Alzheimer’s Disease
76-year-old Iranian Male

76-year-old Iranian Male

 

Decision Point One


Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


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
Decision Point Three
Select what the PMHNP should do next:


Increase Exelon to 6 mg orally BID
Guidance to Student

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. The PMHNP 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, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP 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 the PMHNP 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.


Maintain current dose of Exelon
Guidance to Student

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. The PMHNP 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, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP 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 the PMHNP 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.


Add Namenda (memantine) 5 mg orally per day
Guidance to Student

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. The PMHNP 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, the PMHNP could maintain the current dose until the next visit in 4 weeks, or the PMHNP 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 the PMHNP 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.


Increase Exelon to 6 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client is accompanied today by his son who reports that he had to stop giving his father the medication because he “stopped eating” and had developed vomiting and diarrhea. He states that his father’s behaviors are unchanged
Decision Point Three
Select what the PMHNP should do next:


Discontinue Exelon and begin Namenda (memantine)
Guidance to Student

The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.

There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.

It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.

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.


Decrease Exelon to 3 mg orally BID
Guidance to Student

The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.

There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.

It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.

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.


Augment with an appetite stimulant
Guidance to Student

The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.

There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.

It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.

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.


Discontinue Exelon and begin Namenda (memantine) 10 mg orally BID

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client is accompanied today by his son who reports that his father is unchanged, but now his father is constantly complaining of feeling “dizzy” and he has noticed that his father is having problems with constipation
Decision Point Three
Select what the PMHNP should do next:


Decrease Namenda to 5 mg orally daily
Guidance to Student

The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. The PMHNP should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.

The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.

The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.

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.


Discontinue Namenda and restart Exelon
Guidance to Student

The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. The PMHNP should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.

The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.

The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.

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 Namenda 10 mg orally BID
Guidance to Student

The client is most likely experiencing side effects related to the dose of Namenda. Although the therapeutic goal is 10 mg orally BID, it should not be started this high. Instead, 5 mg orally daily is a good starting point, with increases of about 5 mg orally daily per week. Doses over 5 mg should be divided. The PMHNP should decrease the dose to 5 mg orally daily and then slowly titrate the drug to the therapeutic dose.

The decision to discontinue Namenda and restart Exelon would not be appropriate at this time as the client is not demonstrating an adverse drug reaction. Instead, he is experiencing a side effect of the medication that could possibly be avoided by a slower uptitration.

The decision of continuing Namenda at the current dose is not appropriate as it could lead to falls with injury.

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.