How To Prepare For This Assignment Review This Week's Learni ✓ Solved

To Prepare For This Assignmentreview This Weeks Learning Resources

To prepare for this Assignment: Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for dementia. 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 stop to complete the following: 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.

CASE STUDY 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 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. 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) Decision Point One Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks 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.

Decision Point Two Increase Exelon to 4.5 mg orally BID 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.

Decision Point Three Maintain current dose of Exelon 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.

Sample Paper For Above instruction

The case of Mr. Akkad presents a complex scenario requiring careful consideration of pharmacologic and ethical principles in the management of Alzheimer’s disease. This paper discusses the decisions made at each critical juncture concerning medication management, the expected outcomes, actual results, and the ethical implications of treatment choices. The primary goal is to optimize cognitive and functional outcomes while respecting the patient's dignity and autonomy.

Decision Point One: Initiating Rivastigmine 1.5 mg BID

The initial choice to prescribe rivastigmine at 1.5 mg twice daily was based on evidence supporting its efficacy in early to moderate Alzheimer’s disease (Birks, 2006). Rivastigmine, a cholinesterase inhibitor, enhances cholinergic neurotransmission, which is typically deficient in Alzheimer’s disease (Kepe et al., 2013). Starting with a low dose aims to minimize adverse effects such as gastrointestinal discomfort (Birks, 2006). The goal was to stabilize cognitive decline and improve behavioral symptoms.

By initiating this dose, the expectation was that Mr. Akkad’s cognitive functions, particularly memory and orientation, would stabilize or improve, and disinhibition might diminish (Mukherjee & Radhakrishnan, 2018). However, four weeks later, there was no noticeable clinical improvement, which highlights the often slow and variable response to cholinesterase inhibitors (Atri et al., 2008).

The discrepancy between expected and actual outcomes may be due to individual variability, disease progression, or biological factors influencing drug efficacy, such as age-related pharmacokinetic changes (Mourtzakis et al., 2018). It underscores that cholinesterase inhibitors typically take months to exhibit significant benefits and that early lack of response does not necessarily indicate treatment failure.

Decision Point Two: Increasing Rivastigmine to 4.5 mg BID

The decision to escalate the dose to 4.5 mg BID aligns with clinical guidelines recommending titration to effective doses while monitoring tolerability (Park et al., 2015). The aim was to enhance the therapeutic effects, hoping for further stabilization or improvement in cognitive function and behavioral symptoms. The patient tolerated this increase well, and family reports indicated increased engagement with religious activities, suggesting some functional benefit.

Despite expectations of cognitive stabilization, the patient still showed minimal or no improvement in MMSE scores (Cummings et al., 2011). The results reflect the common clinical reality that response to cholinesterase inhibitors varies among patients, and some may experience only modest benefits. Factors like disease severity, comorbidities, and pharmacodynamics influence outcomes (Kumar et al., 2017).

The difference between expected and observed outcomes emphasizes the importance of realistic goal-setting and the understanding that medication primarily stabilizes rather than reverses neurodegeneration. It also highlights the necessity of holistic care, combining medication with psychosocial interventions (Geldmacher et al., 2015).

Decision Point Three: Maintaining Current Dose and Ethical Considerations

The choice to maintain the current dose reflects confidence in tolerability and some observed functional stabilization. It aligns with guidelines advocating for sustained therapy in the absence of side effects (Farlow et al., 2014). The discussion with the family about the disease trajectory emphasizes transparency, respect for patient autonomy, and informed decision-making.

Ethically, maintaining the current dose respects the patient’s dignity and ensures continuity of care, avoiding unnecessary medication changes that could cause adverse effects or confusion (Beauchamp & Childress, 2013). It also considers the principle of beneficence—aiming to maximize benefits and minimize harm—by observing as the disease progresses.

While increasing the dose could potentially offer additional benefits, ethical considerations about the risk-benefit ratio, quality of life, and the patient’s and family’s preferences are paramount (Verhagen et al., 2014). Transparent communication regarding prognosis, limitations of pharmacotherapy, and the irreversibility of Alzheimer’s disease guides ethical and compassionate care.

Conclusion

The management of Alzheimer’s disease with cholinesterase inhibitors such as rivastigmine requires gradual titration, careful monitoring, and ethical awareness. Expected outcomes are often modest and delayed, underscoring the importance of patient-centered care that balances clinical evidence with individual needs and values. Ethical principles—such as autonomy, beneficence, and non-maleficence—must guide all treatment decisions, ensuring that patients and their families are active participants in the caregiving process.

References

• Birks, J. (2006). Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database of Systematic Reviews, (1), CD005593.
• Beauchamp, T. L., & Childress, J. F. (2013). Principles of Biomedical Ethics (7th ed.). Oxford University Press.
• Cummings, J. L., et al. (2011). Alzheimer's disease drug development: the importance of biomarker-based diagnosis. Journal of Clinical Psychiatry, 72(12), 1573–1574.
• Farlow, M., et al. (2014). Efficacy and safety of rivastigmine in patients with Alzheimer's disease: a meta-analysis. Journal of Alzheimer's Disease, 40(4), 973–984.
• Geldmacher, D. S., et al. (2015). A randomized controlled trial of cognitive-focused interventions in Alzheimer's disease caregivers. International Journal of Geriatric Psychiatry, 30(3), 342–351.
• Kepe, V., et al. (2013). PET imaging of cholinesterase activity in Alzheimer's disease. Journal of Nuclear Medicine, 54(8), 1283–1289.
• Kumar, A., et al. (2017). Pharmacogenomics of cholinesterase inhibitors in Alzheimer's disease. Pharmacogenomics, 18(4), 341–355.
• Mourtzakis, M., et al. (2018). Age-related pharmacokinetic changes and implications for drug therapy in older adults. Clinical Pharmacology & Therapeutics, 104(2), 309–317.
• Mukherjee, S., & Radhakrishnan, M. (2018). Pharmacological management of Alzheimer’s disease: an update. Current Alzheimer Research, 15(4), 357–363.
• Park, J., et al. (2015). Management of Alzheimer's disease: recent guidelines and emerging treatments. Gerontology and Geriatric Medicine, 1, 2333721415586694.
• Verhagen, C., et al. (2014). Ethical considerations in dementia care: balancing beneficence and autonomy. Journal of Medical Ethics, 40(9), 607–611.