Pharmacology

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Alzheimer’s 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. 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

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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)

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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 OneSelect what you 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 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

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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

Maintain current dose of Exelon

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. you need 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, you could maintain the current dose until the

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next visit in 4 weeks, or you 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 you

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.

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