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.
:
Begin Aricept (donepezil) 5mg orally at BEDTIME) 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
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
Discontinue Aricept and begin Namenda 5 mg orally daily
Discontinue Aricept and begin Namenda 5 mg orally daily
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 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.
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.
Assignment
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.
Sample Essay
Mental Status Case Study
Dementia is a condition that affects the memory of an individual and causes other significant changes that affect relationships with other people. The treatment of dementia should be done early to prevent deterioration of the disorder. The condition of Mr. Akkad has been worsening for the last two years. The test results indicate that the patient has moderate dementia. The medications provided to him include and Namenda in varying dosages. The two drugs are used to treat moderate dementia but they have varying effectiveness since they work differently on the body.
The case study is of 76-year-old Iranian man by the name Mr. Akkad. He has been getting worse for the last two years when he started exhibiting strange behavior. His behavior started changing when he became disinterested in religious activities. He also became critical of everyone. He started forgetting things and missing the right words in a conversation. The mini-mental state exam shows he scored 18 out of 30 which indicates possible moderate dementia.
The first decision was to prescribe Aricept 5 mg dosage which is used to treat dementia. When the patient returns to the clinic after four weeks the son reports that the father has not improved. The second decision involved increasing the Aricept dosage to 10 mg. After four weeks the patient is still amused by things he found normal. However, he has started attending religious activities together with the family. The third decision involved to discontinue Aricept and begin Namenda 5 mg dosage. Namenda is used to treat moderate dementia. Aricept was discontinued since increasing the amount may have side-effects and that there is no clinical evidence that over 10 mg of Aricept is effective.
Evidence-based Literature
The decisions made about the patient were evidence-based and thus reliable. The first decision was to prescribe the patient with Aricept 5 mg which is a dosage used to treat dementia (Owen, 2016). The patient presented symptoms that indicated he had moderate dementia. The mental status exam which had 18 out of 30 scores indicates he had mild cognitive impairment. Therefore, the medication was evidence-based since the drug is prescribed for patients with moderate dementia (Manabe et al., 2019). The second decision was also evidence-based since adding the amount of the same drug was appropriate. The reason was that the Aricept dosage can be taken for long without any positive signs. However, after 8 weeks of taking the Aricept dosage the patient has shown positive signs of attending religious activities. This shows the medication was appropriate. Additionally, Aricept cannot be increased to 15 or 20 mg since no clinical evidence to show that any Aricept dosage above 10 mg has any effect (Manabe et al., 2019). Therefore, the decision was also evidence-based. Decision three involved a change of drug to Namenda which works in a different system compared to Aricept thus providing more benefits to the patient.
Desired Outcomes
The decisions involved recommending Aricept and Namenda in different dosages. The hope was to eliminate the symptoms expressed by the patient such as forgetting, missing words in a conversation and being critical. Aricept which was the first dosage works through the brain system for patients with mild dementia (Cooper et al., 2015). I hoped to see the patient expressing better results. However, after the first four weeks, it was evident that the patient may take a longer time. When I decided to increase the dosage the intention was to boost the strength of the daily dosage (Farooqui, Farooqui, Madan, Ong & Ong, 2018). I intended to see better outcomes such as a less critical patient who was fluent in conversation and had a sharp memory. When I changed the dosage to Namenda the desired outcome was to counter dementia using a different brain system (Burckhardt et al., 2016). The intention was to boost the memory of the patient which had hardly improved since the treatment began.
Differences in Expectation
In the first decision, I expected to see the patient with improved memory and attendance to religious activities. However, the results were different since the patient still had poor memory and did not attend religious activities. The second decision involved increasing the dosage of Aricept to 10 mg. The decision bore some fruits. For example, the patient started attending religious activities, but the memory was still poor. In the third decision, the approach was to change the drug to Namenda 10 mg daily dosage. The expectation was to see a patient with improved memory, however, the results since the improvement took a longer time.
Conclusion
Dementia is one of the conditions that can ruin the memory of a person. The mental status case study of Mr. Akkad shows that patients can take long before their behavior can change. The treatment also shows that there is a need to keep altering the prescription drugs depending on the results realized. The case of Mr. Akkad he is taking longer to get an improved memory. The treatment should thus be improved or changed to enhance therapeutic value of the drugs prescribed.
References
Burckhardt, M., Herke, M., Wustmann, T., Watzke, S., Langer, G., & Fink, A. (2016). Omega‐3 fatty acids for the treatment of dementia. Cochrane Database of Systematic Reviews, (4). https://doi.org/10.1002/14651858.CD009002.pub3
Cooper, C., Lodwick, R., Walters, K., Raine, R., Manthorpe, J., Iliffe, S., & Petersen, I. (2015). Observational cohort study: deprivation and access to anti-dementia drugs in the UK. Age and Ageing, 45(1), 148-154. https://doi.org/10.1093/ageing/afv154
Farooqui, A. A., Farooqui, T., Madan, A., Ong, J. H. J., & Ong, W. Y. (2018). Ayurvedic medicine for the treatment of dementia: mechanistic aspects. Evidence-Based Complementary and Alternative Medicine, 2018. https://doi.org/10.1155/2018/2481076
Manabe, T., Mizukami, K., Matsuoka, T., Ogawa, N., Kanesaka, T., Taniguchi, C., … & Akatsu, H. (2019). Effects of drug treatment on the survival time in patients with dementia. Nihon Ronen Igakkai Zasshi. Japanese Journal of Geriatrics, 56(2), 171-180. DOI: 10.3143/geriatrics.56.171
Owen, R. T. (2016). Memantine and donepezil: a fixed drug combination for the treatment of moderate to severe Alzheimer’s dementia. Drugs of Today, 52(4), 239-248. DOI: 10.1358/dot.2016.52.4.2479357
