As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.

· 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.

Write a  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.

You will analyze the decisions you will make in the decision tree exercise and reflect on your experiences in proposing the recommended actions to address the health needs in the patient case study.

 

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Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

Decision Point One

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

Select what you should do next:

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

Select what you should do next:

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.

Start Over

Maintain current dose of Exelon

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.

Start Over

Add Namenda (memantine) 5 mg orally per day

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 need 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.
Start Over

Increase Exelon to 6 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client is accompanied today by his son who reports that he had to stop giving his father the medication because he “stopped eating” and had developed vomiting and diarrhea. He states that his father’s behaviors are unchanged

Decision Point Three

Select what you should do next:

Discontinue Exelon and begin Namenda (memantine)

Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.
There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.
It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.
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.

Start Over

Decrease Exelon to 3 mg orally BID

Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.
There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.
It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.
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.

Start Over

Augment with an appetite stimulant

Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.
There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.
It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.
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.

Start Over

Discontinue Exelon and begin Namenda (memantine) 10 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client is accompanied today by his son who reports that his father is unchanged, but now his father is constantly complaining of feeling “dizzy” and he has noticed that his father is having problems with constipation

Decision Point Three

Select what you should do next:

Decrease Namenda to 5 mg orally daily

Guidance to Student
The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. You should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.
The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.
The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.
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.

Start Over

Discontinue Namenda and restart Exelon

Guidance to Student
The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. You should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.
The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.
The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.
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.
Start Over

Continue Namenda 10 mg orally BID

Guidance to Student
The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. You should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.
The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.
The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.
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.

Start Over

 

//

Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

Decision Point One

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

Select what you should do next:

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

Select what you should do next:

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.

Start Over

Maintain current dose of Exelon

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.

Start Over

Add Namenda (memantine) 5 mg orally per day

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 need 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.
Start Over

Increase Exelon to 6 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client is accompanied today by his son who reports that he had to stop giving his father the medication because he “stopped eating” and had developed vomiting and diarrhea. He states that his father’s behaviors are unchanged

Decision Point Three

Select what you should do next:

Discontinue Exelon and begin Namenda (memantine)

Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.
There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.
It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.
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.

Start Over

Decrease Exelon to 3 mg orally BID

Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.
There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.
It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.
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.

Start Over

Augment with an appetite stimulant

Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.
There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.
It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.
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.

Start Over

Discontinue Exelon and begin Namenda (memantine) 10 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client is accompanied today by his son who reports that his father is unchanged, but now his father is constantly complaining of feeling “dizzy” and he has noticed that his father is having problems with constipation

Decision Point Three

Select what you should do next:

Decrease Namenda to 5 mg orally daily

Guidance to Student
The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. You should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.
The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.
The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.
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.

Start Over

Discontinue Namenda and restart Exelon

Guidance to Student
The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. You should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.
The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.
The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.
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.
Start Over

Continue Namenda 10 mg orally BID

Guidance to Student
The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. You should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.
The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.
The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.
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.

Start Over

 

//

Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

Decision Point One

: 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

Select what you should do next:

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

Select what you should do next:

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.

Start Over

Increase Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 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.

Start Over

Discontinue Aricept and begin Namenda 5 mg orally daily

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.
Start Over

Discontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• The client’s son accompanies the client to his appointment today. The client is in a wheelchair and is somewhat agitated.
• You are informed by the son that his father has not taken his medication since he got out of the hospital. Apparently, about 7 days after starting the Galantamine extended release, the client began having seizures which resulted in a fall and fractured hip. The son reports that his father is agitated with everyone and is asking for help in treating his agitation

Decision Point Three

Select what you should do next:

Restart Razadyne extended release 24 mg

Guidance to Student
Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.
Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).
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.

Start Over

Begin Risperdal (risperidone) 0.5 mg orally BID to treat agitation

Guidance to Student
Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.
Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).
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.

Start Over

Assess for pain

Guidance to Student
Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.
Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).
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.

Start Over

Discontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• Client is accompanied today by his son who reports that his father is unchanged, but now his father is constantly complaining of feeling “dizzy” and he has noticed that his father is having problems with constipation

Decision Point Three

Select what you should do next:

Decrease Namenda extended release to 14 mg orally daily and reassess at next office visit

Guidance to Student
The side effects of dizziness and constipation can be common in those who are started on Namenda. The side effects are often transient and dose dependent. You should decrease the current dose to 14 mg daily and reassess at the next office visit. If the client is tolerating the medication at that point, then the dose may be increased to 21 mg orally daily.
Miralax can be added, but you should attempt to avoid adding medications to treat side effects, especially in older adults, as this can lead to a vicious cycle of polypharmacy—especially if a slower uptitration of this drug could alleviate the constipation. In addition to decreasing the dose, you should counsel the client and his son in strategies to increase fluid in the diet (unless there are other contraindications) as well as how to increase fiber in the diet to help combat constipation.
The presence of side effects that may be dose dependent is not a sufficient reason to discontinue Namenda and begin Razadyne. However, if there were a therapeutic reason to do so, Razadyne immediate release should be dosed twice/day and should be initiated at 4 mg orally BID. To do otherwise may increase the risk of side effects that can be avoided in an older adult through the use of a more cautious titration schedule.
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.

Start Over

Add Miralax (polyethylene glycol) to current medication regimen

Guidance to Student
The side effects of dizziness and constipation can be common in those who are started on Namenda. The side effects are often transient and dose dependent. You should decrease the current dose to 14 mg daily and reassess at the next office visit. If the client is tolerating the medication at that point, then the dose may be increased to 21 mg orally daily.
Miralax can be added, but you should attempt to avoid adding medications to treat side effects, especially in older adults, as this can lead to a vicious cycle of polypharmacy—especially if a slower uptitration of this drug could alleviate the constipation. In addition to decreasing the dose, you should counsel the client and his son in strategies to increase fluid in the diet (unless there are other contraindications) as well as how to increase fiber in the diet to help combat constipation.
The presence of side effects that may be dose dependent is not a sufficient reason to discontinue Namenda and begin Razadyne. However, if there were a therapeutic reason to do so, Razadyne immediate release should be dosed twice/day and should be initiated at 4 mg orally BID. To do otherwise may increase the risk of side effects that can be avoided in an older adult through the use of a more cautious titration schedule.
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.
Start Over

Discontinue Namenda and start Razadyne (galantamine) 12 mg ORALLY at BEDTIME

Guidance to Student
The side effects of dizziness and constipation can be common in those who are started on Namenda. The side effects are often transient and dose dependent. You should decrease the current dose to 14 mg daily and reassess at the next office visit. If the client is tolerating the medication at that point, then the dose may be increased to 21 mg orally daily.
Miralax can be added, but you should attempt to avoid adding medications to treat side effects, especially in older adults, as this can lead to a vicious cycle of polypharmacy—especially if a slower uptitration of this drug could alleviate the constipation. In addition to decreasing the dose, you should counsel the client and his son in strategies to increase fluid in the diet (unless there are other contraindications) as well as how to increase fiber in the diet to help combat constipation.
The presence of side effects that may be dose dependent is not a sufficient reason to discontinue Namenda and begin Razadyne. However, if there were a therapeutic reason to do so, Razadyne immediate release should be dosed twice/day and should be initiated at 4 mg orally BID. To do otherwise may increase the risk of side effects that can be avoided in an older adult through the use of a more cautious titration schedule.
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.
Start Over

 

//

Alzheimer’s Disease

Alzheimer’s Disease
76-year-old Iranian Male

 

Decision Point One

Begin Razadyne (galantamine) 4 mg orally BID

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

Select what you should do next:

Increase Razadyne to 24 mg extended release daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• The client’s son accompanies the client to his appointment today. The client is in a wheelchair and is somewhat agitated
• You are informed by the son that his father has not taken his medication since he got out of the hospital. Apparently, about 7 days after starting the Galantamine extended release, the client began having seizures which resulted in a fall and fractured hip. The son reports that his father is agitated with everyone and is asking for help in treating his agitation

Decision Point Three

Select what you should do next:

Restart Razadyne extended release 24 mg

Guidance to Student
Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.
Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).
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.

Start Over

Begin Risperdal (risperidone) 0.5 mg orally BID to treat agitation

Guidance to Student
Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.
Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).
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.

Start Over

Assess for pain

Guidance to Student
Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If you were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, you should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.
Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).
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.

Start Over

Discontinue Razadyne and begin Aricept (donepezil) 10 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
• The client is accompanied by his son for today’s appointment who informs you that he stopped giving his father the mew medication because after just a few doses, his father began experiencing appetite loss, followed by nausea, diarrhea, and vomiting

Decision Point Three

Select what you should do next:

Restart Aricept at 5 mg orally daily at BEDTIME

Guidance to Student
The client is experiencing usual side effects associated with Aricept. The issue may be that the medication was started at too high of a dose. Many times, especially in older adults, side effects are dose dependent. Aricept is generally started at 5 mg orally daily at bedtime for the first 4–6 weeks, at which point it can be increased to 10 mg orally at bedtime. The fact that the client had such a significant group of side effects at 10 mg indicates that the drug should not be restarted at 10 mg orally at bedtime, as the client would most likely experience these side effects again. Restarting the drug at the appropriate starting dose, while also educating the client and his son about the potential side effects of Aricept, would be appropriate.
The side effect profile that the client is experiencing is most likely dose dependent. Discontinuation of Aricept and initiation of Razadyne can certainly be done, especially with a therapeutic dose of Razadyne such as the one suggested here. However, you should educate the client and his son as to the fact that the side effects experienced may have been dose dependent and transient.
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.

Start Over

Discontinue Aricept and restart Razadyne at 4 mg orally BID

Guidance to Student
The client is experiencing usual side effects associated with Aricept. The issue may be that the medication was started at too high of a dose. Many times, especially in older adults, side effects are dose dependent. Aricept is generally started at 5 mg orally daily at bedtime for the first 4–6 weeks, at which point it can be increased to 10 mg orally at bedtime. The fact that the client had such a significant group of side effects at 10 mg indicates that the drug should not be restarted at 10 mg orally at bedtime, as the client would most likely experience these side effects again. Restarting the drug at the appropriate starting dose, while also educating the client and his son about the potential side effects of Aricept, would be appropriate.
The side effect profile that the client is experiencing is most likely dose dependent. Discontinuation of Aricept and initiation of Razadyne can certainly be done, especially with a therapeutic dose of Razadyne such as the one suggested here. However, you should educate the client and his son as to the fact that the side effects experienced may have been dose dependent and transient.
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.

Start Over

Restart Aricept at 10 mg orally at BEDTIME and educate client and son about side effects of Aricept

Guidance to Student
The client is experiencing usual side effects associated with Aricept. The issue may be that the medication was started at too high of a dose. Many times, especially in older adults, side effects are dose dependent. Aricept is generally started at 5 mg orally daily at bedtime for the first 4–6 weeks, at which point it can be increased to 10 mg orally at bedtime. The fact that the client had such a significant group of side effects at 10 mg indicates that the drug should not be restarted at 10 mg orally at bedtime, as the client would most likely experience these side effects again. Restarting the drug at the appropriate starting dose, while also educating the client and his son about the potential side effects of Aricept, would be appropriate.
The side effect profile that the client is experiencing is most likely dose dependent. Discontinuation of Aricept and initiation of Razadyne can certainly be done, especially with a therapeutic dose of Razadyne such as the one suggested here. However, you should educate the client and his son as to the fact that the side effects experienced may have been dose dependent and transient.
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.

Start Over

Discontinue Razadyne and begin Exelon (rivastigmine) 1.5 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 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

Select what you should do next:

Increase Exelon to 3 mg orally BID

Guidance to Student
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.
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.

Start Over

Continue current dose of Exelon and reevaluate at next office visit

Guidance to Student
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.
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.
Start Over

Augment with Namenda 10 mg orally at BEDTIME

Guidance to Student
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.
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.

Start Over