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Decision Tree for Neurological and Musculoskeletal Disorders

Decision Tree for Neurological and Musculoskeletal Disorders

To prepare:

Reflect on the patient’s symptoms and aspects of the disorder presented in the interactive media piece.
Consider how you might assess and treat patients presenting with the symptoms of the patient case study you were assigned.
You will be asked to make three decisions concerning the diagnosis and treatment for this patient. Reflect on potential co-morbid physical as well as patient factors that might impact the patient’s diagnosis and treatment.

Write a 1- to 2-page summary paper that addresses the following:

Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.

*****Case Study****:
Mr. Akkad is a 76 year old Iranian male who is brought to your office by his eldest son for “strange behavior.” Mr. Akkad was seen by his family physician who ruled out any organic basis for Mr. Akkad’s behavior. All laboratory and diagnostic imaging tests (including CT-scan of the head) were normal.
According to his son, he has been demonstrating some strange thoughts and behaviors for the past two years, but things seem to be getting worse. Per the client’s son, the family noticed that Mr. Akkad’s personality began to change a few years ago. He began to lose interest in religious activities with the family and became more “critical” of everyone. They also noticed that things he used to take seriously had become a source of “amusement” and “ridicule.”
Over the course of the past two years, the family has noticed that Mr. Akkad has been forgetting things. His son also reports that sometimes he has difficult “finding the right words” in a conversation and then will shift to an entirely different line of conversation.


During the clinical interview, Mr. Akkad is pleasant, cooperative and seems to enjoy speaking with you. You notice some confabulation during various aspects of memory testing, so you perform a Mini-Mental State Exam. Mr. Akkad scores 18 out of 30 with primary deficits in orientation, registration, attention & calculation, and recall. The score suggests moderate dementia.

Mental status Exam:

Mr. Akkad is 76 year old Iranian male who is cooperative with today’s clinical interview. His eye contact is poor. Speech is clear, coherent, but tangential at times. He makes no unusual motor movements and demonstrates no tic. Self-reported mood is euthymic. Affect however is restricted. He denies visual or auditory hallucinations. No delusional or paranoid thought processes noted. He is alert and oriented to person, partially oriented to place, but is disoriented to time and event [he reports that he thought he was coming to lunch but “wound up here”- referring to your office, at which point he begins to laugh]. Insight and judgment are impaired. Impulse control is also impaired as evidenced by Mr. Akkad’s standing up during the clinical interview and walking towards the door. When you asked where he was going, he stated that he did not know. Mr. Akkad denies suicidal or homicidal ideation.

Diagnosis: Major neurocognitive disorder due to Alzheimer’s disease (presumptive

Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002). Mini-Mental State Examination (MMSE). Lutz, FL: Psychological Assessment Resources.



Decision Tree for Neurological and Musculoskeletal Disorders

The case study is about Mr. Akkad, a 76-year-old Iranian man diagnosed with major neurocognitive disorder due to Alzheimer’s disease (presumptive). The first treatment choice for the client was Exelon (rivastigmine) 1.5 mg orally BID. Exelon was selected due to its efficacy in improving symptoms of Alzheimer’s Disease and dementia. Exelon works by improving cholinergic function and hence increases the amount of acetylcholine within the brain; this improves cognitive functions and memory (Hampel et al., 2018). It was expected that the cognitive performance, memory, functioning, and behavior would improve due to the medication’s efficacy in improving cognitive functions and memory. However, after four weeks, he did not show any symptom improvement. This can be attributable to the low start dose of Exelon, which was not highly effective.

Therefore, the second treatment choice involved increasing Exelon dose to 4.5 mg orally BID. Dose increment was considered to increase the efficacy of the medication since higher doses of Exelon are associated with increased efficacy. According to Marucci et al (2021), the efficacy of Exelon is dose-dependent and therefore a higher dose is expected to improve cognitive functions, global functioning, memory, and the ability to perform activities of daily living. It was also hoped that Mr. Akkad would not experience side effects from the increased dose. However, the client manifested a slight response to the treatment as he started attending religious services once again with the family. This illustrates that the client was responding to the increased dose as there was symptom improvement. Additionally, he did not report any side effects, indicating that he was tolerating the increased dose.

Since the client manifested a relatively small response to Exelon 4.5 mg, the third treatment decision was to have the Exelon dose increased to 6 mg orally BID. This decision was chosen in order to increase the efficacy of the medication. A higher dose of Exelon will increase the level of acetylcholine in the brain for synaptic transmissions, hence improving the symptoms (Liu et al., 2019). By selecting this decision, the expectations were that the cognitive performance, memory, and the ability of the client to perform activities of daily living would improve. Evidence indicates that a higher dose of Exelon improves cognitive function and the ability to perform activities of daily living in people with Alzheimer’s Disease due to increased efficacy (Chang et al., 2021). It was also expected that the client would not experience any adverse effects with the increased dose.

In conclusion, the PMHNP needs to educate Mr. Akkad’s son about Alzheimer’s Disease, especially the pathophysiology of the disease. This is because cholinesterase inhibitors like Exelon cannot reverse the pathophysiological process of Alzheimer’s Disease, but can only improve symptoms or slow the pathophysiological process.




Chang, C. C., Chan, L., Chou, H. H., Yang, Y. W., Chen, T. F., Chen, T. B., … & Hu, C. J. (2021). Effectiveness of the 10 cm2 Rivastigmine Patch in Taiwanese Patients with Mild-to-Moderate Alzheimer’s Dementia: A 48-Week Real-World Observational Study. Advances in therapy, 38(10), 5286-5301.

Hampel, H., Mesulam, M. M., Cuello, A. C., Farlow, M. R., Giacobini, E., Grossberg, G. T., Khachaturian, A. S., Vergallo, A., Cavedo, E., Snyder, P. J., & Khachaturian, Z. S. (2018). The cholinergic system in the pathophysiology and treatment of Alzheimer’s disease. Brain: a journal of neurology, 141(7), 1917–1933.

Liu, J., Chang, L., Song, Y., Li, H., & Wu, Y. (2019). The role of NMDA receptors in Alzheimer’s disease. Frontiers in neuroscience, 13, 43.

Marucci, G., Buccioni, M., Dal Ben, D., Lambertucci, C., Volpini, R., & Amenta, F. (2021). Efficacy of acetylcholinesterase inhibitors in Alzheimer’s disease. Neuropharmacology, 190, 108352.


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