WEEK 9 Main DQ

Older adults are often affected by a decline in cognition due to Alzheimer’s and dementia.

According to DSM-5 331.83 (31.84), a neurocognitive decline in older adults, also known as

Alzheimer’s disease, is the cause of about 60 to 80 percent of dementia. Dementia impairs the

mental ability to perform activities of daily living. It is not a disease; instead, a cluster of

symptoms that impacts and alters the ability and subsequent deterioration of memory, reasoning,

functioning, and logical thinking in the affected person. Alzheimer’s disease is one cardinal

cause of dementia. As a cluster of symptoms, dementia can be mixed, resulting in the occurrence

of multiple brain changes at the same time. Alzheimer’s disease, also called senile dementia, is a

progressive disease that damages and impedes memory and other vital functions. As the number

one cause of dementia, its pathology affects brain cell connections, and the brain cells degenerate

and die, destroying memory and other vital mental functions. Alzheimer’s disease causes

memory loss and confusion and has no cure. The goal of medication and management strategies

is to improve symptoms and delay their ravaging advancement temporarily.

FDA-approved drug:

The Food and Drug Administration approves the following medications in the USA to help slow

the progression of Alzheimer’s disease and improve memory and cognitive functioning,

donepezil, galantamine, rivastigmine, memantine, and donepezil/memantine combination). Due

to the progressive nature of Alzheimer’s disease, the efficacy of the above five medications will

depend on the stage of the disease. According to FDA, in mild to moderate or moderate to severe

Alzheimer’s disease, Aricept (donepezil) has been approved to be more effective. The National

Institute on Aging, according to research, believes that Aricept (donepezil), galantamine

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(Razadyne), and rivastigmine (Exelon) may assist in slowing down behavioral symptoms in the

interim and delay worsening symptoms.

One non-FDA-approved “off-label” drug:

Medications that fall under antipsychotics, antidepressants, anti-anxiety, and mood stabilizers

can be used to alter the brain waves, thereby improving brain function. A drug like Seroquel can

change a patient's mood, perception, and consciousness with Alzheimer’s disease. The

pharmacist can dispense such medicines because the FDA did not approve them, provided there

is enough evidence documented, other than trial or experimental purposes, to prove that it is an

acceptable practice within the bounds of reasonable standards of health care clinical practice.

One nonpharmacological intervention for treating Alzheimer’s Disease.

Alzheimer’s disease progresses progressively; therefore, a multi-dimensional approach to slow

its progress is a sound clinical decision. Some nonpharmacological interventions that could be

used include cognitive stimulation therapy, validation therapy, and reality reorientation, with

reminiscence therapy as a holistic approach.

Explain the risk assessment you would use to inform your treatment decision-making.

Using the Mini-Mental Examination (MMSE), a set of eleven questions to validate a patient’s

cognitive impairment will guide my decision-making. Other assessment tools that could be used

include the Bristol Activities of Daily Living Scale (BADLS) and Genetic assessment risk

factors obtained through comprehensive family history. There are many clinical guidelines that

real-life modifications can help prevent the cause of the disease, delay disease progression, or

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even improve its ravaging side effects. Such lifestyle modifications include regular exercise, both

physical and mental, moderate alcohol intake, and avoidance of tobacco and head injuries. A

conflicting outcome does exist in the vascular studies that a systolic blood pressure below 140

mmHg is also associated with an increased risk for Alzheimer's disease. A randomized study of

the Guidelines for Neurocognitive disorder treatment conducted by Furey and Wilkins (2019)

used three cholinesterase inhibitors, donepezil, rivastigmine, and galantamine, approved by the

U.S. Food and Drugs as a baseline for the study of dementias. The treatment efficacy is based on

the type of dementia, such as Alzheimer's disease, vascular dementia, and other dementias, and

whether it is mild, moderate, or severe. The participants who received Aricept (donepezil) proved

to have more cognitive functioning and slowed the progression of their dementias than those who

received placebos.

Most of the information to consider is that interdisciplinary and shared clinical decisions are

crucial in the treatment of Alzheimer’s disease. It is what will guide pharmaceutical companies to

comply and dispense a medication approved by FDA for one aliment when it is meant to be used

as a non-approved for what it is prescribed for. It is also essential to verify the ethical and legal

implications of prescribing "off-label medications for the patient’s benefit.

Reference

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American Psychiatric Association. (2016). The American Psychiatric Association practice

guideline on the use of antipsychotics to treat agitation or psychosis in patients with

dementia Links to an external site.. https://doi.org/10.1176/appi.books.9780890426807

American Psychiatric Association (APA) 2013., Diagnostic and statistical manual of mental

disorders 5th ed. DSM-5. American Psychiatric Publishing Washington, DC / London, England

Furey, K. & Wilkins, K. (2019). Prescribing "Off-Label": What Should a Physician Disclose?

AMA J Ethics. 2016;18(6):587-593. DOI 10.1001/journalofethics.2016.18.6.ecas3-1606.

Patterson et al. (2008).Diagnosis and treatment of dementia: 1. Risk assessment and primary

prevention of Alzheim er's disease. CMAJ 2008;178:316-21.

www.cmaj.ca/cgi/content/full/178/5/548/DC1

Rabins, P.V. et al., (2014). Guide watch (October 2014): Practice guidelines for treating patients

with Alzheimer's disease and other dementias. APA Guideline

Watch;

https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimerwatc

h.pd American Psychiatric Association. (2020). Geriatric telepsychiatry Links to an external site.

[Video]. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/geriatric-

telepsychiatry

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Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th

ed.). Wolters Kluwer.” Chapter 33, “Geriatric Psychiatry”

Hi Laura,

Reading your post revealed the challenges a clinician may face when treating a woman with

depression during pregnancy. The challenge is the few medication options/choices suitable

because of the fear of crossing the maternal-placenta barrier to cause a defect in the fetus. Often

time, depression in the first trimester can be missed due to the symptoms of early morning

sickness (Hyperemesis gravidarum ). The treatment plan for depression depends on the type and

severity. If depression is detected early in the pregnancy and still in the mild stage,

psychotherapy, the patient’s support system, and exercise can help the patient. It takes a while for

antidepressants to kick in, educating the patient and family that patience is crucial. Untreated

depression in pregnancy has been linked to differences in the child’s learning and behavior. It is

essential that pregnant women with mental health problems, like depression, are treated for their

own and their baby’s well-being. Taking citalopram in the last month of pregnancy may slightly

increase the risk of postpartum hemorrhage after delivery. It is a treatable side-effect; it is rare

and should not be a reason to stop taking citalopram for most pregnant women. It is important to

note that rarely does SSRI use in pregnancy can cause a problem in the baby, where blood flow

to the lungs is too high. This is called persistent pulmonary hypertension of the newborn

(PPHN). Around one in every 300 babies whose mother takes an SSRI may develop PPHN. As a

precaution, the baby should be checked for breathing problems by a midwife or pediatrician, and

hospital delivery is recommended. SSRIs are commonly taken during pregnancy without any

problem. However, some studies have linked SSRIs to a higher chance of preterm delivery or

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having a baby with low birth weight. However, It is unclear whether these effects are due to

medication or whether they are due to the impact of underlying illness in the mother and other

factors; either way, medication administration in pregnancy should be done with great caution.

Rosenthal, Rosenjack, J., & Laura D. / Burchum. (2018). Lehne's Pharmacotherapeutics for Nurse Practitioners and Physician Assistants (2nd ed.). Elsevier Course Content Deliv

Shweiki, S., & Diav‐Citrin, O. (2021). Pregnancy Outcome after First-Trimester Exposure to Vortioxetine: A case series. Birth Defects Research, 113(6), 511-515.

World Health Organization. (2020). Depression. https://www.who.int/news-room/fact-sheets/detail/depression

Bérard, A., Zhao, J. P., & Sheehy, O. (2017). Antidepressant Use during Pregnancy and the Risk of Major Congenital Malformations in a Cohort of Depressed Pregnant Women: An Updated Analysis of the Quebec Pregnancy Cohort. BMJ Open, 7(1), e013372. https://doi.org/10.1176/appi.ajp.2010.09121743Links to an external site.

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