Week 10: Therapy for Clients with Dementia
In so many countries, to be old is shameful; to be mentally ill as well as old is doubly shameful. In so many countries, people with elderly relatives who are also mentally ill are ashamed and try to hide what they see as a disgrace on the family.
—Dr. Nori Graham, psychiatrist and honorary vice president of Alzheimer’s Disease International
In this quote, Dr. Graham is expressing her observations and experiences in her work with numerous international organizations. Many patients and their families experience feelings of anxiety and shame upon receiving a diagnosis of dementia. Lynda Hogg, an Alzheimer’s patient, shares her feelings that “some people don’t want to be associated with someone with an illness affecting the brain†(Alzheimer’s Disease International, 2012). As a psychiatric mental health nurse practitioner providing care to clients presenting with dementia, it is critically important to consider the impact of these disorders on clients, caregivers, and their families. A thorough understanding of the health implications of these disorders, as well as each client’s personal concerns, will aid you in making effective treatment and management decisions.
This week, you explore strategies to become a social change agent for psychiatric mental health. Then, as you examine the assessment and treatment of clients with dementia, you also consider related ethical and legal implications.
Photo Credit: [Maskot]/[Maskot]/Getty Images
Assignment: Assessing and Treating Clients With Dementia
The Alzheimer’s Association defines dementia as “a general term for a decline in mental ability severe enough to interfere with daily life†(Alzheimer’s Association, 2016). This term encompasses dozens of cognitive disorders of impaired memory formation, recall, and communication. The care and treatment of clients with dementia is dependent on multiple factors, including the stage of dementia, comorbidities, family support, and even the care setting. In your role, as the psychiatric mental health nurse practitioner, you must be prepared to not only treat clients with these various cognitive disorders, but also the multiple behavioral issues that often accompany them. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with dementia.
Reference: Alzheimer’s Association. (2016). What is dementia? Retrieved from
http://www.alz.org/what-is-dementia.asp
Learning Objectives
Students will:
- Assess client factors and history to develop personalized therapy plans for clients with dementia
- Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for dementia
- Evaluate efficacy of treatment plans
- Analyze ethical and legal implications related to prescribing therapy for clients with dementia
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the
Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013).
Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapter, click on the
Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
- Chapter 13, “Dementia and Its Treatmentâ€
Stahl, S. M. (2014b).
The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on
The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:
For insomnia
- donepezil
- galantamine
- memantine
- rivastigmine
Bui, Q. (2012). Antidepressants for agitation and psychosis in patients with dementia.
American Family Physician, 85(1), 20–22. Retrieved from
http://www.aafp.org/journals/afp.html
Note: Retrieved from from the Walden Library databases.
Meltzer, H. Y., Mills, R., Revell, S., Williams, H., Johnson, A., Bahr, D., & Friedman, J. H. (2010). Pimavanserin, a serotonin receptor inverse agonist for the treatment of Parkinson’s disease psychosis. Neuropsychopharmacology, 35, 881–891. Retrieved from
http://www.nature.com/npp/journal/v35/n4/pdf/npp20…
Required Media
Laureate Education. (2016h).
Case study: An elderly Iranian man with Alzheimer’s disease [Interactive media file]. Baltimore, MD: Author.
Note: This case study will serve as the foundation for this week’s Assignment.
To prepare for this Assignment:
- Review this week’s Learning Resources. Consider how to assess and treat clients requiring therapy for dementia.
The Assignment
Examine Case Study: An Elderly Iranian Man With Alzheimer’s Disease. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
- At each decision point stop to complete the following:
- Decision #1
- Which decision did you select?
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
- Decision #2
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
- Decision #1
- Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
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.â€
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 hereâ€- 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
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.â€
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 hereâ€- 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.
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
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
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
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
Select
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
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
Decision Point Three
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
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
Decision Point Three
Select what the PMHNP should do next:
Continue Aricept 10 mg orally at BEDTIME
Increase Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME
Discontinue Aricept and begin Namenda 5 mg orally daily
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
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.
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.
Continue Aricept 10 mg orally at BEDTIME
Increase Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME
Discontinue Aricept and begin Namenda 5 mg orally daily
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
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.
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.
