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Assignment: Decision Tree for Neurological and Musculoskeletal Disorders: Alzheimer Disease
76-year-old Iranian Male
ASSIGNMENT:
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.

CASE STUDY
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 a 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 “amusement” 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 difficulty “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 a 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 toward 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)

Decision Tree for Neurological and Musculoskeletal Disorder
Decision point 1
Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks

RESULTS OF DECISION POINT ONE
The client returns to the 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 2
Increase Exelon to 4.2 mg orally BID
RESULTS OF DECISION POINT TWO
The client returns to the clinic in four weeks.
The 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 3
Increase Exelon to 6mg 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.

Please include a title page, introduction, summary, and references.

Pharmacology

Student’s Name

Institutional Affiliations

Pharmacology

People aged 65 years and above are at increased risk of developing Alzheimer’s disease. Evidence-based research supports the effectiveness of both pharmacological and non-pharmacological interventions in treating patients with Alzheimer’s disease. It is important to consider patient factors such as gender and age when selecting treatment options for patients with neurological disorders (Bailey-Taylor et al., 2022). The purpose of this paper is to describe the most appropriate pharmacological treatment options for Mr. Akkad, a 76-year-old Iranian male who has been diagnosed with a major neurocognitive disorder due to Alzheimer’s disease (presumptive).

Case Summary

The case study describes a 76-year-old Iranian male patient called Mr. Akkad. As reported by the son, Mr. Akkad has strange thoughts and behaviors that have lasted for two years. The reason for visiting the clinic today is that his father’s symptoms are worsening. He presents with multiple symptoms including diminished interest in religious activities with family members, lack of seriousness, personality changes, poor memory, and conversation difficulties. Assessment with the Mini-Mental State Examination (MMSE) tool has revealed a score of 18 out of 30. His primary diagnosis is a major neurocognitive disorder due to Alzheimer’s disease (presumptive).

Decision Point 1

The selected decision: Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.

Reason for selection: Evidence-based literature supports the effectiveness of Exelon (rivastigmine) in improving symptoms of Alzheimer’s disease. According to Lee et al. (2019), rivastigmine is among the current pharmacological management strategies for Alzheimer’s disease. It is recommended that old patients be started on low doses of rivastigmine with a gradual increment.

Expected results: The expected result is that Mr. Akkad’s symptoms will improve after using the recommended dose of rivastigmine BID for four weeks. Precisely, his thoughts and behavioral symptoms, including diminished interest in religious activities with family members, lack of seriousness, personality changes, poor memory, and conversation difficulties should disappear (National Institute on Aging, 2021). Additionally, his MMSE score should drop to a value below 18.

Difference between what was expected and what was achieved: 1.5 mg of Exelon has not improved Mr. Akkad’s symptoms as expected. After 4 weeks of medication use, the patient still has psychological deficits, strange thoughts and behaviors, and his MMSE score is still 18/30.

Decision Point 2

The selected decision: Increase Exelon to 4.5 mg orally BID.

Reason for selection: Prescribing a higher dose of medication increases the drug’s efficacy. Published evidence supports the decision of increasing the Exelon dose from 3 mg to 4.5 mg administered orally BID (Yeh et al., 2021). Yeh et al. (2021) recommend titration to a higher dose than the previous one instead of drug discontinuation or switching.

Expected results: Like in decision one, it is expected that Mr. Akkad’s thoughts and behavioral symptoms, including diminished interest in religious activities with family members, lack of seriousness, personality changes, poor memory, and conversation challenges should disappear (National Institute on Aging, 2021). Additionally, his MMSE score should drop to a value below 18.

Difference between what was expected and what was achieved: Some of the outcomes match the clinician’s expectations while others do not. This indicates that there is a partial improvement in Mr. Akkad’s symptoms.

Decision Point 3

The selected decision: Increase Exelon to 6mg orally BID.

Reason for selection: Considering a higher dose of the drug is the best option as it increases the drug’s efficacy. This decision is supported by evidence-based literature (Yeh et al., 2021).

Expected results: Raising the drug dose from 4.5 mg to 6 mg BID should eliminate Alzheimer’s symptoms and generate an MMSE score lower than 18.

Difference between what was expected and what was achieved: The observed outcomes resemble the expected results. After 4 weeks of drug use, Mr. Akkad reports a significant improvement in his symptoms.

References

Bailey-Taylor, M. J., Poupore, N., Theriot Roley, L., Goodwin, R. L., Mcphail, B., & Nathaniel, T. I. (2022). Gender differences in demographic and pharmacological factors in patients diagnosed with late-onset of Alzheimer’s disease. Brain Sciences, 12(2), 160. https://doi.org/10.3390/brainsci12020160.

Lee, G., Cummings, J., Decourt, B., Leverenz, J. B., & Sabbagh, M. N. (2019). Clinical drug development for dementia with Lewy bodies: past and present. Expert Opinion on Investigational Drugs, 28(11), 951–965. https://doi.org/10.1080/13543784.2019.1681398.

National Institute on Aging. (2021). Treatment of Alzheimer’s disease. https://www.nia.nih.gov/health/how-alzheimers-disease-treated

Yeh, Y. C., Cappelleri, J. C., Marston, X. L., & Shelbaya, A. (2021). Effects of dose titration on adherence and treatment duration of pregabalin among patients with neuropathic pain: A MarketScan database study. PLoS ONE 16(1): e0242467. https://doi.org/10.1371/journal.pone.0242467.