Assessing and Treating Clients with Dementia

Assessing and Treating Clients with Dementia

Assessing and Treating Clients with Dementia

 

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. Assessing and Treating Clients with 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. Assessing and Treating Clients with Dementia

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

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

Alzheimer’s Disease
76-year-old Iranian Male

Decision Point One

: 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 Assessing and Treating Clients with Dementia

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. Assessing and Treating Clients with Dementia

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. Assessing and Treating Clients with Dementia

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. Assessing and Treating Clients with Dementia

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. Assessing and Treating Clients with Dementia

Learning Resources: Assessing and Treating Clients with Dementia

Required Readings (click to expand/reduce)

Gatchel, J. R., Wright, C. L., Falk, W. E., & Trinh, N. (2016). Dementia. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 149–162). Elsevier.

Angermeyer, M. C., Matschinger, H., & Schomerus, G. (2013). Attitudes towards psychiatric treatment and people with mental illness: Changes over two decades. The British Journal of Psychiatry, 203(2), 146–151. https://doi.org/10.1192/bjp.bp.112.122978

Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia. American Family Physician, 85(1), 20–22

Crocker, A. G., Prokić, A., Morin, D., & Reyes, A. (2014). Intellectual disability and co-occurring mental health and physical disorders in aggressive behaviour. Journal of Intellectual Disability Research, 58(11), 1032–1044. https://doi.org/10.1111/jir.12080

Dingfelder, S. F. (2009). Stigma: Alive and well. Monitor on Psychology, 40(6), 56-59. https://doi.org/10.1037/e542802009-028

Erickson, S. C., Le, L., Zakharyan, A., Stockl, K. M., Harada, A. M., Borson, S., Ramsey, S. D., & Curtis, B. (2012). New-onset treatment-dependent diabetes mellitus and hyperlipidemia associated with atypical antipsychotic use in older adults without schizophrenia or bipolar disorder. Journal of the American Geriatrics Society, 60(3), 474–479. https://doi.org/10.1111/j.1532-5415.2011.03842.x

Jenkins, J. H. (2012). The anthropology of psychopharmacology: Commentary on contributions to the analysis of pharmaceutical self and imaginary. Culture, Medicine and Psychiatry, 36(1), 78–79. https://doi.org/10.1007/s11013-012-9248-

Malhotra, A. K., Zhang, J., & Lencz, T. (2012). Pharmacogenetics in psychiatry: Translating research into clinical practice. Molecular Psychiatry, 17(8), 760–769. https://doi.org/10.1038/mp.2011.146

Medication Resources (click to expand/reduce)

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments. Assessing and Treating Clients with Dementia

  • donepezil
  • galantamine
  • memantine
  • rivastigmine

Optional Resources (click to expand/reduce)

Bennett, T. (2015). Changing the way society understands mental health. National Alliance on Mental Illness. http://www.nami.org/Blogs/NAMI-Blog/April-2015/Changing-The-Way-Society-Understands-Mental-Health

Mechanic, D. (2007). Mental health services then and now. Health Affairs, 26(6), 1548–1550. https://web.archive.org/web/20170605094514/http://content.healthaffairs.org/content/26/6/1548.full

Rothman, D. J. (1994). Shiny, happy people: The problem with “cosmetic psychopharmacology.” New Republic, 210(7), 34–38.