Assignment: Assessing and Treating Clients with Dementia

Assignment Assessing and Treating Clients with Dementia

Dementia is a debilitating mental condition that affects individuals of advanced age. A severe mental decline that subsequently affects the daily functioning of an individual accompanies the condition. The condition’s symptomatology include executive function impairment, agnoxia, apraxia, aphasia and amnesia. Whereas dementia occurs as a complex form of several mental conditions, Alzheimer’s disease has the most occurrence frequency among them. Korytkowska and Obler (2016) label Alzheimer’s as a neurodegenerative mental condition that occurs progressively. Consequently, a patient’s reasoning ability, memory, communication, learning capacity, and judgment skills as well as daily functioning become impaired due to the condition. Further, while Alzheimer’s does not have a cure, several medications can manage its symptoms.

In the present case study, a Mr. Akkad, a 76-year old male of Iranian descent was brought to the clinic by his son with the chief complaint being “strange behavior”. According to the son, the strange behaviors began two years ago and have since worsened. The subjective data obtained from his family indicated loss of interest in erstwhile important activities such as religious gatherings, absence of seriousness, forgetfulness, ineffective communication, and lack of commitment to a topic during conversations (Laureate Education, 2016h). The mini-mental examination revealed that MR. Akkad scored 18/30 with attendant deficit in recall, registration, calculation, attention and orientation. As such, Mr. Akkad has developed “major neurocognitive disorder due to Alzheimer’s disease (presumptive)” (Laureate Education, 2016h). Thus, the present paper will develop a personalized therapy for Mr. Akkad, examine factors that affect pharmacokinetic and pharmacodynamics processes in such clients, and evaluate the efficacy of the prescribed pharmacotherapy. Further, the formulation of therapies for clients suffering from dementia requires ethical and legal considerations.

Decision Point One

Selected Decision

Given the available options, the first decision will entail starting the client on 5mg Aricept (donepezil) PO before they go to bed (Laureate Education, 2016h).

Reasons for the Selection

Aricept, also referred to as donepezil, received approval by the Food and Drugs Administration for purposes of managing cognitive decline symptoms including memory loss, inability to reason and cogitate appropriately, and confusion as characterized by Alzheimer’s condition. The drug acts by inhibiting the breakdown of a fundamental second messenger in memory and learning known as acetylcholine (Howard et al., 2015). The inhibition of the breakdown of acetylcholine in the brain leads to the elevation of its levels, allowing it to positively modulate the cognitive symptoms related to Alzheimer’s. Further, the metabolism of the chemical compounds of the drug occurs via two variants of the CYP450 isoenzyme, CYP450 2D6 and CYP450 3A4, which exist in Iranians (Morowatisharifabad et al., 2017). As a consequence, Behrens et al. (2018) report that the elimination half-life of the drug in the people with this enzyme is 70 hours, which makes it effective for the management of Alzheimer’s symptoms. Moreover, Aricept produces self-limiting and moderate adverse effects such as increased frequency of bowel movement, vomiting, anorexia, and nausea. Owing to its extended duration of action and its fast onset of action, Aricept is preferred for the present scenario. Further, the patient experiences memory loss, which makes Aricept perfect as its administration occurs less frequently.

The other two options including administering 1.5mg Exelon (rivastigmine) PO twice daily for two weeks and 4mg Razadyne (galantamine) PO twice daily were not better for Mr. Akkad given his symptoms. While they share the same psychotropic drugs’ classification with Aricept, they possess more severe side effects such as tremors, severe abdominal pain, seizures, diarrhea, and urination trouble (Guzior, Wieckowska, Panek, & Malawska, 2015). Moreover, people of Iranian origins are fast metabolizers of the drugs, making them have a shorter mechanism of action. As a result, they need to be taken twice daily, which makes them less ideal for patients suffering from memory loss such as Mr. Akkad.

Expected Results

According to Behrens et al. (2018), the patient should demonstrate improvements in baseline behavior or memory within 4-to-6 weeks of the administration of Aricept. Further, his cognitive symptoms, interest in activities, communication and conversation competence are expected to improve. The MMSE score should also improve by the aforementioned period.

Differences between Expected Results and Actual Results

After four weeks, the subjective data obtained from Mr. Akkad’s eldest son showed that the symptoms had not improved. The son implied that the drug did not produce any therapeutic effect and that his father still did not attend religious activities and showed little interest in other activities as well. The report was confirmed by a new MMSE score, which remained at 18/30 (Laureate Education, 2016h). The results were not expected but could be attributable to the 5 mg dosage of the drug, which is below the Mr. Akkad’s therapeutic index.

Decision Point Two

Based on the assessment offered above, the second decision will entail increasing the dosage of the 5 mg of Aricept to 10mg PO at bedtime (Laureate Education, 2016h).

Reason for the Selection

The 5 mg dose revealed no response from the patient accompanied by the absence of any side effects. As a result, the response implied that the dose did not reach the therapeutic index. Thus, the dose should be increased to the optimum therapeutic index for it to produce its effects on the patient (Mittapelly et al., 2017). Also, non-compliance was not showed by the patient, making it unnecessary to change the medication to either Namenda (memantine) ER 28 mg PO or Razadyne (galantamine) ER 24 mg PO. In fact, changing the medication from Aricept will only serve to confuse the patient and make him lose trust in the therapy should the absence of therapeutic effects persist (Stahl, 2014b). The new drug might also produce adverse effects on the patient, which may lead to worsening of his condition. Therefore, out of the given option, continuing the Aricept therapy at a higher dose in order to produce the desired therapeutic effects forms the most appropriate decision by the provider.

Expected Results

Mr. Akkad’s son, or whoever will accompany him, should report their father’s improved Alzheimer’s symptomatology the next time they visit the clinic. By the eighth week of the pharmacotherapy, the patient should have regained interest in religious activities, the capacity to exhaustively discuss conversational topics, as well as the capacity to hold effective communication. Lastly, the provider expects the patient’s MMSE scores to improve as a consequence of the 10 mg Aricept dosage.

Differences between the Expected Results and Actual Ones

When Mr. Akkad came back to the clinic accompanied by his son after eight weeks, the provider observed that his moods had

improved. The son reported that the patient had tolerated the medication, with gradual reduction of Alzheimer’s symptoms without side-effects. He had started attending church services, which made his family members proud. Nevertheless, the son reported that their father still found certain things that he previously took serious amusing (Laureate Education, 2016h). While the results had improved, they were below the expectations of the provider.

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Decision Point Three

Selected Decision

The last decision will be to continue the same 10mg dose of Aricept PO at bedtime (Laureate Education, 2016h).

Reason for the Selection

The results that the patient posted upon visiting the clinic were demonstrative of the therapeutic effect of the drug at the 10 mg dose. Further, the patient did not react adversely to the drug, which implies that he was tolerant. Whereas reasons exist to consider increasing the dosage to 23 mg, guidelines recommend that the option can only be used if the patient has been under Aricept for three months yet we are only in week 8 of the pharmacotherapy (Howard et al., 2015). Thus, it is important for the patient to continue taking Aricept at 10 mg since the objective is to manage Alzheimer’s symptoms since resolving them entirely is impossible. In addition, altering Aricept dosage to 15 mg PO taken at bedtime for a period of six weeks, and then further increasing it to 20 mg afterwards is not appropriate since it may lead to side effects. The same applies to the option to discontinue Aricept and replace it with Namenda mg PO daily.

Schutz et al. (2019) postulate that studies conducted previously have shown that Aricept may take months for its effects in managing Alzheimer’s patients’ conditions stabilize. As such, it would be inappropriate to discontinue the drug. Nevertheless, adding Namenda to the regimen may work since research has shown NMDA receptor antagonists as having the capacity to modulate neurotransmitters alongside cholinesterase inhibitors in Alzheimer’s cases to enhance symptoms while minimizing adverse effects.

Expected Results

The provider expected the maintained dose of Aricept to improve the cognitive symptoms of Mr. Akkad’s Alzheimer’s. The provider further expects Mr. Akkad’s interest in daily activities to improve to the optimum level within 4-6 weeks of continuous use of Aricept 10 mg. His memory and concentration are similarly anticipated to improve within the same time span. Lastly, the MMSE score should also improve on the one registered when he visited the clinic for evaluation by week 8.

Differences between Expected Results and Actual Results

By the end of the 12^th week, the patient is expected to hold improved conversations as well as actively participate in religious activities. However, the cognitive symptoms are only expected to partially improve and not resolve fully. The above pharmacotherapy option is consistent with guidelines regarding the management of Alzheimer’s in old patients such as Mr. Akkad.

Ethical Considerations

The management of Alzheimer’s is a complex process given the available array of psychotropic therapies for it alongside the expectations of the family members. As such, the provider needs to incorporate a patient’s family in every decision-making phase during the pharmacotherapy. In addition, the provider should inform the patient’ family of the fact that the cognitive symptoms of the condition cannot be fully resolved irrespective of the adopted therapy (Korytkowska & Obler, 2016). Further, the provider needs to explain to the patient’ family the influence of his genetic makeup on the available drugs and why they should prefer Aricept over the others. By doing this, the provider will have addressed all the legal and ethical requirements as regards the formulation of therapy for such patients.

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.

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

Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for clients with dementia
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for dementia
Evaluate efficacy of treatment plans
Analyze ethical and legal implications related to prescribing therapy for clients with dementia
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.

Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

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

To access the following chapter, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 13, “Dementia and Its Treatment”
Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.

Review the following medications:

For insomnia

donepezil
galantamine
memantine
rivastigmine

Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia. American Family Physician, 85(1), 20–22. Retrieved from http://www.aafp.org/journals/afp.html

Note: Retrieved from from the Walden Library databases.

Meltzer, H. Y., Mills, R., Revell, S., Williams, H., Johnson, A., Bahr, D., & Friedman, J. H. (2010). Pimavanserin, a serotonin receptor inverse agonist for the treatment of Parkinson\’s disease psychosis. Neuropsychopharmacology, 35, 881–891. Retrieved from http://www.nature.com/npp/journal/v35/n4/pdf/npp2009176a.pdf

Required Media
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.

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:

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?

Decision #2

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.

Lopes Write Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.

Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.

Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?

Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.

Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.

If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.

I do not accept assignments that are two or more weeks late unless we have worked out an extension.

As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.

Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

Important information for writing discussion questions and participation

Welcome to class

Hello class and welcome to the class and I will be your instructor for this course. This is a -week course and requires a lot of time commitment, organization, and a high level of dedication. Please use the class syllabus to guide you through all the assignments required for the course. I have also attached the classroom policies to this announcement to know your expectations for this course. Please review this document carefully and ask me any questions if you do. You could email me at any time or send me a message via the “message” icon in halo if you need to contact me. I check my email regularly, so you should get a response within 24 hours. If you have not heard from me within 24 hours and need to contact me urgently, please send a follow up text to

I strongly encourage that you do not wait until the very last minute to complete your assignments. Your assignments in weeks 4 and 5 require early planning as you would need to present a teaching plan and interview a community health provider. I advise you look at the requirements for these assignments at the beginning of the course and plan accordingly. I have posted the YouTube link that explains all the class assignments in detail. It is required that you watch this 32-minute video as the assignments from week 3 through 5 require that you follow the instructions to the letter to succeed. Failure to complete these assignments according to instructions might lead to a zero. After watching the video, please schedule a one-on-one with me to discuss your topic for your project by the second week of class. Use this link to schedule a 15-minute session. Please, call me at the time of your appointment on my number. Please note that I will NOT call you.

Please, be advised I do NOT accept any assignments by email. If you are having technical issues with uploading an assignment, contact the technical department and inform me of the issue. If you have any issues that would prevent you from getting your assignments to me by the deadline, please inform me to request a possible extension. Note that working fulltime or overtime is no excuse for late assignments. There is a 5%-point deduction for every day your assignment is late. This only applies to approved extensions. Late assignments will not be accepted.

If you think you would be needing accommodations due to any reasons, please contact the appropriate department to request accommodations.

Plagiarism is highly prohibited. Please ensure you are citing your sources correctly using APA 7th edition. All assignments including discussion posts should be formatted in APA with the appropriate spacing, font, margin, and indents. Any papers not well formatted would be returned back to you, hence, I advise you review APA formatting style. I have attached a sample paper in APA format and will also post sample discussion responses in subsequent announcements.

Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

Your response needs to be a minimum of 150 words (not including your list of references)
There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
Include in-text citations in your response
Do not include quotes—instead summarize and paraphrase the information
Follow APA-7th edition
Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

A minimum of 6 responses per week, on at least 3 days of the week.
Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
Each response needs to be at least 75 words in length (does not include your list of references)
Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
Follow APA 7th edition
Points will be deducted if the above is not followed
Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
Here are some helpful links
Student paper example
Citing Sources
The Writing Center is a great resource