Week 8: Decision Tree for drug prescribe for patient with psychological disorder – Solution

Decision Tree for drug prescribe for patient with psychological disorder

Welcome to week 8!  This week, you examine types of drugs prescribed to patients with psychological disorders. You also examine potential impacts of pharmacotherapeutics used to treat psychological disorders on a patient’s pathophysiology

How does an advanced practice nurse determine the best treatment option or pharmacotherapeutic to recommend for patients with psychological disorders?  Much like assessing or recommending pharmacotherapeutics for other conditions or disorders, as an advanced practice nurse, you may encounter a patient who presents with a psychological disorder. Understanding the guiding principles related to treating patients with psychological disorders as well as the effects of pharmacotherapeutics on a patient’s overall health and well-being is critical for the safe and effective delivery of care.

Please submit Week 6 assignment and discussion

https://pharmacist.therapeuticresearch.com/Browse/Results?id=%7B6A3A5E7A-2433-478F-82C4-DF306D9DBF38%7D&parentid=%7BDC627F62-2B26-4B04-8246-029B3778309B%7D

Solution

Decision Tree Case Study

Introduction

The case study involves a patient named Akkad, a 76-year-old male of Iranian origin. He presents with severe neurocognitive symptoms suggestive of Alzheimer’s disease. Mr. Akkad’s eldest son, the chief informant, reports that the father is disoriented to time and events with partial orientation to place. The patient also has marked impairment to insight and judgment and tends to stray away from his train of thought in a given conversation (Dubois et al., 2021).

Additionally, Mr. Akkad manifests limitations towards attention, registration, calculation, and memory, as indicated by observable confabulations. He also demonstrates a restricted effect by displaying emotions and feelings towards those around him being limited. In general, this patient presents a declining cognitive ability secondary to Alzheimer’s disease, a neurodegenerative disorder. Mr. Akkad lives with his family, with his eldest son appearing to be the primary caregiver.

It is essential to acknowledge that the client’s care setting is of paramount importance, and having conducted a mini-mental status exam reveals that the patient may have moderate dementia. Its typical manifestations like forgetfulness and disorientation to place, time, and events necessitate a treatment plan. The patient is cooperative throughout the consultation process. It is imperative to develop a patient-specific drug regimen to treat and manage the client’s AD effectively. To achieve the goal, the provider uses a three-decision-point process.

Decision Point 1

Medication interventions to treat AD can be classified into either symptomatic or disease-modifying therapies. According to Pais et al. (2020), symptomatic pharmacotherapies 

have a significant effect on cognition and other accompanying symptoms like agitation, psychosis, and sleep disturbances in about 90% of the patients. The provider, therefore, has a choice of prescribing rivastigmine 1.5 mg PO twice daily with a target dosage to reach 3mg in 14 days. Option 2 is Aricept at 5mg PO taken at bedtime. The third and last option would be Razadyne 4mg PO twice daily.

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In my opinion, the best option is to use Aricept (donepezil) administered orally at a dosage of 5mg twice daily. Birks & Harvey(2018) Aricept, E2020 is a second-generation cholinesterase inhibitor suitable for treating and managing moderate to severe AD. Rivastigmine was unsuitable because it works best in mild to moderate cases, but Mr. Akkad’s case is severe. Similarly, Razadyne is adequate in mild to moderate cases. The primary goal of treatment should be to reduce the rate of cognitive decline in the patient. The outcome of Decision point 1 may not have been as expected, indicating that a5mg daily dosage did not help alleviate the patient’s symptoms. The difference in actual and expected outcomes was due to dosage, indicating that higher dosage could lead to the expected results.

Decision Point 2

Increase the Aricept drug dosage to 10 mg daily. Alternatively, Aricept could be discontinued. Moreover, galantine extended-release was initiated at a dose of 24mg PO daily. Still, Memantine extended-release at a dose of 28 mg PO daily would replace Aricept after the latter’s discontinuation. However, the best option would be to increase Aricept dosage taken to bedtime as it would help establish whether donepezil is either effective or not in this patient.

Moreover, Aricept withdrawal may be accompanied by adverse side effects and withdrawal symptoms (Yiannopoulou et al., 2019). The goal at Decision point 2 is to improve the efficacy of donepezil and therefore improve his cognitive ability. The patient showed some improvement, but most of the cognitive issues did not resolve. The difference between the actual and expected result implies that the donepezil drug is not appropriate to Mr. Akkad. This necessitates that the patient gets a different drug to treat and manage his condition.

Decision Point 3

At Decision point 3, the provider has the option of continuing with Aricept at 10 mg dosage, increasing the dosage to 15 mg for six weeks and eventually a maintenance dose of 20mg, or discontinuing Aricpet administration and initiating Namenda at 5mg daily. The first two options were eliminated because the efficacy of Aricept at high doses is minimal, with little if any alleviation of the patient’s symptoms. Option 3 of discontinuing Aricept and introducing Namenda 5mg was adopted because the former had proved ineffective at optimum dosage. The goal of treatment at this point is to improve cognitive ability. Kuns et al. (2021) 

posit that Memantine is an antagonist of the NMDA(N-Methyl-D-A- Aspartate) – receptor prescribed to slow the neurotoxicity involved in AD amongst other neurodegenerative disorders. Memantine prevents the over-activation of glutamine while allowing the normal activity. The result was not as expected. The difference in the actual and expected result was probably the discontinuation of Aricept, which indicated some effectiveness at optimum dosage. This suggested that Aricept discontinuation was not an excellent choice for its withdrawal effects. This suggests that Memantine should be added to Aricept therapy as the best option.

Conclusion

In conclusion, the best drug regimen for this patient is a combination therapy of Aricept and Namenda. The provider also has an ethical obligation to inform both the patient and the caregivers of each of the decisions made in the treatment plan. All along, the provider should involve Mr. Akkad’s eldest son in the shared decision-making process as he is the patient’s primary caregiver.

References

Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimer’s disease. Cochrane Database of systematic reviews, (6).

Dubois, B., Villain, N., Frisoni, G. B., Rabinovici, G. D., Sabbagh, M., Cappa, S., … & Feldman, H. H. (2021). Clinical diagnosis of Alzheimer’s disease: recommendations of the International Working Group. The Lancet Neurology.

Kuns, B., Rosani, A., & Varghese, D. (2021). Memantine. StatPearls [Internet].

Pais, M., Martinez, L., Ribeiro, O., Loureiro, J., Fernandez, R., Valiengo, L., … & Forlenza, O. V. (2020). Early diagnosis and treatment of Alzheimer’s disease: new definitions and challenges. Brazilian Journal of Psychiatry, 42, 431-441.

Yiannopoulou, K. G., Anastasiou, A. I., Kyrozis, A., & Anastasiou, I. P. (2019). Donepezil treatment for Alzheimer’s disease in chronic dialysis patients. Case reports in nephrology and dialysis, 9(3), 126-136