Assignment 2: Week 8 Practicum: Decision Tree
Assignment 2: Week 8 Practicum: Decision Tree
Assignment 2: Week 8 Practicum: Decision Tree
Introduction
This assignment focuses on a 76-year-old man who presented with suspected Alzheimer’s disease. The client manifested with: sleep problems, forgetfulness, resting tremors, impaired insight, fluctuating energy levels, concentration problems, coordination problems, and impaired attention. The first decision will be about the client’s diagnosis while the second and third decision will be about the client’s treatment options. The ethical aspects likely to affect the treatment plan of the client will also be discussed.
Decision Point One
Major Neurocognitive disorder with Lewy bodies
Rationale for Selecting the Decision
Major Neurocognitive disorder with Lewy bodies was selected because the client’s symptoms fit the diagnostic criteria of the neurological disorder. According to the DSM-5 criteria, major neurocognitive disorder with Lewy bodies is characterized by symptoms such as cognitive changes and decline, rest tremor, dream enactment, decelerating movement, and rapid eye movement sleep behavior disorder (Gomperts, 2016). The client manifests the majority of these symptoms as indicated by symptoms such as sleep problems, forgetfulness, resting tremors, impaired insight, fluctuating energy levels, concentration problems, coordination problems, and impaired attention. Assignment 2: Week 8 Practicum: Decision Tree
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Expected Outcomes
By selecting this decision, it was hoped that the right diagnosis would be made and hence the appropriate treatment regimen would be administered to the client. Other diagnostic tests that would be necessary to confirm the diagnosis would be SPECT or PET imaging (DAT uptake).
Decision Point Two
Begin Rivastigmine 1.5 mg po twice a day
Rationale for Selecting the Decision
The decision to start Rivastigmine was selected because the medication has been shown to be effective in the treatment of major neurocognitive disorder with Lewy bodies. Rivastigmine is a cholinesterase inhibitor and hence is effective in increasing levels of acetylcholine within the brain (Ali et al, 2015). Patients with major neurocognitive disorder with Lewy bodies have degeneration of cholinergic neurons and this leads to reduced levels of acetylcholine and cholinergic function, causing cognitive deficits. Therefore, Rivastigmine will reduce degradation of synaptic acetylcholine, increase the amount of acetylcholine in the brain and therefore improve cholinergic transmission in the client (Ali et al, 2015).
Expected Outcomes
Selection of this decision hoped that the symptoms of the client especially the cognitive symptoms would improve and this will be manifested by improved memory and concentration as well as improved attention, among other cognitive improvements. This is because Rivastigmine has been shown to be effective in treating cognitive deficits in people with dementia (Kandiah et al, 2017). It was also hoped that the client would tolerate the medication well and therefore he would have no adverse effects. Difference between the Expected Outcome and Decision Outcome
There was a significant difference between the expected outcome and the actual outcome. This is because even though the client did not report any adverse effect, there was no symptom improvement. The lack of symptom improvement could be because the medication does not reverse the present cognitive deficits but only slows the disease progression. Moreover, the rapid eye movement sleep behavior disorder worsened as indicated by increased nightmares and increased movements when dreaming as reported by the son.
Decision Point Three
Begin Clonazepam 0.5 mg po at bedtime
Rationale for Selecting the Decision
The reason why this decision was selected is for the Clonazepam to treat the worsening rapid eye movement sleep behavior disorder for the client. Clonazepam is a sedative that has been shown to be effective in reducing acting out and consequent injuries in patients with REM sleep behavior disorder (Devnani & Fernandes, 2015).
Expected Outcome
By choosing this decision, the expectation was that symptoms of REM sleep behavior disorder would reduce and this would be manifested by reduced nightmares and less acting out. This is because Clonazepam is a sedative and has been shown to be effective in treating symptoms associated with REM sleep behavior disorder (Louis et al, 2016).
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Ethical Considerations
The ethical aspects involved in treatment of this client include decision-making capacity, informed consent, and autonomy. The neurological disorder may impair the client’s judgment and also the evident cognitive deficits may impair the client’s ability to make decisions regarding his treatment options (Molineuvo et al, 2016). Regarding the issue of informed consent, the PMHNP should ensure that the client and the son are educated about the available treatment options and their side effects and other associated risks in order to ensure that they make an informed decision (Molineuvo et al, 2016).Assignment 2: Week 8 Practicum: Decision Tree
Conclusion
The first decision involved making a diagnosis for the client and the selected diagnosis was major neurocognitive disorder with Lewy bodies. The second decision was for the client to start Rivastigmine because the medication is effective in treating cognitive deficits in people with dementia. The last decision was for the client to begin clonazepam at bedtime because this medication is effective in treating the rapid eye movement sleep behavior disorder and consequent injuries. Ethical aspects likely to impact the client’s treatment plan include informed consent, decision-making capacity, and autonomy.
References
Ali B, Schleret TR, Reilly BM, Chen W & Abagyan R. (2015). Adverse Effects of Cholinesterase Inhibitors in Dementia, According to the Pharmacovigilance Databases of the United-States and Canada. PLoS ONE. 10(12): e0144337.
Devnani P & Fernandes R. (2015). Management of REM sleep behavior disorder: An evidence-based review. Ann Indian Acad Neurol. 18(1), 1–5.
Gomperts S. (2016). Lewy Body Dementias: Dementia With Lewy Bodies and Parkinson Disease Dementia. Continuum (Minneap Minn). 22(2), 435–463.Assignment 2: Week 8 Practicum: Decision Tree
Kandiah N, Pai M, Looi I, Park K, Karanam A & Ampil E. (2017). Rivastigmine: the advantages of dual inhibition of acetylcholinesterase and butyrylcholinesterase and its role in subcortical vascular dementia and Parkinson’s disease dementia. Clin Interv Aging. 12(1), 697–707.
Louis E, McCarter S & Boeve B. (2016). Ramelteon for Idiopathic REM Sleep Behavior Disorder: Implications for Pathophysiology and Future Treatment Trials. J Clin Sleep Med. 12(5), 643–645.
Molineuvo M, Cami J, Carrillo M, Zaven K, Morris J, Craig R & Jason K. (2016). Ethical challenges in preclinical Alzheimer’s disease observational studies and trials: results of the Barcelona summit. Alzheimers Dement. 12(5): 614–622.
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Assignment 2: Week 8 Practicum: Decision Tree
