Seventy Six Year Old With Alzheimers Disease

Alzheimers Disease
76-year-old Iranian Male
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. Akkads 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 clients son, the family noticed that Mr. Akkads 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 . 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 todays 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. Akkads 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 Alzheimers disease (presumptive)
Decision Point One
Select what you should do: Begin Aricept (donepezil) 5mg 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 10mg orally at BEDTIME
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Clients 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 10mg 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 Alzheimers 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.
To Prepare
Review the interactive media piece assigned by your Instructor.
Reflect on the patients 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 as well as patient factors that might impact the patients diagnosis and treatment.
By Day 7 of Week 8
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.