Dementia Case Study & Blackboard Discussion

Alzheimer's Disease (AD) Case: Part 1 Treatment of Dementia

Patient: JB is an 80 year old female.

Past Medical History: Hypertension for 15 years, well controlled

Medications:
• Hydrochlorothiazide 25 mg daily x 15 years
• Ramipril 5 mg daily x 3 years
• Omeprazole 20mg daily x 2 years
• Oxybutinin 5 mg daily x 1 month
• Dextromethorphan 15mg/5mL qid prn x 2 weeks

Renal Function: Serum creatinine 130 mmol/L (55-104), creatinine clearance 30mL/min

History of Present Illness / Disease Course:

JB was a lively, outgoing person until age 72, when gradual changes in her memory and
personality began to occur.

From age 72 to 74
• JB begins to forget where she places objects and forgets names of people she knows well.
• Her doctor found no memory deficit on clinical interview.

From age 74 to 76, although JB was living independently in her own apartment, her daughter,
Rose, was becoming increasingly worried about her because she was:
• becoming more forgetful
• has difficulty remembering the names of people that she has recently met and has trouble
remembering the story line when reading a book
• she denies any memory problems and seems to be anxious
• still able to prepare meals and maintain usual household routines
• at her last doctor visit, she performed well on the MMSE

From age 76-78

• more socially withdrawn and having difficulty doing housework and preparing meals
• but still recognized Rose and manages with a little help from people in the building
• Rose helps with finances
• generally unaware of current events
• rarely leaves the apartment without Rose accompanying her.
• personality is now much less vibrant
• when shopping, she only goes to familiar stores
• when Rose uses a debit card to pay for items, JB does not understand this
• Rose is surprised at the number of routine things that JB does not know
Age 78-80 In the past 2 years JB has been living with her daughter and son-in-law. Her condition
can be described as follows:
• her personality has changed significantly and her memory has declined further
• sleeps in longer in the morning and stayed up longer a night.
• becomes frustrated easily at not being able to do things, remember the right words or
remember the names of people
• has no interest in the TV or radio but seemed to enjoy background music
• requires reminding to bathe, comb her hair and brush her teeth.
• wears the same clothes each day if not reminded to put on other clothes.
• responds to questions but otherwise, speaks very little during the day.

Due to these symptoms, Rose took JB to see a gerontologist who prescribed donepezil 5 mg at
bedtime x 2 weeks, then increase to 10 mg at bedtime.
JB seemed to tolerate donepezil well for the first 2 weeks except for diarrhea that lasted only 2
days and occasional dizziness, but no falls.
After 3 weeks of the 10 mg at bedtime dose, side effects became significant: confusion, falls,
one of which caused a broken arm, excessive salivation, anorexia, muscle cramps, insomnia and
fatigue. At this point Rose stopped donepezil and took JB to the gerontologist to see if there
were any other drugs that could be tried.

The gerontologist discontinued donepezil and prescribed rivastigmine 1.5 mg bid x 2 weeks and
then increase to 3 mg bid. Rivastigmine was well tolerated for the first 2 weeks and seemed to
be helping. However, since the dose was increased to 3 mg twice daily, nausea and
vomiting have become a big problem.

AAMI MCI Mild Moderate Severe

JB’s age 72-74 74-76 76-78 78-80
MMSE 30 26 24 18-10 <9
Duration in 2 years 2 years 2 years 2 years
JB’s case
Typical 8 years 10 years 3-5 years 2-5 years 5-8 years
duration
AAMI=age associated memory impairment
MCI= mild cognitive impairment
Case Developed by: Larry Jackson

Assignment
The class has been divided into therapeutics groups. Using the therapeutic thought process students in
each group should work-up the above patient case including both patient assessment and care plan.

As a group, students should work on the patient assessment as summarized in the table below.
Students within each group are assigned to prepare selected parts of the care plan. One student from
each group should put together the completed care plan.
 • State the current signs & symptoms and describe the urgency of the situation
• Explain whether or not the signs and symptoms are due to a disease or
secondary to current drug therapy
PATIENT • Explain whether or not the signs and symptoms require therapy
GROUP
ASSESSMENT • Identify and state the actual and potential drug therapy problems (post on
blackboard discussion forum by 3rd day of module)
• Review the non-drug alternatives
• Review the drug alternatives
• Identify general and specific goals for therapy [Remember specific goals of
Goal therapy have 3 components: 1) a realistic, measureable, clinical parameter,
Setter and 2) degree of change that occurs within 3) an appropriate time frame.]

CARE PLAN • Select a therapeutic regimen and non-drug therapy plan to resolve the drug
(Post to therapy problem [Remember to identify drugs to 1) start- including drug,
Planner discussion dose, route, frequency, duration; 2) stop, 3) change and; 4) continue.]
board on 4th Provide justification for plan including why other alternatives were ruled in
day of and out and why the specific alternative was selective over other alternatives.
module) • Identify and describe relevant patient education and counselling points
Educator
(Remember IESC)
• Develop an evaluation and monitoring plan (Remember to consider positive
Monitor and negative endpoints, measureable, clinical parameters, degree of change
and an appropriate time frame for evaluation.)

Day 3: Post Drug Therapy Problems identified by the group

Day 4: Drug Therapy Problem discussion:

Once drug therapy problems (DTPs) have been posted to the blackboard discussion forum, students are
required to discuss the following:
1. Do you agree with the DTPs that have been stated? Are there any other actual or potential
DTPs? How would you prioritize the DTPs?

Day 4: Post Care Plan prepared by the group

Day 5: Care Plan discussion:

Once therapeutic plans have been posted to the blackboard discussion forum, students are required to
critique posted therapeutic plans. Discuss the following points related to the posted therapeutic plans:
1. How well do you think the care plans will resolve the DTP? Explain
2. What changes might you make? Why?
3. How well will potential side effects be managed? Explain