Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.”

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.

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.

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 “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 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.

References

Hussien, R. M., & Shoukry, A. A. (2020). Rivastigmine patch (Exelon patch) compared to melatonin patch in prevention of postoperative delirium in the elderly. Ain-Shams Journal of Anesthesiology, 12(1), 1-7. https://asja.springeropen.com/articles/10.1186/s42077-020-00087-6

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic advances in drug safety, 9(3), 171-178. https://doi.org/10.1177%2F2042098617750555

Yoon, S. J., Choi, S. H., Na, H. R., Park, K. W., Kim, E. J., Han, H. J., … & Na, D. L. (2017). Effects on agitation with rivastigmine patch monotherapy and combination therapy with memantine in mild to moderate Alzheimer\’s disease: a multicenter 24?week prospective randomized open?label study (the Korean EXelon Patch and combination with mEmantine Comparative Trial study). Geriatrics & Gerontology International, 17(3), 494-499. https://doi.org/10.1111/ggi.12754

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

• Chapter 11, “Basic Principles of Neuropharmacology” (pp. 67–71)
• Chapter 12, “Physiology of the Peripheral Nervous System” (pp. 72–81)
• Chapter 12, “Muscarinic Agonists and Cholinesterase Inhibitors” (pp. 82–89)
• Chapter 14, “Muscarinic Antagonists” (pp. 90-98)
• Chapter 15, “Adrenergic Agonists” (pp. 99–107)
• Chapter 16, “Adrenergic Antagonists” (pp. 108–119)
• Chapter 17, “Indirect-Acting Antiadrenergic Agents” (pp. 120–124)
• Chapter 18, “Introduction to Central Nervous System Pharmacology” (pp. 125–126)
• Chapter 19, “Drugs for Parkinson Disease” (pp. 127–142)
• Chapter 20, “Drugs for Alzheimer Disease” (pp. 159–166)
• Chapter 21, “Drugs for Seizure Disorders” (pp. 150–170)
• Chapter 22, “Drugs for Muscle Spasm and Spasticity” (pp. 171–178)
• Chapter 59, “Drug Therapy of Rheumatoid Arthritis” (pp. 513–527)
• Chapter 60, “Drug Therapy of Gout” (pp. 528–536)
• Chapter 61, “Drugs Affecting Calcium Levels and Bone Mineralization” (pp. 537–556)

Expert Answer and Explanation

Decision Tree for Neurological and Musculoskeletal Disorders

Summary of the Case and Decision Made

The case study assigned was about Mr. Akkad is a 76-year-old Iranian male who brought a nurse’s office by his son because he exhibits strange behavior, which started two years ago. The patient’s family doctor ruled any organic basis for this behavior. Lab results, including CT-scan, show that the patient is healthy. The patient’s son mentions that the patient has lost interest in things he viewed as significant in his life. The patient is also forgetful.

Diagnosis tests presumed that the patient has major neurocognitive disorder due to Alzheimer’s disease. Therefore, it was recommended that he start taking 1.5mg rivastigmine orally BID and increase the dose to 3mg orally BID in two weeks. When he did show any positive result, the dose was increased to 4.5 mg orally BID for one month. After four weeks, the current dose was maintained because it showed positive results.

Justification of the Decisions Made 

Rivastigmine was prescribed to the patient because it is one of the drugs used to treat the effects of moderate and mild Parkinson’s disease and Alzheimer’s condition. According to Regenold et al. (2018), rivastigmine has been used for the treatment of dementia diseases because it has proved to be effective in improving thinking and memory of people who experience deterioration of mental health. Also, the drugs have been used because it can increase the patient’s functional activities.

The patient has had behavioral problems. Thus, it was used to improve the patient his strange behaviors. Khoury et al. (2018) report that the drug should be prescribed from 1.5 mg, and if the patient does not show positive improvement, it should be increased gradually. The drug has shown significant symptomatic effects when used by dementia patients (Kadohara et al., 2017). Thus, it was used so that it can improve the independence of the patient.

The Possible Results for the Decisions

When making the decisions for this case, I was hoping to achieve the following results. First, I was hoping that the medication would improve the thinking of the patient, and thus make him embark on the activities he previously deemed important, such as going for religious functions. It was hoped that the drug could improve the reasoning of the patient, and this would make it less amused when he encounteres elements, he deemed serious (Khoury et al., 2018). Also, it was hoped the patient’s behavior would change after he takes the prescribed medication.

Comparison Between the Results Expected and the Ones Achieved 

Exelon to 4.5 mg orally BID dose was prescribed because it was hoped that the medication could improve the mental condition of the patient. However, the actual results were different. The patient’s son returned to the hospital, complaining that the medication did not work after four weeks. As a result, the dosage was increased to 3 mg. The dosage was increased with the hope that the patient’s condition could improve. However, the patient still scored 18 out of 30 with key deficits in the recall, registration, calculation and attention, and orientation.

Also, his son complained that his father was still not interested in significant activities, such as religious functions. Therefore, the dose was increased to 4.5, and it was aimed that this drug would work this time. Weeks later, the patient’s son came back to the hospital complaining that the health of this father I still not better. However, he reports that the patient can now attend religious functions. Thus, I decided that the current medication should be maintained for four more weeks because it has proven to be somehow effective.

References

Kadohara, K., Sato, I., Doi, Y., Arai, M., Fujii, Y., Matsunaga, T., & Kawakami, K. (2017). Prescription patterns of medications for Alzheimer’s disease in Japan from 2010 to 2015: a descriptive pharmacy claims database study. Neurology and therapy, 6(1), 25-37. https://link.springer.com/article/10.1007/s40120-016-0057-1

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic advances in drug safety, 9(3), 171-178. https://journals.sagepub.com/doi/full/10.1177/2042098617750555

Regenold, W. T., Loreck, D. J., & Brandt, N. (2018). Prescribing Cholinesterase Inhibitors for Alzheimer Disease: Timing Matters. American family physician, 97(11), 700-700. Retrieved from https://www.semanticscholar.org/paper/Prescribing-Cholinesterase-Inhibitors-for-Alzheimer-Regenold-Loreck/d42dcbd248bf0595610e9963718617ddb3bee3c3

Alternative Expert Answer and Explanation

Elderly patients are prone to attack by different lifestyle diseases due to the decreasing ratio of cell formation against cell degeneration. Among some of the systems that are largely affected by the ageing process is the nervous system. Diseases such as Alzheimer’s condition and dementia result from the impaired functions of the neurons working in different organs of the body (Epperly, Dunay, & Boice, 2017). This essay analyses the case of Mr. Akkad, a patient diagnosed with MND following attack by Alzheimer’s disease.

Summary of the Case and the Decisions

Mr. Akkad is 76 y.o. Iranian male pt. who is presented to the facility following strange behavior observed by the son. Besides demonstrating strange thought and behavioral patterns, Mr. Akkad’s personality has been changing, where he lost interest in religious activities and also developed a large critical and ridicule spirit.

He is also overly forgetful, and he scores 18 out of a possible 30 in the mental state exam, suggesting moderate dementia. Further diagnosis suggests that he suffers from Major Neuro-cognitive Disorder (MND), and he is taken through three therapy decision point. In the first decision point, he is given Exelon 1.5mg orally bid, with titration to 3mg orally bid in 14 days.

Four weeks later, the client returns and says the condition is not any much better. The second decision point involves taking a higher dosage of the same drug 6mg orally bid, and the symptoms improve with the introduction of significant side effects. Lastly, the patient dosage is decreased to 3mg oral bid, and the physician advises that consistency in the drug would help to achieve the desired outcomes.

Justification of the Decisions

Each of the three decisions made in the case of Mr. Akkad are evidence-based, as Exelon (also called Rivastigmine) is widely used to treat dementia as well as other symptoms of Parkinson’s and Alzheimer’s diseases (Hussien & Shoukry, 2020). The failure to select a different dosage or drug is also justified by evidence as some of the other suggested medications such as anti-inflammatory drugs could lead to significant interactions that could make the condition of the patient to worsen (Haake et al., 2020). An increase in the dosage of Exelon is also justified by evidence as it had significant increase in the drug/body weight balance.

What I hoped to Achieve

The first aim of giving Mr. Akkad the dosage was to reduce the evident symptoms of the disease. Specifically, I hoped to increase the mental health score from 18 to around 25, through the restoration of the neurotransmitters that could help aid in the process of memory control (Yoon et al., 2017). Decision two of increasing the dosage was meant to increase the effects of the drug, and decision three was to reduce the side effects that the patient experienced.

Difference between what I Expected and the Outcomes

While the mental score increased significantly following the decisions, it was unclear about the timeline that would be necessary in eliminating all the symptoms of the disease completely. Specifically, the results were not evident after four weeks of administration of the drug, but an increase in the dosage resulted to the side effects of vomiting and diarrhea (Khoury et al., 2018). Eventually, the patient’s health improved as expected using the initial dosage used.

Ethical Considerations

One of the ethical consideration that should be accounted for in the healthcare of ageing patients is confidentiality. While most of the patients with the characteristics such as those of Mr. Akkad may not follow up on whether their data was kept confidential, it is the responsibility of the healthcare giver to protect the information from all other sources that should not access it. Another ethical consideration is autonomy, where the freedom of the patient (in this case either Mr. Akkad or his son) should be respected.

Conclusion

The management of neurological disorders among ageing patients should be based on evidence-based practice, where only the best medicines and dosages are used to treat the patients. Exelon is one of the suitable drugs for this condition, and it should be administered on small dosages consistently as the results may not be evident within short periods, yet higher dosages show significant side effects. Care givers should also include confidentiality and autonomy as part of their key ethical considerations.

References

Epperly, T. D., Dunay, M. A., & Boice, J. L. (2017). Alzheimer disease: pharmacologic and nonpharmacologic therapies for cognitive and functional symptoms. American family physician, 95(12), 771-778. https://www.aafp.org/afp/2017/0615/p771.html

Haake, A., Nguyen, K., Friedman, L., Chakkamparambil, B., & Grossberg, G. T. (2020). An update on the utility and safety of cholinesterase inhibitors for the treatment of Alzheimer’s disease. Expert Opinion on Drug Safety, 19(2), 147-157. https://doi.org/10.1080/14740338.2020.1721456

Hussien, R. M., & Shoukry, A. A. (2020). Rivastigmine patch (Exelon patch) compared to melatonin patch in prevention of postoperative delirium in the elderly. Ain-Shams Journal of Anesthesiology, 12(1), 1-7. https://asja.springeropen.com/articles/10.1186/s42077-020-00087-6

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic advances in drug safety, 9(3), 171-178. https://doi.org/10.1177%2F2042098617750555

Yoon, S. J., Choi, S. H., Na, H. R., Park, K. W., Kim, E. J., Han, H. J., … & Na, D. L. (2017). Effects on agitation with rivastigmine patch monotherapy and combination therapy with memantine in mild to moderate Alzheimer\’s disease: a multicenter 24? Week prospective randomized open? Label study (the Korean EXelon Patch and combination with mEmantine Comparative Trial study). Geriatrics & Gerontology International, 17(3), 494-499. https://doi.org/10.1111/ggi.12754

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