Decision Tree for Neurological and Musculoskeletal Disorders
Decision Tree for Neurological and Musculoskeletal Disorders Essay
Decision Tree for Neurological and Musculoskeletal Disorders Essay
Assignment:
For your Assignment, your Instructor will assign you one of the decision tree interactive media pieces provided in the Resources. As you examine the patient case studies in this module’s Resources, consider how you might assess and treat patients presenting symptoms of neurological and musculoskeletal disorders.
Prep:
Review the interactive media piece assigned by your Instructor.
Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece. Decision Tree for Neurological and Musculoskeletal Disorders Essay
Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.
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Instructions:
Write a paper addressing the following?
Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Decision Tree for Neurological and Musculoskeletal Disorders Essay
Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.
The Case Study
Background: Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal. Decision Tree for Neurological and Musculoskeletal Disorders Essay
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.
Subjective: During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so you perform a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia. Decision Tree for Neurological and Musculoskeletal Disorders Essay
Mental Status Exam: Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When you asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.
Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)
Results of decision 1:
Client returns to clinic in four weeks. Decision Tree for Neurological and Musculoskeletal Disorders Essay
The client is accompanied by his son who reports that his father is “no better” from this medication. He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors
You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall
Results of decision 2:
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 Tree for Neurological and Musculoskeletal Disorders Essay
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. you 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, you could maintain the current dose until the next visit in 4 weeks, or you 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 you 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.
Alzheimer’s disease is the most commonly diagnosed neurodegenerative disorder, which is characterized by a gradual onset of loss in language, cognition, speech and inability to perform activities of daily life. Alzheimer’s diseases influence significant changes in patients’ sleep patterns, personality, and behavior. Currently, Alzheimer’s disease has no cure. Drugs such as antidepressants and benzodiazepines are used to manage non-cognitive symptoms. This paper examines the decisions at three different points in managing a patient who was diagnosed with Alzheimer’s disease. It also discusses the ethical considerations that are likely to influence the treatment plan and communication with the patient and families. Decision Tree for Neurological and Musculoskeletal Disorders Essay
Case Overview
This case involves a 76-year-old patient named Mr. Akkad who was brought to the psychiatric unit for his ‘strange behaviors’. Mr. Akkad was previously seen by his family physician who ruled out the likelihood of an organic basis for his behavior. His diagnostic imaging tests and laboratory tests were normal. Mr. Akkad was reportedly demonstrating strange behaviors and thoughts for the last two years and his clinical status kept worsening. The patient’s family noted that Mr. Akkad started with losing interest in religious activities and became more critical. Apart from being so forgetful, Mr. Akkad found ridicule and amusement in issues that he previously took so seriously. During a conversation, Mr. Akkad would shift to an entirely different communication line if he found difficulty ‘finding the right words’.
During the clinical interview, Mr. Akkad was cooperative, pleasant and seemed to enjoy the conversation. It was however noted that he had some confabulation during memory testing which prompted an MSE whose score was 18 out of 30. The MSE revealed that the patient had primary registration, orientation, calculation, attention and recall deficits suggesting moderate dementia. Mr. Akkad had poor eye contact and a clear but tangential speech. He demonstrated no tics and made no unusual motor movements. His effect was restricted, denied auditory and visual hallucinations, paranoid and delusional thoughts.
Mr. Akkad is alert and oriented in person, partially oriented in place and disoriented in time. His judgment, insight and impulse control are impaired and he denied homicidal and suicidal ideation. Decision Tree for Neurological and Musculoskeletal Disorders Essay
Decision 1
The best decision is to start the patient on Aricept (donepezil) 5mg orally at bedtime. Aricept is recommended for the management of dementia since it targets all levels of Alzheimer’s disease and is dosed once daily (Birks & Harvey, 2018). Exelon (rivastigmine) 1.5 mg would be a good choice it has immediate action, it is dosed frequently and has several GI effects such as dyspepsia, nausea, and vomiting, which are detrimental to a patient aged 76 years old (Khoury, Rajamanickam & Grossberg, 2018). Similarly, Razadyne (galantamine) 4 mg orally twice daily is not recommended since it is clear that Mr. Akkad does not tolerate the drug even at higher dosages.
After four weeks, the patient returned to the clinic accompanied by his son who informed that his father had not improved with the medication. Apart from showing disinterest to attend religious activities, Mr. Akkad exhibited disinhibition behaviors and confabulation. A repeat of the MSE revealed that he had primary deficits in registration, orientation, calculation, attention, recall, and scored 18 out of 30. Since the goal of treatment is to slow the progression of functional, behavioral and cognitive symptoms, the patient’s outcome is expected. According to current literature, Aricept takes up to six weeks for a patient to show improvement in cognition, function, and behavior (Birks & Harvey, 2018). Decision Tree for Neurological and Musculoskeletal Disorders Essay
Decision 2
Based on the patient’s progress, the best decision is to increase the dose of Aricept to 10mg orally at bedtime since a higher dosage is likely to result in more serious adverse effects (Arcangelo et al., 2017). Stopping Aricept and starting Razadyne extended-release 24 mg orally daily is not a good decision since the FDA recommends starting Razadyne extended-release at 8 mg daily dose titrating to 24mg/daily in 4 weeks. It is also not advisable to discontinue Aricept and begin Namenda extended-release 28 mg orally daily as this can lead to withdrawal symptoms for Mr. Akkad hence a deteriorating clinical status (Arcangelo et al., 2017).
At this point, the goal of management is to slow down the progress of symptoms by up to 50% in the behavioral, functional and cognitive symptoms of Alzheimer’s disease. After four weeks, the patient returned to the clinic accompanied by his son who reported that his father tolerated the medication well. Although he was still concerned that Mr. Akkad was no better and easily amused by things he previously found serious, he attended religious services, an improvement that interested all family members. This outcome is expected since the drug Aricept does not reverse the degenerative process that occurs in Alzheimer’s disease. Besides, it will take up to a minimum of three months to influence some stability in the degenerative course, which is irreversible (Birks & Harvey, 2018).
Decision 3
The best decision is to continue with Aricept 10mg orally at bedtime since it is inarguable that the patient is tolerating that dose well and a dosage increase can potentially lead to unwanted adverse effects. Increasing the dosage of Aricept to 15 mg orally at bedtime for 6 weeks, then 20 mg orally at bedtime is not recommended since according to the FDA, the dosage of Aricept can only be 5mg, 10mg, and 23mg (Arcangelo et al, 2017). Similarly, abruptly discontinuing Aricept to begin Namenda 5 mg orally daily is not advisable as this can easily result in significant withdrawal symptoms such as deterioration in behavior and memory. The goal of therapy at this point is to maintain and improve Mr. Akkad’s independence, functioning and quality of life with minimal side effects. Decision Tree for Neurological and Musculoskeletal Disorders Essay
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Conclusion with Ethical Considerations and Communication
Alzheimer’s diseases are the most commonly diagnosed neurodegenerative disorder among people with advanced age. Those diagnosed with it cannot recognize familiar places, people and objects since they experience significant changes in behavior, personality, and sleep. Therefore, it is important for a PMHNP to determine a patient’s mental status capacity since only those who are mentally competent have the legal right to decline treatment (Arcangelo et al., 2017). Similarly, a PMHNP who fails to manage an adult who cannot consent to treatment amounts to medical negligence, which has legal, ethical and professional implications. The PMHNP also has the role of maintaining open and honest communication with the patient and his family, as this is one of the ways to promote quality care. Decision Tree for Neurological and Musculoskeletal Disorders Essay
References
Arcangelo, V. P., Peterson, A. M., Wilbur, V., & Reinhold, J. A. (Eds.). (2017).
Pharmacotherapeutics for advanced practice: A practical approach (4th ed.). Ambler, PA: Lippincott Williams & Wilkins.
Birks, J. S., & Harvey, R. J. (2018). Donepezil for dementia due to Alzheimer’s disease. Cochrane Database of systematic reviews, (6).
Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic advances in drug safety, 9(3), 171-178.
Decision Tree for Neurological and Musculoskeletal Disorders Essay
