Pharmacological Intervention for Major Neurocognitive Disorder Due to Alzheimer’s Disease

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 a 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.”

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 difficulty “finding the right words” in a conversation and then will shift to an entirely different line of conversation.

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SUBJECTIVE

During the clinical interview, Mr. Akkad is pleasant and cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so you perform 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. Pharmacological Intervention for Major Neurocognitive Disorder Due to Alzheimer’s Disease

MENTAL STATUS EXAM

Mr. Akkad is a 76-year-old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear and coherent but tangential at times. He makes no unusual motor movements and demonstrates no tic. The self-reported mood is euthymic. Affect, however, is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes were 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 toward the door. When you asked where he was going, he stated that he did not know. 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.

You will focus on neurological and musculoskeletal diseases.   Please make sure to include dosing and side effects in your assignment.

This week you will be assigned an interactive media piece that will help construct your assignment.

Please access the link for the week 8 decision tree.
http://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_10/index.html

There is a decision tree at the bottom to select from that says Decision Point 1.   Please select Razadyne 4 mg PO BID  You will then be taken through subsequent assessments based on your initial selection.

RESULTS OF DECISION POINT ONE

•  The client returns to the 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

Discontinue Razadyne and begin with Exelon (rivastigmine) 1.5 mg Orally BID

RESULTS OF DECISION POINT TWO

•  The client returns to the clinic in four weeks
•  The 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 still not interested in attending religious services with the family, and he is still concerned that his father is still easily amused by things he once found serious

Decision Point Three

Continue the current dose of Exelon and reevaluate on the next office visit.

(above choice should be adjusted already instead of maintaining the dose, Please make a suggestion based on the guidelines below, I am considering adding Namenda on the course once the therapeutic level of Exelon is achieved without side effects.)

Cholinesterase inhibitors can take months to demonstrate any stabilization in the degenerative course of Alzheimer’s disease. Since the client has had no side effects, it would be prudent to consider increasing the Exelon dose to 3 mg orally BID. Recall that the target dose of Exelon is 12 mg orally daily in divided doses, or a transdermal patch delivering 9.5 mg daily could be used. Slow titration of the drug toward a therapeutic dose will decrease the risk of side effects. These should be teaching points directed toward the client and his son. Pharmacological Intervention for Major Neurocognitive Disorder Due to Alzheimer’s Disease

You could maintain the current dose of Exelon and reevaluate at the next office visit, but since the client is having no side effects and the client has been on the current dose for at least 4 weeks, it would probably be advisable to increase at this time to facilitate the goal of arriving at a therapeutic dose of the medication.

It may be early to augment with Namenda. Maximization of the Exelon dose should first occur, then augmentation with an NMDA receptor antagonist would be appropriate, but Namenda should be started at 5 mg orally daily and then titrated up to a maximum dose of 10 mg orally BID. Doses over 5 mg orally daily should be divided into two doses, or the drug can be switch to an extended release preparation.

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.