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

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

affects the majority of elderly people in the United States and around the world. According to several studies, Alzheimer’s is a neurodegenerative disease that begins slowly and then degenerates over time. According to epidemiological data, this disease affects more than 70% of the world’s elderly people with dementia. The presence of recent memory lapses in a patient’s life is the most revealing symptomology of the condition. As the condition worsens, additional symptoms such as mood swings, behavioral issues, language difficulties, disorientation, and a lack of self-care management emerge. The body will gradually lose all of its vital functions, which will eventually lead to death. According to Houmani and his colleagues (2018), the disease’s lifespan varies from patient to patient, but it does not exceed nine years after diagnosis. More fundamentally, there is no cure for Alzheimer’s disease, so the only option is to manage it so that a patient has a better quality of life before passing away.

In the present case study, an Iranian man whose son charges that he displays strange behaviors will be examined and pharmacologically treated by the present nurse practitioner. According to the patient interview, Mr. Akadi displayed a loss of interest in things that were initially dear to him. Moreover, the patient has become forgetful in the recent

past and confabulation was noticeable from his mental health testing procedure. Additional symptoms evident from the diagnostic process include impaired judgment and impulse as well as restricted affect. According to a mini-mental status examination that was conducted, the patient also suffers from a major neurocognitive disorder. The nurse suspected that the condition may have been caused by presumptive Alzheimer. Therefore, the present paper will seek to elucidate the assessment outcomes and create a pharmacological treatment therapy based on informed standard procedures. According to studies, while the condition is essentially untreatable, it can be managed pharmacologically. The pharmacological management is, however, influenced by factors such as dosage, proper selection of drugs, and time of use and administration route. Importantly, it is important for the nurse practitioner to monitor the responsiveness of a patient to drugs and their dosages and make fundamental adjustments after periodic assessment.

Decision Point One

Selected Decision

Decision point one presented the nurse practitioner with three important options. The first option was to start the patient on Razadyne (galantamien) 4 mg daily. The second option would see the nurse prescribe Aricept (donepezil) 5 mg orally during bedtime. Lastly, the nurse can also think of beginning begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks. Out of the three options, the nurse chose to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks for various pharmacokinetic and pharmacodynamics reasons…..CONTD

Assignment Instructions

Mr. Akkad is a 76-year-old Iranian man who has been brought to your office by his eldest son for “abnormal behavior.” Mr. Akkad was examined by his family physician, who ruled out any organic cause for his behavior. All laboratory and diagnostic imaging tests (including a head CT scan) came back normal.

His son claims that he has been having strange thoughts and behaviors for the past two years, but things appear to be getting worse. According to the client’s son, the family noticed a change in Mr. Akkad’s personality a few years ago. He began to lose interest in family religious activities and became more “critical” of everyone. They also noticed that things he once took seriously had turned into a source of “amusement” and “ridicule.”

Mr. Akkad’s family has noticed that he has been forgetting things over the last two years. His son also reports that he sometimes has difficulty “finding the right words” in a conversation and then switches to a completely different topic.

An Elderly Iranian Man Suffering from Alzheimer’s

Alzheimer’s disease is one of the most debilitating neurodegenerative conditions, according to research. According to researchers, the condition begins slowly and then worsens over time. According to statistics, the condition affects more than 70% of all demented people worldwide. Alzheimer’s disease manifests itself as memory lapses regarding recent events in a person’s life. According to Houmani et al. (2018), as the disease progresses, such patients will exhibit language difficulties, mood swings, disorientation, behavioral issues, a lack of self-care management, and disorientation symptomatology. These authors also believe that the above symptoms will precede, albeit gradually, the eventual loss of bodily functions. Importantly, there is no cure for Alzheimer’s disease, but doctors can manage it to improve a patient’s quality of life. Because there is no cure, a person suffering from the condition has a life expectancy of about nine years after diagnosis.

In this assignment, an elderly Iranian man named Mr. Akkad walks into the office of a clinicia due to what his son describes as “strange behaviors.” The 76-year-old was subjected to physical and diagnostic examinations, which ruled out organic causes for his behaviors. His family, on the other hand, noticed that their elderly father had begun to exhibit strange thoughts and behaviors. They noticed he had lost interest in his favorite activities, particularly religious activities. Furthermore, Mr. Akkad had become critical of everyone in the family and had developed a sense of amusement and ridicule for things that he had taken seriously at first. Worryingly, Mr. Akkad had begun to experience memory lapses, making it difficult for him to hold conversations. He received an 18 out of 30 on a Mini-Mental Status Exam, indicating rudimentary deficiencies in recall, attention and calculation, registration, and orientation. Some of the above-mentioned symptoms were also revealed during a mental status examination. As a result, Mr. Akkad was diagnosed with a presumptive major neurocognitive disorder caused by Alzheimer’s disease by the PMNHP. As a result, based on data from three checkpoints, the current paper will attempt to manage Mr. Akkad’s condition through psychopharmacology and various manipulations of the chosen therapy.

SUBJECTIVE

Mr. Akkad is pleasant, cooperative, and appears to enjoy speaking with you during the clinical interview. Because you observe some confabulation during various aspects of memory testing, the PMHNP administers a Mini-Mental State Exam. Mr. Akkad receives an 18 out of 30 for orientation, registration, attention & calculation, and recall. The result indicates moderate dementia.

EXAMINATION OF MENTAL STATUS

Mr. Akkad is a 76-year-old Iranian man who is willing to participate in today’s clinical interview. His eye contact is inadequate. Speech is clear and coherent, but occasionally tangential. He does not exhibit any unusual motor movements or tics. Euthymic is the self-reported mood. However, affect is limited. He denies experiencing visual or auditory hallucinations. There were no delusional or paranoid thought processes observed. He is alert and oriented to person, partially oriented to place, but disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he starts laughing]. Perception and judgment are impaired. Mr. Akkad’s standing up during the clinical interview and walking towards the door demonstrates poor impulse control. When the PMHNP asked where he was going, he said he had no idea. Mr. Akkad denies having suicidal or homicidal thoughts.

RESOURCES

• Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.

Decision Point One

Select what the PMHNP should do:

• 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

Decision Point One

Begin Razadyne (galantamine) 4 mg orally BID

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 Razadyne to 24 mg extended release daily

RESULTS OF DECISION POINT TWO

•  Client returns to clinic in four weeks
•  The client’s son accompanies the client to his appointment today. The client is in a wheelchair and is somewhat agitated
•  You are informed by the son that his father has not taken his medication since he got out of the hospital. Apparently, about 7 days after starting the Galantamine extended release, the client began having seizures which resulted in a fall and fractured hip. The son reports that his father is agitated with everyone and is asking for help in treating his agitation

Decision Point Three

• Restart Razadyne extended release 24 mg

Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If the PMHNP were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, the PMHNP should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

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.

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

• Increase Exelon to 6 mg orally BID

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.

• Begin Aricept (donepezil) 5 mg orally at BEDTIME

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 Aricept to 10 mg orally at BEDTIME

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

Continue Aricept 10 mg orally at BEDTIME

Guidance to Student

At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

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.

The Assignment

. 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:

o    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?

o    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?

o    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.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Case Study: An Elderly Iranian Man with Alzheimer’s Disease Decision Tree Assignment

Here is a general framework for what I am looking for on the decision tree assignments.

Provide an introduction to the disease state discussed in the case. I am looking for a high-level summary that briefly describes the key aspects of that disease state. I do not want several pages of information related to the diagnosis of the disease state.

Provide a high-level summary of the important pieces of information from the case-study that is presented. I do not want the entire case study presented. The goal is that you would be able to give your essay to someone that does not know anything about the assignment and for that individual to be able to understand the purpose of your essay. Again….focus on the important pieces of information that will help you make your decision.

You also want to mention the purpose of the assignment. This can be brief.

Decision Point 1, 2, and 3.

At each decision point, list the options that are presented and describe your rationale for choosing the option you chose.

I do not want general answers….”I chose sertraline because sertraline is an SSRI and SSRIs are approved for depression/anxiety”. I want VERY SPECIFIC reasons you chose the option you chose. These reasons must be backed by good evidence. Feel free to include studies comparing agents, side effects, dosing, patient considerations, therapeutic practice guidelines, comorbid conditions, etc….  You will also need to explain your rationale for not choosing the other two options.  This is very important in your learning. Please remember that you will have MANY more medications to chose from than three in clinical practice. When you make your choice, you also need to describe your goals of treatment. What do you want to achieve by initiating the therapy you picked. Again….be specific. Defend your choices like you are in a courtroom.

After each decision, you will be presented with the outcome of that decision. You need to discuss how that outcome was what you expected or if it was different than what you expected and why.

You will do the above for all three decision points.

You need to use evidence to support your rationale. [Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. Credible reference material only will be accepted. Sites such as WebMD and drugs.com (among others) will not be counted.]

Don’t forget to include information related to the ethical considerations and how they might impact your treatment plan and communication with your clients.

In summary: What needs to be in your essay.

• Introduction regarding disease state
• High-level summary of patient case
• Purpose of the essay statement

Decision 1

• What options were listed
• What option did you choose?
• Why did you select that option?
• Why didn’t you select the other two options?
• What was your goal of treatment
• Was the outcome what you expected? Why?

Decision 2

• What options were listed
• What option did you choose?
• Why did you select that option?
• Why didn’t you select the other two options?
• What was your goal of treatment
• Was the outcome what you expected? Why?

Decision 3

• What options were listed
• What option did you choose?
• Why did you select that option?
• Why didn’t you select the other two options?
• What was your goal of treatment
• Was the outcome what you expected? Why?

Conclusion with Ethical considerations

***Do not use the start over button and complete several different times. That is not the point. If you do use the START OVER button, I do not want your paper to reflect this. I have had students do it multiple times and address incorrect outcomes in their paper. I have also had students submit a paper that defends using all three options presented at decision point number one. You will need to click the option to move to the next screen which will provide you with the outcome and the options for the next decision point.  You will receive a ZERO on the assignment if you do not follow the instructions correctly. I had a handful of students last semester complete the assignment incorrectly.  Please ask questions if you do not understand.

Alzheimer’s condition is a neurodegenerative disease that begins slowly and worsens over a long period of time. The condition has been associated with almost 70% of all dementia cases in the world. The most prevalent early symptoms entail the absence of memory concerning recent events. As the condition progresses, other symptoms such as language difficulties, mood swings, disorientation, behavioral issues, lack of self-care management, and disorientation may occur (Houmani et al., 2018). In a gradual manner, all the bodily functions will be lost resulting in eventual death. As much as the disease’s life expectancy varies, the typical expectancy does not go beyond nine years after diagnosis. Importantly, the disease does not have a cure but it could be managed to ensure that the quality of life of patients suffering from it is improved.

The case study for the present assignment entails the examination and treatment of an elderly Iranian man who displays strange behaviors according to his son. Mr. Akan has lost interest in things that erstwhile interested him. Further, the client has been forgetting things and his subjective test revealed confabulation during mental health testing process. Mr. Akad also has restricted affect and impaired impulse and judgment. A mini-mental state examination reveals that Mr. Akad suffers from major neurocognitive disorder caused by presumptive Alzheimer’s disease. This paper describes the assessment outcomes and treatment options for an elderly Iranian man, who has been diagnosed with Alzheimer’s. The condition can be treated with pharmacological interventions, which are dependent on among other factors dosage, proper selection of drug, and time of use, and administration route.

Decision Point One

For this decision, there were three options listed. One was to begin Razadyne (galantamien) 4 mg daily. The second one was to begin Aricept (donepezil) 5 mg orally at bedtime. While the third one, which was the one that I selected was to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.

An Elderly Iranian Man with Alzheimer’s

In the United States, and around the world, Alzheimer’s disease affects the vast majority of the elderly. Alzheimer’s is a neurological disease that begins slowly and worsens over time, according to numerous research. The disease affects more than 70 percent of older dementia sufferers worldwide, according to epidemiological data. The condition’s most telling sign is a patient’s inability to recall recent events from their life. As the disease progresses, other symptoms such as mood swings, behavioral challenges, language difficulties, confusion, and the absence of self-care management begin to emerge.. As the body loses its ability to perform all of its critical activities, it will finally die. However, despite the fact that the condition has a variable life expectancy among patients, Houmani and colleagues (2018) claim that the average post-diagnosis lifespan is no more than nine years. Furthermore, Alzheimer’s disease remains incurable, and the only option is to control it so that a patient can experience a better quality of life prior to their eventual death.

Nurse practitioner examines and treats an Iranian guy whose kid claims that he exhibits unusual habits in the current case study. Mr. Akan, according to the conversation with the patient, seems to have lost interest in some of the things he used to care about. Furthermore, the patient has recently grown forgetful and confabulated during mental health examinations. The diagnostic process reveals other symptoms, including impaired judgment and impulse control, and a restricted emotional response. The patient also has a significant neurocognitive problem, according to a mini-mental status evaluation. The nurse had a sneaking suspicion that probable Alzheimer’s was to blame for the patient’s condition. As a result, the goal of this study is to provide insight into the results of the assessment and develop a pharmacological treatment strategy based on established best practices. The illness is essentially untreatable, but it can be managed with the use of medication. But parameters like dosage, drug selection, administration duration, and route have an impact on pharmacological management. In addition, the nurse practitioner must keep tabs on a patient’s response to medication and dosages and make necessary adjustments based on frequent evaluations.