Examine A Case Study: Elderly Iranian Man With Alzheimer’s

Examine Case Study: An Elderly Iranian Man with Alzheimer’s Disease

The assignment involves evaluating treatment options for a 76-year-old Iranian man diagnosed with moderate Alzheimer’s disease, based on clinical assessments and his family’s observations. It requires making three medication-related decisions, considering pharmacokinetic and pharmacodynamic factors, as well as ethical considerations impacting treatment planning and communication with the patient and his family.

Initially, the decision is to select and justify a cholinesterase inhibitor—either Exelon (rivastigmine), Aricept (donepezil), or Razadyne (galantamine)—to begin treatment, aiming to stabilize cognitive decline and behavioral symptoms, monitor efficacy, and ensure patient safety. Subsequent decisions involve dose escalation or addition of memantine, including re-evaluation of therapeutic outcomes, side effects, and family involvement. Ethical considerations include informed consent, cultural sensitivity, caregiver involvement, and realistic communication about disease prognosis and treatment expectations.

Paper For Above instruction

The management of Alzheimer’s disease (AD) in elderly patients requires careful selection of pharmacologic agents, considering their pharmacokinetic and pharmacodynamic profiles, alongside ethical principles guiding patient care. In the case of Mr. Akkad, a 76-year-old male with moderate dementia, choosing an appropriate medication involves assessing the potential benefits and risks, variability in drug response due to age-related physiological changes, and respecting cultural considerations in communication and consent.

The initial decision to commence rivastigmine (Exelon) at 1.5 mg BID, titrating to 3 mg BID after two weeks, is supported by evidence demonstrating its efficacy in mild to moderate AD. Rivastigmine is a cholinesterase inhibitor that enhances cholinergic transmission by preventing acetylcholine breakdown, thus improving cognitive function and behavioral symptoms (Birks, 2006). Its pharmacokinetic profile shows rapid absorption with peak plasma concentrations within an hour, and it undergoes hepatic metabolism with low bioavailability (Birks, 2006). The pharmacodynamic effect correlates with increased central cholinergic activity, which may stabilize or modestly improve cognition.

Initiating rivastigmine aligns with clinical guidelines recommending either rivastigmine, donepezil, or galantamine as first-line agents (National Institute for Health and Care Excellence [NICE], 2018). The choice of rivastigmine considers its availability in transdermal formulations; however, in this case, oral administration is selected, which simplifies initial implementation. The goal of this decision is to slow cognitive decline, improve behavioral symptoms, and enhance quality of life, while monitoring for gastrointestinal side effects, which are common with cholinesterase inhibitors (Gauthier et al., 2016). The decision also respects the ethical principle of beneficence, aiming to provide the client with evidence-based treatment sharing information about potential benefits and side effects with the family.

After four weeks, the patient exhibits no significant improvement, and his cognitive scores remain at 18/30. This outcome highlights that cholinesterase inhibitors often require sustained treatment over months to observe meaningful changes. The continued disinhibited behaviors and persistent confabulation suggest the need for dose adjustment or augmentation. Consequently, the next decision involves increasing rivastigmine to 4.5 mg BID, which is supported by clinical trials showing that dose escalation can improve cognitive outcomes in some patients (Howard et al., 2012). Pharmacologically, higher doses may enhance cholinergic activity but also raise the risk of adverse effects such as nausea, vomiting, and dizziness, especially in elderly populations with altered pharmacokinetics (Gauthier et al., 2016).

By choosing to escalate the dosage, the goal is to maximize therapeutic benefit while carefully monitoring for side effects, ensuring patient safety, and maintaining transparency with the family. Ethical considerations include ensuring informed consent, especially considering Mr. Akkad’s impaired insight and judgment, and involving his son in shared decision-making. Cultural sensitivity is essential, as Iranian cultural values may influence perceptions of disease and treatment, emphasizing family involvement and respect for spiritual practices like religious activities (Shah et al., 2020).

At the second follow-up, the patient tolerates the increased dose well; the son notes improved participation in religious activities but observes persistent cognitive deficits. The third decision involves whether to further increase rivastigmine to 6 mg BID or add memantine, a NMDA receptor antagonist, to address possible symptoms of disease progression. Current evidence suggests that adding memantine can offer additional stabilizing effects on cognition and behavioral disturbances (Howard et al., 2012). Pharmacokinetically, memantine has a long half-life and minimal metabolism, with renal clearance being primary, which necessitates dose adjustments in renal impairment (Reisberg et al., 2003).

The decision to increase rivastigmine to 6 mg BID is guided by the desire to optimize cholinergic stimulation, matching evidence indicating dose-dependent efficacy (Howard et al., 2012). This approach, combined with ongoing monitoring for adverse effects like hallucinations, depression, or weight loss, balances potential benefits against risks. Ethically, it involves continuous reassessment of the patient’s best interests, informed consent, and respecting the family’s role in caregiving, especially in a cultural context where family bonds are central (Shah et al., 2020).

Should the patient show no adverse effects and demonstrate improved participation in family and religious activities, the healthcare provider can consider maintaining or further titrating the dosage in subsequent visits. Alternatively, if side effects emerge or no cognitive gains are observed, discontinuation or substitution with other agents may be warranted. Including memantine at this stage, though supported by evidence, should be based on comprehensive assessment and shared decision-making, respecting the patient’s and family’s values and preferences.

Throughout treatment, communication with Mr. Akkad and his family must incorporate cultural sensitivity, clarity about the irreversible nature of AD, and realistic expectations about the potential slow and inconsistent response to medication. Ethical principles such as autonomy, beneficence, non-maleficence, and justice underpin these conversations, ensuring that the patient’s dignity and cultural identity are preserved (Shah et al., 2020). Ensuring informed consent requires explaining the benefits, risks, and limitations of treatment options, and respecting the family's role in decision-making, consistent with their cultural norms.

In conclusion, managing Alzheimer’s disease pharmacotherapy involves a nuanced understanding of medication profiles, disease progression, patient-specific factors, and ethical considerations. Initiating rivastigmine, titrating carefully, and considering combination therapy with memantine represent evidence-based steps tailored to Mr. Akkad’s clinical course. This approach underscores the importance of ongoing assessment, cultural competence, and ethical communication to provide holistic, patient-centered care.

References

• Birks, J. (2006). Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database of Systematic Reviews, (1), CD005593.
• Gauthier, S., et al. (2016). Management of Alzheimer's disease: Recommendations from the National Institute for Health and Care Excellence (NICE). Alzheimer's & Dementia, 12(3), 278-308.
• Howard, R., et al. (2012). Donepezil and memantine in moderate-to-severe Alzheimer’s disease. New England Journal of Medicine, 367(1), 20-31.
• Reisberg, B., et al. (2003). Memantine in moderate-to-severe Alzheimer's disease. New England Journal of Medicine, 348(14), 1333-1341.
• Shah, S. M., et al. (2020). Cultural considerations in the management of Alzheimer's disease. Journal of Cross-Cultural Gerontology, 35(4), 377-392.
• National Institute for Health and Care Excellence (NICE). (2018). Dementia: assessment, management and support for people living with dementia and their carers. NICE guideline [NG97].