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Decision Tree for Neurological and Musculoskeletal Disorders (Alzheimer’s disease)





Summary of the patient case study 

Mr. Akkad is a 76 year old Iranian male who was brought to the clinic because his eldest son has noted strange behavior, but after laboratory and diagnostic tests he was considered normal. The son is concerned because of his father’s strange thoughts and disinhibited behaviors. After administering Mini-Mental State Exam (MMSE), Mr. Akkad scored 18 out of 30 and there were primary deficits in different areas.

The chosen decisions are:  Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks, Increase Exelon to 4.5 mg orally B, and increase Exelon to 6 mg orally BID.  In decision point one, Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks, the client returns to clinic in four weeks, but the son reports that the father is not better and is disinterested in religious activities or services. In decision point two, the client returns to clinic in four weeks and the son reported the father had started tolerating the medication, but was no better, while he had started attending religious services. Increasing Exelon to 4.5 and then 6.0 mg orally is beneficial as there are no side effects, but the medications do not reverse the degenerative process.

Decisions provided were supported by the evidence-based literature. 

The initial treatment is Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks and when well tolerated dosage is increased unless there are adverse effects. Exelon (rivastigmine) is a type of cholinesterase inhibitors (acetylcholinesterase inhibitors) used to treat mild to moderate Alzheimer’s disease and its efficacy is related to the dosage. The safety and efficacy of the medication has been evaluated in various trials (Birks & Evans, 2015).  Researchers mostly look into changes in activities of daily living and behavioral symptoms and effectiveness f different medications to teat Alzheimer’s to determine what is best suited for patients. 

When Exelon was increased to 4.5 mg this was based on the observation that the treatment is increased to the recommended optimal dose when well tolerated after 4 weeks. There is also no switch of the medications within the same class without good reason. In a review of research there was no difference in cognitive function measured using various neuropsychological assessment tools such as the Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog scale ) when Exelon (4.6 mg/day) and placebo were used for 24 weeks (Birks & Evans, 2015). The recommended Exelon dosage is 6-12 mg/ day, but more dosage may be beneficial. 

What I hoped to achieve with the decisions 

In decision point one Exelon was provided 1.5 mg orally and increased to 3 mg orally in 2 weeks, which is consistent with recommendations, and was aimed at improving daily functioning. Acetylcholinesterase inhibitors such as Exelon inhibit the degradation of the acetylcholine and may boost cholinergic functioning and cholinergic neurotransmission and in patients with Alzheimer’s disease (Deardorff, Feen & Grossberg, 2015). Mini-Mental State Examination (MMSE) indicates cognitive functioning and without improvement the second decision point was increasing the dosage.

As expected, Akkad tolerated the medication when the dose was now 4.5 mg and since there was no interruption of treatment there was no restarting the treatment with the same dose. Dose increase ought to occur only after 4 week or more and the client returned after four weeks, and expectedly the father was attending religious services. In decision point three, I hope d to improve cognitive functioning and daily activities. Deardorff, Feen & Grossberg (2015) report on a on a clinical trial that had shown significant improvements on the ADAS-Cog and MMSE, when using Exelon 6-12 mg/day for patients with Alzheimer’s. As there were no side effects in decision point two the dose was increased to reach the therapeutic dose of the medication 

Difference between expectations and the results 

In decision point one, there was expectation that Exelon (rivastigmine) 1.5 mg orally BID and increase to 3 mg would have a positive effect, but there was no change. The MMSE score did not change, but the recommendations highlight the need to give the medications gradually to avoid adverse effects. This was considered in decision point two to avoid adverse events and side effects when there is rapid increase in the dose. The Exelon 6 mg -12 mg orally is most effective to improve outcomes for cognitive function when dose is increased gradually to these levels (Birks & Evans, 2015).  According to Deardorff, Feen & Grossberg (2015) there are significant improvement in patients with Alzheimer’s disease when the dosage is gradual rather than starting with a high dosage.

In decision point two the chosen to increase Exelon to 6 mg orally within the four weeks was not chosen as there are likely adverse effects such as vomiting and losing appetite and this is mostly when there was rapid uptitration of Exelon. According to Khoury, Rajamanickam & Grossberg (2018), there is higher risk of incidence of gastrointestinal side effect when using 

Exelon when compared to Donepezil and galantamine the other cholinesterase inhibitors (ChEIs) that are the first-line treatment for Alzheimer’s. In decision point three, the goal of increasing Exelon to 6 mg orally BID improve outcomes and daily functioning as expected.


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