine in Alzheimer’s disease: Systematic review and meta-analysis. British Journal of Psychiatry, 215(2), 575-581.
  • Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Psychological Assessment Resources, Lutz, FL.
  • Alzheimer's Association. (2023). 2023 Alzheimer's disease facts and figures. Alzheimer’s & Dementia, 19(4), 1-84.

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