Assessing and Treating Clients With Dementia

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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

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)

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 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

· Select what the PMHNP should do next:

· Increase Exelon to 4.5 mg orally BID

· Increase Exelon to 6 mg orally BID

· Discontinue Exelon and begin Namenda (memantine) 10 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

· Decision Point Two

· Select what the PMHNP should do next:

· Increase Aricept to 10 mg orally at BEDTIME

· Discontinue Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily

· Discontinue Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

Alzheimer’s Disease 76-year-old Iranian Male

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

· Decision Point Two

· Select what the PMHNP should do next:

· Increase Razadyne to 24 mg extended release daily

· Discontinue Razadyne and begin Aricept (donepezil) 10 mg orally daily

· Discontinue Razadyne and begin Exelon (rivastigmine) 1.5 mg orally BID