Alzheimer’s Disease
76-year-old Iranian Male

76-year-old Iranian Male

 

Decision Point One


: Begin Aricept (donepezil) 5 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Increase Aricept to 10 mg orally at BEDTIME

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:


Continue Aricept 10 mg orally at BEDTIME
Guidance to Student

At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

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 Aricept to 15 mg orally at BEDTIME x 6 weeks, then increase to 20 mg orally at BEDTIME
Guidance to Student

At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

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 Aricept and begin Namenda 5 mg orally daily
Guidance to Student

At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

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 Aricept and begin Razadyne (galantamine) extended release 24 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • The client’s son accompanies the client to his appointment today. The client is in a wheelchair and is somewhat agitated.
  • You are informed by the son that his father has not taken his medication since he got out of the hospital. Apparently, about 7 days after starting the Galantamine extended release, the client began having seizures which resulted in a fall and fractured hip. The son reports that his father is agitated with everyone and is asking for help in treating his agitation
Decision Point Three
Select what the PMHNP should do next:


Restart Razadyne extended release 24 mg
Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If the PMHNP were to consider restarting Razadyne, it should be restarted at a proper starting dose as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, the PMHNP should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

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.


Begin Risperdal (risperidone) 0.5 mg orally BID to treat agitation
Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If the PMHNP were to consider restarting Razadyne, it should be restarted at a proper starting dose as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, the PMHNP should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

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.


Assess for pain
Guidance to Student

Razadyne extended release 24 mg is a “target” dose—not a starting dose. Side effects of Razadyne include GI side effects as well as dizziness. Rare side effects include seizures. If no other medications were added to the client’s medication regimen and no other physical issues were present (e.g., metabolic derangements), then the high dose of Razadyne in this client would most likely be responsible for his seizures, which resulted in the fall and the hip fracture. This would represent malpractice. If the PMHNP were to consider restarting Razadyne, it should be restarted at a proper starting dose as side effects are often dose dependent.

Risperdal would not be appropriate to treat agitation in this client as the FDA has issued a black box warning against the treatment of agitation in dementia with antipsychotic medications. Although they can still be used despite black box warnings, the PMHNP should conduct a comprehensive assessment of this client to see if a physical issue is causing the agitation. A hip fracture is often associated with pain, and untreated pain may be the cause of the client’s agitation. Therefore, assessment for pain would be the correct choice in this scenario.

Never use psychotropic drugs to treat behaviors until physical causes of the behavior have been ruled out (e.g., pain, infection, constipation).

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 Aricept and begin Namenda (memantine) extended release, 28 mg orally daily

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 extended release to 14 mg orally daily and reassess at next office visit
Guidance to Student

The side effects of dizziness and constipation can be common in those who are started on Namenda. The side effects are often transient and dose dependent. The PMHNP should decrease the current dose to 14 mg daily and reassess at the next office visit. If the client is tolerating the medication at that point, then the dose may be increased to 21 mg orally daily.

Miralax can be added, but the PMHNP should attempt to avoid adding medications to treat side effects, especially in older adults, as this can lead to a vicious cycle of polypharmacy—especially if a slower uptitration of this drug could alleviate the constipation. In addition to decreasing the dose, the PMHNP should counsel the client and his son in strategies to increase fluid in the diet (unless there are other contraindications) as well as how to increase fiber in the diet to help combat constipation.

The presence of side effects that may be dose dependent is not a sufficient reason to discontinue Namenda and begin Razadyne. However, if there were a therapeutic reason to do so, Razadyne immediate release should be dosed twice/day and should be initiated at 4 mg orally BID. To do otherwise may increase the risk of side effects that can be avoided in an older adult through the use of a more cautious titration schedule.

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 Miralax (polyethylene glycol) to current medication regimen
Guidance to Student

The side effects of dizziness and constipation can be common in those who are started on Namenda. The side effects are often transient and dose dependent. The PMHNP should decrease the current dose to 14 mg daily and reassess at the next office visit. If the client is tolerating the medication at that point, then the dose may be increased to 21 mg orally daily.

Miralax can be added, but the PMHNP should attempt to avoid adding medications to treat side effects, especially in older adults, as this can lead to a vicious cycle of polypharmacy—especially if a slower uptitration of this drug could alleviate the constipation. In addition to decreasing the dose, the PMHNP should counsel the client and his son in strategies to increase fluid in the diet (unless there are other contraindications) as well as how to increase fiber in the diet to help combat constipation.

The presence of side effects that may be dose dependent is not a sufficient reason to discontinue Namenda and begin Razadyne. However, if there were a therapeutic reason to do so, Razadyne immediate release should be dosed twice/day and should be initiated at 4 mg orally BID. To do otherwise may increase the risk of side effects that can be avoided in an older adult through the use of a more cautious titration schedule.

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 start Razadyne (galantamine) 12 mg ORALLY at BEDTIME
Guidance to Student

The side effects of dizziness and constipation can be common in those who are started on Namenda. The side effects are often transient and dose dependent. The PMHNP should decrease the current dose to 14 mg daily and reassess at the next office visit. If the client is tolerating the medication at that point, then the dose may be increased to 21 mg orally daily.

Miralax can be added, but the PMHNP should attempt to avoid adding medications to treat side effects, especially in older adults, as this can lead to a vicious cycle of polypharmacy—especially if a slower uptitration of this drug could alleviate the constipation. In addition to decreasing the dose, the PMHNP should counsel the client and his son in strategies to increase fluid in the diet (unless there are other contraindications) as well as how to increase fiber in the diet to help combat constipation.

The presence of side effects that may be dose dependent is not a sufficient reason to discontinue Namenda and begin Razadyne. However, if there were a therapeutic reason to do so, Razadyne immediate release should be dosed twice/day and should be initiated at 4 mg orally BID. To do otherwise may increase the risk of side effects that can be avoided in an older adult through the use of a more cautious titration schedule.

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.