Assessing and Treating Clients with Dementia
Introduction
Major Neurocognitive Disorder due to Alzheimer’s disease is a common condition that clinicians encounter. The condition requires clinicians to make the best decisions during the treatment process. In the case of Mr. Akkad, he requires Aricept which is essential in reducing encroachment of the disease in various functioning areas of the brain. It is also important to monitor the progress of the patient before increasing the dose to 10mg. During the treatment, it is important to adhere to ethical codes of conduct such as respecting the culture of the client and educating them about treatment to seek consent (Stahl, 2013). The purpose of the paper is to describe the various decisions, their rationale, and expected outcomes while aligning all decisions to ethical considerations.
Decision #1
The first decision is to prescribe Aricept 5mg orally at bedtime.
Rationale
The reason for selecting Aricept 5mg orally at bedtime is due to the proven track record that the medication is effective in elderly patients. Aricept is also approved by the FDA for the treatment of the symptomatic treatment of mild and moderate Alzheimer’s disease (Kumral & Zirek, 2017). Therefore, it is effective for Mr. Akkad who started showing various signs for the last two years. Aricept is also one of the cholinesterase inhibitor medications available for Alzheimer’s disease (Kumral & Zirek, 2017). The medication inhibits the breakdown of acetylcholine thus boosting the level of acetylcholine in the brain. High levels of acetylcholine in the brain promotes communicating between various cells thus enhancing cognitive functions such as memory, thinking and judgment.
Aricept is effective in suppressing the progression of Alzheimer’s disease which can cause severe dementia. The drug is effective in elderly patients with minimal side effects. It is also important since it enhances cognition that enables patients to carry out daily tasks (Steenblock, 2018). The temporary relieve of dementia is also important to help the patient resume joining the family in religious activities. It also helps boost memory that will be effective in preventing loss of concentration or track of conversation (Steenblock, 2018). For example, Aricept improves reasoning and language capabilities. The medication will thus help Mr. Akkad to avoid criticizing issues he previously took seriously. It will also improve the ability to hold conversations and express himself clearly.
Selecting Aricept was a prudent decision compared to the other available options including Razadyne 4mg orally BID and Exelon 1.5mg orally BID. First, it was not possible to administer all the drugs since polypharmacy is not safe while treating mental conditions such as dementia (Luck et al., 2017). According to Stahl (2013), polypharmacy is unsafe since it can lead to adverse effects which can undermine the speed of recovery. Clinicians are also cautious about prescribing Exelon since it does not stop the progression of Alzheimer’s disease, yet it is one of the projected outcomes during the treatment (Canevelli et al., 2017). Additionally, there is little evidence to prove that the medication is effective, especially among elderly patients. Razadyne is another drug that is not effective since it triggers adverse effects (Atukeren et al., 2017). The adverse effects such as loss of appetite can lead to weight loss which is unhealthy for the 76-year-old patient. Losing weight can also undermine the immunity of the patient thus exposing them to other health issues.
PMHNP also did not select Exelon 1.5mg since it can cause side effects such as bleeding. Bleeding is unhealthy for elderly patients since it can lower their immunity. Other side effects of Exelon 1.5mg is heart failure, liver issues, Q-T prolongation, and myocardial infarction (Finn et al., 2017). However, research shows that administering the drug through transdermal route can lower the risk of side effects. However, transdermal patches can hinder effective absorption of the drug thus minimizing their therapeutic effect (Finn et al., 2017). Also, the patient will require a higher dose of Exelon 1.5mg after four weeks. A higher dose can cause more complications which undermine treatment. Therefore, Aricept was better compared to Exelon.
Razadyne is another medication which is not preferable compared to Aricept. One of the factors is that the risk of non-compliance is high for elderly patients. In some instances, clinicians prefer injections to prevent non-compliance (Lee et al., 2020). Therefore, taking the drug twice a day can increase risk of non-adherence. Patients who are taking Razadyne should also take various precautions such as taking healthy meals and taking a lot of water (Lee et al., 2020). Failure to observe the precautions will minimize their effect on the patient. Therefore, based on the ‘do no harm’ principle, it was prudent to select Aricept whereas discarding the other two options.
Expected Results
The prescription of Aricept is intended to lower the progression of memory loss. During the early stages of Alzheimer’s disease, the focus is to avoid deterioration of the condition. Improvements will focus on boosting the quality of thinking, judgment, reasoning, and memory (Quitterer & AbdAlla, 2020). While prescribing the medication, it is important to notify the patient that the medication is only meant to slow down the progression of the disease, but not to reverse the condition. Alzheimer’s disease has no cure but the medications are important to slow down the disease from progressing too fast (Quitterer & AbdAlla, 2020). The information should be relayed to the son verbally and also by providing educational materials. The information will also ensure the expectations of the family are aligned to the treatment expectations.
During the prescription, it is also important to educate the son that the father should continue taking the medication even if there are no significant changes in the first few days or weeks. The son should be aware that the treatment of Alzheimer’s disease can take time before significant results are evident (Quitterer & AbdAlla, 2020). It is also important to notify the patient about the side effects of the medication. Educating patients is an important precaution to boost adherence to the medication and subsequent clinic.
Expected Outcomes vs. Results
According to Stahl (2013), Aricept does not generate results instantly, and thus even without any result, the patient should continue taking the medication. The patient should report back to the clinic after four weeks. One of the reasons why the patient should report to the clinic although little changes are expected is to check the compliance and determine if there is any side effect. One of the outcomes during the first clinic is that the client is still confused about why he came to the office. He still does not join the family in religious activities and loses track of conversations. He is also critical about issues he was previously serious about. A mental examination report also shows that the patient has 18 points out of 30. It is normal for patients to show minimal or no progress within the first four weeks of treatment. One of the expected positive reports is that the patient is taking the medication consistently with minimal side effects.
Decision #2
The second decision is to increase the dose to 10mg. Therefore, the patient will now take Aricept 10mg orally during bedtime.
Rationale
One of the reasons for increasing the dose to 10mg is to enhance the therapeutic ability and trigger positive results. In the initial decision, it was safe to prescribe 5mg which is effective in assessing how the patient will react to the disease (Quitterer & AbdAlla, 2020). For example, in the case of elderly patients, absorption, metabolism and excretion of the drug should be considered carefully to avoid negative effects. In some instances, high doses can affect the patient’s health such as liver. Stahl (2013), also indicate that clinicians should always start with a low dose while treating mental disorders and increase it gradually. If adverse effects were evident in the patient, it would be prudent to reduce the dose (Smagula et al., 2019). However, since the patient had no negative outcomes it is now safe to increase the dose. The patient will also continue taking the medication once thus increasing the compliance. Non-compliance can trigger adverse effects and increase risk of relapse.
The rationale of continuing with the drug is prudent compared to changing the medication. According to Stahl (2013), changing medications for mental disorders treatment can affect a patient negatively. Clinicians should also be cautious not to change psycho drugs abruptly as the decision can undermine the process of recovery (Smagula et al., 2019). PMHNP should also not add another drug since it can cause negative effects. Adding another drug should only be made when there is a compelling reason (Rees et al., 2019). For instance, Namenda is an effective augmentation of Aricept but it can only be prescribed if there Aricept is not working after several weeks.
Expected Results
The patient should continue taking the current medication without any non-compliance. After 10 weeks of taking the medication, it is expected that the patient will improve his ability to hold a conversation without losing track. The drug is effective in boosting cognitive abilities including memory, thinking, judgment, and learning (Rees et al., 2019). It is also expected that he will start joining the family in their regular religious activities. The patient should also be less critical to the issues he was previously serious about (Rees et al., 2019). The family including the son should also continue encouraging him to take the medication consistently. It is also expected that the patient will not experience any side effects.
Expectations vs. Outcomes
The client should return to the clinic after six weeks of taking the medication. When the patient comes to the clinic, the son is happy that the father started joining the family in religious activities a few weeks ago. Another positive outcome is that he is less critical about issues. However, the son reports that the father is making gradual progress. For example, although he can lose track of the conversation, it is not comparable to two months ago before they began treatment. He states that ‘my father is making progress, although it is slow, we happy as a family.’
It is evident that the projected results were evident in the outcomes. However, although the patient is making slow progress, it is an indication that eventually his condition will improve significantly. During the second clinic it is important to remind the son that the treatment is only meant to stop deterioration of the condition. Therefore, the patient should continue taking the medication. It is also important to notify the son that the father may need to take the medication for months to reduce encroachment of the disease in various areas of the brain.
Decision #3
The third decision is to continue taking Aricept 10mg orally during bedtime.
Rationale
The reason for continuing with the drug is that the current medication is working effectively to reduce the symptoms in the patient. The patient has made significant improvements which are essential in the recovery process. Therefore, it is not important to change the medication or increase the dosage (Stahl, 2013). One of the precautions PMHNP take is to increase the drug unnecessarily. Increasing the dose beyond 10mg can cause adverse effects on patients. Clinicians also limit the dose especially among elderly patients (Kumral & Zirek, 2017). The metabolism, distribution, and excretion of high amounts of drugs can take more time. Therefore, when the toxic amounts are left in the body, they can undermine the recovery process.
Expected Outcomes
The patient should continue taking the medication for another period of 6 weeks. However, it could be necessary to take the medication for months to hinder the progression of the disease. The expectations include making substantial improvements in conversations. He should also continue participating in regular religious activities. The memory should also improve to help him know where he is going and why. Despite the major improvements, the patient should continue taking the medication to avoid relapse.
Ethical Issue Affecting Treatment
PMHNP should provide treatment to patients from diverse cultural backgrounds with great competency. Cultural competency in healthcare is required in treating the elderly Iranian patient (Stahl, 2013). It is important to treat them with respect whereas avoiding putting them off. For example, some cultures do not believe in injections whereas others believe the mental problem is a curse and does not need treatment (Kumral & Zirek, 2017). In the case of Mr. Akkad there is need to educate him and the son on the need to take the medication regularly. The compliance with the medication will promote fast recovery. It is also important to provide educational materials to the patient to ensure they understand the need to adhere to treatment.
The process of educating the patient should also involve providing precaution about the side effects. Some of the side effects of Aricept include nausea, weight loss, vomiting, dizziness, muscle tremor, and trouble sleeping (Steenblock, 2018). Educating the patient will ensure they do not get surprised when the side effects occur. It is also a way of seeking the consent of a patient. Ethically, patients should consent to treatment and they should not be coerced (Steenblock, 2018). For example, in the case of Mr. Akkad, he is an elderly patients and without necessary precaution, the side effects can overwhelm them. Therefore, it will be important to alter the treatment by providing a low dose such as Aricept 5mg (Canevelli et al., 2017). The dosage is then only increased when there is proof that the medication does not take a huge toll on his health.
Clinicians should strive to ensure they make the best decisions to promote positive patient outcomes. The American Nursing Association (ANA) require PMHNP to apply the ‘do no harm’ principle. It is an ethical issue that calls upon clinicians to ensure they minimize the side effects or errors during treatment (Finn et al., 2017). For example, in the case of Mr. Akkad, it was important to select Aricept since it a quality drug with credible evidence of positive results in the past. It has minimal side effects compared to the other available options. Clinicians also take precautions to avoid starting with a high dose in the treatment of mental conditions (Finn et al., 2017). The gradual increase in the dose helps clinicians to monitor the progress of patients and thus minimize the risk of adverse effects. It is also important to avoid giving in to the patient demands which can include asking for a specific drug that will harm them (Finn et al., 2017). Clinicians should only prescribe medication they know will improve the projected health outcomes.
Conclusion
Treatment of patients with dementia is a process that requires a series of careful decisions. One of the considerations is the pharmacokinetics and pharmacodynamics of a drug on a patient. PMHNP should thus select the best medication that will cause minimal or no side effects. In the case of Mr. Akkad, he is diagnosed with presumptive major neurocognitive disorder due to Alzheimer’s disease. One of the best drugs is Aricept which helps patients to improve cognitive abilities. Improvements include learning, cognitive, judgment, and memory. It also helps in deterring further progression of the disease. When Mr. Akkad came to the clinic for the first time, he was in a bad shape. However, after taking the medication for 10 weeks, his condition had improved significantly. During treatment, some of the ethical considerations include educating the patient or guardian, selecting the best medication, and respecting their culture. Treatment of patients with Alzheimer’s disease requires a careful prescription of drugs to promote positive outcomes and minimize negative results.
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