Alzheimer’s Disease: Diagnosis, Medications And Palliative Care

Expected Medications

The patient Amy first reported problems in finding appropriate words and was also found to repeat herself, while participating in conversations. This was noticed by her son Eric, who also noted that his mother faced difficulties in concentrating on certain tasks for long period of time. Furthermore, memory deficits were also heightened by the fact that she forgot to pay the telephone bills for two consecutive months. This behaviour was quite unlikely of her and made her son worried. Furthermore, it is quite evident from Amy’s story that she is gradually facing problems in remembering things or words that have already been communicated, such as the visit of her son with his partner. The aforementioned symptoms and presenting complaints led to the diagnosis of Alzheimer’s disease. This was usually diagnosed based on the medical history, the information from the close relatives and behavioural observations. Persisting neuropsychological and neurological features also supported the diagnosis of Alzheimer’s disease that can ne defined as a condition involving a chronic neurodegenerative disease. This condition usually worsens over time (1). This has also been established as the major reason of dementia in around 60-70% individuals.

Research evidences have investigated the most common symptoms of the condition as short term memory loss that makes it difficult for the affected individuals to remember recent events. The gradual loss of bodily functions often makes it difficult for the individual to form an active part of the society and community, and ultimately results in death (2). According to the reports, there were approximately 46.8million people suffering from dementia on a global scale. management, the report also suggested that 58% of individuals with dementia and Alzheimer’s disease live in middle and low income countries (3). The fastest growth is observed among the elderly population in India, China, and other south Asian and western Pacific regions.

The genetic heritability of the condition is based on different twin and family studies that have been conducted on a large scale. Most research studies provide evidence for the fact that 0.1% of the diseases are familial kinds of autosomal dominant inheritance that shows an onset near 60-65 years of age (4). Most of the autosomal dominant familial condition can be attributed to presence of mutations in one of the three genes, namely amyloid precursor protein (APP), presenilins 1 and presenilins 2 (5). Furthermore, the amyloid hypothesis postulatws that extracellular deposits of amyloid beta (A_β) acts as the contributing factor to the development of the disease (6). In addition, abnormalities or misfolding of the tau proteins have also been identified as major risk factors for the condition. These give rise to the formation of neurofibrillary tangles inside the cyton of neurons, thereby resulting in disintegration of the microtubules (7).

Summary of assumption

Laboratory tests conducted on the patient included FBC, ESR, thyroid function test, vitamin B12 and folate, cholesterol tests, LFT, U&E, and calcium and magnesium tests. The results were within the normal range for each of these tests. An advanced medical imaging of the patient Amy with CT scan and MRI showed loss of synapses and neurons from the cerebral cortex and subcortical regions of the brain. This eventually leads to atrophy of the regions affected, including a gradual degeneration of the parietal and temporal lobe, and specific portions of the cingulate and frontal cortex (8). Furthermore, her diagnosis was confirmed by the mini-mental state examination (MMSE), which evaluated presence of cognitive impairment. This was followed by an assessment of the intellectual functioning of the patient that included tests for memory and helped in further characterizing the state of the prevailing disease (9). The patient Amy, exhibited loss of motivation, mood swings, problems in language comprehension and disorientation. Hence, all the aforementioned test results confirmed Alzheimer’s disease.

The medications were administered by the nurse unit manager Misha, to manage the presenting complaints of the patient. There is no absolute cure for Alzheimer’s disease. However, the commonly administered treatments are found to offer relatively small benefits, although being palliative in nature. The patient Amy was under several medications that were administered to treat the cognitive problems that she suffered from. The major medications that were given to her include acetylcholinesterase inhibitors, NMDA receptor antagonists. One characteristic feature of the condition is a reduction in the activity of cholinergic neurons. Acetylcholinesterase inhibitors are generally administered with the aim of reducing or eliminating high rates of breakdown of the neurotransmitter acetylcholine (ACh), thereby increasing ACh concentration in the brain (10). This helps to combat the loss of the neurotransmitter that occurs due death of cholinergic neurons. There are several evidences that have investigated the effectiveness these medications in treating mild to moderate Alzheimer’s disease. Upon administration of this medication, some common side effects that might have been encountered by Amy include vomiting and nausea, both of which are associated with cholinergic excess. These adverse effects are mild in their severity and generally get adjusted with the medication doses (11). Rivastigmine was administered via a transdermal patch and reduced the severity of the presenting symptoms.

On the other hand, the NMDA receptor antagonist belongs to a class of anesthetics that were prescribed for inhibiting the action of the NMDA receptors. This can be attributed to the fact that hypofunction of these receptors are most common with aging of the brain, which in turn contributes to the aging associated with memory deficits (12). Memantine was frequently administered as the NMDA antagonist that acted on the glutamergic system and blocked the receptors, thereby inhibiting glutamate overstimulation. However, some of the major side effects that might have been encountered due to the prescribed medication include headache, fatigue, dizziness, and confusion (13).

With a progress of the neurodegenerative condition in the patient Amy, her behavioural and neuropsychiatric changes became more prevalent. Some of the most common manifestations were in the form of irritability, wandering, and labile affect. This often resulted in outbursts, crying or unpremeditated aggression. Furthermore, a resistance was also displayed towards caregiving. Approximately 30% of individuals, suffering from AD are known to develop delusion and other illusionary misidentification related symptoms (14). In this case scenario, the patient probably lost an insight of her disease process and suffered from anosognosia. These advanced age symptoms often created stress for the carers and relatives, which was partly reduced by moving the patient Amy from home care to and aged-care facilities. During her final stages, the patient was found to be completely dependent upon her caregivers.

The language comprehension ability was reduced to single words and simple phrases that eventually resulted in complete speech loss. Despite the loss of ability that pertained to verbal language disabilities, the patient could often return emotional signals. Furthermore, Amy also became unsteady on her feet and faced difficulties in performing simple tasks independently. The overall objective of palliative care is to improve the quality of life of the patient. The palliative approach was provided in a way that was not only beneficial at the end-of-life but often during the months in advanced stage of the disease (15). Involvement of a palliative care team was useful for Amy in a plethora of ways. Palliative care assisted in helping the patient cope with some of the major Alzheimer’s disease symptoms, such as, anxiety, depression, and sleeping difficulties. Owing to the fact that Amy has been shifted to a palliative care unit due to deterioration of her symptoms, it is expected that the care team focused on administration of antidepressant drugs (16). The antidepressant that was prescribed for Amy in palliative care include selective serotonin reuptake inhibitors. Research evidences suggest that SSRI drugs increase the extracellular serotonin levels, thereby limiting the absorption of the neurotransmitter into the presynaptic bulb. This increases the levels of serotonin that is available in the synaptic cleft to bind to the postsynaptic receptors.

Furthermore, SSRIs have also been established as the first line of treatment for severe depression in most individuals. Individuals suffering from Alzheimer’s disease are at an increased likelihood of suffering from depression (17). Hence, SSRIs were administered during the palliative care. It is well known that the neurological changes that occur in the brain in Alzheimer’s disease and other dementia forms are incapable to causing pain (18). However, people with Alzheimer’s are more susceptible to experiencing pain due to the fact that they remain at increased risk of accidents, falls, and injuries, which might result in pain. The primary task of palliative care professionals is to provide assistance to individuals who suffer distress due to pain, at the end of their lives. An impairment in physical mobility results in pain. It is expected that the health professionals administered morphine as the first line treatment for pain management. It belongs to the opioid class of drugs and directly acts on the central nervous system to reduce feelings of pain (19). It primarily interacts with the μ-opioid receptors that are located distinctly in the hypothalamus, thalamus, amygdala, putamen and nucleus caudatus (20).

Upon binding to the receptors, morphine has proved successful in initiating sedation and analgesia. Keeping in consideration the health status of the patient, a low dose of morphine was prescribed for Amy. Further evidences suggest that morphine creates little or no effect on the survival rate of a patient in palliative care settings (21). However, care was taken to prevent overdose of the drug, in order to eliminate risks of respiratory distress or asphyxia. During transition of the patient to the end-stage of the condition, symptoms related to severe pain, exhaustion and apathy are likely to get exacerbated. Furthermore, there will be complete loss of the ability to speak, and the patient will become completely bedridden, and was unable to feed herself. One of the major techniques that will be used in planning her end-of-life daily care is related to maintenance of a routine.

Effective comfort care was provided to the patient in a way that made the caregivers display essential skills to assess the facial expressions, reactions and movement. In addition to providing good physical support, the spiritual and emotional distress of the patients was also addressed. This was achieved by creating provisions for counseling, in addition to administration of SSRIs. Furthermore, respite care was also provided, in combination with grief support for the family members. They were also responsible for monitoring the patient to view any adverse effects of the medicines on patient health. Supplementary oxygen delivery also proved beneficial during the advanced stage, which in turn helped in treating respiratory distress (22).

Dr. Borgart (Hyopothetical)

Neurologist

Date: May 2 2018

Re: Ms. Amy’s Medication Management Review Referral Report

Dear Dr. Borgart,

Thank you for referring Ms. Amy, a 59 year old patient, for a MMR. Ms. Amy does not have a sound understanding of her medical condition and the current medical regimen. She is suffering from memory deficits and faces difficulties in mobility and language comprehension. Moreover, she also reports of acute pain that has deteriorated, with a progress of her condition. She also shows noncompliance to the medications.

Please consider the following recommendations and suggest if you consider them beneficial for Ms. Amy.

1. Memory deficits: She finds it extremely difficult to remember her name or recognize her family members. Further problems are related with onset of dysphagia. Please suggest if increasing the dose of rivastigmine would benefit her.
2. Depression: Her depressive symptoms are worsening with time. Please suggest if administration of citalopram, in combination with fluoxetine would help.
3. Pain: She is constantly reporting symptoms of pain due to mobility impairment. Please suggest if administration of oxycodone, twice daily would help her.

Please refer to the table of recommendation attached herewith, which will provide evidence for the medication and proposed changes in medication plan. These recommendations have been formulated by taking into consideration the medical history and presenting complaints of the patient, in addition to the diagnostic results. An improvement in the patient’s condition would require further amendments to the recommendations.

I look forward to receiving your suggestions. Please do not hesitate to contact me for discussing any additional information.

Yours faithfully,

(Name and date)

Name:	Amy (Lan)
Address:	—————
Phone number:	_______
Date of Birth:	22.10.1959
Marital status:	Divorced
Gender:	Female
BMI	22.4
Allergies:	Allergy to pollen
LF:	Not compromised
Pregnancy	Yes
Breastfeeding	Yes
Smoking:	Yes
Alcohol:	Occasionally
Carer details	Nurse unit manager, family members, medical interpreter
Treating Dr. details	Neurologist

Advanced stage Alzheimer’s disease

Patient History

She has a history of smoking since the age of 20. Medication history of Amy indicates that she had suffered from angina at 45 years of age.

Presenting complaints

• Memory loss
• Episodes of forgetfulness
• Forgetting names of family members
• Confused state of mind
• Sleep problems
• Poor thinking ability
• Restricted mobility
• Repeating same terms
• Anxious and depressed state of mind
• Pain
• Speech problems

Brand/Generic and Strength	Dose/Duration/frequency	Date initiated	Current/ceasing date
Aspirin	Twice daily	02.03.2004	Till date
Atenolol	50 mg orally, once a day	02.03.2006	Till date

Brand/Generic strength	Dose/duration/frequency	AMH or MIMS recommended dose duration or frequency
Morphine	5mg	Every 6 hours
Rivastigmine	4.6mg, transdermal	q24hr
Memantine	5mg	b.d
Escitalopram	10mg	q.d

Parameters	Normal reference	Amy’s results	Significance
CT Scan	No plaques in the brain	Greater deposition of amyloid plaques in brain	Positive diagnosis of AD
MRI	No change in brain structure and cells	Loss of brain mass, atrophy in hippocampus	AD confirmed
MMSE	Score of 30 points	Score of 11	AD confirmed
FBC	WBC: 4.0-11.0 Platelets: 150-450 Neutrophils: 1.8-7.5 Lymphocytes: 1.5-4.0 Monocytes: 0.2-0.8 Eosinophils: 0.1-0.4 Haematocrit: 0.4-0.52 Haemoglobin: 130-175	WBC: 7.0 Platelets: 320 Neutrophils: 5.8 Lymphocytes: 3.7 Monocytes: 0.51 Eosinophils: 0.33 Haematocrit: 0.42 Haemoglobin: 159	No abnormalities
ESR	0-29 mm/hr	19 mm/hr	No abnormalities
Vitamin B12	160-200 to 1000 pg/mL	753 pg/mL	No deficiency
Folate	4.0-19.9 ng/mL	11.3 ng/mL	No abnormalities/anemia
Thyroid function test	TSH: 0.5-4.7 mU/L T3: 0.92-2.78 nmol/L FT3: 0.22-6.78 pmol/L T4: 58-140 nmol/L FT4: 10.3-35 pmol/L	TSH: 3.7 mU/L T3: 1.98 nmol/L FT3: 5.58 pmol/L T4: 113 nmol/L FT4: 22.1 pmol/L	No abnormalities
U&E	Creatinine: 0.8-1.3 mg/dL Blood urea nitrogen: 8-21 mg/dL Ferritin: 12-150 ng/mL Glucose: 65-110 mg/dL	Creatinine: 0.92 mg/dL Blood urea nitrogen: 13.5 mg/dL Ferritin: 127.56 ng/mL Glucose: 89 mg/dL	No abnormalities
LFT	ALT: 7-56 units/liter AST: 10-40 units/liter	ALT: 36 units/liter AST: 27 units/liter	No abnormalities
Cholesterol test	Total cholesterol: LDL cholesterol: HDL cholesterol: >60 mg/dL Triglycerides: Non-HDL-C: TG to HDL ratio:	Total cholesterol: 168 mg/dL LDL cholesterol: 112 mg/dL HDL cholesterol: 87 mg/dL Triglycerides: 109 mg/dL Non-HDL-C: 115 mg/dL TG to HDL ratio: 1.2 mg/dL	No abnormalities
Calcium test	8.5-10.2 mg/dL	9.1 mg/dL	No deficiency
Magnesium test	1.5-2.5 mEq/L	1.9 mEq/L	No deficiency

Current condition/drug problem	Current managements EBM discussions and things you already did	Recommended actions or change	Expected outcome
Memory deficits	Patient demonstrates worsening of memory that is disrupting the daily life.  Low dose of rivastigmine did not slow down the symptoms.	Increase dosage of rivastigmine	Prevent further deterioration of cognitive faculties related to thinking and memory and reduce decline of functional activities
Pain	Morphine failed to cure the severe pain, which has made the patient bedridden	Administration of oxycodone, twice daily	It will provide relief from the severe pain
Depression	Gradual memory loss and mobility impairment are adding to her depression	Administration of citalopram, in combination with fluoxetine	Reduction in depressive symptoms

 

Domains of QoL in Alzheimer disease patients often include the ability to perform daily activities and competent cognitive functioning. The QoL can be enhanced by helping the patient engage in display of appropriate social behavior. There is a need to gain a deeper understanding on the condition and learn about the progress of the disease. Efforts must be taken ask Amy about her preferences and opinions (23). Building on her strength and abilities and supporting her to remain as independent as possible will be beneficial.

Creating a living space that is familiar and able to provide her with a sense of security will also improve the overall health and wellbeing. Respecting the need for companionship and fostering development of effective relationship of the patient with her family and friends are integral to the practice (24). Involving the family members in shared decision making process will also create significant improvements on her quality of life.

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