Case Study: An African American Child Suffering From

Case Study: An African American Child Suffering From Depression

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Pediatric depression has become common among children and adolescents with manifest debilitating effects on their academic, health, and social functioning. Thus, familiarity with the variables associated with initiating and then hastening the condition amongst pediatric populations can aid with the recognition of patients that may need to be subjected to screening instruments such as the Children’s Depression Rating Scale (Isa et al.¸2014). Accurately diagnosing the severity of the condition plays an important role in determining the nature of intervention that a psychiatric mental health nurse practitioner will prefer. Whereas therapy has always formed the first line of management of the condition, primary care physicians and PMNHPs also employ the usage of pharmacotherapy plan in conjunction with patients and their families. During the formulation of a psychopharmacological intervention, the PMHNP needs to consider factors such as safety and tolerability of a drug as affected by certain patient aspects including ethnicity (Stahl, 2014b). In the event that the abatement of depression symptomatology is not achieved within the first four weeks of pharmacotherapy, a review needs to be conducted and consideration given to options such as increasing dosage, changing to a new psychotropic medication or augmenting the existing medication with another one. The present paper will thus explore the above by examining the case of an 8-year old African-American who presents with significant depression according to his Children’s Depression Rating Scale score. In addition, while formulating an intervention for the patient, the PMNHP also needs to become cognizant of the ethical considerations so as not to expose themselves.

Decision Point One

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Selected Decision

Begin Zoloft 25 mg orally.

Reasons for the Selection

According to clinical guidelines and evidence-based care recommendations for the management of pediatric depression, sertraline (Zoloft), Fluoxetine (Prozac), and citalopram (Celexa) form the first line treatments for the management of pediatric depression (Zuckerbrot et al., 2018). Sertraline acts by selectively inhibiting the reuptake of central serotonin thus enhancing serotoninergic transmission. Studies reveal that Sertraline has selectivity as it does not possess significant affinity for certain receptors such as alpha1-adrenergic, muscarinic receptors and H1-histamine thus leading to lower incidences of adverse events including sedation, anticholinergic effects, and orthostatic hypotension. In addition, due to the genetic variations of the hepatic isoenzyme 2D6 of the cytochrome P450 system (CYP2D6) in the African-American child, the metabolism of sertraline takes significantly longer, which some studies have credited with the increased efficacy of Zoloft in the management of the pediatric depression symptoms (Sanchez, Reines, & Montgomery, 2014). Further, Sertraline reaches peak serum concentration at 4.5 hours, which positively impacts its efficacy.

However, Paxil and Wellbutrin could not be countenanced in the present situation because of safety and tolerability concerns. Scholarship on the usage of both drugs discounts them as they are not first line medications for the condition and they produce adverse events such as nausea, diarrhea, vomiting, and sleepless nights even at their starting doses. Specifically, Paxil cannot be approved because it leads to increased risk of suicidal ideation and suicidality in children as per a clinical trial conducted by its manufacturer in 2003, which revealed that 3.2% of those taking it demonstrated those tendencies as compared to 1.5% in the placebo (Nevels, Gontkovsky, & Williams, 2016). Consequently, the FDA has not approved the drug as an antidepressant intervention in children and this is relevant in the present case as the client does not interact with his peers or classmates, making it dangerous for him to be given such a drug. In addition, some studies have also revealed that the efficacy of Paxil in pediatric depression is questionable.

Similarly, Wellbutrin also has a black box label warning from the manufacturer encompassing increased suicidal behaviors and thoughts in pediatrics, adolescents and young adults (Monden et al., 2018). Moreover, bupropion causes strong epileptic seizures, which caused its recall from the market in the year 1986. Other evidence-based studies studies have found that Wellbutrin causes decrease in appetite and sleep disturbances particularly when administered late at night. The existence of these adverse effects disqualify Wellbutrin from consideration as a first line of treatment for pediatric depression. Therefore, the foregoing supports the decision to Select Zoloft 25 mg as the initial pharmacotherapy for the present case.

Expected Results

Experimental studies on the effectiveness of Zoloft in depression reveal that the pharmacological effect of the drug should be felt within the first two weeks (Cheung, Kozloff, & Sacks, 2013). Thus, by the fourth week when the patient visits the clinic for evaluation, he should demonstrate improved mood. Further, the nurse would expect the patient to show improved interest in activities and also interact well with his classmates. Lastly, the patient should also register some improvement in his appetite as well as become less irritated.

Differences between Expected Results and Actual Results

However, upon coming to the clinic for review, the patient did not show any signs of improvement in the symptoms of depression. Hence, the expectations of the nurse during the formulation of the therapy were not met as a consequence. The absence of resolution or improvement of the symptoms could be attributed to either underdosage or lack of response from the patient. Also, the patient did not show any adverse effects towards the drug, which was expected given the dosage that was used.

Decision Point Two

Selected Decision

Increase dosage to 50 mg orally

Reasons for the Selection

The 25 mg that was given at the commencement of the pharmacotherapy is the starting dose of Sertraline therapy. Guidelines and EBP-based recommendations have identified 50 mg as the effective dose of Zoloft wherein the therapeutic effect of the drug begins to occur (Cipriani et al., 2016). The option to increase the dosage to 37.5 mg is a non-starter as that is not the effective dose, thus applying it could still fail to improve the symptoms. Also, changing to Prozac 10 mg orally daily could expose the patient to withdrawal symptoms as children have a higher rate of drug metabolism compared to adults thus making them susceptible to this phenomenon as postulated by Cipriani et al. (2016). For these reasons, increasing the dosage to 50 mg is the best decision and is consistent with treatment guidelines.

The Expected Results

With the increase of Zoloft dosing to 50 mg, which is its effective dosage according to studies, the symptoms of depression in the child should decrease significantly. The 8-year-old African American clients should thus show improvements in mood, reduction in irritation, interest in activities and improved interactions with his peers at school, as well as improved appetite (Sanchez, Reines, & Montgomery, 2014). At 50 mg, Zoloft is anticipated to positively modulate the levels of neurotransmitters in the brain hence these results.

Differences between Expected Results and Actual Results

The pediatric client visited after four weeks and revealed that the symptoms had improved. The Children’s Depression Rating Scale buttressed these claims by revealing that indeed the symptoms had reduced by 50%. This was consistent with the anticipated results by the nurse at the point of reviewing the initial intervention. Further, the nurse expected certain side effects associated with Zoloft such as headaches, insomnia/sedation, and gastrointestinal upsets. Nevertheless, none of them appeared pointing to excellent tolerance by the client. Even then, the most important expectation, the improvement of depression symptoms, was achieved by this decision.

Decision Point Three

Selected Decision

Increase the dose to 75 mg orally daily.

Reasons for the Selection

The patient registered a 50% in the reduction of symptoms at 50 mg of the Zoloft dosage. Whereas this is a sufficient symptom reduction and response to therapy was demonstrated, a full remission has not been achieved. Given that the client has tolerated the drug well even at 50 mg, the nurse should consider increasing the dosage to 75 mg while instructing the client’s support system to monitor for adverse events (Kunitosha et al., 2018). Further, given that response to Zoloft has already been realized, the option to change the drug to SNRI cannot be adopted as this will raise complications including suicidal ideations by the client.

Expected Results

The administration of Zoloft at 75 mg orally daily is expected to lead to a full remission of the depression symptoms in the pediatric client. According to literature, the maximum dosage of Zoloft is 200 mg whole effective dosage is at 50 mg (Stahl, 2014b). Given that the client had already responded to the 50 mg dosage while registering a 50% improvement in symptoms, the nurse is expected to pursue full remission in consultation with the client and his parent (Zuckerbrot et al., 2018). Thus, four weeks after the introduction of the 75 mg dose, the client is expected to have a full resolution of sadness, fully interact with classmates and peers, demonstrate proper appetite and zero instances of irritation.

Differences between Expected Results and Actual Results

The decision to increase the dosage to 75 mg appears to be in line with the standard guideline for addressing depression symptoms in pediatric clients. It is advised that in the presence of excellent tolerance, the dosage can be increased in order to achieve full remission of symptoms instead of maintaining it at the effective dose. Whereas this increase may introduce some side effects, the psychiatric nurse practitioner is justified to pursue full remission as these adverse effects have not emerged yet.

Impact of Ethical Considerations on the Treatment Plan

The usage of antipsychotics in depression care plan exposes a client to many side effects irrespective of the chosen drug. These risks include the causation of suicidal tendencies in pediatric clients, especially when they do not interact with their peers or classmates. Thus, during the formulation of the therapy, the psychiatric nurse practitioner should inform the client and his family of the possible side effect associated with each drug option (Weihs et al., 2018). In the present scenario, the PMNHP should discuss the advantages and disadvantages of increasing the Zoloft dosage from the effective dose of 50 mg to 75 mg in order to achieve full resolution of the symptoms. By doing this, the clients would be empowered to make their decision regarding the direction of the therapy.

Conclusion

Depression in children and adolescents leaves significant and often debilitating imprints on multifarious functioning of their lives. However, with accurate diagnosis and appropriate pharmacological interventions, the symptomatology of the disease can undergo full resolution. During the administeration of a pharmacotherapy, a psychiatric nurse practitioner needs to consider few variables such as safety, tolerability and in some cases metabolism of a pharmacological agent. Further, during the formulation of such interventions, a nurse needs to be cognizant of their ethical responsibility towards a patient in order to increase compliance.

References

Cheung, A. H., Kozloff, N., & Sacks, D. (2013). Pediatric depression: an evidence-based update on treatment interventions. Current psychiatry reports, 15(8), 381.

Cipriani, A., Xinyu Zhou, Del Giovane, C., Hetrick, S. E., Bin Qin, Whittington, C., … Zhou, X. (2016). Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis. Lancet, 388(10047), 881–890. https://doi.org/10.1016/S0140-6736(16)30385-3

Isa, A., Bernstein, I., Trivedi, M., Mayes, T., Kennard, B., & Emslie, G. (2014). Childhood Depression Subscales Using Repeated Sessions on Children’s Depression Rating Scale – Revised (CDRS-R) Scores. Journal of Child & Adolescent Psychopharmacology, 24(6), 318–324. https://doi.org/10.1089/cap.2013.0127

Kunitoshi Kamijima, Mahito Kimura, Kazuo Kuwahara, Yuri Kitayama, & Yoshihiro Tadori. (2018). Randomized, double-blind comparison of aripiprazole/ sertraline combination and placebo/sertraline combination in patients with major depressive disorder. Psychiatry & Clinical Neurosciences, 72(8), 591–601. https://doi.org/10.1111/pcn.12663

Sanchez, C., Reines, E., & Montgomery, S. (2014). A comparative review of escitalopram, paroxetine, and sertraline: Are they all alike? Int. Clin Psychopharmacology, 29(4), 185-96.

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Weihs, K. L., Murphy, W., Abbas, R., Chiles, D., England, R. D., Ramaker, S., & Wajsbrot, D. B. (2018). Desvenlafaxine Versus Placebo in a Fluoxetine-Referenced Study of Children and Adolescents with Major Depressive Disorder. Journal of Child & Adolescent Psychopharmacology, 28(1), 36–46. https://doi.org/10.1089/cap.2017.0100

Zuckerbrot, R., Cheung, A., Jensen, P., Stein, R., & Laraque, D. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part i. Practice preparation, identification, assessment, and initial management. American Academy of Pediatrics, 144(3), e1299.

Monden R., Roest, A.M., van Ravenzwaaij D., Wagenmakers E.J., Morey R., Wardenaar K.J., de Jonge, P. (2018). The comparative evidence basis for the efficacy of second-generation antidepressants in the treatment of depression in the US: A Bayesian meta-analysis of Food and Drug Administration reviews. Journal of Affective Disorders. 235: 393–398.

Nevels, R. M., Gontkovsky, S. T., & Williams, B. E. (2016). Paroxetine-The Antidepressant from Hell? Probably Not, But Caution Required. Psychopharmacology bulletin, 46(1), 77-104.

An African American Child Suffering From Depression

African American Child

BACKGROUND INFORMATION

The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

Client complained of feeling “sad”
Mother reports that teacher said child is withdrawn from peers in class
Mother notes decreased appetite and occasional periods of irritation
Client reached all developmental landmarks at appropriate ages
Physical exam unremarkable
Laboratory studies WNL
Child referred to psychiatry for evaluation

Case Study: An African American Child Suffering From Depression

MENTAL STATUS EXAM

Alert & oriented X 3, speech clear, coherent, goal directed, spontaneous. Self-reported mood is “sad”. Affect somewhat blunted, but child smiled appropriately at various points throughout the clinical interview. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. Judgment and insight appear to be age-appropriate. He is not endorsing active suicidal ideation, but does admit that he often thinks about himself being dead and what it would be like to be dead.

You administer the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

RESOURCES

§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

Case Study: An African American Child Suffering From Depression

Decision Point One

Select what you should do:

Begin Zoloft 25 mg orally daily

Begin Paxil 10 mg orally daily

Begin Wellbutrin 75 mg orally BID

Mood disorders can impact every facet of a child’s life, making the most basic activities difficult for

Case study: An African American child suffering from depression

clients and their families. This was the case for 13-year-old Kara, who was struggling at home and at school. For more than 8 years, Kara suffered from temper tantrums, impulsiveness, inappropriate behavior, difficulty in judgment, and sleep issues. As a psychiatric mental health nurse practitioner working with pediatric clients, you must be able to assess whether these symptoms are caused by psychological, social, or underlying growth and development issues. You must then be able recommend appropriate therapies.

This week, as you examine antidepressant therapies, you explore the assessment and treatment of pediatric clients with mood disorders. You also consider ethical and legal implications of these therapies.

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Case Study: An African American Child Suffering From Depression

When pediatric clients present with mood disorders, the process of assessing, diagnosing, and treating them can be quite complex. Children not only present with different signs and symptoms than adult Case study: An African American child suffering from depression clients with the same disorders, but they also metabolize medications much differently. As a result, psychiatric mental health nurse practitioners must exercise caution when prescribing psychotropic medications to these clients. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat pediatric clients presenting with mood disorders.NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment

Note: This Case Study: An African American Child Suffering From Depression Assignment is the first of 10 assignments that are based on interactive client case studies. For these assignments, you will be required to make decisions about how to assess and treat clients. Each of your decisions will have a consequence. Some consequences will be insignificant, and others may be life altering. You are not expected to make the “right” decision every time; in fact, some scenarios may not have a “right” decision. You are, however, expected to learn from each decision you make and demonstrate the ability to weigh risks versus benefits to prescribe appropriate treatments for clients.

Case Study: An African American Child Suffering From Depression

NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment

Case Study: An African American Child Suffering From Depression Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

Note: To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 6, “Mood Disorders”

Chapter 7, “Antidepressants”

Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

Note: To access the following medications, click on the The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Review the following medications:

amitriptyline
bupropion
amitriptylinebupropioncitalopramclomipraminedesipraminedesvenlafaxinedoxepinduloxetineescitalopramfluoxetinefluvoxamineimipramine
ketamine

mirtazapine

nortriptyline

paroxetine

selegiline

sertraline

trazodone

venlafaxine

vilazodone

vortioxetine
citalopram
clomipramine

Case Study: An African American Child Suffering From Depression
Magellan Health, Inc. (2013). Appropriate use of psychotropic drugs in children and adolescents: A clinical monograph. Retrieved from http://www.magellanhealth.com/media/445492/magellan-psychotropicdrugs-0203141.pdf

Rao, U. (2013). Biomarkers in pediatric depression. Depression & Anxiety, 30(9), 787–791. doi:10.1002/da.22171

Case Study: An African American Child Suffering From Depression

Note: Retrieved from Walden Library databases.

Vitiello, B. (2012). Principles in using psychotropic medication in children and adolescents. In J. M. Rey (Ed.), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions. Retrieved from http://iacapap.org/wp-content/uploads/A.7-PSYCHOPHARMACOLOGY-072012.pdf

Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

Note: Retrieved from Walden Library databases.

Case Study: An African American Child Suffering From Depression Required Media

Laureate Education (2016e). Case study: An African American child suffering from depression [Interactive media file]. Baltimore, MD: Author.

Note: This case study will serve as the foundation for this week’s Assignment.

Case Study: An African American Child Suffering From Depression Optional Resources

El Marroun, H., White, T., Verhulst, F., & Tiemeier, H. (2014). Maternal use of antidepressant or anxiolytic medication during pregnancy and childhood neurodevelopmental outcomes: A systematic review. European Child & Adolescent Psychiatry, 23(10), 973–992. doi:10.1007/s00787-014-0558-3

Gordon, M. S., & Melvin, G. A. (2014). Do antidepressants make children and adolescents suicidal? Journal of Pediatrics and Child Health, 50(11), 847–854. doi:10.1111/jpc.12655

Seedat, S. (2014)NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment . Controversies in the use of antidepressants in children and adolescents: A decade since the storm and where do we stand now? Journal of Child & Adolescent Mental Health, 26(2), iii–v. doi:10.2989/17280583.2014.938497

To prepare for this Case Study: An African American Child Suffering From Depression Assignment:

Review this week’s Learning Resources. Consider how to assess and treat pediatric clients requiring antidepressant therapy.

The Case Study: An African American Child Suffering From Depression Assignment

Examine Case Study: An African American Child Suffering From Depression. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment

Decision #1: Case Study: An African American Child Suffering From Depression: NURS 6630

Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2: Case Study: An African American Child Suffering From Depression: NURS 6630

NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment

Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.

BACKGROUND INFORMATION

The client is an 8-year-old African American male who arrives at the ER with his mother. He is exhibiting signs of depression.

Client complained of feeling “sad”
Mother reports that teacher said child is withdrawn from peers in class
Mother notes decreased appetite and occasional periods of irritation
Client reached all developmental landmarks at appropriate ages
Physical exam unremarkable
Laboratory studies WNL
Child referred to psychiatry for evaluation
Client seen by Psychiatric Nurse Practitioner

Case Study: An African American Child Suffering From Depression

MENTAL STATUS EXAM

The PMHNP administers the Children’s Depression Rating Scale, obtaining a score of 30 (indicating significant depression)

Case Study: An African American Child Suffering From Depression RESOURCES

§ Poznanski, E., & Mokros, H. (1996). Child Depression Rating Scale–Revised. Los Angeles, CA: Western Psychological Services.

Decision Point One

Select what the PMHNP should do:

Begin Zoloft 25 mg orally daily
Begin Paxil 10 mg orally daily
Begin Wellbutrin 75 mg orally BID

Case Study of the above client

Decision Point One

I selected Zoloft 25 mg orally daily

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks

No change in depressive symptoms at all

Decision Point Two

Increase dose to 50 mg orally daily

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Depressive symptoms decrease by 50%. Cleint tolerating well

Decision Point Three

Maintain current dose

Guidance to Student

At this point, sufficient symptom reduction has been achieved. This is considered a “response” to therapy. Can continue with current dose for additional 4 week to see if any further reductions in depressive symptoms are noted. An increase in dose may be warranted since this is not “full” remission- Discuss pros/cons of increasing drug dose with client at this time and empower the client to be part of the decision. There is no indication that the drug therapy should be changed to an SNRI at this point as the client is clearly responding to this therapy.

Case Study: An African American Child Suffering From Depression

SAMPLE DECISION TREE ASSIGNMENT

An Elderly Iranian Man with Alzheimer’s

Alzheimer’s condition is a neurodegenerative disease that begins slowly and worsens over a long period of time. The condition has been associated with almost 70% of all dementia cases in the world. The most prevalent early symptoms entail the absence of memory concerning recent events. As the condition progresses, other symptoms such as language difficulties, mood swings, disorientation, behavioral issues, lack of self-care management, and disorientation may occur (Houmani et al., 2018). In a gradual manner, all the bodily functions will be lost resulting in eventual death. As much as the disease’s life expectancy varies, the typical expectancy does not go beyond nine years after diagnosis. Importantly, the disease does not have a cure but it could be managed to ensure that the quality of life of patients suffering from it is improved.

The case study for the present assignment entails the examination and treatment of an elderly Iranian man who displays strange behaviors according to his son. Mr. Akan has lost interest in things that erstwhile interested him. Further, the client has been forgetting things and his subjective test revealed confabulation during mental health testing process. Mr. Akad also has restricted affect and impaired impulse and judgment. A mini-mental state examination reveals that Mr. Akad suffers from major neurocognitive disorder caused by presumptive Alzheimer’s disease. This paper describes the assessment outcomes and treatment options for an elderly Iranian man, who has been diagnosed with Alzheimer’s. The condition can be treated with pharmacological interventions, which are dependent on among other factors dosage, proper selection of drug, and time of use, and administration route.

Decision Point One

For this decision, there were three options listed. One was to begin Razadyne (galantamien) 4 mg daily. The second one was to begin Aricept (donepezil) 5 mg orally at bedtime. While the third one, which was the one that I selected was to begin Exelon (rivastigmine) 1.5 mg orally BID with an increase to 3 mg orally BID in 2 weeks.

Exelon from the chemical compound grevastigmine has been proven to be an effective drug regarding the treatment of Alzheimer’s. The medication works through the enhancement of its cholinergic function. Revastigmine is present in the cerebrospinal fluid 10 hours after administration and has a maximum inhibition of 65%. Further, the drug undergoes rapid and complete absorption with its peak plasma concentration being achieved after an hour of oral administration (Park et al., 2017). In addition, the drug’s bioavailability is about 36% after administration. In addition, the drug is weakly associated to plasma proteins at 40% above the therapeutic range. In addition, the drug is quickly eliminated from the system with over 97% being cleared though the urine (Park et al., 2017). Thus, the drug’s tolerability, safety, and effectiveness in the management of Alzheimer’s are the reasons for its election. On the other hand, Razantine (galantamiem) could not be used as its less effective while its tolerability and safety levels are also low. Studies have shown that the drug may not produce any impact at the starting dosage yet increasing it may not prove effective either. In fact, increasing the dosage may expose the client to side-effects. The same concerns are held for Aricept (Chen et al., 2017). Therefore, starting the client on Exelon is the best decision.

The prescription of Exelon is expected to start the process of remission of Alzheimer’s symptoms. The client is expected to show slight improvements in his behaviors (Yoon et al., 2017). In addition, the Mr. Akid is expected reduction in confabulations and should also show interest in going to church. However, most of these responses are not evident upon his return to the clinic four weeks later. In fact, his son states that his father still did not fancy attending religious activities. He also continues to exhibit disinhibited behaviors. In addition, the client still has confabulation and his MMSE score is still at 18 out of 30. Evidently, Mr. Akid has not responded to the dosage that was administered and necessary action is required.

Case Study: An African American Child Suffering From Depression

Decision Point Two

The options for decision point two involved the following: Increase Exelon to 4.5 mg orally BID, increase Exelon to 6 mg orally BID, Maintain current dose of Exelon, and Add Namenda (memantine) 5 mg orally per day. From these options, the selected decision would be to increase the dosage to 4.5 mg orally BID.

The Exelon dosage that the client has shown is so far safe. Importantly though, the patient has shown some improvement in some of their symptoms as manifested by his participation in church activities. Therefore, the maintenance dose should be increased to 4.5 mg to improve the effect of the drug on the patient’s symptoms (Stahl, 2014b). Whereas the dosage could also be increased to 6 mg, it is important to increase to 4.5 as the nurse continues to monitor the patient’s tolerability. Further, the utilization of Namada at this point is not necessary as the Exelon has not yet reached its full dosage (Yoon et al., 2017). Hence, it is important for that option to be pursued before augmentation is considered. Moreover, the dosage cannot be maintained at current level as there is room to improve the symptoms even further though increasing Exelon’s dosage.

When Exelon’s dosage is increased, the disinhibition symptom is expected to improve. Also, the patient’s confabulation is expected to disappear as a consequence of this increase. Upon the client returning to the clinic after four weeks, he showed good tolerance to the medication. Further, the son states that the father is attending religious services with his family. However, the father still finds amusement in things that he initially used to enjoy. All the results were expected as Exelon could only improve certain symptoms and not some (Chen et al., 2017). The fact that the Mr. Akkid finds some activities amusing to him is due to the fact that the medication does not improve cognitive function.

Decision Point Three

After another four weeks, the client comes back to the clinic. The decisions available to the client entail increasing Exelon to 6 m and maintaining the dose at 4.5 mg. The nurse will choose to increase the dosage to 6 mg.

According to studies, the maximum dosage of Exelon is 6 mg. However, this is subjective to tolerability and safety of the medication. Given that the client has tolerated the medication at 4.5 mg without showing any side-effects, it becomes paramount to increase its dose to 6 mg (Park et al., 2017). Thus, maintaining the dosage at 4.5 is not recommended. In addition, augmentation with Namenda should not be contemplated as the nurse has not explored the optimum dosage of Exelon.

Given that 6 mg is the maximum dose of Exelon. Consequently, its impact is expected to be at full-strength. For this reason, some of the symptoms of the conditions are expected to improve further. While this was the case, some symptoms still persisted. This was consistent with the standard expectation regarding the condition. According to studies, the degenerative aspect of the condition cannot be managed by cholinesterase inhibitors such as Exelon. Thus the existence of some of the original symptom in the patient was expected by the nurse.

Case Study: An African American Child Suffering From Depression

Conclusion

The treatment of various conditions is always undertaken under the objective of complete remission of the symptoms. However, the treatment of Alzheimer’s is varied as the symptoms cannot be totally obliterated. To this end, the nurse needs to constantly remind the client’s family of the painful trajectory of presumptive Alzheimer’s treatment. In the nurse’s communication, he should always remind the family of this fact in a compassionate way. Even as the nurse reminds the family of this, they should be cognizant of the fact that they need to improve the life of the patient notwithstanding.

References

Chen, R., Chan, P., Chu, H., Lin, Y., Chang, P., Chen, C., & Chou, K. (2017). Treatment effects between monotherapy of donepezil versus combination with memantine for Alzheimer disease: A meta-analysis. Plos ONE, 12(8), 1-14. doi:10.1371/journal.pone.0183586.

Houmani, N., Vialatte, F., Gallego-Jutglà, E., Dreyfus, G., Nguyen-Michel, V., Mariani, J., & Kinugawa, K. (2018). Diagnosis of Alzheimer’s disease with Electroencephalography in a differential framework. Plos ONE, 13(3), 1-19. doi:10.1371/journal.pone.0193607

Park, K. W., Kim, E., Han, H. J., Shim, Y. S., Kwon, J. C., Ku, B. D., & … Kim, B. C. (2017). Efficacy and tolerability of rivastigmine patch therapy in patients with mild-to-moderate Alzheimer’s dementia associated with minimal and moderate ischemic white matter hyperintensities: A multicenter prospective open-label clinical trial. Plos ONE, 12(8), 1-14. doi:10.1371/journal.pone.0182123

Yoon, S. J., Choi, S. H., Na, H. R., Park, K., Kim, E., Han, H. J., & … Na, D. L. (2017). Effects on agitation with rivastigmine patch monotherapy and combination therapy with memantine in mild to moderate Alzheimer’s disease: a multicenter 24-week prospective randomized open-label study (the Korean EXelon Patch and combination with mEmantine Comparative Trial study)*. Geriatrics & Gerontology International, 17(3), 494-499. doi:10.1111/ggi.12754

Rubric Detail

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Name: NURS_6630_Week4_Assignment_Rubric

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Excellent

Point range: 90–100
Good

Point range: 80–89
Fair

Point range: 70–79
Poor

Point range: 0–69
Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.

8 (8%) – 8 (8%)
The response accurately summarizes the case for the Assignment.

The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.

7 (7%) – 7 (7%)
The response inaccurately or vaguely summarizes the case for the Assignment.

The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.

0 (0%) – 6 (6%)
The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.

The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
Decision #1 (1–2 pages)

• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.

16 (16%) – 17 (17%)
The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.

14 (14%) – 15 (15%)
The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.

0 (0%) – 13 (13%)
The response inaccurately and vaguely explains the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.
Decision #2 (1–2 pages)