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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.

Case Scenario: 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 “musement” 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 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 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.
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 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.

To Prepare

· Review the interactive media piece assigned by your Instructor.
· Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
· Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
· You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

Instructions

Write a 1- to 2-page summary paper that addresses the following:
· Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
· Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
· What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
· Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

Exelon (Rivastigmine)

Decision Point one : Exelon (Rivastigmine)

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

Increase Exelon to 6 mg orally BID

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. you 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, you could maintain the current dose until the next visit in 4 weeks, or you 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 you 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.

Aricept (Donepezil)

Decision Point One: Aricept (Donepezil)

: 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

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 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 you 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.
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.

Learning Resources

Required Readings (click to expand/reduce)

Required Media (click to expand/reduce)

Laureate Education (Producer).
(2019b). Alzheimer’s
disease [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you
will engage in a set of decisions for prescribing and recommending
pharmacotherapeutics to treat Alzheimer’s disease.

Laureate Education (Producer).
(2019e). Complex regional
pain disorder [Interactive media file]. Baltimore, MD: Author.

In this interactive media piece, you
will engage in a set of decisions for prescribing and recommending
pharmacotherapeutics to treat complex regional pain disorders.

Disorders of The Nervous
System
Reflect on
the comprehensive review of disorders of the nervous system and think about how
you might recommend or prescribe pharmacotherapeutics to treat these disorders.
(15m)

Rubric Detail

Select Grid View or List View to change the rubric’s layout.
Name: NURS_6521_Week8_Assignment_Rubric

· Grid View
· List View

Excellent
Good
Fair
Poor
Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific.
18 (18%) – 20 (20%)
The response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented.
16 (16%) – 17 (17%)
The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.
14 (14%) – 15 (15%)
The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented.
0 (0%) – 13 (13%)
The response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing.
Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
23 (23%) – 25 (25%)
The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature.
The response includes specific and relevant outside reference examples that fully support the explanation provided.
20 (20%) – 22 (22%)
The response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature.
The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.
18 (18%) – 19 (19%)
The response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature.
The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.
0 (0%) – 17 (17%)
The response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing.
The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
18 (18%) – 20 (20%)
The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned.
The response includes specific and relevant outside reference examples that fully support the explanation provided.
16 (16%) – 17 (17%)
The response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned.
The response includes relevant outside reference examples that lend support for the explanation provided that are accurate.
14 (14%) – 15 (15%)
The response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned.
The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided.
0 (0%) – 13 (13%)
The response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing.
The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.
The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise.
16 (16%) – 17 (17%)
The response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.
The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise.
14 (14%) – 15 (15%)
The response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise.
The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise.
0 (0%) – 13 (13%)
vaguely explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise, or is missing.
The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance.
5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity.
4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time.
3.5 (3.5%) – 3.5 (3.5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time.
0 (0%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation
5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors
4 (4%) – 4 (4%)
Contains a few (1–2) grammar, spelling, and punctuation errors
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3–4) grammar, spelling, and punctuation errors
0 (0%) – 3 (3%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list.
5 (5%) – 5 (5%)
Uses correct APA format with no errors
4 (4%) – 4 (4%)
Contains a few (1–2) APA format errors
3.5 (3.5%) – 3.5 (3.5%)
Contains several (3–4) APA format errors
0 (0%) – 3 (3%)
Contains many (≥ 5) APA format errors
Total Points: 100

 

 

 

 

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