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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Assess cognitive deficits and noncognitive/behavioral symptoms of Alzheimer disease (AD).

  • Evaluate the drug therapy regimens for medications that could interfere with the AD process and future drug therapy recommendations.

  • Recommend appropriate pharmacotherapy to manage the cognitive and behavioral symptoms of AD.

  • Determine appropriate education and counseling to provide to patients and caregivers about AD, the possible benefits and adverse effects of pharmacotherapy for the disorder, and the importance of adherence to therapy.

  • Propose at least three theories of AD etiologies and agents under investigation based on those theories.

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PATIENT PRESENTATION

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Chief Complaint

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“Mom has become apathetic and tearful in the last month. She complains that someone is stealing from her and she is not always cooperative. She lives on her own, but I am considering moving her to a nursing home.”

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HPI

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Norma Dale is a 74-year-old woman who presents to the geriatric care clinic for a routine visit accompanied by her daughter Ann. Norma was diagnosed with AD 6 years ago. Her initial symptoms included forgetting times and dates easily, misplacing and losing items, repeating questions and current events, inability to answer questions, and increasing difficulty with managing finances. She was initially treated with rivastigmine which was eventually discontinued due to intolerable side effects although it worked well to slow her decline. Treatment with donepezil 10 mg at bedtime has been well tolerated for the past 4 years, and Norma has been participating more actively in family and social functions. Behavioral problems have been infrequent since diagnosis and have not been treated in the past. Since her last clinic visit, Norma began using Depend undergarments as extra protection for urinary incontinence.

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Norma lives on her own; her daughter and son share the duties of visiting her twice a day. They have been able to maintain a regular routine with her mother’s daily activities, nutrition, and financial responsibilities, using lists and notes to help Norma orient herself. Ann sets up a medication box weekly for Norma. Ann is moving in 1 month to live closer to her own daughter to help with grandchildren and has asked her youngest unmarried brother, Sam, to help take care of their mother. Sam has agreed to be his mother’s caregiver. He lives and works across town and is not sure if he wants to move his mother into his home. There has been discussion about placing Norma in a long-term care facility. Norma displays lack of interest, apathy, and tearfulness lately, especially when Ann and Sam are talking about her care. Ann asks about Norma’s current Alzheimer’s medication and her recent lack of cooperation and mood.

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PMH

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  • Osteoarthritis in hands and hip × 6 years

  • Hypertension × 15 years

  • Dyslipidemia × 6 years

  • AD ...

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