What are the parameters for monitoring success of therapy

Question Details

Assignment Details

– Word document using a minimum of five evidence-based resource articles, not older than three years, and the course textbook.

M. W. is a 70-year-old Caucasian with a medical history of hypertension, osteoarthritis, atrial fibrillation, and total hysterectomy who lives by herself in a two-story row home. She visits the primary care clinic with her daughter, who is concerned because M. W. has bounced a few checks and can no longer pay her bills without assistance. M. W. admits that she has been forgetful and appears anxious as she describes an incident in which she went shopping and could not remember where she parked her car. Her daughter states that her mother’s memory has progressively worsened over the past year.

Medications

Fosinopril 20 mg PO daily

Metoprolol Succinate ER 50 mg PO daily

Warfarin 5 mg PO daily

Vitamin D 1,000 IU PO daily

Acetaminophen 325 mg 2 tablets (650 mg) PO tid

A careful evaluation and workup was ordered.

Diagnosis: Mild AD with an MMSE score of 22

List specific goals of treatment for M. W.

What drug therapy would you prescribe for M. W.? Why?

What are the parameters for monitoring success of therapy?

Discuss specific patient education based on the prescribed therapy.

List one or two adverse reactions for the selected agent that would cause you to change therapy.

Would there be any over-the-counter and/or alternative agents appropriate for M. W.?

What lifestyle changes would you recommend to M. W.?

Describe one or two drug-drug or drug-food interactions for the selected agent.

Directions

Craft a Therapeutic Plan.

Using Beers Criteria and rational drug prescribing, review the medications and diagnoses listed for M. W. What three prioritized changes would you make to the medication regimen? Include a detailed and evidence-based rationale for all changes, including, but not limited to, monitoring, drug-drug interactions, drug-disease interactions, pharmacokinetics/pharmacodynamics, age, gender, and culture.

What would be your pharmacological-related patient education?

Would you order any laboratory testing? Provide rationale for all decisions.

Describe a follow-up plan of care with rationale.

Question Guide

Therapeutic Plan for M. W.

Patient Profile:

• M. W., a 70-year-old Caucasian female with a medical history of hypertension, osteoarthritis, atrial fibrillation, and total hysterectomy.
• Presenting symptoms: Memory impairment, anxiety, financial difficulties, and difficulties with daily activities.
• Medications:
  1. Fosinopril 20 mg PO daily (for hypertension)
  2. Metoprolol Succinate ER 50 mg PO daily (for hypertension and atrial fibrillation)
  3. Warfarin 5 mg PO daily (for atrial fibrillation)
  4. Vitamin D 1,000 IU PO daily (for vitamin D deficiency)
  5. Acetaminophen 325 mg 2 tablets (650 mg) PO tid (for pain)

Diagnosis:

• Mild Alzheimer’s Disease (AD) with an MMSE score of 22.

Specific Goals of Treatment:

1. Slow the progression of Alzheimer’s Disease.
2. Improve memory and cognitive function.
3. Manage anxiety and emotional distress.
4. Enhance M. W.’s ability to manage her daily activities and finances.

Drug Therapy: For the treatment of Mild AD, I would prescribe donepezil (Aricept) 5 mg PO daily initially, with a gradual titration to 10 mg PO daily. Donepezil is an acetylcholinesterase inhibitor that can help improve cognitive function and slow the progression of AD. It is considered a first-line treatment for Mild AD. The rationale for this choice includes its proven efficacy in improving cognitive function and its relatively favorable side effect profile.

Parameters for Monitoring Success of Therapy:

• Regular cognitive assessments to evaluate improvement in MMSE score.
• Monitoring for adverse drug reactions.
• Assessing M. W.’s ability to manage daily activities and finances.
• Evaluating her emotional well-being and anxiety levels.

Patient Education:

1. Medication Adherence: Emphasize the importance of taking donepezil as prescribed and regularly attending follow-up appointments.
2. Memory Strategies: Teach memory-enhancing strategies and techniques to help cope with memory loss.
3. Side Effects: Explain common side effects of donepezil (e.g., nausea, diarrhea) and the importance of reporting any unusual symptoms.
4. Monitoring: Discuss the need for regular cognitive assessments and monitoring for improvement.
5. Lifestyle Modification: Encourage a brain-healthy lifestyle, including a balanced diet, physical exercise, and mental stimulation.

Adverse Reactions for Donepezil:

1. Gastrointestinal Distress: Nausea and diarrhea are common adverse effects. If severe, they may warrant a change in therapy.
2. Bradycardia: Although rare, donepezil can potentially exacerbate bradycardia in patients on metoprolol. Monitor heart rate closely.

Over-the-Counter and/or Alternative Agents: There are various dietary supplements and alternative therapies advertised for cognitive enhancement, but their efficacy is not well-established. It is advisable to discuss any potential supplements with M. W.’s healthcare provider before use.

Lifestyle Changes:

• Regular physical exercise to promote cognitive health.
• A balanced diet rich in fruits, vegetables, and omega-3 fatty acids.
• Mental stimulation through puzzles, reading, and social interaction.

Drug-Drug or Drug-Food Interactions:

1. Donepezil and Metoprolol: Monitor for potential additive bradycardia when these drugs are used together. Adjust metoprolol dose if necessary.
2. Donepezil and Warfarin: Monitor INR closely as donepezil may affect warfarin metabolism, potentially increasing the risk of bleeding.

Beers Criteria and Medication Changes: Considering the Beers Criteria and rational drug prescribing:

1. Acetaminophen: Given M. W.’s age, the risk of acetaminophen-related liver toxicity is a concern. I would recommend replacing it with a safer alternative for pain management, such as non-steroidal anti-inflammatory drugs (NSAIDs) with gastroprotective agents or tramadol.
2. Warfarin: Considering the risk of bleeding and potential interactions with donepezil, I would consider evaluating the need for warfarin therapy in consultation with a cardiologist and potentially switching to a novel oral anticoagulant (NOAC) with fewer drug interactions.
3. Vitamin D: Continue the current vitamin D supplementation for osteoarthritis and overall bone health.

Pharmacological-Related Patient Education:

1. Medication Changes: Explain the rationale for discontinuing acetaminophen and considering a change in warfarin therapy, if applicable.
2. New Medication: Educate M. W. about the new medication, donepezil, its purpose, and how to take it.
3. Potential Side Effects: Discuss potential side effects of donepezil and when to contact the healthcare provider.

Laboratory Testing: Regular monitoring of INR for warfarin therapy management and liver function tests if acetaminophen is continued for pain management.

Follow-up Plan of Care:

• Schedule regular follow-up appointments every 3 months to monitor cognitive improvement, assess medication efficacy, and manage potential side effects.
• Adjust the treatment plan as needed based on M. W.’s progress and changing clinical needs.
• Involve a multidisciplinary team, including a neurologist, cardiologist, and social worker, to provide comprehensive care and support for M. W.’s cognitive and emotional well-being.