Assessing and Treating Clients With Dementia
Decision Point One

: Begin Aricept (donepezil) 5 mg orally at BEDTIME

RESULTS OF DECISION POINT ONE

· Client returns to clinic in four weeks

· The client is accompanied by his son who reports that his father is “no better” from this medication

· He reports that his father is still disinterested in attending religious services/activities, and continues to exhibit disinhibited behaviors

· You continue to note confabulation and decide to administer the MMSE again. Mr. Akkad again scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall

Decision Point Two

Increase Aricept to 10 mg orally at BEDTIME

RESULTS OF DECISION POINT TWO

· Client returns to clinic in four weeks

· Client’s son reports that the client is tolerating the medication well, but is still concerned that his father is no better

· He states that his father is attending religious services with the family, which the son and the rest of the family is happy about. He reports that his father is still easily amused by things he once found serious

Decision Point Three

Continue Aricept 10 mg orally at BEDTIME

Guidance to Student

At this point, it would be prudent for the PMHNP to continue Aricept at 10 mg orally at bedtime. Recall that this medication can take several months before stabilization of deterioration is noted. At this point, the client is attending religious services with the family, which has made the family happy. Disinhibition may improve in a few weeks, or it may not improve at all. This is a counseling point that the PMHNP should review with the son.

There is no evidence that Aricept given at doses greater than 10 mg per day has any therapeutic benefit. It can, however, cause side effects. Increasing to 15 and 20 mg per day would not be appropriate.

There is nothing in the clinical presentation to suggest that the Aricept should be discontinued. Whereas it may be appropriate to add Namenda to the current drug profile, there is no need to discontinue Aricept. In fact, NMDA receptor antagonist therapy is often used with cholinesterase inhibitors in combination therapy to treat Alzheimer’s disease. The key to using both medications is slow titration upward toward therapeutic doses to minimize negative side effects.

Finally, it is important to note that changes in the MMSE should be evaluated over the course of months, not weeks. The absence of change in the MMSE after 4 weeks of treatment should not be a source of concern.