Advanced Pharmacology Nurs 6521
Introduction
The case study focuses on Mr. Akkad a 76-year-old Iranian man who was diagnosed with major neurocognitive disorder due to Alzheimer’s disease (presumptive). The MMSE score for the client was 18/30 indicating moderate dementia. This paper, therefore, aims to make three decisions on the mediations to prescribe to the client. In addition, the ethical considerations likely to affect communication and the treatment plan for the client will be discussed.
Decision Point One
The first pharmacological agent that was selected for the client is to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks. The rationale for selecting rivastigmine is due to the medication’s efficacy in treating dementia and Alzheimer’s Disease. According to Su et al (2015), pathological changes associated with dementia of Alzheimer type include deficits in cholinergic neuronal pathways. Accordingly, the rivastigmine works by enhancing the cholinergic function by stopping the breakdown of acetylcholine. This improves the synaptic transmissions within the brain and thus improves memory as well as other cognitive functions (Kandiah et al, 2017). Because the client has dementia of Alzheimer type, he has low quantities of acetylcholine in the brain and thus rivastigmine will improve the symptoms the client is manifesting. Additionally, Birks et al (2015) explain that FDA recommended that the initial dose should be 1.5 mg BID and if the client does not experience significant side effects and tolerates the initial dose well after taking rivastigmine for two weeks, the dose should be increased to 3 mg BID.
Selection of this decision expected that the cognitive performance, behavior, function, as well as the ability to conduct activities of daily living for the client, would improve. This is because the efficacy of Exelon (rivastigmine) in treating has been demonstrated in several studies (Kandiah et al, 2017).
However, the expected outcome and the actual outcome of the first decision were different. This is because there was no symptom improvement as the son reported and also there was no change in the MMSE score. The lack of symptom improvement can be attributed to the low dose of rivastigmine prescribed to the client. The low dose of rivastigmine did not avail adequate levels of acetylcholine in the brain that could have led to symptom improvement (Kandiah et al, 2017).
Decision Point Two
The second decision that was selected is to have the rivastigmine dose increased to 4.5 mg orally BID. The reason for increasing the dose is because evidence indicates that an increased dose of rivastigmine has higher efficacy for people with Alzheimer’s Disease (Stahl, 2014). Evidence has shown that the efficacy of rivastigmine is dose-dependent when it comes to symptoms such as activities of daily living, cognitive functions, and global functioning. Therefore, it is expected that an increased dose will be more effective (Su et al, 2015).
The decision to increase the dose to 4.5 mg orally BID hoped that the cognitive function and other symptoms for this client would improve. It was also expected that the client would tolerate the higher dose well (Birks et al, 2016).
The actual outcome of the selected decision and the expected outcome were relatively similar. This is because the client manifested slight symptom improvement as evidenced by his attendance to religious service with the family. This shows that the increased dose of rivastigmine led to symptom improvement for the client, however slight (Kandiah et al, 2017). Moreover, as anticipated, the client tolerated the increased dose well as he did not report any side effect with the higher dose.
Decision Point Three
The last decision was to have the rivastigmine dose increased to 6 mg orally BID. As aforementioned, higher dose of rivastigmine increases the amount of acetylcholine within the brain and thus increases the efficacy of the medication (Sadowsky et al, 2015).
The decision to increase the dose to 6 mg orally BID hoped that there will be notable symptom improvement for the client, especially with the cognitive functioning and the capacity to carry out activities of the daily living. A study performed by Su et al (2015) showed that the administration of higher doses of rivastigmine to people with Alzheimer’s disease led to better symptom improvement especially symptoms such as cognitive functioning and the capacity to carry out activities of daily living. Since cholinesterase inhibitors like rivastigmine can only improve symptoms and not reverse the generative process, it will be important to educate the client and the son as well about how the medication works (Stahl, 2014).
Another expectation was that the client would still tolerate the incr
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