NURS 6521: Assessing and Treating Clients with Anxiety Disorder

NURS 6521: Assessing and Treating Clients with Anxiety Disorder
Case Study: An Elderly Iranian Man with Alzheimer’s Disease Decision Tree Assignment

Case Study: An Elderly Iranian Man with Alzheimer’s Disease SAMPLE INTRO

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Most elderly people in the United States and across the world suffer from Alzheimer’s condition. According to several studies, Alzheimer’s as a neurodegenerative condition, which starts slowly and then degenerates over a sustained period. Epidemiological data regarding the condition reveals that this disease affects over 70 per cent of elderly people with dementia in the world. The most revealing symptomology of the condition involves the presence of memory lapse concerning latest events in a patient’s life. As the condition advances, additional symptoms including mood swings, behavioral issues, language difficulties, disorientation, and the absence of self-care management begin to manifest. Gradually, the body will lose all of its vital functions, a phenomenon that will eventually culminate into death. Houmani and his colleagues (2018) assert that the lifespan of the disease varies from one patient to another yet the expectancy does not exceed nine years post-diagnosis. More fundamentally, Alzheimer’s condition lacks a cure and the only available respite is to manage it so as to make certain that a patient enjoys an improved quality of life before their eventual demise.

In the present case study, an Iranian man whose son charges that he displays strange behaviors will be examined and pharmacologically treated by the present nurse practitioner. According to the patient interview, Mr. Akadi displayed a loss of interest in things that were initially dear to him. Moreover, the patient has become forgetful in the recent
Case Study An Elderly Iranian Man with Alzheimer’s Disease

Case Study An Elderly Iranian Man with Alzheimer’s Disease

past and confabulation was noticeable from his mental health testing procedure. Additional symptoms evident from the diagnostic process include impaired judgment and impulse as well as restricted affect. According to a mini-mental status examination that was conducted, the patient also suffers from a major neurocognitive disorder. The nurse suspected that the condition may have been caused by presumptive Alzheimer. Therefore, the present paper will seek to elucidate the assessment outcomes and create a pharmacological treatment therapy based on informed standard procedures. According to studies, while the condition is essentially untreatable, it can be managed pharmacologically. The pharmacological management is, however, influenced by factors such as dosage, proper selection of drugs, and time of use and administration route. Importantly, it is important for the nurse practitioner to monitor the responsiveness of a patient to drugs and their dosages and make fundamental adjustments after periodic assessment.
Decision Point One

Selected Decision

Decision point one presented the nurse practitioner with three important options. The first option was to start the patient on Razadyne (galantamien) 4 mg daily. The second option would see the nurse prescribe Aricept (donepezil) 5 mg orally during bedtime. Lastly, the nurse can also think of beginning begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks. Out of the three options, the nurse chose to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks for various pharmacokinetic and pharmacodynamics reasons…..CONTD
Assignment Instructions

Case Study: An Elderly Iranian Man with Alzheimer’s Disease 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 the PMHNP performs 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 the PMHNP 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)
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RESOURCES

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.

Decision Point One

Select what the PMHNP should do:

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks
Begin Aricept (donepezil) 5 mg orally at BEDTIME
Begin Razadyne (galantamine) 4 mg orally BID

Decision Point One

Begin Razadyne (galantamine) 4 mg orally BID

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

Increase Razadyne to 24 mg extended release daily

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks
 The client’s son accompanies the client to his appointment today. The client is in a wheelchair and is somewhat agitated
 You are informed by the son that his father has not taken his medication since he got out of the hospital. Apparently, about 7 days after starting the Galantamine extended release, the client began having seizures which resulted in a fall and fractured hip. The son reports that his father is agitated with everyone and is asking for help in treating his agitation

Decision Point Three

Restart Razadyne extended release 24 mg

Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If the PMHNP were to consider restarting Razadyne, it should be restarted at a proper starting dose, as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, the PMHNP should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

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.
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

 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

Increase Exelon to 4.5 mg orally BID

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks
 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 Three

Increase Exelon to 6 mg 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. The PMHNP 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, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP 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 the PMHNP 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.

Begin Aricept (donepezil) 5 mg 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

Increase Aricept to 10 mg orally at BEDTIME

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks
 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 Three

Continue Aricept 10 mg orally at BEDTIME

Guidance to Student

At this point, it would be prudent for the PMHNP 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 the PMHNP 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 Alzheimer’s 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.
The Assignment

Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

· At each decision point stop to complete the following:
o Decision #1

§  Which decision did you select?
§  Why did you select this decision? Support your response with evidence and references to the Learning Resources.
§  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
§  Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

o Decision #2

§  Why did you select this decision? Support your response with evidence and references to the Learning Resources.
§  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
§  Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

o Decision #3

§  Why did you select this decision? Support your response with evidence and references to the Learning Resources.
§  What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
§  Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

· Also include how ethical considerations might impact your treatment plan and communication with clients.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
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Case Study: An Elderly Iranian Man with Alzheimer’s Disease Decision Tree Assignment

Here is a general framework for what I am looking for on the decision tree assignments.

Provide an introduction to the disease state discussed in the case. I am looking for a high-level summary that briefly describes the key aspects of that disease state. I do not want several pages of information related to the diagnosis of the disease state.

Provide a high-level summary of the important pieces of information from the case-study that is presented. I do not want the entire case study presented. The goal is that you would be able to give your essay to someone that does not know anything about the assignment and for that individual to be able to understand the purpose of your essay. Again….focus on the important pieces of information that will help you make your decision.

You also want to mention the purpose of the assignment. This can be brief.

Decision Point 1, 2, and 3.

At each decision point, list the options that are presented and describe your rationale for choosing the option you chose.

I do not want general answers….”I chose sertraline because sertraline is an SSRI and SSRIs are approved for depression/anxiety”. I want VERY SPECIFIC reasons you chose the option you chose. These reasons must be backed by good evidence. Feel free to include studies comparing agents, side effects, dosing, patient considerations, therapeutic practice guidelines, comorbid conditions, etc…. You will also need to explain your rationale for not choosing the other two options. This is very important in your learning. Please remember that you will have MANY more medications to chose from than three in clinical practice. When you make your choice, you also need to describe your goals of treatment. What do you want to achieve by initiating the therapy you picked. Again….be specific. Defend your choices like you are in a courtroom.

After each decision, you will be presented with the outcome of that decision. You need to discuss how that outcome was what you expected or if it was different than what you expected and why.

You will do the above for all three decision points.

You need to use evidence to support your rationale. [Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. Credible reference material only will be accepted. Sites such as WebMD and drugs.com (among others) will not be counted.]

Don’t forget to include information related to the ethical considerations and how they might impact your treatment plan and communication with your clients.

In summary: What needs to be in your essay.

Introduction regarding disease state
High-level summary of patient case
Purpose of the essay statement

Decision 1

What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Decision 2

What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Decision 3

What options were listed
What option did you choose?
Why did you select that option?
Why didn’t you select the other two options?
What was your goal of treatment
Was the outcome what you expected? Why?

Conclusion with Ethical considerations

***Do not use the start over button and complete several different times. That is not the point. If you do use the START OVER button, I do not want your paper to reflect this. I have had students do it multiple times and address incorrect outcomes in their paper. I have also had students submit a paper that defends using all three options presented at decision point number one. You will need to click the option to move to the next screen which will provide you with the outcome and the options for the next decision point. You will receive a ZERO on the assignment if you do not follow the instructions correctly. I had a handful of students last semester complete the assignment incorrectly. Please ask questions if you do not understand.
An Elderly Iranian Man with Alzheimer’s Sample

Alzheimer’s condition is a neurodegenerative disease that begins slowly and worsens over a long period of time. The condition has been associated with almost 70% of all dementia cases in the world. The most prevalent early symptoms entail the absence of memory concerning recent events. As the condition progresses, other symptoms such as language difficulties, mood swings, disorientation, behavioral issues, lack of self-care management, and disorientation may occur (Houmani et al., 2018). In a gradual manner, all the bodily functions will be lost resulting in eventual death. As much as the disease’s life expectancy varies, the typical expectancy does not go beyond nine years after diagnosis. Importantly, the disease does not have a cure but it could be managed to ensure that the quality of life of patients suffering from it is improved.

The case study for the present assignment entails the examination and treatment of an elderly Iranian man who displays strange behaviors according to his son. Mr. Akan has lost interest in things that erstwhile interested him. Further, the client has been forgetting things and his subjective test revealed confabulation during mental health testing process. Mr. Akad also has restricted affect and impaired impulse and judgment. A mini-mental state examination reveals that Mr. Akad suffers from major neurocognitive disorder caused by presumptive Alzheimer’s disease. This paper describes the assessment outcomes and treatment options for an elderly Iranian man, who has been diagnosed with Alzheimer’s. The condition can be treated with pharmacological interventions, which are dependent on among other factors dosage, proper selection of drug, and time of use, and administration route.

Decision Point One

For this decision, there were three options listed. One was to begin Razadyne (galantamien) 4 mg daily. The second one was to begin Aricept (donepezil) 5 mg orally at bedtime. While the third one, which was the one that I selected was to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.

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