Decision Tree for Neurological and Musculoskeletal Disorders

Alzheimer’s is a neurodegenerative disease that begins gradually and worsens with time. This disorder is linked to 70 percent of cases of dementia worldwide. The key manifestation is the loss of recollection of recent occurrences (Alzheimer’s Association, 2018). Other manifestations entail changes in behavior, verbal challenges, loss of self-esteem, bewilderment, and mood swings, which develop as the disorder advances. The physical abilities are slowly impaired, which leads inevitably to death. It is significant to mention that it is not possible to cure Alzheimer’s disease but can be managed to enable the continuity of life of a patient (Alzheimer’s Associated, 2018)Decision Tree for Neurological and Musculoskeletal Disorders.

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The case scenario provided presents the assessment and care of Mr. Akkad, a 76-year-old Iranian man. Mr. Akkad’s eldest son mentioned his odd behavior and that he had little involvement in family religious practices. In addition, Mr. Akkad always forgot stuff, and confabulation was identified in his case after several memory checks. The instinct and reasoning of Mr. Akkad were affected. Afterward, there was a mini-mental condition examination, which revealed that Mr. Akkad had a severe neurocognitive condition that possibly developed as a result of Alzheimer’s disease. This condition has no cure, only pharmacological strategies that are based on different factors such as the proper selection of drugs, effective medication dosage, duration of usage, and administration route may manage and treat this condition Decision Tree for Neurological and Musculoskeletal Disorders.

Decision 1

There were three alternatives in this decision, first choice was to commence Exelon 1.5 mg orally BID with a raise to 3 mg in two weeks, the second alternative was to commence Aricep 5 mg orally during bedtime, and the third choice was to commence Razadyne 4 mg orally BID. I chose to commence 1.5 mg of Exelon and raising the dosage in two weeks at 3 mg. The reason for this is that this medication acts as the first-line treatment and is useful for the usual functionality of the brain in language, recollection, and processing (Tartrate & Exelon, 2019). Exelon is a cholinesterase inhibitor that improves the functionality of the brain’s nerve cells. With the administration of Exelon, Acetylcholine levels increase and are sufficient for synaptic transmissions by the Ach hydrolysis inhibition by the use of cholinesterase (Birks & Evans, 2015) Decision Tree for Neurological and Musculoskeletal Disorders.

Decision 2

Three choices were also mentioned in this decision, the first choice was to raise Aricept to 10 mg, the second choice was to commence Razadyne and withdraw Aricep, and the third choice was to commence Namenda and withdraw Aricept. I expected that the first decision would have no impact on the symptoms of the patient and would begin to emulate them. The first decision results revealed that after 4 weeks the patient came back to the facility and his family demonstrated that Mr. Akkad’s interests and behavior had not improved. The mini-mental status test is still the same as before. decision two involved raising the Exelon dosage at 4.5 mg orally BID. This dosage will assist in restoring the brain’s neurotransmitter regulation, enhancing perception and memory, and participating in exciting things(Sadowsky et al., 2014).

Decision 3

Three choices were also mentioned in this decision. after the second decision, the client began to react and put up with therapy, and his family stated that he had started to take part in religious events, but certain behaviors had not changed. The third choice was to introduce Namenda 5 mg a day orally. During intolerance, I wanted this medication to enhance the Exelon. Namenda improves cognition, mood, and performance of day-to-day activities (Glinz et al., 2019). Combination treatment led to significant symptomatic changes of both behavioral and cognitive effectiveness tests, showing a synergistic or additive capacity in the integral mechanisms of action of memantine and ChEIs in slowing down symptomatic declination in Alzheimer’s disorder (Glinz et al., 2019). I also informed Mr. Akkad’s son of his Alzheimer’s course that it has no cure but can be treated and managed for a prolonged amount of time with pharmacological approaches Decision Tree for Neurological and Musculoskeletal Disorders.

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References

Alzheimer’s, A. (2015). 2018) Alzheimer’s disease facts and figures. Alzheimer’s & dementia: the journal of the Alzheimer’s Association, 11(3), 332.

Birks, J. S., & Evans, J. G. (2015). Rivastigmine for Alzheimer’s disease. Cochrane Database of Systematic Reviews, (4).

Glinz, D., Gloy, V. L., Monsch, A. U., Kressig, R. W., Patel, C., McCord, K. A., … & Raatz, H. (2019). Acetylcholinesterase inhibitors combined with memantine for moderate to severe Alzheimer’s disease: a meta-analysis. Swiss medical weekly, 149(2526).

Sadowsky, C. H., Micca, J. L., Grossberg, G. T., & Velting, D. M. (2014). Rivastigmine from capsules to patch: therapeutic advances in the management of Alzheimer’s disease and Parkinson’s disease dementia. The primary care companion for CNS disorders, 16(5).

Tartrate, G., & Exelon, B. (2019). Exelon (Rivastigmine Tartrate): Side Effects, Interactions, Warning, Dosage & Uses. Retrieved from https://www.rxlist.com/exelon-drug.htm#indications

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.” Decision Tree for Neurological and Musculoskeletal Disorders

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 Decision Tree for Neurological and Musculoskeletal Disorders.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive)

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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: Decision Point Two

Select what you should do next:

Increase Razadyne to 24 mg extended release daily

Discontinue Razadyne and begin Aricept (donepezil) 10 mg orally daily

Discontinue Razadyne and begin Exelon (rivastigmine) 1.5 mg orally BID

 Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks Decision Tree for Neurological and Musculoskeletal Disorders

B RESULTS OF DECISION POINT ONE

  •  Client returns to clinic in four weeks
  •  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

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

: Beg RESULTS OF DECISION POINT TWO Increase Exelon to 6mg orally BID Decision Point Two

Select what you should do next:
 Client returns to clinic in four weeks

  •  Client is accompanied today by his son who reports that he had to stop giving his father the medication because he “stopped eating” and had developed vomiting and diarrhea. He states that his father’s behaviors are unchanged Decision Tree for Neurological and Musculoskeletal Disorders

in Aricept (donepezil) 5 mg orally at BEDTIME

Begin Razadyne (galantamine) 4 mg orally BID

Decision point three augment with an appetite stimulant

 Guidance to Student
The symptoms that the client is experiencing are most likely related to the rapid uptitration of Exelon. Decreasing the drug to 3 mg orally BID would be the most appropriate choice in this situation.

There are no indications to discontinue Exelon and begin Namenda at this point—although later in the treatment, Namenda can be used to augment Exelon. At this decision point, the concern is that the client stopped eating and developed vomiting and diarrhea.

It is generally not appropriate to add additional medications to treat side effects of other medications. In this case, decreasing the dose of Exelon until side effects abated then initiating a slower uptitration would be a more appropriate course of action.

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 Decision Tree for Neurological and Musculoskeletal Disorders

Assignment: 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 disorders. Photo Credit: Getty Images/Science Photo Library RF To Prepare • 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. • 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. You will submit this Assignment in Week 8. Submission and Grading Information To submit your completed Assignment for review and grading, do the following: • Please save your Assignment using the naming convention “WK8Assgn+last name+first initial.(extension)” as the name. • Click the Week 8 Assignment Rubric to review the Grading Criteria for the Assignment. • Click the Week 8 Assignment link. You will also be able to “View Rubric” for grading criteria from this area. • Next, from the Attach File area, click on the Browse My Computer button. Find the document you saved as “WK8Assgn+last name+first initial.(extension)” and click Open. • If applicable: From the Plagiarism Tools area, click the checkbox for I agree to submit my paper(s) to the Global Reference Database. • Click on the Submit button to complete your submission. Grading Criteria To access your rubric: Week 8 Assignment Rubric Check Your Assignment Draft for Authenticity To check your Assignment draft for authenticity: Submit your Week 8 Assignment draft and review the originality report. Submit Your Assignment by Day 7 of Week 8 To participate in this Assignment: Week 8 Assignment Rubric Detail Select Grid View or List View to change the rubric\’s layout. Name: NURS_6521_Week8_Assignment_Rubric • Grid View • List View Excellent Good Fair Poor Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented. Be specific. 18 (18%) – 20 (20%) The response accurately and thoroughly summarizes in detail the patient case study assigned, including specific and complete details on each of the three decisions made for the patient presented. 16 (16%) – 17 (17%) The response accurately summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. 14 (14%) – 15 (15%) The response inaccurately or vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented. 0 (0%) – 13 (13%) The response inaccurately and vaguely summarizes the patient case study assigned, including details on each of the three decisions made for the patient presented, or is missing. 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. 23 (23%) – 25 (25%) The response accurately and thoroughly explains in detail how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes specific and relevant outside reference examples that fully support the explanation provided. 20 (20%) – 22 (22%) The response accurately explains how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes relevant outside reference examples that lend support for the explanation provided that are accurate. 18 (18%) – 19 (19%) The response inaccurately or vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature. The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided. 0 (0%) – 17 (17%) The response inaccurately and vaguely explains how the decisions recommended for the patient case study are supported by the evidence-based literature, or is missing. The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing. 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. 18 (18%) – 20 (20%) The response accurately and thorough explains in detail what they were hoping to achieve with the decisions recommend for the patient case study assigned. The response includes specific and relevant outside reference examples that fully support the explanation provided. 16 (16%) – 17 (17%) The response accurately explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. The response includes relevant outside reference examples that lend support for the explanation provided that are accurate. 14 (14%) – 15 (15%) The response inaccurately or vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned. The response includes inaccurate or vague outside reference examples that may or may not lend support for the explanation provided or are misaligned to the explanation provided. 0 (0%) – 13 (13%) The response inaccurately and vaguely explains what they were hoping to achieve with the decisions recommended for the patient case study assigned, or is missing. The response includes inaccurate and vague outside reference examples that do not lend support for the explanation provided, or is missing. Explain any difference between what you expected to achieve with each of the decisions and the results of the decisions in the exercise. Describe whether they were different. Be specific and provide examples. 18 (18%) – 20 (20%) The response accurately and clearly explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides specific, accurate, and relevant examples that fully support whether there were differences between the decisions made and the decisions available in the exercise. 16 (16%) – 17 (17%) The response accurately explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides accurate examples that support whether there were differences between the decisions made and the decisions available in the exercise. 14 (14%) – 15 (15%) The response inaccurately or vaguely explains any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise. The response provides inaccurate or vague examples that may or may not support whether there were differences between the decisions made and the decisions available in the exercise. 0 (0%) – 13 (13%) vaguely explains in detail any differences between what they expected to achieve with each of the decisions and the results of the decisions in the exercise, or is missing. The response provides inaccurate and vague examples that do not support whether there were differences between the decisions made and the decisions available in the exercise, or is missing. Written Expression and Formatting – Paragraph Development and Organization: Paragraphs make clear points that support well developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. 5 (5%) – 5 (5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity. 4 (4%) – 4 (4%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. 3.5 (3.5%) – 3.5 (3.5%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. 0 (0%) – 3 (3%) Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. Written Expression and Formatting – English writing standards: Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%) Uses correct grammar, spelling, and punctuation with no errors 4 (4%) – 4 (4%) Contains a few (1–2) grammar, spelling, and punctuation errors 3.5 (3.5%) – 3.5 (3.5%) Contains several (3–4) grammar, spelling, and punctuation errors 0 (0%) – 3 (3%) Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running head, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%) Uses correct APA format with no errors 4 (4%) – 4 (4%) Contains a few (1–2) APA format errors 3.5 (3.5%) – 3.5 (3.5%) Contains several (3–4) APA format errors 0 (0%) – 3 (3%) Contains many (≥ 5) APA format errors Total Points: 100 Name: NURS_6521_Week8_Assignment_Rubric