Decision Tree for Neurological and Musculoskeletal Disorders

Instructions:  Decision Tree for Neurological and Musculoskeletal Disorders

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 disorder

To Prepare

• Review the interactive media piece assigned by your Instructor. 

http://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_10/index.html

• Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
• 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.

By Day 7 of Week 8

Write a 1- to 2-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.
• 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.

Patients with AD might experience substantial alterations in personality, sleep, and behavior (Alzheimer's Association, 2017). For instance, in the case media provided, Mr. Akkad's personality begun to change a few years ago, and he started to lose interest in religious activities with family and to become more “critical” of everyone. Again, all the things Mr. Akkad used to take seriously became a source of “amusement” and “ridicule.” Most importantly, the patient has been forgetting things and has difficulties in “finding the right words” in a conversation because he will shift to an entirely different conversation line indicating that the disease was already affecting his personality and mental functions. However, medications such as antipsychotic agents, benzodiazepines, and antidepressants are often utilized to treat the non-cognitive symptoms of AD (Alzheimer's Association, 2017). 

Decision 1

The first treatment option is to either start the patient on Exelon (rivastigmine) 1.5 mg orally BID and increasing to 3 mg orally BID after two weeks, start Aricept (donepezil) 5 mg orally at BEDTIME or initiate Razadyne (galantamine) 4 mg orally BID. In this case, the PMHNP can start Aricept (donepezil) 5 mg orally at bedtime since this Aricept is dosed once per day; thus, it can significantly benefit forgetful patients like Mrs. Akkad as it also targets all levels of AD. This decision is made because it is not advisable to start the patient on Exelon (rivastigmine) 1.5 mg as this drug is an immediate-acting medication that requires frequent dosing and possesses gastrointestinal side effects (Alzheimer's Association, 2017). Moreover, even though a drug like Razadyne (galantamine) 4 mg orally twice daily may apply for this patient, it is not recommended at this time since evidence indicates that patients in most cases, patients are not able to tolerate the drug, especially at higher doses (Li et al., 2019).

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Mr. Akkad returned to the clinic after four weeks in the company of his son, who stated that his father is “no better” from this medication. The patient is still disinterested in attending religious activities and continues to display disinhibited behaviors. The PMHNP still noted confabulation and decides to administer the MMSE again. The treatment goal is to reduce the progression of the cognitive, functional, and behavioral symptoms of AD. The outcomes were as anticipated since Aricept can take up to 6 weeks to display improvement from the initial state (Stahl, 2018).  

Decision 2

Considering the outcomes, the PMHNP can decide to either, increase the Aricept to 10 mg orally at BEDTIME, terminate Aricept, or begin Razadyne (galantamine) extended-release 24 mg orally daily or discontinue Aricept and begin Namenda (memantine) extended-release, 28 mg orally daily. In this case, the PMHNP chooses to increase Aricept dose to 10 mg orally at bedtime since a higher dose is more effective with no adverse effect and better than the other drugs for AD (Alzheimer's Association, 2017). At this stage, terminating Aricept and beginning Razadyne extended-release 24 mg orally per day is not recommended (Stahl, 2018). Again, terminating Aricept to start Namenda extended-release 28 mg orally daily is not recommended because it can result in withdrawal side effects. 

The treatment goal at this stage is to slow the progression of symptoms by 50% in the cognitive, functional, and behavioral domains of AD. Mr. Akkad returns to the clinic in four weeks. He tolerates the medication but is still concerned that the client is no better but is attending religious services with the family. However, Mr. Akkad is still easily amused by things he initially found serious. This result is as anticipated since Aricept does not necessarily reverse the degenerative process and it may take at least three months to display stabilization in the degenerative course is evident, and it does not reverse.

Decision 3

At this stage of treatment, the PMHNP can proceed with Aricept 10 mg orally at BEDTIME, increase it to 15 mg orally at BEDTIME x 6 weeks, then raise to 20 mg orally at BEDTIME or terminate Aricept and start Namenda 5 mg orally daily. In this case, the PMHNP decides to proceed with Aricept 10 mg orally at bedtime because the patient appears to be tolerant to the dose and increasing the dose could lead to adverse effects (Davies ET AL., 2018). Increasing the Aricept to 15 mg orally at bedtime x 6 weeks, then increase to 20 mg orally at bedtime is not recommended because Aricept is dosed at 5mg, 10 mg, and 23mg (Alzheimer's Association, 2017). Sudden cessation of Aricept to start with Namenda 5 mg orally daily can result in withdrawal symptoms. The goal of this therapy is to maintain and optimize the patient’s functional ability, quality of life, and independence with reduced side effects. 
References

Alzheimer's Association. (2017). 2017 Alzheimer's disease facts and figures. Alzheimer's & Dementia, 13(4), 325-373.

Davies, S. J., Burhan, A. M., Kim, D., Gerretsen, P., Graff-Guerrero, A., Woo, V. L., & Rajji, T. K. (2018). Sequential drug treatment algorithm for agitation and aggression in Alzheimer’s and mixed dementia. Journal of Psychopharmacology, 32(5), 509-523. 

Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience, 13, 472.

Stahl, S. (2018). Stahl's Illustrated Alzheimer's Disease and Other Dementias. Cambridge University Press.