Posted: June 26th, 2024

Assessing and Treating Clients with Alzheimer Disease

Assessing and Treating Clients with Alzheimer Disease
Introduction
Alzheimer’s disease is a progressive neurological disorder that profoundly impacts millions of lives worldwide. It is a neurodegenerative condition characterized by cognitive and behavioral impairment, which considerably affects social and occupational functioning. It is an irreversible, gradually worsening disease that affects the brain’s memory and thinking abilities. A person with Alzheimer’s will slowly start becoming forgetful until it is significantly noticeable among their family and friends. Later in the development of this disease, they will also begin to change in personality and require increasing assistance in completing simple everyday tasks. AD is a complex disease, and it is improbable that any treatment approach or intervention can successfully treat it. Approaches are currently focused on helping patients to maintain mental functions, manage behavioral symptoms, and reduce the associated symptoms.
The impact of Alzheimer’s extends beyond the individual, affecting families, caregivers, and healthcare systems. As the population ages, the prevalence of Alzheimer’s is expected to rise, creating an urgent need for improved diagnostic tools, treatment options, and support services. Research continues to explore potential risk factors, genetic components, and environmental influences that may contribute to the development of this devastating condition.
Alzheimer’s disease has been associated with around 70% of all dementia cases in the world (Alzheimer Association, 2015). The most common first signs of AD include the loss of memory in the short term e.g., forgetting appointments, frequently misplacing objects, or asking repetitive questions. The patient’s comprehension and vocabulary become impoverished. Other cognitive deficits seem to involve several functions, such as language dysfunction exhibited by difficulty thinking of common words and errors in writing or speaking (Morris et al., 2014). Impaired reasoning is often witnessed, characterized by difficulty in handling tasks and poor judgment. Other signs and symptoms are seen from the visuospatial dysfunction, which is the inability to recognize common objects and faces. Spatial disorientation results in difficulty of circumnavigating objects.
Early detection of Alzheimer’s is crucial for optimal management and care planning. Healthcare providers are increasingly employing advanced neuroimaging techniques, such as PET scans and MRIs, to identify brain changes associated with Alzheimer’s before symptoms become apparent. Additionally, biomarker tests that measure specific proteins in blood or cerebrospinal fluid are showing promise in identifying individuals at higher risk of developing the disease, potentially opening avenues for early intervention and treatment.
A large majority of Alzheimer patients show behavioral concerns during the course of the disease (Alzheimer Association, 2015). Depression, apathy, lack of or sleep disturbance may be seen at an early stage. Psychotic symptoms, physical and verbal aggression, psychomotor agitation, and inappropriate sexual conduct appears during the later stages of dementia. In the progressive stages of Alzheimer’s, some patients tend to develop motor signs like urinary inconsistencies, myoclonus, gait disturbance, and tremor (Morris et al., 2014). Additionally, a seizure can also be witnessed in patients with AD.
Managing the behavioral symptoms of Alzheimer’s requires a multidisciplinary approach. Non-pharmacological interventions, such as cognitive stimulation therapy, reminiscence therapy, and music therapy, have shown benefits in improving quality of life and reducing agitation in some patients. Environmental modifications, establishing routines, and providing social support can also help manage behavioral symptoms. When necessary, medications may be prescribed to address specific issues like depression, anxiety, or sleep disturbances, always weighing potential benefits against risks.

This case study examines the examination and treatment of an elderly Iranian man displaying strange behaviors. According to his son, Mr. Akkad has lost interest in some of the things that he used to enjoy. At the same time, the client forgets things frequently. In the last two years, the client has continued to show a decline in behavioral and cognitive functioning. Progressive reports show that Mr. Akkad continuously portrays strange behaviors and thoughts, which have significantly affected his personality to the level that he does not show any interest in religious family engagements and criticizes those around him. Mr. Akkad has also shown a dramatic change in attitude, particularly on things that he used to take seriously, which he tends to ridicule.

The case of Mr. Akkad highlights the complex nature of Alzheimer’s disease and the challenges faced by both patients and their families. Cultural factors often play a significant role in how symptoms are perceived and reported. In this instance, the changes in Mr. Akkad’s religious engagement are particularly noteworthy, as they represent a stark departure from his previous values and behaviors. This underscores the importance of considering cultural and personal history when assessing and treating Alzheimer’s patients, ensuring that care plans are tailored to individual needs and backgrounds.

Mr. Akkad’s son states that his father’s memory loss is progressively getting worse and experiences difficulty remembering certain things. In most cases, he sometimes fails to make up the right words in a conversation and tends to deviate from the main discussion to a totally unrelated topic. The results of the memory test indicate grey confabulations after the client is subjected to PMHNP performance testing. This is a type of mini-mental state examination. One major area of concern is that the client scored 18 out of 30 in the mini-mental state examination. Major deficiencies were shown on calculation, orientation, attention, and registration. It can be concluded that the client had moderate dementia.

The use of standardized cognitive assessments, such as the Mini-Mental State Examination (MMSE), provides valuable insight into the severity of cognitive impairment. However, it’s important to note that these tests should be interpreted in conjunction with other clinical findings and the patient’s overall presentation. Factors such as education level, language proficiency, and cultural background can influence test performance. In Mr. Akkad’s case, the MMSE score of 18/30 suggests moderate dementia, but a comprehensive evaluation including neuroimaging and possibly more detailed neuropsychological testing could provide a more complete picture of his cognitive status and guide treatment planning.

Decision Point 1

Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.

I have chosen this treatment approach because Exelon is considered as an effective and powerful drug that can treat issues associated with the normal functioning of the brain in aspects such as thought process, memory, and language. Exelon can help improve the normal functioning of the brain’s nerve cells (Fife, 2016). It is one of the first-line agents in the treatment of Alzheimer’s disease and also one of the most effective. Aricept and Razadyne are second-line agents for Alzheimer’s disease treatment; therefore, it would be wise not to use them ahead of Exelon at the beginning of the therapy. It, therefore, becomes the best option, to begin with.

The decision to start with Exelon (rivastigmine) reflects current best practices in Alzheimer’s treatment. As a cholinesterase inhibitor, Exelon works by increasing levels of acetylcholine, a neurotransmitter important for memory and cognition. The gradual dose escalation is standard practice to minimize side effects and improve tolerability. It’s worth noting that while these medications can help manage symptoms, they do not alter the underlying disease process. Patients and caregivers should be educated about realistic expectations and the importance of adherence to the medication regimen for optimal benefit.

Exelon is a very effective drug within the first two weeks of treatment. In four weeks, the client returns to the clinic, and his son reports a lack of improvement from the medication. Mr. Akkad is still showing a lack of interest in religious services, which used to interest him and continues to show disinhibited behaviors. Confabulation can still be noted, and I administered the MMSE once again, and the score was the same (18 out of 30).

There is a big difference between the actual results and the results I expected. The client still experienced the same symptoms and had no improvement from the medication. The MMSE was administered, and the score was 18 out of 30. The results are short of my expectations because I thought the client would show some little improvement.

The lack of immediate improvement is not uncommon in Alzheimer’s treatment. It’s important to remember that response to cholinesterase inhibitors can vary among individuals, and it may take several weeks to months to observe significant changes. The persistence of behavioral symptoms and the unchanged MMSE score don’t necessarily indicate treatment failure at this stage. Continued monitoring and patience are crucial, as are discussions with the family about the nature of the disease and the realistic timeline for potential improvements. It may also be beneficial to explore non-pharmacological interventions to address behavioral symptoms alongside medication management.

Decision Point 2

Increase Exelon to 4.5 mg orally BID

From the first line of treatment, it is clear that the patient does not respond to the treatment and does not show any signs of improvement. Increasing the Exelon to 4.5 mg orally BID would help determine if the initial dosage was insufficient and could fasten the recovery process. It helped restore the balance of neurotransmitters in the brain and seems to improve the awareness, memory, and ability to take part in the daily activities (Fife, 2016).

The decision to increase the Exelon dosage is a logical next step in the treatment process. This approach allows for optimization of the medication’s effects while still remaining within the recommended dosage range. It’s important to monitor for potential side effects as the dose is increased, particularly gastrointestinal symptoms like nausea or diarrhea. If such side effects occur, strategies such as taking the medication with food or temporarily reducing the dose might be considered. Additionally, it may be beneficial to discuss with the family the importance of maintaining a consistent daily routine and engaging Mr. Akkad in cognitively stimulating activities to complement the pharmacological treatment.

By the end of 4 weeks, I expect the client to report a reduction in the symptoms, start attending religious services, and starts showing interest in some activities or events that he used to enjoy. His thought process and personality should show some improvement as well. When the client reported to the clinic, his son reports that he is tolerating the medication well. This is per my expectation. However, he is still concerned that Mr. Akkad has not had much improvement. He also reports that he has started joining the family for religious services, and the rest of the family are very happy. However, he is still amused by some of the things that he used to treat seriously. I am not worried about the results because I believe the patient is heading in the right direction, and therapy is starting to show effect.

The partial improvement observed in Mr. Akkad’s behavior, particularly his return to religious services, is an encouraging sign. It suggests that the increased dosage may be having some positive effects. The persistence of some symptoms, such as being amused by things he used to treat seriously, may reflect ongoing cognitive changes or could be a coping mechanism. It’s important to continue monitoring these behaviors and to provide support to the family in managing them. Encouraging the family to maintain familiar routines and environments can help Mr. Akkad feel more secure and potentially reduce some behavioral symptoms.

Decision Point 3

Increase Exelon to 6 mg orally BID

From the second line of treatment, it is evident that the patient started responding to the medication because he can now attend religious family service but still amused by some things he used to treat seriously. Increasing Exelon to 6 mg orally BID will speed the recovery process and improve cognition, mood, and ability to engage in daily activities.

It is expected that an increase in dose will be effective and alleviate the generalized symptoms of Alzheimer’s. No side effects are expected because the dose is appropriate. The patient should be able to overcome the condition within some time. However, I would advise the client’s to be patient with him because the trajectory of treating Alzheimer’s is that the disease is irreversible and can take a significantly long time to control (Anderson, Murphy & Troyer, 2012).

The decision to increase Exelon to 6 mg BID represents the maximum recommended dose for this medication. This aggressive approach may yield further improvements in Mr. Akkad’s cognitive function and behavior. However, it’s crucial to closely monitor for potential side effects at this higher dose, such as increased gastrointestinal disturbances or dizziness. Regular follow-ups should be scheduled to assess the patient’s response and tolerability. Additionally, it may be beneficial to consider adjunctive therapies, such as cognitive stimulation or occupational therapy, to complement the pharmacological treatment and potentially enhance overall outcomes.

Ethical Consideration

The clinician needs to educate the patient and family about the available medical treatments that Mr. Akkad can be subjected to and the reason for choosing Exelon as well as its associated side effects. They should also be informed about the importance of taking the medications regularly and a sufficient dosage for the patients. The client’s son should also be counseled regarding the trajectory of presumptive Alzheimer’s disease, considering the fact that it is an irreversible disease, and even though cholinesterase inhibitors can stabilize the associated symptoms, the process can take several months.

Ethical considerations in Alzheimer’s treatment extend beyond medication management. It’s crucial to discuss advance care planning with Mr. Akkad and his family while he still has the capacity to make decisions. This includes discussions about future care preferences, legal and financial matters, and potential need for long-term care. The principle of patient autonomy should be respected as much as possible, balancing safety concerns with the patient’s right to make decisions about their care. Regular reassessment of Mr. Akkad’s decision-making capacity is important, as is involving his family in care decisions as the disease progresses.

Conclusion

Exelon is one of the cholinesterase inhibitor drugs that can temporarily stabilize and reduce the cognitive decline in patients suffering from Alzheimer’s disease. In the treatment of the disease, it is important to consider the first line of treatment before considering the possibility of using the second line.

While Exelon and other cholinesterase inhibitors play a crucial role in managing Alzheimer’s symptoms, it’s important to remember that a comprehensive approach to care is essential. This includes addressing non-cognitive symptoms, supporting caregivers, and considering the patient’s overall quality of life. As research in Alzheimer’s disease continues to advance, new treatment options may become available, potentially offering more targeted or effective therapies. Regular monitoring of Mr. Akkad’s condition and staying informed about the latest developments in Alzheimer’s care will ensure he receives the most appropriate and up-to-date treatment possible.

References
Aye, S., Handels, R., Winblad, B. and Jönsson, L., 2024. Optimising Alzheimer’s disease diagnosis and treatment: assessing cost-utility of integrating blood biomarkers in clinical practice for disease-modifying treatment. The Journal of Prevention of Alzheimer’s Disease, pp.1-15.

Clay, F., Howett, D., FitzGerald, J., Fletcher, P., Chan, D. and Price, A., 2020. Use of immersive virtual reality in the assessment and treatment of Alzheimer’s disease: A systematic review. Journal of Alzheimer’s Disease, 75(1), pp.23-43.

Hauber, B., Paulsen, R., Krasa, H.B., Vradenburg, G., Comer, M., Callahan, L.F., Winfield, J., Potashman, M., Hartry, A., Lee, D. and Wilson, H., 2023. Assessing what matters to people affected by Alzheimer’s disease: a quantitative analysis. Neurology and Therapy, 12(2), pp.505-527.

Order | Check Discount

Tags: Assessing and Treating Clients with Alzheimer Disease