NURS 6630 Week 10-Special Considerations for Patient Populations Paper

This case study involves an 82-year-old male patient with gradual cognitive decline. The 82-year-old gentleman has shown decreased engagement with the community, trouble with mental tasks, and difficulties in spatial disorientation over the past year. Neuropsychological testing for this patient revealed mild neurocognitive disorder. This paper will discuss the most appropriate medication to prescribe from the given options of lorazepam, olanzapine, and memantine, along with dosing, education, side effects, and other clinical considerations.

Medication Selection and Rationale

Of the medications listed, memantine would be the most appropriate to prescribe for this patient. Memantine is an N-methyl-D-aspartate (NMDA) antagonist indicated for the treatment of moderate to severe Alzheimer’s disease (Kuns et al., 2022; Vanderah, 2023). Even though this patient carries a diagnosis of mild neurocognitive disorder and not Alzheimer’s disease, memantine has been reported to have potential benefits for cognitive function, global status, and behavioral symptoms in patients with mild-to-moderate vascular cognitive impairment.

The rationale for selecting memantine includes its mechanism of action, which is believed to be a modulation of glutamatergic neurotransmission involved in the physiology of learning and memory, and it may exert neuroprotective effects against excitotoxicity without affecting physiological actions of glutamate, which are needed for cognitive function. Other studies show that memantine improves cognitive function and global status in patients with mild-to-moderate vascular cognitive impairment in a way similar to this particular patient’s presentation (Kuns et al., 2022; Vanderah, 2023). Furthermore, memantine has some beneficial actions on behavioral symptoms in patients with dementia and may benefit the irritability of the patient. The drug is critically tolerated in elderly patients and has less potential to cause significant side effects when compared to the other medication options.

Dosing Schedule

The recommended dosing schedule for memantine in this patient would involve a gradual titration to help minimize potential side effects. The schedule would begin with 5 mg once daily for the first week, increasing to 5 mg twice daily in the second week. The third week would see a further increase to 10 mg in the morning and 5 mg in the evening (Kuns et al., 2022; Vanderah, 2023). From the fourth week onward, the full dose of 10 mg twice daily would be administered. The therapeutic endpoint would be the improvement or stabilization of cognitive symptoms and daily functioning, which should be assessed after 3-6 months of treatment at the full dose.

Patient Education

It is important to educate the patient on the proper use of medication and to manage their expectations. Among the key issues that can be discussed with the patient and his family is that memantine operates by regulating certain chemicals in the brain that deal with memory and thinking (Kuns et al., 2022; Vanderah, 2023). Further, it is crucial to emphasize to the patient that while the medication may help retard cognitive decline, it is not capable of curing the underlying disease. The administration instructions should contain information regarding the taking of medication at the same time every day, either with or without food.

Commonly discussed side effects could include dizziness, headache, constipation, and confusion (Kuns et al., 2022; Vanderah, 2023). These may especially occur at the beginning of treatment. The patient should be advised to seek medical attention for signs of allergic reaction or severe confusion/disorientation. Explaining that regular follow-up appointments will be needed to assess the medication’s effectiveness and any side effects is also vital. The healthcare provider should encourage continued social engagement, cognitive stimulation, and physical activity as tolerated to support overall brain health.

Risks, Benefits, and Potential Side Effects

The benefits of memantine include potential improvement or stabilization of cognitive symptoms, possible reduction in behavioral symptoms like irritability, and generally good tolerability in elderly patients (Kuns et al., 2022; Vanderah, 2023). Risks and potential side effects include common occurrences like dizziness, headache, constipation, and confusion. Less common side effects may include fatigue, pain, hypertension, and vomiting. Rare but serious side effects can include seizures, heart failure, and hepatitis. Overall, the risk-benefit profile is favorable for this patient, given the potential cognitive and behavioral benefits and the relatively low risk of serious adverse effects.

Explanation for Rejecting Other Medications

Lorazepam, a benzodiazepine, is not recommended for long-term use in elderly patients due to increased risk of falls, cognitive impairment, and dependence (Ghiasi et al., 2023). It does not address the underlying cognitive decline and may worsen confusion and memory problems. Also, olanzapine, an antipsychotic, is not indicated for mild cognitive impairment without psychotic symptoms. It carries a black box warning for increased mortality in elderly patients with dementia-related psychosis (Thomas & Saadabadi, 2023). Side effects like sedation and metabolic changes pose significant risks for this patient.

Necessary Labs and Diagnostics

Before prescribing memantine, several tests should be conducted. A comprehensive metabolic panel is needed to assess renal and hepatic function. A complete blood count should be performed to rule out other causes of cognitive changes (Kuns et al., 2022; Vanderah, 2023). It is necessary to check thyroid function tests to rule out disturbances in thyroid disorders that may affect cognition. The levels of vitamin B12 and folate must also be measured in order to exclude deficiency. Imaging of the brain by CT or MRI should be considered if it has not already been done to exclude other neurological causes for progressive cognitive decline.

Monitoring Efficacy and Side Effects

The efficacy must be monitored by regular cognitive assessment with standardized tools like the Mini-Mental State Examination (Kuns et al., 2022; Vanderah, 2023). This should also include a functional assessment of activities of daily living and the caregiver’s report on behavior and cognitive function. Monitoring for side effects should include regular vital signs, blood pressure, assessing dizziness, confusion, or changes in gait. Further, monitoring for mood or behavior changes is crucial. Renal function tests should be done periodically. This is especially important if the patient has a history of renal impairment.

Additional Collaboration and Education

The care for this patient is complex and involves not only interdisciplinary care but also education of the family (Bendowska & Baum, 2023). His children should be informed about the nature of his cognitive decline and what realistic expectations are for treatment, involving them in ways they can support him best. The coordination of care with the primary care provider will also be done in order to ensure the overall management of health conditions and medications being taken by the patient. Also important is considering referral for occupational therapy regarding home safety assessment and strategies in support of daily functioning and exploring community resources for activities on cognitive stimulation and caregiver support. For a patient with a history of getting disoriented while driving, a formal driving evaluation should be recommended for safety.

Addressing Potential Nonadherence

There are several factors that provide clues to potential medication nonadherence. On admission, the patient’s level of cognitive function and ability to remember and self-manage medications should be assessed. The extent to which the family is involved in medication management should be assessed. Also important is considering the complexity of the whole medication regimen that the patient will have to take, not just the new prescription being discussed, and assessing whether the patient seems to understand and accept the diagnosis and its treatment.

Other alternative treatment options to boost adherence include the implementation of a reminder system by means of pill organizers or mobile applications (Al, 2024). Also, seeking support from other family members would help administer medications. If possible, the overall medication regimen should be simplified. Long-acting or extended-release formulations for other medications prescribed to the patient should be considered.

A new treatment plan for a nonadherent patient could involve a daily pill organizer to be filled weekly by a family member. Medication reminders should be provided on the patient’s and a family member’s smartphones. The number of follow-up appointments should be increased, such as monthly, to check on adherence to the regimen and provide early response to any issues. If necessary, home health visits would help assist with medication management. Lastly, written instructions should be clear, showing a schedule and purpose for each medication.

Conclusion

Memantine, therefore, is the most appropriate medication in this 82-year-old male patient for mild neurocognitive disorder. Gradual dosing with due education of the patient and monitoring can go a long way in managing his cognitive symptoms while limiting risks as much as possible. It is also essential to develop open communication with family members and other health providers for proper adherence to medication and optimization of care. Any change in the patient’s condition or other issues of complication will indicate further reassessment of the treatment plan. The healthcare providers will be able to maintain this patient’s quality of life and cognitive function for as long as possible by adopting a holistic approach to care that incorporates pharmacological and non-pharmacological interventions.

References

Al, A. Z. (2024). Policy solutions for medication non-adherence: What can governments do? Expert Review of Pharmacoeconomics & Outcomes Research. https://doi.org/10.1080/14737167.2024.2321242

Bendowska, A., & Baum, E. (2023). The significance of cooperation in interdisciplinary health care teams as perceived by polish medical students. International Journal of Environmental Research and Public Health, 20(2). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9859360/

Ghiasi, N., Bhansali, R. K., & Marwaha, R. (2023, January 31). Lorazepam. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532890/

Kuns, B., Rosani, A., & Varghese, D. (2022). Memantine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK500025/#:~:text=Memantine%20is%20an%20antagonist%20of

Thomas, K., & Saadabadi, A. (2023, August 28). Olanzapine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK532903/

Vanderah, T. W. (2023). Katzung’s basic and clinical pharmacology (16th ed.). McGraw Hill Professional.

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NURS 6630 Week 10-Special Considerations for Patient Populations Paper

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 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 self. 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 that is 6 weeks postpartum. She presents with depressed mood, sadness, easily emotional, 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: 10-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

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:

1. Determine which medication would be most appropriate to prescribe from the assigned vulnerable population patient case medication choices.
2. Explain your rationale for choosing this medication. Explain why the other medications listed are not appropriate for this patient.
3. Explain the dosing schedule for the specific patient including the therapeutic endpoint.
4. Provide necessary education to the patient to review risks, benefits, and potential side effects of the medication.
5. Describe any necessary labs or additional diagnostics needed prior to prescribing this medication.
6. Explain how you might monitor efficacy or side effects of the medication.
7. 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.
8. 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 upon 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 Paper. provides an example of those required elements. All papers submitted must use this formatting.

BY DAY 7 OF WEEK 10
Submit by Day 7 of Week 10.

SUBMISSION INFORMATION
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• To submit your completed assignment, save your Assignment as WK10Assgn2_LastName_Firstinitial
• Then, click on Start Assignment near the top of the page.
• Next, click on Upload File and select Submit Assignment for review.