Managing Major Neurocognitive Disorder due to Alzheimer’s Disease: Evidence-based Decision Making

QUESTION

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 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)

Select what you should do:

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

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

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 needs 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 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.

QUESTIONS TO ANSWER

1) Summarize case study and medication chosen.

2)Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.

3What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.

4)Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide

ANSWER

Managing Major Neurocognitive Disorder due to Alzheimer’s Disease: Evidence-based Decision Making

Introduction

This case study focuses on Mr. Akkad, a 76-year-old Iranian male presenting with symptoms suggestive of major neurocognitive disorder, most likely due to Alzheimer’s disease. The initial diagnosis is supported by the Mini-Mental State Exam (MMSE) results and the presence of cognitive deficits. Treatment decisions involving the use of Exelon (rivastigmine) are made, and subsequent outcomes are evaluated.

Summary of Case Study and Medication Chosen

Mr. Akkad’s son brought him to the clinic due to his “strange behavior.” After ruling out an organic basis for his symptoms, a diagnosis of major neurocognitive disorder due to Alzheimer’s disease was made. The initial treatment decision involved starting Mr. Akkad on Exelon (rivastigmine) at a dose of 1.5 mg orally twice daily, which was later increased to 3 mg orally twice daily. The second decision involved further increasing the Exelon dosage to 4.5 mg orally twice daily.

Evidence-based Support for Decisions

The decisions made in this case study align with the evidence-based literature on the management of Alzheimer’s disease:

Use of Cholinesterase Inhibitors: Rivastigmine, a cholinesterase inhibitor, is commonly used in the treatment of Alzheimer’s disease to manage cognitive symptoms. The decision to initiate treatment with Exelon is supported by multiple clinical trials and systematic reviews demonstrating its efficacy in improving cognitive function and stabilizing symptoms (Birks, 2006).

Dose Escalation: The decision to increase the dosage of Exelon to 4.5 mg orally twice daily is in line with the recommended dose escalation strategy for cholinesterase inhibitors. Evidence suggests that dose optimization can lead to improved outcomes and better symptom control in patients with Alzheimer’s disease (Birks, 2006).

 Treatment Goals and Expected Outcomes

The primary goal of the recommended decisions is to improve and stabilize Mr. Akkad’s cognitive symptoms and mitigate behavioral changes associated with Alzheimer’s disease. Cholinesterase inhibitors like Exelon aim to enhance cholinergic neurotransmission and slow down the cognitive decline in patients with Alzheimer’s disease (Birks, 2006). The expected outcomes include:

Stabilization of Cognitive Symptoms: The use of Exelon aims to stabilize cognitive function, particularly in areas such as orientation, attention, calculation, and recall. Although the MMSE score may not improve significantly, the progression of cognitive decline may be slowed or stabilized (Birks, 2006).

Reduction of Behavioral Disturbances: Cholinesterase inhibitors may also help mitigate behavioral symptoms such as disinhibition, agitation, and irritability. While improvements in these symptoms may vary among individuals, the goal is to enhance overall functioning and quality of life (Birks, 2006).

Evaluation of Decisions and Results

In this case, the decisions made align with evidence-based recommendations for the management of Alzheimer’s disease. However, it is important to note that changes in cognitive function and behavioral symptoms may take several months to become apparent. The absence of significant improvement in the MMSE score after four weeks should not be a cause for concern. It is crucial to manage patient and family expectations, emphasizing the long-term nature of treatment and the limitations of available therapies in reversing the degenerative process.

Conclusion

The decisions made in this case study, including the initiation and dose escalation of Exelon (rivastigmine), are supported by the evidence-based literature on the management of Alzheimer’s disease. The goals of treatment include stabilizing cognitive symptoms and reducing behavioral disturbances. However, it is important to emphasize the chronic and progressive nature of Alzheimer’s disease, manage patient and family expectations, and closely monitor long-term outcomes to provide the best possible care for patients with this debilitating condition.