Case Summary
The case was based on the atypical behavior of Mr. Akkad, who recently showed impaired spatiotemporal orientation and refusal of everyday family activities. The interview results showed deficits in registration, attention, counting, and recall. Based on the absence of organic causes for the observed condition, the patient was tentatively diagnosed as having a severe neurocognitive disorder due to Alzheimer’s disease after memory and cognitive function testing. The present paper evaluates the outcomes of medication decisions and critically discusses the reasons for those decisions.
Treatment Considerations
The first point to note is that the treatment of Alzheimer’s disease (provisional diagnosis) is nuanced. For example, drug therapy can improve a patient’s quality of life and increase the rate of loss of cognitive function. Still, therapy cannot restore or replenish processes that have been lost due to degeneration (Gupta, 2022). In other words, if the disease has destroyed a patient’s neural connections, it is unlikely that medication will restore them.
Another nuance is that the administration of psychotropic medications should be started at low, off-target doses to ensure that side effects, including vomiting and dizziness, do not occur (Patel & Gupta, 2023). Pharmaceutical treatment was decided to start with Rivastigmine for several reasons.
First, studies show that Rivastigmine is efficacious in improving cognitive function compared to a placebo (Birks & Evans, 2015). Second, Rivastigmine is compatible with other medications, which is especially relevant for elderly patients, who usually take multiple medications. Third, the indicated starting dose (1.5 mg orally BID) was appropriate to initiate without anticipating side effects, with slow dose doubling (MC, 2023). Although transdermal patches have shown better results for symptom relief than oral capsules, taking Rivastigmine still produces results, especially in the initial stages of treatment (Birks & Evans, 2015).
Treatment Decisions and Expected Outcomes
No change was detected from the first decision; however, the MMSE is assessed over months, and 4 weeks may not be sufficient to detect change. The second decision was to slowly increase the Rivastigmine dosage to 4.5 mg orally BID, which was suggested for two reasons. First, the permitted dose increase is 1.5 mg every 2 weeks, which aligns with Mr. Akkad’s previous treatment plan (Patel & Gupta, 2023). Secondly, the initial dose (1.5 mg BID) may be too low to achieve treatment goals; if tolerance to side effects is established, the dose can be increased.
At the end of two months of treatment, the patient is experiencing clear improvement in his condition and is attending family activities again. It followed that the third phase of treatment could involve either maintaining the dose at 4.5 mg BID or continuing to increase it to 6 mg BID (but not above this point). The most relevant strategy was maintaining the dosage at 4.5 mg BID and rechecking the patient after 4 weeks.
Since Rivastigmine has been scientifically proven to be effective, its use was expected to improve the patient’s cognitive abilities. Since no side effects were observed after 2 months of follow-up, the drug was well tolerated, and the dosage could be increased systematically to 12 mg daily (Patel & Gupta, 2023). Overall, multiple studies conclude that Rivastigmine administration does contribute to patient improvement, including through dual inhibition of acetylcholinesterase and butyrylcholinesterase, so expected outcomes were comparable to actual results (Nguyen et al., 2021; Marucci et al., 2021; Haake et al., 2020). However, there is no need to expect rapid changes, as the effects of such drugs are cumulative; therefore, months of follow-up are required.
References
Birks, J. S., & Evans, J. G. (2015). Rivastigmine for Alzheimer’s disease.
Gupta, A. (2022). Effectiveness of ways to treat Alzheimer’s via studying ways to treat inflammatory processes in Alzheimer’s disease. Journal of Positive School Psychology, 6(4), 5748-5775.
Haake, A., Nguyen, K., Friedman, L., Chakkamparambil, B., & Grossberg, G. T. (2020). An update on the utility and safety of cholinesterase inhibitors for the treatment of Alzheimer’s disease. Expert Opinion on drug Safety, 19(2), 147-157.
Marucci, G., Buccioni, M., Dal Ben, D., Lambertucci, C., Volpini, R., & Amenta, F. (2021). Efficacy of acetylcholinesterase inhibitors in Alzheimer’s disease. Neuropharmacology, 190, 1-15.
MC. (2023). Rivastigmine (oral route). Mayo Clinic.
Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management, 11(1), 35-48.
Patel, P. H., & Gupta, V. (2023). Rivastigmine. NIH.