Assessing and Treating Clients with Alzheimer Disease
Alzheimer’s disease is a neurodegenerative condition that is characterized by cognitive and behavioral impairment, which considerably affects social and occupational running. It is an irreversible, gradually worsening disease that affects the brain’s memory and thinking abilities. A person with Alzheimer’s will slowly start becoming forgetful until it is significantly noticeable among their family and friends. Later in the development of this disease, they will also begin to change in personality and require increasing assistance in completing simple everyday tasks. AD is a complex disease, and it is improbable that any treatment approach or intervention can successfully treat it. Approaches are currently focused on helping patients to maintain mental functions, manage behavioral symptoms, and reduce the associated symptoms. Alzheimer’s disease has been associated with around 70% of all dementia cases in the world (Alzheimer Association, 2015). The most common first signs of AD include the loss of memory in the short term e.g., forgetting appointments, frequently misplacing objects, or asking repetitive questions. The patient’s comprehension and vocabulary become impoverished. Other cognitive deficits seem to involve several functions, such as language dysfunction exhibited by difficulty thinking of common words and errors in writing or speaking (Morris et al., 2014). Impaired reasoning is often witnessed, characterized by difficulty in handling tasks and poor judgment. Other signs and symptoms are seen from the visuospatial dysfunction, which is the inability to recognize common objects and faces. Spatial disorientation results in difficulty of circumnavigating objects. A large majority of Alzheimer patients show behavioral concerns during the course of the disease (Alzheimer Association, 2015). Depression, apathy, lack of or sleep disturbance may be seen at an early stage. Psychotic symptoms, physical and verbal aggression, psychomotor agitation, and inappropriate sexual conduct appears during the later stages of dementia. In the progressive stages of Alzheimer’s, some patients tend to develop motor signs like urinary inconsistencies, myoclonus, gait disturbance, and tremor (Morris et al., 2014). Additionally, a seizure can also be witnessed in patients with AD.
This case study examines the examination and treatment of an elderly Iranian man displaying strange behaviors. According to his son, Mr. Akkad has lost interest in some of the things that he used to enjoy. At the same time, the client forgets things frequently. In the last two years, the client has continued to show a decline in behavioral and cognitive functioning. Progressive reports show that Mr. Akkad continuously portrays strange behaviors and thoughts, which have significantly affected his personality to the level that he does not show any interest in religious family engagements and criticizes those around him. Mr. Akkad has also shown a dramatic change in attitude, particularly on things that he used to take seriously, which he tends to ridicule. Mr. Akkad’s son states that his father’s memory loss is progressively getting worse and experiences difficulty remembering certain things. In most cases, he sometimes fails to make up the right words in a conversation and tends to deviate from the main discussion to a totally unrelated topic. The results of the memory test indicate grey confabulations after the client is subjected to PMHNP performance testing. This is a type of mini-mental state examination. One major area of concern is that the client scored 18 out of 30 in the mini-mental state examination. Major deficiencies were shown on calculation, orientation, attention, and registration. It can be concluded that the client had moderate dementia.
Decision Point 1
Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.
I have chosen this treatment approach because Exelon is considered as an effective and powerful drug that can treat issues associated with the normal functioning of the brain in aspects such as thought process, memory, and language. Exelon can help improve the normal functioning of the brain’s nerve cells (Fife, 2016). It is one of the first-line agents in the treatment of Alzheimer’s disease and also one of the most effective. Aricept and Razadyne are second-line agents for Alzheimer’s disease treatment; therefore, it would be wise not to use them ahead of Exelon at the beginning of the therapy. It, therefore, becomes the best option, to begin with.
Exelon is a very effective drug within the first two weeks of treatment. In four weeks, the client returns to the clinic, and his son reports a lack of improvement from the medication. Mr. Akkad is still showing a lack of interest in religious services, which used to interest him and continues to show disinhibited behaviors. Confabulation can still be noted, and I administered the MMSE once again, and the score was the same (18 out of 30).
There is a big difference between the actual results and the results I expected. The client still experienced the same symptoms and had no improvement from the medication. The MMSE was administered, and the score was 18 out of 30. The results are short of my expectations because I thought the client would show some little improvement.
Decision Point 2
Increase Exelon to 4.5 mg orally BID
From the first line of treatment, it is clear that the patient does not respond to the treatment and does not show any signs of improvement. Increasing the Exelon to 4.5 mg orally BID would help determine if the initial dosage was insufficient and could fasten the recovery process. It helped restore the balance of neurotransmitters in the brain and seems to improve the awareness, memory, and ability to take part in the daily activities (Fife, 2016).
By the end of 4 weeks, I expect the client to report a reduction in the symptoms, start attending religious services, and starts showing interest in some activities or events that he used to enjoy. His thought process and personality should show some improvement as well. When the client reported to the clinic, his son reports that he is tolerating the medication well. This is per my expectation. However, he is still concerned that Mr. Akkad has not had much improvement. He also reports that he has started joining the family for religious services, and the rest of the family are very happy. However, he is still amused by some of the things that he used to treat seriously. I am not worried about the results because I believe the patient is heading in the right direction, and therapy is starting to show effect.
Decision Point 3
Increase Exelon to 6 mg orally BID
From the second line of treatment, it is evident that the patient started responding to the medication because he can now attend religious family service but still amused by some things he used to treat seriously. Increasing Exelon to 6 mg orally BID will speed the recovery process and improve cognition, mood, and ability to engage in daily activities.
It is expected that an increase in dose will be effective and alleviate the generalized symptoms of Alzheimer’s. No side effects are expected because the dose is appropriate. The patient should be able to overcome the condition within some time. However, I would advise the client’s to be patient with him because the trajectory of treating Alzheimer’s is that the disease is irreversible and can take a significantly long time to control (Anderson, Murphy & Troyer, 2012).
The clinician needs to educate the patient and family about the available medical treatments that Mr. Akkad can be subjected to and the reason for choosing Exelon as well as its associated side effects. They should also be informed about the importance of taking the medications regularly and a sufficient dosage for the patients. The client’s son should also be counseled regarding the trajectory of presumptive Alzheimer’s disease, considering the fact that it is an irreversible disease, and even though cholinesterase inhibitors can stabilize the associated symptoms, the process can take several months.
Exelon is one of the cholinesterase inhibitor drugs that can temporarily stabilize and reduce the cognitive decline in patients suffering from Alzheimer’s disease. In the treatment of the disease, it is important to consider the first line of treatment before considering the possibility of using the second line.
Alzheimer’s Association. (2015). 2015 Alzheimer’s disease facts and figures. Alzheimer’s & dementia: the journal of the Alzheimer’s Association, 11(3), 332.
Anderson, N. D., Murphy, K. J., & Troyer, A. K. (2012). Living With Mild Cognitive Impairment: A Guide to Maximizing Brain Health and Reducing Risk of Dementia. Oxford: Oxford University Press.
Fife, B. (2016). Stop Alzheimer’s Now: How to Prevent and Reverse Dementia, Parkinson’s, ALS, Multiple Sclerosis, and Other Neurodegenerative Disorders. Colorado Springs, CO: Piccadilly Books, US.
Morris, J. C., Storandt, M., Miller, J. P., McKeel, D. W., Price, J. L., Rubin, E. H., & Berg, L. (2014). Mild cognitive impairment represents early-stage Alzheimer’s disease. Archives of neurology, 58(3), 397-405.
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