Dementia is a degenerative and devastating disease that majorly affects the elderly (Collins, 2018). The disease has an overlapping pathogenetic mechanism and clinical manifestation. The disease accounts for 70% of all forms of dementia in the elderly (James & Jackman, 2017).
The client
76 years old man from Iran was brought by his son with complaints of strange behaviour. From the past medical history from a family physician, the client prognosis rules out the organic basis of his behaviour. The diagnostic test from the CT and the laboratory were normal. The past medical history, as reported by his son, indicates that the client exhibited strange behaviours and thoughts over the past two years. On physical examination, Akkad is cooperative and pleasant. In Mini-Mental State Exam, the client scored 18 out of 30. The only deficits noticed were recall, orientation, attention, registration, and calculation. As per my findings, it suggested moderate dementia. As per MSE, the client's eye contact was poor but with coherent and clear speech. The other exams revealed no tic and unusual movements. The diagnosis revealed major neurocognitive disorder secondary to Alzheimer’s disease.
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Plan of care and medication
Informing the son on the side effects of the drugs of choice (Donepezil, Galantamine, and Rivastigmine).
Selecting and administering (Donepezil, Galantamine, and Rivastigmine).
The alternative medical decision on other available drugs.
Decision One: Informing the son on Side Effects of the AD drugs
Before initiation of treatment, I had to inform the son on the side effects of the drugs I was to administer. I chose this decision due to the side effects associated with the medication used to relieve the symptoms of Alzheimer’s. I relayed the concerns to the son due to mental incapacitation experienced by Akkad due to the degenerative effect of the condition. In the mental health assessment results, it is evident that the client has a cognitive impairment and may not notice the side effects of the acetylcholinesterase inhibitor drugs. Before the prescription of the acetylcholinesterase inhibitors to relieve the symptoms of Alzheimer's disease (AD), it is imperative to notify the son of Akkad on the side effects of the medication. In the decision, I notified the son to monitor the major side effects associated with the use of the drugs and include weight loss, loss of appetite, nausea, neurotoxicity, and vomiting. In the decision also, I informed the son to check for less common adverse effects of the drug regiments and which included confusion, myalgia, weight loss, constipation, urinary incontinence, and insomnia. Assessing and monitoring of side effects of drugs is an important aspect to achieve therapeutic effectiveness desired.
What I was hoping to achieve by this decision
The prime role of informing the son of Akkad on the side effects of the five drug regiments used to manage Alzheimer’s disease was to help identify early the side effects and plan for prompt interventions. With early identification of the side effects, there will be higher chances of achieving therapeutic outcomes of the treatment. I also chose to inform the son, to increase reliance and good perception about the drug by the son and other neighbours of Akkad. To conform to the legal obligations of informing the patient on the side effects of the planned prescription, I chose this decision. I also chose this decision to increase the rate of recovery and the odds of survival of Akkad.
Difference between what I expected to achieve with the decision and the results of the decision.
Results from follow up assessment on the effectiveness of medication of the disease revealed that Akkad experienced the classical symptoms of adverse effects of acetylcholinesterase inhibitor drugs. From my decision, I expected that the son would have monitored and reported the side effects of the medication, but on the contrary, he never reported. The contrary expectation might be due to reduced social relationships between Akkad and his son and which made assessment and monitoring to be technically difficult.
Decision two: Selection of effective drugs to treat Alzheimer’s disease and the route of administration
Mode of administration
Oral administration of donepezil (OD) (5mg)/6weeks
Administration of 1.5 mg of Rivastigmine twice per day for 4 weeks
Galantamine 4 mg – administered orally for 4 weeks
Why I chose the decision.
Selected Drugs (Galantamine, donepezil, and Rivastigmine)
I chose these drugs due to high effectiveness in managing all forms of AD. I also chose the three drugs since the FDA approves all of them. I chose donepezil due to its high efficacy in the management of stages of AD.
During the administration of Galantamine, it is important to consider the patients with underlying chronic liver disease (Hubbard, Mamo & Hopper, 2018). Galantamine is metabolized in the hepatocytes through P450 isoenzymes 2D6 and 3A4, and therefore there is the likelihood to interact with other drugs like cimetidine and theophylline. Even though Akkad never had chronic liver disease, it is important always to carry out a baseline test to rule out the condition.
Donepezil should not be used with other drugs like paroxetine due to drug interaction (Zucchella et al., 2018). The donepezil drug is extensively metabolized by cytochrome P450 isoenzymes 2D6 and 3A4 in the liver. The two drugs share the same metabolic route and enzymes and which reduce the efficacy.
What I was hoping to achieve by making this decision
In the selection of the drugs, the prime target was to achieve a full mental and cognitive return of functions of Akkad. I wanted to eliminate the cognitive and neurological impairments the client was experiencing. I was also expecting to achieve improved memory function, restored normal behaviours, and restoration of normal pleasures. I also intended to restore clarity and coherence in the speech of Akkad.
Explain any difference between what you expected to achieve in the decision and the results
Even though I initiated the therapeutic regiments, there were minimal changes in cognitive, neurological, and behavioural changes in the client. On a return visit, the son indicated that Akkad had begun to show interest in his activities even though he had not fully returned to his former self. The only changes that the drugs brought in the process included muscle cramps, increased bowel movements, nausea, and vomiting. The new changes experienced by the client is due to the side effects of the drugs and which are common.
Decision 3: Alternative medical decisions on other available drugs
Drug; Memantine
Dosage; 10mg
Why I selected this decision
Since the memory, reasoning, and attention had not improved from the prior prescription, I chose this drug to restore these functions. I choose this decision to allow Akkad and his son to choose another treatment regimen available in our institution freely. The following decisions offered narrow spaces to make any decision on the best regimen to initiate. I selected the decision due to side effects and minimal effects noticed from the treatment offered.
What were you hoping to achieve by making the decision?
for the decision, I intended to restore the attention, memory, and reasoning. In the decision I chose, I was expecting that there are minimal side effects of the new alternative. Also, I was expecting to see an overall improvement in the mental functions and cognitive abilities of the client. In short, I wanted Akkad to be fully recovered and return to his normal operations.
Explain any difference between what you expected to achieve and the results.
Even though the client did not fully recover, attention and memory improved. The client also experienced dizziness, headache, confusion, and constipation and which I concluded as side effects. Since pharmacological treatment lasts longer, Akkad might slowly recover as evidenced by other recoveries.
Ethical considerations that might affect treatment.
Consent
The ability of the client to agree to treatment regimens is bound by ethics (Smith et al., 2018). Patients must consent first before any treatment is initiated. For Akkad, his medical condition prevented him from consenting, and his son had to take the task. Treatment choices rely on one’s preference and the willingness to consent to treatment plans.
References
Collins, M. E. (2018). Occupational therapists' experience with assistive technology in the provision of service to clients with Alzheimer's disease and related dementias. Physical & Occupational Therapy In Geriatrics , 36 (2-3), 179-188.
Hubbard, H. I., Mamo, S. K., & Hopper, T. (2018, July). Dementia and hearing loss: interrelationships and treatment considerations. In Seminars in speech and language (Vol. 39, No. 03, pp. 197-210). Thieme Medical Publishers.
James, I. A., & Jackman, L. (2017). Understanding behavior in dementia that challenges: a guide to assessment and treatment . Jessica Kingsley Publishers.
Smith, G. E., & Farias, S. T. E. (2018). APA handbook of dementia . American Psychological Association.
Zucchella, C., Sinforiani, E., Tamburin, S., Federico, A., Mantovani, E., Bernini, S., ... & Bartolo, M. (2018). The multidisciplinary approach to Alzheimer's disease and dementia. A narrative review of non-pharmacological treatment. Frontiers in neurology , 9 , 1058.
