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Decision Tree for a 76-year-old Man with Presumptive Alzheimer’s Disease

Decision Tree for a 76-year-old Man with Presumptive Alzheimer’s Disease

NURS – 6521N: Advanced Pharmacology

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Decision Tree for a 76-year-old Man with Presumptive Alzheimer’s Disease

Mr. Akkad in this case study is a 76-year-old Iranian man whom his son brought to the office. According to the client’s son, the client exhibited “strange behavior” which was reflected in changes in personality and behavior. The client became harsh with everyone as he lost interest in religious activities. The client also presented other symptoms including forgetfulness, speech impairment, as well as other cognitive deficits. The client’s MMSE His score is 18 out of 30, suggesting moderate dementia with significant problems with attention, arithmetic, memory, orientation, and memory. Clients were rated as having poor eye contact, confusion, restricted emotions, normal mood, and poor impulse control. This paper explains a 3-step decision tree towards improving the symptoms of the client.

First Decision

The client begins with Exelon (rivastigmine) 1.5 mg oral BID at the first decision point. The choice of rivastigmine was informed by its benefits and effectiveness in treating Alzheimer’s disease and dementia. Symptoms of severe neurocognitive impairment which are caused by Alzheimer’s disease often result from pathological alterations in cholinergic pathways. Rivastigmine is therefore a good choice as it improves cholinergic function. Rivastigmine works by inhibiting the breakdown of acetylcholine, increasing acetylcholine availability in the brain, and improving synaptic transmission. It improves memory as well as carries out other cognitive functions in people with severe neurocognitive impairment and Alzheimer’s disease (Khoury et al., 2018). In addition, rivastigmine slows down the progression of the disease by reducing the number of cells that are responsible for producing acetylcholine in the brain (Oh et al, 2015). Because of the various side effects, including vomiting, anorexia, dizziness, diarrhea, tremors, and muscle spasms that are linked to donepezil, the decision to give Aricept (donepezil) 5 mg orally at bedtime was not made (Chen et al, 2017). In addition, the administration of Aricept (donepezil) at bedtime is associated with sleep disturbances, which is another reason why the patient was not given this drug at bedtime (Weiser, 2014). The key reason for this decision was to improve the client’s symptoms. This is reflected in improvements in cognitive performance, as selected agents have been successful in improving cognitive performance and other symptoms of the patient associated with Alzheimer’s disease as well as other significant neurocognitive disorders (Oh et al., 2015). There was no significant improvement in the client’s symptoms. She had problems with orientation, attention, and memory, and her MMSE score was still at 18//30, so the actual and expected results were different. 

Second Decision

The second decision was to raise the oral dosage of rivastigmine to 4.5mg. The increase of the client’s rivastigmine dose is because there is evidence that higher doses of rivastigmine are more effective, as the efficacy of rivastigmine is dose-dependent (Oh et al., 2015). As a result, higher doses of rivastigmine are expected to be more effective in improving the patient’s cognitive performance as well as other behavioral problems and increasing the effectiveness of the medication (Oh et al, 2015). It was also decided to not increase Exelon from 1.5mg. This is because increasing the dose from 1.5 mg to about 6 mg would rapidly increase drug levels in the bloodstream and risk patients experiencing or suffering side effects. because it may increase. According to Nour et al. (2016), rivastigmine dose escalation should be done gradually to ensure drug tolerability. The reason for going with the option of not stopping Exelon and starting Namenda is that it takes time for the drug to stabilize symptoms in people with presumed Alzheimer’s disease, so they may start to improve. over time (Mahoney et al, 2014). Increasing the dose of rivastigmine to 4.5 mg was decided so as to stabilize and improve presumed Alzheimer’s disease symptoms in the patient. There was also hope that the patient would tolerate increased doses and experience fewer side effects because Exelon’s efficacy is dose-dependent, so higher doses are likely to be more beneficial and effective in patients (Khoury et al, 2018). Additionally, the gradual increase in drug dosage results in a gradual increase in the level of concentration of drug in the bloodstream, minimizing side effects for patients. In general, there wasn’t a significant difference between the expected and actual results of the decision. As a result of this decision, the patient’s symptoms began to improve. This is evidenced by the patient’s willingness to attend church services with his family. The tolerance of the drug by the client was also very impressive as he did not show signs of side effects after increasing the dose. 

Third Decision

For the third decision, the Exelon dosage should be increased to 6 mg. The reason for this decision is that the efficacy of Exelon is dose-dependent. This means that higher doses increase acetylcholine levels in the brain, increasing drug efficacy (Mahoney et al., 2014). Increased acetylcholine levels are thought to improve cognitive function and other problematic behaviors in clients. Because the effectiveness of Exelon depends on the dosage, no decision is made to maintain the current dose of Exelon, therefore doses must be increased to improve efficacy and consequently improve patient symptoms. (Mahoney et al., 2014). Because of the decision to optimize the dose of Exelon as a cholinesterase inhibitor before the prescription of Exelon was renewed, Namenda 5 mg was not added, which was expected to result in further improvement in the client’s symptoms. This is reflected in improved cognitive function and the ability of the client to engage in activities of daily living. Also, as expected, the client tolerated increased doses well with little to no side effects.  

Conclusion

In summary, your first option is to start taking Exelon 1.5 mg. This decision was made because Exelon has been shown to be effective in the treatment of cognitive function in patients with Alzheimer’s disease because of its enhanced cholinergic activity. It was noted that the expected improvement was not seen because cholinesterase inhibitors take longer to work. Because Exelon is dose-dependent and higher doses are more effective in treating Alzheimer’s symptoms, hence the decision to increase the dose. The second and third decisions led to a significant decrease in the client’s illness symptoms as he was able to participate in religious activities with his family. Finally, as a result of the impairment of the client’s cognitive function, the treatment of the client may be altered due to ethical considerations such as informed consent, judgment, and decision-making.

References:

Chen, R., Chan, P. T., Chu, H., Lin, Y. C., Chang, P. C., Chen, C. Y., Chou, K. R. (2017). Treatment effects between monotherapy of donepezil versus combination with memantine for Alzheimer disease: A meta-analysis. PLoS One. 2017 Aug 21;12(8):e0183586. doi: 10.1371/journal.pone.0183586. PMID: 28827830; PMCID: PMC5565113.

Khoury, N. M., Lutz, J., Schuman-Olivier, Z. (2018). Interoception in Psychiatric Disorders: A Review of Randomized, Controlled Trials with Interoception-Based Interventions. Harv Rev Psychiatry. 2018 Sep/Oct;26(5):250-263. doi: 10.1097/HRP.0000000000000170. PMID: 30188337; PMCID: PMC6129986.

Mahoney, J. W., Gucciardi, D. F., Ntoumanis, N., Mallett, C. J. (2014). Mental toughness in sport: motivational antecedents and associations with performance and psychological health. J Sport Exerc Psychol. 2014 Jun;36(3):281-92. doi: 10.1123/jsep.2013-0260. Erratum in: J Sport Exerc Psychol. 2014 Aug;36(4):429. Mallet, Cliff J [corrected to Mallett, Cliff J]. Erratum in: J Sport Exerc Psychol. 2014 Aug;36(4):429a. PMID: 24918311.

Nour, J. M., Chouliaras, L., Hickey, L. (2016). High dose rivastigmine in the symptom management of Lewy body dementia. BMJ Case Rep. 2016 Nov 29;2016:bcr2016217240. doi: 10.1136/bcr-2016-217240. PMID: 27899389; PMCID: PMC5174755.

Oh, Y., Lee, J. E., Lee, P. H., Kim, J. S. (2015). Neuropsychiatric symptoms in Parkinson’s disease dementia are associated with increased caregiver burden. J Mov Disord. 2015 Jan;8(1):26-32. doi: 10.14802/jmd.14019. Epub 2015 Jan 13. PMID: 25614783; PMCID: PMC4298716.

Weiser, D. (2021). Aricept (donepezil). https://www.medicalnewstoday.com/articles/drugs-aricept#about