PMHNP Role Adults and Older Adults Report

Neurocognitive Disorders

Neurocognitive disorders are conditions that describe diminished mental function related to a medical disease other than a psychiatric condition leading to cognitive deficit attributed by a metabolic brain disease. These conditions are categorized and diagnosed depending on the severity of the patient’s symptoms. Notably, major cognitive disorders affect approximately 1 to 2% of people aged by age of 65 years and 30% of people by 85 years (). More importantly, neurocognitive disorders are not developmental conditions but can be caused by brain damage in sections associated with learning, planning, decision making, memory and understanding language. Patients suffering from neurocognitive disorders present various symptoms including making concrete decisions, diminished memory, struggle performing daily activities, trouble focusing on tasks and inability to name people and objects as well as speaking and behaving in an unacceptable social manner (APA, 2013). Alzheimer conditions account for major neurocognitive conditions including frontotemporal degeneration, Lewy body disease not limited to traumatic brain disease. This paper seeks to explore a case study of 76-year-old Caucasian male and make three decisions and discussing the rationale of each decision. In addition, the paper will discuss various ethical considered that would influence the treatment plan as well as the communication with the patient and the family.

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Decision #1: Differential Diagnosis

Major Neurocognitive disorder with Lewy bodies

Rationale

Based on the clinical manifestations presented, Mr. Wingate is diagnosed with Major Neurocognitive disorder with Lewy bodies characterized by diminished performance in various cognitive domains such as engaging in tasks that need complex attention (APA, 2013). According to DSM-5 diagnostic criteria, Mr. Wingate conditions has an insidious onset and has gradually developed since for the last 6 months has had coordination problem and the family doctor suggested a “late-onset Parkinson’s diseases” fulfilling criterion B of the diagnosis. In addition, his cognition has been fluctuating and he could spell “WORD” in reverse despite his academic qualification, nightmares and cognitive decline fulfilling criterion C of MNDLB (APA, 2013). More importantly, there is no evidence that Mr. Wingate’s diminished cognition may be caused by delirium.

Mr. Wingate could not be diagnosed with major neurocognitive disorder due to Alzheimer’s disease since there is no evidence his condition is related to an Alzheimer disease. Based on DSM-5, for one to be diagnosed with major neurocognitive disorder due to Alzheimer’s disease, one must present evidence that the causative Alzheimer disease is a genetic mutation from family history or genetic testing evidence (APA, 2013). Despite Mr. Wingate presenting mild apathy and diminished executive abilities, he could not be diagnosed with the major frontotemporal neurocognitive disorder (FTNCD). To meet the diagnostic criteria for FTNCD, he must present three or more behavioral indicators including apathy, loss of empathy or sympathy, hyperorality and dietary changes as well as behavioral disinhibition and stereotyped or compulsive behavior. In addition, Mr. Wingate does not present any language variant including a decline in language ability, word finding, word comprehension, object naming or speech production (APA, 2013)

Decision #2: Pharmacological Treatment Plan

Begin Rivastigmine 1.5 mg BID orally

Rationale

On my second decision I chose to administer Mr. Wingate’s condition with Begin Rivastigmine 1.5 mg BID orally since the drug is a cholinesterase inhibitor and a proven class 1 evidence in the treatment of MNDLB (). The drug presents a deep decrease in cholinergic function with comparative neuronal preservation on patient’s suffering from MNDLB and hence improvement in memory and attention. According to (Boot, 2015), the drug has a significant impact on patients presenting symptoms such as hallucinations, delusion, anxiety, and apathy. On the other hand, it would inappropriate to administer Olanzapine given the drug has adverse effects on parkinsonism and might increase extrapyramidal symptoms. Moreover, olanzapine which is an antipsychotic drug is not approved by the FDA to geriatric patients with dementia due to increased mortality rate (Gabbard, 2014). As well, administering Remolten in used in the treatment of insomnia and there is no evidence on the efficiency of the drug in addressing cognitive impairment.

Expected outcomes

Upon administration and strict adherence to Rivastigmine 1.5 mg BID orally, Mr. Wingate symptom is expected to diminish significantly. As such, the medication will prohibit further development of the condition and his memory, attention and cognitive function are expected to improve significantly. According to Boot (2015), the dosage of cholinesterase inhibitors will help to suppress the MNDLB with minimal side effects.

Expected outcomes against actual outcomes

After the client returned to the clinic after four weeks, Mark the elder son to Mr. Wingate revealed that his father seems to tolerate the medication despite no improvement in Mr. Wingate’s condition. However, he reported his condition has not improved or worsened and his father’s nightmare seems to be worsening and he seems to “act out” his nightmare more. According to Stahl (2014), Rivastigmine takes time before it takes effect on the patient’s condition

Decision #3: Psychopharmacological Treatment Plan

Begin Clonazepam 0.5mg orally at bedtime

Rationale

In my third decision, I opted to begin a low dose of Clonazepam 0.25mg orally at bedtime in the treatment of REM disorders in Mr. Wingate’s condition. Clonazepam is a benzodiazepine with a long life and is highly recommended in the treatment of REM disorder. Stahl (2014), asserts that the drug should initially be administered in low doses and gradually increased based on patient’s response. On the other hand, it did not recommend beginning Seroquel at bedtime. Despite the effectiveness of Seroquel, the medication which falls under antipsychotic drugs is linked with increased risk of severe side effects on MNDLB geriatric patients including malignant neuroleptic syndrome, somnolence, extrapyramidal symptom and increased mortality (Behrman, Burgess & Topiwala, 2018). As well, it would not be prudent to educate the patient and the family that Rivastigmine takes time to take time to stop the nightmares as the drug seems to worsen Mr. Wingate condition. More importantly, there is no evidence established of Rivastigmine in treating REM disorders.

Expected Outcomes

Upon administration of Clonazepam 0.25mg orally at bedtime for four weeks, the client is expected to tolerate the drug with minimal or no side effects. In addition, the client is expected to report reduced REM symptoms and overall diminished symptoms of his MNDLB condition characterized by improved attention, memory and cognitive functions

Ethical Implications

It is crucial to note that communication between health professionals, the patient, and their families can impact significantly on the health wellbeing of the patient in addition to the outcome and quality of care. As such, a competent PHMNP should put themselves in patient’s position to be able to render quality of care and ensure their views or opinions should not interfere with their capacity to launch a positive communication with the client and their families (Loghmani, Borhani & Abbaszadeh, 2014). However, PMHNPs can offer their professional view in a therapeutic manner including explaining the side effects of drug prescribed. More importantly, the treatment plan followed the ethical standards and guidelines in communicating, diagnosing and treating the patient and engaging the son. The whole treatment observed the bioethical principles of beneficence and nonmaleficence. As such, all decisions recommended were in the best interest and benefit the patient anchored on the bioethical principle of beneficence (do good). More so, all decisions achieved, and drugs prescribed were evidence-based and the medications were openly communicated to the patient and the family member.

Conclusion

In conclusion, neurocognitive disorders are primarily acquired cognitive disorders or developmental disorders interfering with independence characterized by cognitive decline not due to delirium or other psychiatric condition. Mr. Wingate was diagnosed with the major neurocognitive disorder with Lewy bodies characterized by poor memory, fluctuating alertness, poor coordination, disrupted sleep patterns and nightmares as well as short concentration span. As such, I recommended to Begin Rivastigmine 1.5 mg BID orally and after four weeks, I administered Mr. Wingate with Clonazepam 0.5mg orally at bedtime to address his MNDLB condition. All decisions recommended were meant to benefit the patient and as well communicated to the patient and the family member.

PMHNP Role Adults and Older Adults Report

References

American Psychiatric Association. (APA) (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Behrman, S., Burgess, J., & Topiwala, A. (2018). Prescribing antipsychotics in older people: A mini-review. Maturitas, 116, 8-10.

Boot, B. P. (2015). Comprehensive treatment of dementia with Lewy bodies. Alzheimer’s research & therapy, 7(1), 45.

Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.

Loghmani, L., Borhani, F., & Abbaszadeh, A. (2014). Factors affecting the nurse-patient’ family communication in the intensive care unit of kerman: a qualitative study. Journal of caring sciences, 3(1), 67.

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.

PMHNP Role Adults and Older Adults Report