Alzheimer’s Disease Discussion

Posted: January 3rd, 2023

Alzheimer’s Disease Discussion

The client in this case study is a 76-year-old man who presented with the son. The son reported that the client exhibited strange behaviors and personality change. The MMSE score for the client was 18/30, with major deficits in attention, orientation, memory, calculation, and registration, indicating moderate dementia. The diagnosis for the client was neurocognitive disorder due to Alzheimer’s disease (presumptive). In this assignment, three decisions about the treatment choices will be made. The ethical considerations likely to impact the client’s treatment plan will be discussed.  Alzheimer’s Disease Discussion

ORDER A PLAGIARISM-FREE PAPER HERE

Decision Point One

The selected decision is for the client to begin Exelon (rivastigmine) 1.5 mg, with the recommended dose increment (3 mg orally BID in 2 weeks). Exelon was selected due to its efficacy in the treatment of neurocognitive disorders and Alzheimer’s Disease (Su et al, 2015). In neurocognitive disorders, the pathological changes occur within the cholinergic neuronal pathways and lead to cognitive deficits. Accordingly, since Exelon works by increasing the amount of acetylcholine in the brain, this improves the cholinergic function and consequently improves the cognitive symptoms (Kandiah et al, 2017). The decision to start Razadyne (galantamine) was not chosen because it is recommended for mild and moderate neurocognitive disorders, and not major neurocognitive disorder. The decision to start Aricept was not selected because the medication is associated with some major side effects such as bradycardia, gastrointestinal symptoms, and abnormal liver function (Zhang & Gordon, 2018).

Selection of Exelon for the client expected that the cognitive deficits and behavioral problems for this client would improve. This is due to the efficacy of Exelon in improving the cholinergic function and thus improving the cognitive deficits associated with neurocognitive disorders (Birks et al, 2015).

The client, however, did not manifest any improvement as anticipated. The son reported that there was no symptom improvement. Exelon works gradually and may take even months before symptom improvement (Khoury et al., 2018). This explains the lack of symptom improvement after four weeks. Alzheimer’s Disease Discussion

Decision Point Two

The second decision that was chosen is to have the dose increased to rivastigmine dosage to 4.5 mg. The rationale for deciding to increase the dose is because the efficacy of Exelon is dose-dependent where higher doses are associated with increased efficacy (Su et al, 2015). Therefore, it was expected that with the higher dose the client would manifest symptom improvement due to the increased efficacy. The decision to increase Exelon to 6 mg was not selected because the dose increase should be gradual to ensure the client can tolerate the prescribed dose before increasing (Birks et al, 2015). The decision to stop Exelon and start Namenda 10 mg orally was not selected because Namenda PO (capsules) is the appropriate form of treatment in major neurocognitive disorder and not Namenda oral prescription (Cummings et al., 2015).

By selecting the decision to increase Exelon dose, it was expected this would increase the medication’s efficacy and thus lead to symptom improvement. Higher doses of Exelon are associated with better efficacy and increased symptom improvement (Birks et al., 2016). Secondly, it is hoped that the client would tolerate the increased dose without major side effects.

With the increased Exelon dose, the client manifested symptom improvement as he started attending religious activities. The symptom improvement is attributable to the increased efficacy of Exelon with the increased dose (Birks et al., 2016). The client also tolerated the increased dose well as no side effects were reported.

Decision Point Three

The third decision was to increase Exelon to 6 mg orally BID. The reason for deciding to increase the dose is because a higher dose would increase the amount of acetylcholine in the brain leading to increased symptom improvement (Sadowsky et al., 2015). The decision to maintain the current dose of Exelon was not selected because a gradual increase of the dose is recommended to ensure gradual symptom improvement. The decision to add Namenda was not selected because it is recommended that augmenting agents should be added after maximizing the dose of a cholinesterase inhibitor like Exelon (McDermott & Gruenewald, 2019).

By selecting the decision to increase Exelon to 6 mg, the expectations are that the client will continue showing symptom improvement. This is because an increased dose of cholinesterase inhibitors has been shown to lead to increased symptom improvement (Su et al., 2015). It was also hoped the client would tolerate the increased dose and not report any side effects.

Ethical Considerations

Treatment of individuals with mental disorders that impair cognitive abilities is likely to be associated with various ethical challenges. Mental disorders like major neurocognitive disorder significantly impair cognitive abilities. Therefore, this brings ethical issues such as informed consent and capacity determination. Cognitive impairments deter the capability of an individual to understand the treatment options and also impairs an individual’s judgment. Therefore, the client may not be able to consent to the treatment or decide about his treatment because of impaired judgment and inability to understand information about available treatment choices (Fields & Calvert, 2015). Alzheimer’s Disease Discussion

Conclusion

The first decision that was selected is for the client to begin Exelon (rivastigmine) 1.5 mg orally. Exelon was selected due to its efficacy in improving the cholinergic function and thus improving the cognitive functions in people with neurocognitive disorders. However, with this decision, the client did not manifest any symptom improvement and thus the second dose was to increase Exelon dose of Exelon to 4.5 mg. With the increased dose, the client manifested symptom improvement as indicated by his participation in religious activities. The client tolerated the increased dose and thus the third dose was to increase the Exelon dose to 6 mg. It was expected that with the increased dose the client would continue manifesting symptom improvement and tolerate the increased dose. Mental disorders like major neurocognitive disorder significantly impair cognitive abilities and thus this may hinder the ability of the client to make his treatment decisions. Therefore, the ethical considerations relevant to the treatment of this client include informed consent and capacity determination.

References

Birks J, Chong L & Grimley J. (2015). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. 9(2).

Birks J, Chong L & Grimley J. (2016). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews. Cochrane Dementia and Cognitive Improvement Group.

Cummings, J. L., Isaacson, R. S., Schmitt, F. A., & Velting, D. M. (2015). A practical algorithm for managing Alzheimer’s disease: what, when, and why? Annals of clinical and translational neurology, 2(3), 307–323. https://doi.org/10.1002/acn3.166.

Fields L & Calvert J. (2015). Informed consent procedures with cognitively impaired patients: A review of ethics and best practices. Psychiatry and Clinical Neurosciences, 1(69), 462–471.

Kandiah N, Pai M, Looi I, Ampil E, Park K, Karanam A & Christopher S. (2017). Rivastigmine: the advantages of dual inhibition of acetylcholinesterase and butyrylcholinesterase and its role in subcortical vascular dementia and Parkinson’s disease dementia. Clin Interv Aging. 1(12), pp: 697–707.

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic advances in drug safety, 9(3), 171–178. https://doi.org/10.1177/2042098617750555.

McDermott, C. L., & Gruenewald, D. A. (2019). Pharmacologic Management of Agitation in Patients with Dementia. Current geriatrics reports, 8(1), 1–11. https://doi.org/10.1007/s13670-019-0269-1

Sadowsky C, Micca J, Grossberg G & Velting D. (2014). Rivastigmine From Capsules to Patch: Therapeutic Advances in the Management of Alzheimer’s Disease and Parkinson’s Disease Dementia. Prim Care Companion CNS Disord. 16(5).

Su J, Liu Y, Liu Y & Ren L. (2015). Long-term effectiveness of rivastigmine patch or capsule for mild-to-severe Alzheimer’s disease: a meta-analysis. Expert Rev Neurother, 15(9),1093–1103.

Zhang, N., & Gordon, M. L. (2018). Clinical efficacy and safety of donepezil in the treatment of Alzheimer’s disease in Chinese patients. Clinical interventions in aging, 13, 1963–1970. https://doi.org/10.2147/CIA.S159920.

Assignment_10_Background_Information

The_Assignment_Week_10

Alzheimer’s Disease Discussion