Caring And Treatment Decisions For A Patient With Alzheimer’

Caring and Treatment Decisions for a Patient with Alzheimer’s Disease

Mr. Akkad is a 76-year-old Iranian male brought to your office by his eldest son due to "strange behavior." Despite comprehensive laboratory and imaging tests, including a CT scan of the head, no organic causes were identified for his behavioral changes. The family reports that over the past two years, Mr. Akkad's personality has shifted—he has become less interested in religious activities, more critical, and displays a tendency to find serious matters amusing. Additionally, he experiences progressive memory decline, difficulty finding words, and shifts in conversational topics. During the clinical assessment, Mr. Akkad scores 18 out of 30 on the Mini-Mental State Examination (MMSE), indicating moderate dementia, with deficits in orientation, registration, attention, calculation, and recall.

He presents as cooperative and pleasant, with poor eye contact, clear but tangential speech, and no abnormal motor movements. He is oriented to person, partially to place, and disoriented to time and event. His insight and judgment are impaired, and he exhibits impaired impulse control, as evidenced by attempting to leave during the interview. He denies hallucinations, delusions, or homicidal ideation. The clinical diagnosis is presumptive Major Neurocognitive Disorder (Alzheimer’s disease).

Decision #1: Initiate Donepezil 5 mg at bedtime

The initial decision was to begin treatment with Aricept (donepezil) 5 mg orally at bedtime, with plans for re-evaluation in four weeks. The rationale aligns with evidence supporting the use of cholinesterase inhibitors in mild to moderate Alzheimer’s disease to improve cognitive function and slow decline (Birks, 2006). Donepezil increases cholinergic activity in the brain, which is deficient in Alzheimer’s pathology, thereby enhancing memory and executive functions (Birks & Harvey, 2018). The goal was to stabilize cognitive decline and improve quality of life for Mr. Akkad.

The expectation was to observe mild cognitive benefits or stabilization over four weeks, potentially reflected by improved MMSE scores or functional status. However, the family reports no noticeable improvement, and behavioral symptoms such as disinhibition persist. This discrepancy may be explained by the pharmacodynamics of donepezil, which may require more time to produce noticeable effects or dose titration for optimal benefit (Howard et al., 2012). Additionally, moderate to severe dementia often exhibits limited responsiveness to cholinesterase inhibitors, and individual variability may influence outcomes (Howard et al., 2012). Therefore, the failure to observe significant improvement within four weeks is consistent with current evidence, which suggests that benefits may be modest and slow to manifest.

Decision #2: Increase donepezil to 10 mg at bedtime

The second decision involved increasing the dose of donepezil to 10 mg orally at bedtime after four weeks, given the persistent cognitive and behavioral symptoms. The rationale stems from evidence indicating that higher doses of cholinesterase inhibitors can offer additional cognitive benefits in some patients with moderate Alzheimer’s disease (Birks & Harvey, 2018). Studies have shown that titrating donepezil to 10 mg improves cognitive performance and potentially delays functional decline compared to 5 mg (Howard et al., 2012).

The goal of increasing the dose was to achieve better control of cognition and behavior, aiming to stabilize or improve the patient's condition further. The family reports that Mr. Akkad continues to experience challenges, although he now attends religious services, which is viewed positively. The expectation was that higher dose might lead to measurable cognitive improvements or behavioral stabilization. However, the family notes that despite the dosage increase, Mr. Akkad's cognitive status remains largely unchanged, consistent with evidence that higher doses may yield modest or no additional benefit in some individuals (Birks & Harvey, 2018). The lack of significant change might be attributed to disease progression beyond the moderate stage or individual differences in drug response.

Decision #3: Continue donepezil at 10 mg, monitor and consider additional interventions

The third decision was to maintain donepezil at 10 mg daily, with ongoing monitoring and consideration of adjunctive non-pharmacological interventions. The rationale recognizes that pharmacotherapy alone often provides limited benefits, especially in moderate to severe stages of Alzheimer’s disease (McKhann et al., 2011). Continuing the current medication aligns with guidelines recommending maintenance therapy to slow cognitive decline while addressing behavioral symptoms with supportive measures.

Achieving continued stabilization of symptoms and preventing further decline was the primary aim. It was also expected that ongoing medication could sustain any cognitive or behavioral stabilization observed so far, with adjustments made based on the patient's evolving needs. The family notes some improvement in social engagement, which aligns with the goal of maintaining a supportive environment. The primary outcome hoped for was slowed progression, improved quality of life, and preserved daily functioning.

The differences between expected and actual outcomes across decisions highlight the progressive nature of Alzheimer’s disease, which often limits the efficacy of pharmacological interventions. Despite medication adjustments, cognitive decline often persists, emphasizing the importance of comprehensive care—including behavioral interventions, caregiver support, and safety measures (McKhann et al., 2011). Ethical considerations, such as respecting patient autonomy, informed consent, and honest communication about prognosis and treatment limitations, are crucial in managing Alzheimer's disease. Ensuring that Mr. Akkad and his family are involved in decision-making fosters trust and aligns treatment with their values and preferences (American Psychiatric Association, 2013).

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 dementia due to Alzheimer’s disease. Cochrane Database of Systematic Reviews, (6), CD001190.
• Howard, R., McShane, R., Lindesay, J., et al. (2012). Memantine for Alzheimer's disease. Cochrane Database of Systematic Reviews, (3), CD003673.
• McKhann, G. M., Knopman, D. S., Chertkow, H., et al. (2011). The diagnosis of dementia due to Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups. Alzheimer's & Dementia, 7(3), 263–269.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).