Dementia Assessment and Treatment

Alzheimer’s Disease and Cognitive Impairment

Alzheimer’s disease diminishes an individual’s capacity to perform routine daily activities (Budson & Solomon, 2015). Individuals may acquire moderate cognitive impairment, which may evolve to increased memory loss and cognitive disorder. This report examines the condition and treatment of an old Iranian man who was taken to the hospital by his son for evaluation. The individual suffers from cognitive impairments, with symptoms resembling Alzheimer’s disease.

Treatment with Anti-Dementia Medications

After diagnosing the patient with a serious neurocognitive problem caused by Alzheimer’s disease, the PMHNP should start the patient on anti-dementia medications (Stahl, 2013). In this scenario, I would recommend Aricept (Donepezil) 5 mg orally, preferably before bedtime. While Aricept does not cure dementia, it will help to minimize the symptoms of dementia, especially those that affect the patient’s memory and thinking. Aricept will increase the number of neurotransmitters in the brain to boost memory as well as thought (Stahl, 2014). Taking a tablet of Aricept does not immediately guarantee the required therapeutic effect as it has a gradual process. Therefore, the patient may need to take for four weeks and return for a review.

Additional Medications

PMHNP should also put the patient on Exelon 1.5mg, BID (twice a day) that should be taken orally (Budson & Solomon, 2015). After that, he should shift the patient on a maintenance dose of 3 mg within two weeks that would be taken orally. Exelon is a brand of Rivastigmine hydrogen tartrate, which is indicated for the treatment of moderate dementia that results from Alzheimer’s disease. Since the patient has moderate dementia, it is wise, to begin with, a small dosage and shift to 3mg as a maintenance dosage. The drug helps in patients that have developed this condition at least two years earlier just like the patient in this case. Additionally, the PMHNP should prescribe Razadyne (Galantamine) 4 mg to be taken orally twice a day (BID). Razadyne is often indicated for treating moderate dementia resulting from Alzheimer just as in this case. The patient will be required to come back for review after four weeks.

Second Decision for Improvement

After the patient returns for review and the son complains that the father has not improved then PMHNP will require making a second decision to improve the quality of life of the patient. The initial decision might not have worked because of the low dosage administered because one has to start on a low dosage (Bui, 2012). Besides, drugs such as Aricept have a gradual process, therefore, one might not obtain the desired results immediately.

Decision Point 2

In the first review, the PMHNP should not only maintain Aricept but also increase the dosage to 10 mg to be taken orally at bedtime (Sihna & Chakrabarti, 2012). Aricept has a common adverse effect such as nausea and diarrhea. In the first decision, the PMHNP gave a lower dosage to allow the patient to easily tolerate this drug before increasing to an initial maintenance dosage of 10mg daily. While shifting this dosage may cause the patient to experience diarrhea and nausea more frequently. However, this effects should stop after a few days. After two weeks, discontinue Aricept and increase the dosage of Razadyne to 24mg to be consumed daily (Stahl, 2014). The increased dosage of Razadyne increases reduces cholinergic loss and improves the cholinergic function thus minimizing cognitive impairment. The drug achieves this therapeutic effect by partially inhibiting hydrolysis. The patient will also be put on Namenda (Memantine) extended release 28 mg OD. Namenda is a NMDA receptor antagonist hence useful in the treatment of severe dementia. Since the patient did not improve on dosage for moderate dementia, it is possible that the condition had progressed and become critical. Therefore, it is wise to recommend Namenda (Scherder, 2011). The patient will be required to return for the second review to see how he is tolerating the drugs plus any signs of improvement.

Decision Point 3

At this point, the man came for a review; the son reported that there are signs of improvement given that he has lately developed an interest to attend religious activities, something he initially did not do. The improvement is a plus since the medication takes several months before the patient stabilizes. It is, therefore, necessary that the PMHNP continues the patient with the oral administration of Aricept 10mg OD at bedtime (Solomon, Soiniinen, & Kivipelto, 2013). The patient will be checked on the improvement of disinhibition, and there is no guarantee of stabilization especially if the patient’s condition had progressed to critical levels; in the case of slow or minimal improvement, I would recommend counseling on the patient

Combination Therapy and Ethical Considerations

Aricept has severe side effects when taken in amounts exceeding 10mg OD; given that there exist no documented evidence relating improvement in dementia patients when subjected to 15mg OD (Stahl, 2013), I find it unnecessary to subject the patients to the high doses. The amounts will lead to diarrhea, nausea, insomnia and other severe side effects. These adverse side effects will be countered by the combination of Aricept and Namenda. From the patient’s review, there exist no clinical manifestation that the patient is reacting negatively to Aricept (Aging, 2017). Guided by these observations, there is no necessity to discontinue Aricept. It is, however, proven that the cholinesterase inhibitors, when combined with NMDA receptor antagonists, offers an ideal therapy in patients with Alzheimer’s disease; the therapy offer treatment with reduced side effects as the two drugs is slow release to amounts that are tolerated by the body yet useful in the treatment. These facts informed a decision to combine the Aricept and Namenda (Stahl, 2013). The results of this decision led to improved cognitive ability.

Conclusion

Ethical practices were fully applied in the diagnosis and treatment of this case. The son explained the condition of the father in an enabling environment systematically. There was no coercion and every decision made was communicated to the family. Finally, the treatment and the condition of the patient remained confidential.

References

Aging, N. I. (2017, April 12). Alzheimer’s Disease. Retrieved from Medline Plus: https://medlineplus.gov/

Budson, A. E., & Solomon, P. R. (2015). Memory Loss, Alzheimer’s Disease, and Dementia: A Practical Guide for Clinicians. Elsevier Health Sciences.

Bui, Q. (2012, April 2). Antidepressants for agitation and psychosis in patients with dementia. Retrieved from American Family Physian: http://www.aafp.org/journals/afp.html

Scherder, E. . (2011). Aging and Dementia: Neuropsychology, Motor Skills, and Pain. VU Uitgeverij.

Sihna, M., & Chakrabarti, S. (2012). Brain Aging and Therapeutic Interventions. Springer Science & Business Media.

Solomon, A., Soiniinen, H., & Kivipelto, M. (2013). Alzheimer’s Disease: Advances for a New Century. IOS Press.

Stahl, S. M. (2013). Essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York: Cambridge University Press.

Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York: Cambridge University Press.