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PLEASE FOLLOW THE INSTRUCTIONS AS INDICATED BELOW:
ZERO (0) PLAGIARISM
5 REFERENCES NO LESS 5 YEARS
PLEASE SEE ATTACHED RUBRIC DETAILS.
For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. 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.
Write a 1- to 2-page summary paper that addresses the following:
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.
Decision Point One
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
Decision Point One
: Begin Aricept (donepezil) 5 mg orally at BEDTIME
RESULTS OF DECISION POINT ONE
Decision Point One
Begin Razadyne (galantamine) 4 mg orally BID
RESULTS OF DECISION POINT ONE
Decision Point Two
Decision Point Two
Increase Razadyne to 24 mg extended release daily
RESULTS OF DECISION POINT TWO
Decision Point Two
Discontinue Razadyne and begin Aricept (donepezil) 10 mg orally daily
RESULTS OF DECISION POINT TWO
Decision Point Two
Discontinue Razadyne and begin Exelon (rivastigmine) 1.5 mg orally BID
RESULTS OF DECISION POINT TWO
Decision Point Three
Decision Point Three
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.
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