Assessing and Treating Clients With Dementia Assignment

Assessing and Treating Clients With Dementia Assignment

The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life” (Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia.Assessing and Treating Clients With Dementia Assignment.

Reference: Alzheimer's Association. (2016). What is dementia? Retrieved from http://www.alz.org/what-is-dementia.asp

 

 

ASSIGNMENT- Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease –WK1063N

Laureate Education. (2016h). Case study: An elderly Iranian man with Alzheimer’s disease [Interactive media file]. Baltimore, MD: Author.

 

Note: This case study will serve as the foundation for this week’s Assignment.

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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:

Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes

    • 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.Assessing and Treating Clients With Dementia Assignment. 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.

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.Assessing and Treating Clients With Dementia Assignment.

  // Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

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.”Assessing and Treating Clients With Dementia Assignment

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 here”- 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.Assessing and Treating Clients With Dementia Assignment. Mr. Akkad denies suicidal or homicidal ideation.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

 

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

 

  // Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

Assessing and Treating Clients With Dementia Assignment

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)Assessing and Treating Clients With Dementia Assignment. 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.Assessing and Treating Clients With Dementia Assignment

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.

  // Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

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

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Increase Exelon to 6 mg orally BID

Assessing and Treating Clients With Dementia Assignment

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.Assessing and Treating Clients With Dementia Assignment

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.

  // Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

Decision Point One

 

: 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

Assessing and Treating Clients With Dementia Assignment

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.Assessing and Treating Clients With Dementia Assignment

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.Assessing and Treating Clients With Dementia Assignment