CASE STUDY ON ALZHEIMER’S DISEASE
5
Running head: CASE STUDY ON ALZHEIMER’S DISEASE
1
Case Study on Alzheimer’s Disease
Name
Course
May 1, 2019
Faculty
Case Study on Alzheimer’s Disease
Introduction
This case study involves a 76-year-old Iranian male, Mr. Akkad, who suffers from a major neurocognitive disorder presumably caused by Alzheimer’s disease. He presents with severe disorientation to time and events and partial orientation to place. He has impaired insight and judgement and tends to stray away his line of thought in a conversation. Also, Mr. Akkad exhibits limitations in his registration, attention, calculation, and memory. In fact, there are noticeable confabulations in various aspects of his memory. His affect is restricted which means that his display of emotions and feelings towards other people is limited. In summation, Mr. Akkad presents a decline in cognitive ability due to a neurodegenerative illness known as Alzheimer’s disease.
Summary
In this case study, Mr. Akkad lives with his family and the primary caregiver seems to be his eldest son who brings him to the hospital. The care setting of the client is of vital importance to his manageability of the illness. During the consultation the PMHNP conducts a Mini-Mental State Exam which reveals that Mr. Akkad may have moderate dementia. Further diagnosis shows that he has Alzheimer’s disease which is a type of dementia. He is often forgetful and loses orientation to place, time and events. This aspect is crucial in developing a treatment plan for Mr. Akkad. Nonetheless, the client is generally co-operative during his consultation and appears to enjoy conversation.
Purpose of essay
The aim is to develop an individualized drug regimen for the client’s neurocognitive disorder.
Decision 1
There were three options of drugs listed for treatment. The first choice was administering rivastigmine 1.5mg orally twice a day and the dosage would increase to 3mg in two weeks. The second option was Aricept (donepezil) at a dose of 5mg to be taken orally at bedtime. The last choice was Razadyne (galantamine) administered at 4mg orally twice a day. The suitable option at this point was Aricept (donepezil) which would be taken at a dosage of 5mg orally. This drug is appropriate because it is a cholinesterase inhibitor approved by the Food and Drug Administration to treat all stages of Alzheimer’s disease. Alzheimer’s Association (2017) writes that Aricept is best known for treatment all stages of Alzheimer’s but mostly prescribed for moderate to severe Alzheimer’s. In this case scenario, Mr. Akkad presents with major neurocognitive disorders which means shows the severity of his condition. Therefore, Aricept would be the best fit. The first choice of rivastigmine was unsuitable as it is mostly prescribed for mild to moderate Alzheimer’s. Furthermore, Foster et al. (2016) conducted a study to investigate which drug between Rivastigmine and donepezil was more effective in treating Alzheimer’s disease. The findings revealed that donepezil was more effective because of the region of the brain that it targets. Donepezil caused increase blood flow to the anterior frontal lobe and parietal lobe while rivastigmine increased the flow to the hippocampal region and prefrontal cortex. The areas targeted by the donepezil drug are associated with vigilant attention and working memory. Hence, patients who use it performed better compared to those who use rivastigmine. The last option, Razadyne, was also a poor option because it is often used to treat mild to moderate Alzheimer’s and would be inefficient in treating Mr. Akkad’s severe Alzheimer’s. The goal of this treatment was to reduce the patient’s cognitive decline. The outcome of the donezepil drug was not as expected. It did not improve the patient’s condition at all. The difference may have been caused by the dosage of 5mg daily. Seemingly, a higher dose may bring the expected results. Also, a different drug may also be necessary.
Decision 2
The options available at this point were to increase the Aricept drug to a dosage of 10mg per day to be taken orally. The second choice was to discontinue Aricept and begin galantamine drug extended release at a dose of 24mg orally daily. The last option was to discontinue Aricept and administer memantine extended release at 28mg orally daily. The best option is to increase the dosage of Aricept to 10mg orally to be taken at bedtime. This choice is suitable because it would give a chance for confirmation that donepezil is effective or completely ineffective on the patient. Cummings et al. (2015) report that during a clinical trial, an increased dose of donezepil, from 10mg and above, for moderate to severe Alzheimer’s portrayed an increased cognitive ability on the patients. The second and third option of discontinuing donezepil and starting galantamine extended release or memantine extended release was unfavorable because risk of withdrawal symptoms. Bond et al. (2012) explain that withdrawal of donezepil will often be accompanied by worsening of symptoms. The article adds that initial lack of benefits from the donezepil drug is common but the drug will later respond. The goal of this treatment was to improve the efficacy of donezepil thus improving the cognitive ability of the patient. The outcome was not as expected. The patient showed slight improvement but most of the cognitive issues were still prominent. The difference between the expectation and the outcome is that the drug donezepil is not appropriate for Mr. Akkad. Yan & Chen (2016) state that drug treatment of Alzheimer’s disease is often effective for only half of the patients. Therefore, it is probable that Mr. Akkad needed a different drug for treatment.
Decision 3
The options present were to continue with Aricept at the same 10mg dosage. The second choice was to increase the dosage of Aricept to 15mg for six weeks after which the dose will be increased to 20mg. The third alternative was to discontinue Aricept and begin Namenda drug at 5mg daily orally. The most suitable course of action was to discontinue Aricept and begin administering the new drug, Namenda at 5mg daily. This choice was appropriate because the Aricept drug proved to be ineffective in alleviating the patient’s condition. Increasing the dosage of the Aricept drug only showed very little effectiveness. The first choice was not appropriate because sticking to the same drug would most likely have no benefits to the patient. The second option was to increase the dosage which was also not a good alternative since the improvement shown will likely be very slight. The goal of the treatment is to improve the cognitive ability of the patient. According to the outcome, the patient showed improvement in his willingness to attend religious activities. However, his disinhibition was not guaranteed to change. This result was not as expected. Discontinuing Aricept was not a good choice due to withdrawal effect. Instead, adding Namenda as combined therapy was the best route.
Conclusion
The best drug regimen for Mr. Akkad was the combined therapy of Aricept and Namenda. In terms of ethical consideration, properly informing the patient and caregivers is crucial to the treatment plan. In this case, the eldest son was well involved which helped with the follow-up consultations. Aside from this, all the drugs administered were FDA approved.
References
Alzheimer’s Association. (2017). FDA-approved treatments for Alzheimer’s. Retrieved from https://www.alz.org/media/Documents/fda-approved-treatments-alzheimers-ts.pdf
Bond, M., Rogers, G., Peters, J., Anderson, R., Hoyle, M., Miners, A., Moxham, T., & Davis, S. (2012). The effectiveness and cost-effectiveness of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer’s disease (Review of Technology Appraisal No. 111): a systematic review and economic model. Health Technology Assessment, 16(1), 470-490.
Cummings, J., Isaacson, R., Schmitt, F., & Velting, D. (2015). A practical algorithm for managing Alzheimer’s disease: what, when, and why? Annals of Clinical and Translational Neurology, 2(3), 307-323.
Foster, S., Drago, V., Roosa, M., Campbell, W., Witt, C., & Heilman, K. (2016). Donepezil Versus Rivastigmine in Patients with Alzheimer’s disease: Attention and Working Memory. Journal of Alzheimer’s and Neurodegenerative Diseases, 22(2), 1-5.
Yang, K., & Chen, H. (2016). Probabilistic Cost-Effectiveness Analysis of Vaccination for Mild or Moderate Alzheimer’s Disease. Current Alzheimer’s Research, 13(7), 809-816.