Alzheimer’s Disease
76-year-old Iranian Male

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.

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.

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)

RESOURCES

§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.

Decision Point One

Select what you should do:

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

: Begin Aricept (donepezil) 5 mg orally at BEDTIME

Begin Razadyne (galantamine) 4 mg orally BID

Go to Databases and then go to a Search Engine like PUBMED, CINAHL and/or COCHRANE DATABASE for Systematic Reviews to search for evidence-based research studies. Use search terms like “Alzheimers” and the drug names from the decision tree. Read the abstracts of the studies that seem appropriate to determine which one fits the scenario the best. Then read the complete study and use the knowledge gained as evidence to support your treatment decisions. The study results should be used to determine which of the 3 options is the most appropriate treatment at each decision point in the decision tree. You may need to do a search at each decision point if you are unable to find a study that supports all 3 of the decision points.

Note, the decision tree provides feedback after each decision point. Do NOT include the feedback from the decision tree in your paper. I will not award any points for doing so.

Write a 3-page summary paper that addresses the following:

• Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
  • In this scenario, pretend you are seeing this patient for a visit at your office. Decide which one of the three decisions would be most appropriate (decision point 1). Once you click on your decision, the tree will provide information on what happened since the last visit (4 weeks ago) and you need to decide which of the next three options will be the best (decision point 2). Once you click on your decision, the tree will guide you to the final visit (4 weeks later), provide information on what happened the last 4 weeks and present you with the next three decisions (decision point 3).
  • Include a brief description of the most important information from the patient case. Then describe your decisions at decision points #1, #2 and #3. Note, points are not awarded based on what your decision at each step was (there is no wrong answer, though there is a more appropriate choice at each decision point).
  • This section of your paper should take up no more than half of a page and will serve as the introduction.

• 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 (EBL). Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
  • EBL refers to primary research studies done on this disease state and the drugs used to treat it. Primary research includes randomized controlled trials and systematic reviews.
  • You need to provide a short summary of the research study you identified by using PUBMED, CINAHL and/or COCHRANE DATABASE of Systematic Reviews. Include information on the study design e.g. the number of patients, treatment drugs, duration of treatment.
  • Do NOT cite a textbook.
• 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.
  • Research studies are used to determine a.) time to therapeutic effect, b.) the size of the therapeutic effect, c.) side effects one can expect from a drug treatment and d.) if one treatment is more effective than others.
  • For this section, you need to include the results from the study you based your decision on for decision points #1, #2 and #3.
• 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.
  • One can expect similar outcomes in practice as was found in clinical trials if the study fits your patient.
  • Here you need to compare the results from the research study to what happened in practice (the feedback provided by the decision tree). Refer to a.) time to therapeutic effect, b.) the size of the therapeutic effect, c.) side effects one can expect from a drug treatment and d.) if one treatment is more effective than others.