Genato, Charles Ronald K. Dec.

30, 2022
BSP3A Prof. Lapig
Centro Escolar University
School of Pharmacy
PRPM141 – Clinical Pharmacy and Therapeutics 1
CLASS PARTICIPATION – CP 30%

CASE 1
The wife of Mr. Raymond, a 68-year-old Filipino male, is asking for some advice from the
community pharmacist because she is concerned about the changes in behavior her husband has
been showing over the last few months. In contrast with Mr. Raymond’s previous personality, his
mood is now very volatile and somewhat unpredictable, his memory and concentration seem to be
very poor, and, at times, he may be very impulsive indeed. For the first time in his life, he is now
using words and language expressions that are both rude and vulgar. The assessment carried out
by the local old age psychiatrist showed that Mr. Raymond’s was mildly confused, with both a
decrease in blood pressure (100/65 mmHg) and a sodium level of 155 mmol/L. He was finally
diagnosed with Alzheimer’s type dementia.

Questions:
1. What are the Alzheimer’s type dementia clinical signs and symptoms?
The signs and symptoms of Alzheimer’s type dementia are the following:
a. Memory loss, which manifests in various ways such as difficulty
taking/remembering information, repeating questions or conversations, losing
objects forgetting about events or appointment; wandering, or getting lost.
b. Cognitive deficits, which is synonymous to difficulty with reasoning,
completing tasks and judgement, a reduced understanding of safety and risks,
difficulty with money or paying bills, difficulty making decisions, difficulty
completing tasks that have several stages, such as getting dressed
c. Problems with recognition that may manifest through the patient’s lesser
ability to recognize faces or objects or less able to use basic tools. These
issues are not due to problems with eyesight.
2. Expand briefly on the neuropathological changes observed in Alzheimer’s dementia,
comment on Mr. Raymond’s clinical and laboratory data.
 Alzheimer's dementia causes degenerative changes in the patient’s neurotransmitter
systems. These include alterations in the function of the monoaminergic neural systems
that release neurotransmitters such as glutamate, norepinephrine, and serotonin that
plays significant roles in memory, learning, emotions among others. Alzheimer's
dementia also significantly degenerates selected brain regions, including the temporal
and parietal lobes and restricted regions within the frontal cortex and cingulate gyrus.
In the case of Mr. Raymond, his clinical and laboratory data indicates decrease blood
pressure which means there is an imbalance in neurotransmitter norepinephrine that
causes the patient to also have an altered emotional state (unpredictable mood, use of
vulgar language). It may also be a sign of insufficient blood flowing towards the brain
when the patient is sitting or standing. Meanwhile increase sodium levels may indicate
hypernatremia because of thirst impairment due to Alzheimer’s dementia diagnosis of
patient.
3. What are the suitable treatment options for Mr. Raymond?
Apart from laboratory tests to rule out other potential causes of memory loss and
confusion, Mr. Raymond must also be subjected to periodic MRI and other screening
tests to check his mental status and assess his memory and other thinking abilities.
Mental status test is given to assess memory and other thinking skills. Longer forms of
neuropsychological testing such as Ascertain Dementia 8 (AD8), Functional Activities
Questionnaire (FAQ), Mini-cog, Mini- mental State Exam (MMSE), Neuropsychiatric
inventory questionnaire (NPI-Q), may also be used to track progression of the disease.
Suitable treatment options for Mr. Raymond includes prescribing him with cholinesterase
inhibitors such as galantamine, rivastigmine, and donepezil that are designed to treat
mild to moderate Alzheimer’s symptoms. These drugs may help reduce or control some
cognitive and behavioral symptoms.
4. Outline a pharmaceutical care plan for Mr. Raymond.
Health Care Pharmacoth Recommend Monitoring Desired Frequency
Need erapeutic ation for parameters Endpoint
Goal therapy
Cognitive Reduce the Administrati Periodic Maximize Take
Impairment rate of on of Neurologic period in Galantamin
and Apathy neurodegen Galantamin screening which e ER
due to eration of e test patient can (extended-
Alzheimer’s disease. (MMSE) still operate release) 8
 Interview independent mg OD with
with the ly food.
caregiver
Low Treat Maintenanc Ensure that Regain Replace
Sodium moderate e of caregiver balance of water deficit
Level hypernatrem intravenous must make electrolytes over 48
ia fluids to patient drink in the body hours in
prevent water (8 addition to
water loss glasses/day) daily
to prevent maintenance
fluid loss. , with IV
sodium
In addition, chloride
the 0.9% and
following glucose 5%
lab tests (see table
must be for rates)
performed In addition,
to checked replace
hypernatrem ongoing
ia: losses mL
• Serum for mL
electroly (excluding
tes (Na urine) with
+, K +, IV sodium
Ca 2 +) chloride
• Glucose 0.9%
level.
• Urea.
• Creatini
ne.
• Urine
electroly
tes (Na
+, K +)
• Urine
and
plasma
osmolali
ty.
• 24-hour
urine
volume.
Plasma
arginine
vasopressin
(AVP) level
 (if
indicated)
5. What are the goals of therapy in Alzheimer’s dementia?
The goals of therapy in treating Alzheimer’s dementia is management of behavioral
symptoms, avoidance of pain and depression, as much functional independence as
possible, and eventually dying with dignity. Also, there must also be provision to lower
caregiver strain and stress.
Non-pharmaceutical care must also be done to ensure patient does not have severe
hypernatremia as indicated with his high sodium level. Most often occurs in people
suffering from dementia, they don’t/forget to drink enough water, because of impaired
thirst or mental judgement. Symptoms vary based on the condition's severity, but include
thirst, restlessness and fatigue. Treatment may include drinking more water or
intravenous fluids.
6. Expand on the monitoring of long-term treatment with antidementia medication.
In the event that Mr. Raymond develops co-morbidities and suffer moderately severe
hepatic impairment, the maximum dosage should usually not exceed 16mg/day. Once
patient has severe liver impairment, it is a contraindication for treatment with
galantamine whether oral capsule/tablet is immediate or extended release.
7. Describe the prognosis and long-term complications of Alzheimer’s dementia.
People with Alzheimer's disease live an average of between 3-11 years after diagnosis.
However, some survive 20 years or more. The severity of impairment at diagnosis can
affect life expectancy. Untreated vascular risk factors such as hypertension are
associated with a faster rate of progression of Alzheimer's disease.
8. What are the social pharmacy issues and pharmacoeconomic issues related to the case of
Mr. Raymond?
Social pharmacy issues include patients forget taking their prescribed medicines if they
don’t have a dedicated family member or caregiver to ensure proper administration of
medication for the patients. With an incidence rate of dementia in the Philippines is 16
cases per 1000 persons, the reported financial burden per Filipino patient diagnosed
with Alzheimer’s disease is roughly around P196,000.00 in a year for medical
treatments.