PsychoPharmacology10 Assignment

NURS 6630: Psychopharmacologic Approaches to Treatment of Psychopathology

H

Walden University.

2020

Introduction

According to Gefen et al. (2012), dementia is a condition that results following progressive neuropathology of Alzheimer’s disease. The authors state that slow but steady progressive mental and intellectual function deterioration are peculiar characteristics of Alzheimer’s disease (AD). Arcangelo and Peterson, in their 2013 publication, point out that AD condition is the sixth leading cause of deaths for people across ages globally. Also, AD is the fifth leading cause of death among people aged 65 years and above. These high percentage figures show that AD is surprisingly one of the conditions with high mortality rates among older adults. In recent years, however, society has made huge steps towards better treatment and management of AD. However, it has not stopped AD from continually becoming an endemic problem among older adults in society. Currently, there is no known dementia cure meaning that there is no treatment capable of reversing or halting its progression. With this understanding, practitioners dealing with patients who have dementia must adapt therapeutic interventions that target to improve cognitive function or treat symptoms (Buckley & Salpeter, 2015). The authors state that the current pharmacological approach in the treatment of AD only help in controlling or managing the intellectual inadequacies the patient is exhibiting like inability to remember things, uneasiness, apprehension, psychotic tendencies, and non-cognitive behavioral symptoms. Advanced mental health practitioners will encounter clients presenting with a history of AD disorders, and must diagnose, assess, and treat them accurately.

This paper will discuss the case scenario of a 76-year Iranian male in the company of the son because client is manifesting unusual and surprising behaviors in an unsettling manner for the past two years and is getting increasingly worse. According to his son, the patient has personality changes characterized by forgetting facts, events or situations; losing interest in activities, and getting the right words to use when conversing. A prior evaluation of the client by the family physician showed that his diagnostic and laboratory imaging tests were regular. Client has a score of 18 out of 30 in a Mini-Mental State Exam (MMSE) with outstanding shortfalls being in areas of attentiveness, orientation, computing facts/figures or situations, and recalling or registering events. All these indicators suggest that the client has moderate dementia. This practitioner will utilize the decision tree in selecting the three best practices in managing and treating the client’s disorder, at the same time considering the legal and ethical implications.

Decision one

AD occurs due to changes in the brain cells resulting in a decrease in the number of nerve cells called cholinergic neurons. Nerve cells are responsible for transmitting signals/information across a chemical synapse from one neuron to the target neuron through the body’s chemical messengers/neurotransmitter known as acetylcholine. Each neurotransmitter has a different function. In the process of AD, a neurotransmitter called acetylcholinesterase antagonizes acetylcholine, which is another neurotransmitter (Stahl,2013.) The drug of choice this practitioner will select in the treatment of AD is acetylcholinesterase inhibitor to increase the amount of acetylcholine the brain needs to maintain normal function. The client’s information depending on his evaluation outcome, indicates that the client has a Major Neurocognitive disorder secondary to AD (Laureate Education, 2016h).

The practitioner’s first decision is to start a client on Aricept (Donepezil) 5 mg by mouth at bedtime. Aricept falls under the class of cholinesterase inhibitor (ChEIs) and is the first-line treatment for AD. US Food and Administration approves it for the treatment of Alzheimer’s disease (Stahl 2014b). Casey, Antimisiaris, and O’Brien (2010) point out that ChEIs have the primary goal of increasing acetylcholine bioavailability in the synaptic cleft by binding to several cholinesterase enzymes that are responsible for breaking down acetylcholine. Aricept possesses fewer side effects, and the client will need to take it once daily due to its long acting effect (Stahl, 2013).

The practitioner will not select Razadyne and Exelon at this point because they are best effective in the mild stage of AD (California Department of State Health Services, 2018). The practitioner will eliminate using them on the client as they require a double dosage for them to be active, and the client is showing symptoms of forgetfulness. Unlike the Aricept, that is once daily and is a significant factor that stimulates better compliance chances from the client. The primary goal in this phase is to enhance the client’s mental and intellectual functions with possible three-point score increase in his MMSE and minimal or zero side effects to medication. Also, to recapture interest in functions that appeals to the client like family and religious activities.

The client came back for a doctor’s appointment after four weeks of taking Aricept 5mg p o daily at nighttime, in his son’s company. Unlike what the practitioner predicted, the son reports that the client is not getting better from the medication as the client is still disinterested in family and religious activities and is still exhibiting disinhibited behaviors. Furthermore, the client has 18 out of 30 scores in the MMSE, with outstanding shortfalls still in areas of attentiveness, orientation, computing facts/figures or situations, and recalling or registering events. Though client did not have side effects to the medication, it indicates that Aricept 5mg has minimal therapeutic effect to the client’s symptoms. Stahl (2014b), states patient will not show immediate curative benefits but will take up to six weeks before manifestation of progress in their behavioral or baseline memory symptoms. Stahl also points out that Aricept needs slow titration. Therefore, practitioners can increase the dosage to 10mg daily after four to six weeks of initiating therapy.

Decision Two

The practitioner decides to increase Aricept to 10 mg, orally at bedtime. This decision aims to increase the therapeutic response towards reducing the symptoms of the client’s neurocognitive disorder. Adopting any of the other two options in this phase will not be the best approach for the client at this treatment phase. Rather the dose Aricept should be increased to the appropriate dose to elicit a therapeutic response (Birks & Harvey, 2018). Studies have shown more significant improvement in symptoms of AD when managed with 10mg of Aricept, unlike when managed with a 5mg dose of Aricept (Birks & Harvey, 2018). The decision made at this point is to reduce the client’s symptoms by reducing his MMSE score during his next visit, as well as having the client participate actively in his care. Following this second decision, the client, during the next visit, the son reports that his father seems to tolerate the medication and has been active in religious activities with his family during the next visit. However, the son notifies the practitioner family has a concern about the father’s newly acquired behavior of getting amused by things that he once considered severe. Stahl (2014b) states that Aricept has a gradual improvement of up to months on clients’ symptoms.

Decision Three

At this stage, the practitioner decides to maintain the client on this current dosage of Aricept 10 mg orally at bedtime. This decision will give the practitioner more time to reevaluate the client in another four weeks. A reason for sticking with this medication is that it can take even months before the stabilization of symptoms improves. The practitioner is anticipating that sticking the client on Aricept 10 mg will see his disinhibition improve in the coming few weeks.

The practitioner will decline the two other options available at this phase of the treatment because there is currently no evidence showing that increasing the dosage has any therapeutic benefits to patients. This act, however, can cause side effects. Therefore, the practitioner decides against exercising this option (Stahl, 2014b).

Ethical Considerations

Psych Mental Health Practitioners are accountable for their actions, and thus practitioners must provide the best possible care to their patients. It is imperative to keep in mind that age is one of the significant risk factors to consider when assessing and treating dementia. Casey et al. (2010) approximate that 96% of the patients suffering from AD are elderly, with an additional 50% being over 85 years of age and above. Though these patients have memory loss, the PMHNP has a responsibility to respect and acknowledge these patients’ dignity. Utilization of approach emanating from suitable and appropriate pharmacological agents that augments with high quality of care are vital in decent care of patients with dementia. The fact that most of the people ailing from dementia are old predisposes them to polypharmacy. Polypharmacy increases the risk of patient to drug interactions because of various medications patients are getting for treatment of intellectual defects and behavioral or mood swings as well as other medical health related issues. It is essential for practitioners also to pay attention to toxicity. There is a tendency among older patients having decreased hepatic function, making it hard for the adequate expulsion of medication from their bodies at due process. Agitation or anxiety that is not responding to proper medication management may be an indication of nephron toxicity, and the practitioner needs to manage these conditions. Another significant hurdle that psych practitioners will encounter when dealing with an elderly client suffering from AD is falling due to medications used in managing dementia. A good example is in the case of using benzodiazepines drugs are in the treatment of episodic agitation, and anxiety can lead to over sedation.

Conclusion

In conclusion, the paper’s information shows that dementia is increasing globally and is more among the older population, implying that older people dying from or with dementia are growing globally. Due to this, it brings home the need for the importance of advanced health planning that would improve end-of-life care (Ampe et al. 2016). Gove et al. (2016) point out that dementia is a condition characterized by memory loss, difficulties in problem-solving, thinking, and due to damage to the brain cells and nerves, especially from Alzheimer’s disease. Psych mental practitioners need to understand that due to the degenerative nature of the disease means that care is mostly palliative to patients suffering from AD. Family members will participate in the care of these patients and practitioners need to educate family members that care for them continually, it will take several months before the effects of the medications will show (McCormack, Tillock, & Walmsley, 2017). Delusions, aggression, irritability, and psychotic-like symptoms cause the most anguish to family members of these patients. The anguish and nature of symptoms expose caretakers to the risk of emotional distress as they care for these patients. Many suffer from burnout effects because of being overwhelmed by the task of providing care to these patients.

According to author Laureate (2016h), practitioners will educate family members that due to the degenerative nature of this disease, that care is palliative. Furthermore, family members need to be aware that the use of Aricept in the treatment of dementia may take several months before the client’s therapeutic response will manifest. For patients with a major neurocognitive disorder, Aricept may take several months before stabilization of deterioration in cognitive function and behavior is noted (Laureate 2016h).

References:

Ampe, S., Sevenants, A., Smets, T., Declercq, A., & Van Audenhove, C. (2016). Advance care

planning for nursing home residents with dementia: policy vs. practice. Journal Of Advanced Nursing, 72(3), 569-581. doi:10.1111/jan.12854

Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for advanced practice:A practical approach (3rd ed.). Ambler, PA: Lippincott Williams & Wilkins.

Birks, J.S., & Harvey, R. J. (2018). Donepezil for people with dementia due to Alzheimer’s

Disease. Retrieved from

https://www.cochrane.org/CD001190/dementia_donepezilpeople-dementia-due Alzheimer’s-disease.

Buckley, J., & Salpeter, S. (2015). A Risk-Benefit Assessment of Dementia Medications: Systematic Review of the Evidence. Drugs & Aging, 32(6), 453-467. doi:10.1007/s40266- 015-0266-9.

California Department of State Health Services. (2018). Alzheimer’s Disease: Clinical best

Practices. Retrieved from

https://dshs.California.gov/alzheimers/ClinicalBestPractices.aspx.

Casey, D. A., Antimisiaris, D., & O’Brien, J. (2010). Drugs for Alzheimer’s Disease: Are They

Effective? Pharmacy and Therapeutics, 35(4), 208–211. Retrieved from the Walden University Databases

Gefen, T., Gasho, K., Rademaker, A., Lalehzari, M., Weintraub, S., Rogalski, E., & … Mesulam, M. (2012). Clinically concordant variations of Alzheimer pathology in aphasic versus amnestic dementia. Brain: A Journal of Neurology, 135(5), 1554-1565. doi:10.1093/brain/aws076

Laureate Education. (2016h). Case study: An elderly Iranian man with Alzheimer’s disease

[Interactive media file]. Baltimore, MD: Author.

McCormack, L., Tillock, K., & Walmsley, B. D. (2017). Holding on while letting go: trauma and growth on the pathway of dementia care in families. Aging & Mental Health, 21(6), 658-  667. doi:10.1080/13607863.2016.1146872

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University

Press.