Case Study – Special Considerations for Patient Populations

Case Study – Special Considerations for Patient Populations

Medications for certain patients must be controlled according to the patient’s conditions and circumstances. The aging process is associated with cognitive decline, which poses difficulties that require specific and appropriate approaches to prescribing. This paper focuses on an 82-year-old male patient with mild neurocognitive disorder to identify the suitable medication, dosing schedule, patient education, monitoring, and collaboration to increase medication adherence and optimize the results.

Patient Profile

Patient 1 is an 82-year-old male being investigated for cognitive impairment. He had always been active and participated in activities like playing cribbage and serving as a crossing guard in the community. He has become less mobile over the past year and has shown declining performances in tasks involving cognitive functions such as mathematical skills used in playing cribbage. He also got lost while driving home once and felt lost; he had to stop volunteering. He has been given a neuropsychological diagnosis of mild neurocognitive disorder. The patient understands these are sensitive issues and may become irritated when discussing them with his children.

Medication Selection

Chosen Medication: Memantine

Among the given medications, memantine should be considered the most suitable for this patient. This is an NMDA receptor antagonist that has been used in cases of moderate to severe Alzheimer’s disease. Due to its effectiveness in treating cognitive disorder symptoms and enhancing cognition, it is most appropriate for patients with mild to moderate neurocognitive disorder. Memantine affects the levels of glutamate, which is responsible for learning and memory; therefore, it helps in the management of the progression of cognitive features, as stated by Kuns et al. (2022).

The Rationale for Choosing Memantine

Memantine is chosen because it has been demonstrated to have efficacy in enhancing cognition and daily functioning in patients with Alzheimer’s and MND. It has been verified that memantine can sustain cognitive skills and overall function longer than no treatment, enhancing the patient’s quality of life (Kuns et al., 2022). Furthermore, the side effects of memantine are not severe, which is crucial since elderly patients are more likely to develop side effects than younger patients.

Why Other Medications Are Not Appropriate

Lorazepam is a benzodiazepine and is commonly prescribed for anxiety or insomnia. It is not recommended for the treatment of dementia. It has several side effects for older adults, such as worsening confusion, increasing the risk of falls, and leading to functional dependence. Also, benzodiazepines have been found to worsen cognition, and as a result, their use in managing neurocognitive disorders is ineffective.

On the other hand, off-label uses of olanzapine include behavioral disturbances in dementia, as indicated in a recent publication by Thomas and Saadabadi (2022). However, it carries a black box warning for increased mortality in elderly patients with dementia-related psychosis. The risks of severe side effects, such as weight gain, diabetes, and cardiovascular issues, make olanzapine inappropriate for treating mild neurocognitive disorders. Additionally, olanzapine does not address the primary symptoms of cognitive decline but rather targets behavioral disturbances.

Dosing Schedule for Memantine

The dosing schedule for memantine should begin with a low dose and gradually increase to minimize the risk of side effects and allow the patient to adjust to the medication (Kuns et al., 2022). The initial dose is 5 mg once daily, increased by 5 mg increments to reach the target maintenance dose of 20 mg per day, taken as 10 mg twice daily. This titration schedule typically follows a weekly increase, starting with 5 mg daily for one week, then 10 mg daily (5 mg twice daily) for the next week, 15 mg (5 mg and 10 mg separately), and finally 20 mg (10 mg twice daily).

Patient Education and Medication Monitoring

Education

• Benefits: It is essential to explain to the patient how memantine works and how it could help him function better in his daily life and have a better quality of life is essential. It may also assist in halting the worsening of his symptoms.
• Risks and Side Effects: Explain possible risks and complications such as dizziness, headache, confusion, and constipation. Stress the need to seek medical attention in case of any other symptoms or severe ones. Inform the patient that side effects are usually mild and can be overcome, as supported by Bhattad and Pacifico (2022).
• Adherence: Emphasize the need to follow the prescription to the letter to gain the best results from the drug. Share tips, which include using a pill box and alarms on the phone to remind the patient when to take his medicine.

Labs and Diagnostics

• Baseline Tests: Check creatinine and estimated glomerular filtration rate before starting memantine due to renal elimination.
• Follow-Up: Follow up with the patient to assess cognitive function, change the dosage if needed, and screen for any side effects. Advise to take kidney function tests from time to time before using the medicine.

Monitoring Efficacy and Side Effects

Efficacy Monitoring

• Administer baseline and follow-up neuropsychological tests, including the MMSE or MoCA, to monitor the patient’s cognitive decline (Wang et al., 2022).
• Assess changes in activities of daily living, interpersonal relationships, and overall life satisfaction.

Side Effects Monitoring

• Look for symptoms of dizziness or confusion, significantly if the dose has recently been adjusted, as these are side effects of memantine.
• Screen for gastrointestinal problems, including constipation, and address them as necessary, adjusting diet or using laxatives as appropriate.

Enhancing Medication Adherence

Strategies

• Simplified Regimen: Prescribe a pill organizer so the patient can follow the correct medication schedule. In this case, use a phone alarm or a medication reminder app to establish daily reminders.
• Education: Explain the purpose of the medication, its usage, and its benefits verbally and in writing to the patient. Ensure the patient and his family fully comprehend the given instructions.
• Family Involvement: Involve family members or caregivers to ensure the patient complies with the recommendations. Encourage them to remind the patient to take his medication and look out for side effects or changes in behavior.

Collaboration and Additional Support

It is essential to consult the patient’s primary care physician and any other doctors involved in the patient’s care so as to maintain continuity of care. In addition, it is vital to explain the patient’s condition and treatment plan to his family and educate them so that they can help the patient better.

Nonadherence Assessment and Alternative Treatment Plan

Assessment for Nonadherence

• Determine possible causes for nonadherence, including misunderstanding, forgetfulness, or intolerance to side effects.
• The Morisky Medication Adherence Scale (MMAS) can determine barriers to adherence and enable interventions (Basu et al., 2019).

Alternative Treatment Solutions

• If nonadherence continues, switch to a medication with a longer half-life to further reduce dosing frequency.
• Discuss other management approaches, like cognitive therapy or changes in behavior, that will work in conjunction with the medication.

New Treatment Plan

• In the case of nonadherence, reconsider the current medication plan and possibly make it even simpler using extended-release preparations.
• The patient and his caregivers should be informed of further education and support on medication compliance and handling of any perceived issues with the treatment (Aremu et al., 2022).
• Strengthen the follow-up calendar to track compliance and change it quickly and closely if needed.

Conclusion

Among the drugs used to treat neurocognitive disorders, memantine is the most suitable for this 82-year-old male patient. Lorazepam and olanzapine are eliminated due to side effects and their ineffectiveness in enhancing cognitive function. The chosen dosing schedule and the patient education plan will give maximum benefits while posing minimal risks. Patient follow-up and engagement of family members are essential to check on compliance and address side effects, if any. Subsequently, this would enhance the patient’s quality of life and cognitive abilities.

References

Aremu, T. O., Oluwole, O. E., Adeyinka, K. O., & Schommer, J. C. (2022). Medication adherence and compliance: Recipe for improving patient outcomes. Pharmacy, 10(5). https://doi.org/10.3390/pharmacy10050106

Basu, S., Garg, S., Sharma, N., & Singh, Mm. (2019). Improving the assessment of medication adherence: Challenges and considerations with a focus on low-resource settings. Tzu Chi Medical Journal, 31(2), 73. https://doi.org/10.4103/tcmj.tcmj_177_18

Bhattad, P. B., & Pacifico, L. (2022). Empowering patients: Promoting patient education and health literacy. Cureus, 14(7). https://doi.org/10.7759/cureus.27336

Kuns, B., Rosani, A., & Varghese, D. (2022). Memantine. PubMed; StatPearls Publishing. https://pubmed.ncbi.nlm.nih.gov/29763201/

Thomas, K., & Saadabadi, A. (2022). Olanzapine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532903/#:~:text=Olanzapine%20is%20an%20atypical%20(second

Wang, G., Estrella, A., Hakim, O., Milazzo, P., Patel, S., Pintagro, C., Li, D., Zhao, R., Vance, D. E., & Li, W. (2022). Mini-mental state examination and Montreal cognitive assessment as tools for following cognitive changes in Alzheimer’s disease neuroimaging initiative participants. Journal of Alzheimer’s Disease, 90(1), 263–270. https://doi.org/10.3233/jad-220397

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We’ll write everything from scratch

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To complete this assignment, you will utilize the case study assigned to you by faculty for a patient population for special consideration during prescribing practices. You will consider the specific patient and determine the appropriate medication to prescribe, based on the patient specifics and medication attributes in various case studies. You will construct a 4- to 5-page paper in which you determine the medication, the dosing, necessary patient education, and potential side effects. You will also indicate why the other medications would not be appropriate, as well as any necessary labs or diagnostics that might be needed. You will develop a plan to enhance medication adherence for the nonadherent patient.

Special Considerations for Patient Population Cases:

Patient 1: 82-year-old male presenting with cognitive decline. He had always been a very active individual. Over the past year, he has become less active in the community. Previously, he played cribbage weekly with friends at the local senior center but has been struggling with the math involved with the game and no longer attends the weekly card game. He had also volunteered as a crossing guard for the local public school. He quit doing that after he took the wrong turn to get home and drove around the town feeling lost. He acknowledges he is “sensitive” to this and can be irritable towards his children when they bring up these concerns. He was diagnosed with mild neurocognitive disorder after completing neuropsychological testing. Of the following medications, which would be the most appropriate to prescribe? Explain why you chose this medication. What would be the dosing schedule for this patient? Provide education to the patient and review the risks, benefits, and potential side effects of the medication. In addition, explain why the other medications listed are not appropriate for this patient. Med List: lorazepam, olanzapine, memantine
Patient 2: 76-year-old female who recently moved from her home to an assisted living. After 1 week of moving in, she has become extremely confused. Staff have attempted to re-orient her, and she struggles to focus on what they are saying. She is only oriented to herself. She has become very agitated and has even thrown breakable objects in her room. Her family is concerned stating she is “out of it.” The PCP ordered labs and UA. Labs are unremarkable outside of mild leukocytosis and positive dipstick analysis for nitrite and red blood cells. Med List: valproate, alprazolam, trimethoprim
Patient 3: A 33-year-old female who is 6 weeks postpartum. She presents with depressed mood, sadness, easily emotional, and difficulties with sleep even when the infant is sleeping. She has lost weight and has a poor appetite. You note psychomotor retardation. She has limited interests in hobbies or bonding with the infant. Her partner is concerned and reports she is typically active and “bubbly” and enjoys the outdoors. She is diagnosed with major depressive disorder, with postpartum onset. She denies suicidal ideation, homicidal ideation, or infanticidal ideation. No psychotic symptoms are present. She is nursing the infant and wants to continue this hoping it will assist with bonding with the infant. Med List: lithium, paroxetine, sertraline
Patient 4: 1A 0-year-old male who comes in with his father. He has been diagnosed with generalized anxiety disorder. He has constant worries that he cannot control. He feels nervous and tense. He is easily irritable. He struggles to settle down or relax. He is also quite fidgety and restless. He and his father are interested in medications to manage these symptoms. Med List: quetiapine, duloxetine, fluoxetine
Patient 5: 27-year-old male with a diagnosis of schizophrenia. He has been hospitalized three (3) times in the past 1 year due to symptoms. When symptomatic, he becomes disorganized and paranoid. He will respond to auditory hallucinations. He will scream out at night after seeing a shadow in his room. He has delusions that the CIA is poisoning food and will not eat for multiple days. He has unintentionally hurt his mother after “slapping” food out of her hand, as he did not want her to ingest the “poisoned food.” Symptoms are treated very well with paliperidone, but he struggles to remember to take it. Med List: paliperidone palmitate, clozapine, lamotrigine
RESOURCES

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.

WEEKLY RESOURCES

TO PREPARE:
Review the Learning Resources.
Carefully review your assigned vulnerable population patient.
Carefully review the medication list to determine the best medication to prescribe.
Consider the implications, impact, advantages, and disadvantages of the listed medications.
THE ASSIGNMENT (4–5 PAGES)
Construct a paper concerning your assigned vulnerable population patient case. In your paper include the following:

Determine which medication would be most appropriate to prescribe from the assigned vulnerable population patient case medication choices.
Explain your rationale for choosing this medication. Explain why the other medications listed are not appropriate for this patient.
Explain the dosing schedule for the specific patient including the therapeutic endpoint.
Provide necessary education to the patient to review the risks, benefits, and potential side effects of the medication.
Describe any necessary labs or additional diagnostics needed prior to prescribing this medication.
Explain how you might monitor the efficacy or side effects of the medication.
Include any additional collaboration or education to others that would be necessary for this patient. Consider family members, home health care, primary care providers, etc.
What would you need to include in your assessment for a patient who may become nonadherent with your prescribing plan for your scenario? What are alternative treatment solutions based on how you assessed? Describe your new treatment plan.
This Assignment requires a minimum of five (5) peer-reviewed, evidence-based scholarly references outside of course resources.

Note: You will need to include the APA style formatting.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Walden Writing Center Sample PaperLinks to an external site. provides an example of those required elements. All papers submitted must use this formatting.
Week 10

This week, you will dive more in depth into special patient populations. You will look at considerations for older adult clients, women of reproductive years, children and adolescents, and those who are most likely to struggle with medication adherence. You will also practice the act of prescribing.

Learning Objectives:

Students will:

Assess specific patient variables, needs, and safety considerations in prescription psychiatric medications
Analyze treatment for solutions for those that struggle with medication adherence
Identify specific medications that contain special considerations when prescribing for special populations of patients
Demonstrate ability for writing prescriptions accurately

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