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Walden Neurocognitive Disorder with Lewy Bodies Case Assignment

Part 1

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6670/08/mm/decision_tree/index.html

Examine Case 3: You will be asked to make three decisions concerning the diagnosis and treatment for this client. Be sure to consider co-morbid physical as well as mental factors that might impact the client’s diagnosis and treatment.

At each Decision Point, stop to complete the following:

  • Decision #1: Differential Diagnosis
    • 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: Treatment Plan for Psychotherapy
    • 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: Treatment Plan for Psychopharmacology
    • 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 and their family.

Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO MR. WINGATE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

Major frontotemporal neurocognitive disorder (FTNCD)

Major neurocognitive disorder due to Alzheimer’s disease

Major neurocognitive disorder with Lewy bodies

My decision: Major neurocognitive disorder with Lewy bodies RESULTS OF DECISION

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Begin Rivastigmine 1.5 mg orally twice a day

Begin Olanzapine 5 mg orally at bedtime

Begin Ramelteon 8 mg at bedtime

My decision: Begin Rivastigmine 1.5 mg orally twice a day

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks

Upon his return to your office, Mr. Wingate’s son reported that Mr. Wingate seems to be tolerating the medication well, but he has not noticed any improvement in his father’s memory. He denies any worsening of other symptoms, but also reports no improvement either.

Mr. Wingate’s son does report that Mr. Wingate’s nightmares appear to be getting worse in that he seems to “act out” his nightmares more.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Begin Clonazepam 0.5 mg orally at bedtime

Begin Seroquel 25 mg orally at bedtime

Educate Mr. Wingate and his son regarding the fact that it will take time for the Rivastigmine to stop the nightmares

My decision: Educate Mr. Wingate and his son regarding the fact that it will take time for the Rivastigmine to stop the nightmares

Guidance to Student

In the case of Mr. Wingate, he meets the diagnostic criteria for major neurocognitive disorder as evidenced by a decline from a previous level of performance in more than one cognitive domain—in this case, complex attention and executive function. The decline is based on a knowledgeable informant, as well as a clinician (the patient’s primary care provider) who referred him to you, as well as substantial impairment in another quantified clinical assessment (the MMSE). Cognitive deficits that Mr. Wingate demonstrates interfere with independence in everyday activities and he requires help with complex IADLs such as medication management and paying bills.

Nothing in the scenario suggests that delirium could be responsible for the cognitive decline, nor is anything in the scenario suggestive of another mental disorder.

While one may be initially inclined to consider major neurocognitive disorder due to Alzheimer’s disease, probable Alzheimer’s would require evidence of a causative genetic mutation either from family history or genetic testing, and/or decline in memory and learning and at least one other cognitive domain; steadily progressive, gradual decline in cognition without extended plateaus; and no evidence of mixed etiology (i.e., absence of other neurodegenerative or cerebrovascular disease, or another neurological, mental, or systemic disease or condition likely contributing to the cognitive decline). Similarly, while there is some evidence of mild apathy, and decline in executive abilities, there is insufficient evidence of three or more behavioral symptoms that would be needed to make a diagnosis of major frontotemporal neurocognitive disorder (e.g., behavioral disinhibition, loss of sympathy or empathy, perseverative, stereotyped or compulsive/ritualistic behavior, hyperorality and dietary changes, or prominent decline in social cognition and/or executive abilities) nor is there evidence of prominent decline in language ability, in the form of speech production, word finding, object naming, grammar, or word comprehension that would suggest major frontotemporal neurocognitive disorder.

In Mr. Wingate’s case, there is clear evidence of fluctuating cognition, and spontaneous features of Parkinsonism, which had their onset subsequent to the development of cognitive decline. These symptoms, coupled with the presence of a rapid eye movement sleep behavior disorder, are suggestive of MNDLB. Diagnostic testing should focus on determining the presence of a synucleinopathy.

Since Mr. Wingate’s symptoms are more consistent with MNDLB, the addition of Seroquel may result in severe side effects that could be life threatening and include severe sedation, muscle rigidity, delirium, neuroleptic malignant syndrome, and depending on the source of the study reviewed, neuroleptics may be associated with a 2- to 3-fold increase in mortality, including cerebral vascular accident. Although Seroquel can be used off-label to induce sleep in some patients, there is an FDA warning against the use of antipsychotics in older adults with dementia as they have been associated with an increase in mortality. Therefore, in consideration of the probably diagnosis and presenting symptoms, antipsychotics would not be appropriate.

Acetylcholinesterase inhibitors may be useful in the treatment of NDAD, but there is limited data of their efficacy with MNDLB. If the PMHNP decides to try an acetylcholinesterase inhibitor, the PMHNP should always begin with the lowest starting dose, and then slowly titrate upward, being mindful of the development of side effects. Mr. Wingate and his son should be educated on the fact that acetylcholinesterase inhibitors may slow disease progression, but will not have a significant impact on existing cognitive deficits.

The addition of low-dose Clonazepam (0.25 or even 0.125 mg) may be considered as a treatment for REM sleep disorders in individuals with MNDLB. Since clonazepam has a long half-life, the PMHNP should begin at a low dose, and slowly titrate upward, being mindful to educate the client and family about potential side effects and therapeutic end-goals. Remember that safety is always the first priority with prescribing.

There is no evidence that Rivastigmine has any effect on REM sleep disorders; therefore, the PMHNP should not tell Mr. Wingate or his son that this is an expected outcome of the drug.

Part 2

To prepare for this Assignment:

  • Select an adult or older adult client with an obsessive-compulsive disorder you have seen in your practicum.

In 3–4 pages, write a treatment plan for your client in which you do the following:

  • Describe the HPI and clinical impression for the client.
  • Recommend psychopharmacologic treatments and describe specific and therapeutic endpoints for your psychopharmacologic agent. (This should relate to HPI and clinical impression.)
  • Recommend psychotherapy choices (individual, family, and group) and specific therapeutic endpoints for your choices.
  • Identify medical management needs, including primary care needs, specific to this client.
  • Identify community support resources (housing, socioeconomic needs, etc.) and community agencies that are available to assist the client.
  • Recommend a plan for follow-up intensity and frequency and collaboration with other providers.
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