**Practicum Assignment: Prescribing for Special Patient Populations**
**Title: Medication Management for Special Populations: A Case Study Analysis**
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### Introduction
In advanced practice nursing, prescribing medication requires careful consideration of patient-specific factors, including age, medical history, and current symptoms. This paper examines a patient from a vulnerable population and outlines the appropriate prescribing practices, medication choices, dosing, patient education, and strategies to enhance medication adherence. The case study selected for this assignment involves an 82-year-old male presenting with cognitive decline, and the goal is to determine the most suitable medication from a list of options.
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### Patient Case: 82-Year-Old Male with Cognitive Decline
**Patient Overview:**
– **Age:** 82
– **Chief Complaint:** Cognitive decline, irritability, difficulty with daily activities.
– **Medical History:** Mild neurocognitive disorder.
– **Current Symptoms:** Decline in cognitive function, irritability, disorientation.
**Medications to Consider:**
1. Lorazepam
2. Olanzapine
3. Memantine
### Medication Selection and Rationale
**1. Memantine**
**Rationale:**
– **Indication:** Memantine is indicated for the treatment of moderate to severe Alzheimer’s disease and other types of neurocognitive disorders. It works by regulating the activity of glutamate, a neurotransmitter involved in learning and memory (Sitsapesan et al., 2016).
– **Benefits:** Helps improve cognitive function and daily living activities in patients with neurocognitive disorders. It is considered safer and more appropriate for cognitive decline compared to other options (Van Dyck, 2013).
– **Risks and Side Effects:** Potential side effects include dizziness, headache, and constipation. Memantine is generally well-tolerated and has a favorable safety profile (Zhao et al., 2017).
**2. Lorazepam**
**Rationale:**
– **Indication:** Lorazepam is a benzodiazepine used for anxiety and agitation. It is not suitable for cognitive disorders due to its sedative effects and potential to exacerbate cognitive impairment (Haddad, 2015).
– **Risks:** Prolonged use can lead to dependence, worsening cognitive function, and increased fall risk in the elderly.
**3. Olanzapine**
**Rationale:**
– **Indication:** Olanzapine is an atypical antipsychotic used for managing psychotic symptoms. It is not indicated for neurocognitive disorders and may lead to side effects such as weight gain, diabetes, and sedation (Muench & Hamer, 2010).
– **Risks:** Potential for significant side effects, including metabolic syndrome, which is not suitable for a patient primarily presenting with cognitive decline without psychotic symptoms.
### Dosing Schedule and Therapeutic Endpoint
**Memantine:**
– **Starting Dose:** 5 mg orally once daily.
– **Adjustment:** Increase by 5 mg weekly as tolerated, up to a maximum of 20 mg daily.
– **Therapeutic Endpoint:** Improved cognitive function and daily living activities, with a goal of stabilizing or slowing the progression of cognitive decline.
### Patient Education
– **Risks and Benefits:** Explain that memantine can help improve symptoms of cognitive decline and slow the progression of the disorder. Common side effects include dizziness and headache.
– **Administration:** Instruct the patient to take the medication exactly as prescribed and not to miss doses.
– **Monitoring:** Advise regular follow-ups to assess efficacy and side effects.
### Necessary Labs and Diagnostics
– **Labs:** No specific labs required for memantine, but regular assessments to monitor cognitive function and overall health are beneficial.
– **Diagnostics:** Periodic neuropsychological assessments to evaluate cognitive function and progression of the disorder.
### Monitoring Efficacy and Side Effects
– **Efficacy:** Regular follow-up appointments to assess improvements in cognitive function and daily living activities.
– **Side Effects:** Monitor for any adverse effects such as dizziness or gastrointestinal issues and adjust the dosage if necessary.
### Collaboration and Education
– **Family Involvement:** Educate family members about the patient’s condition and the importance of medication adherence. Provide them with information on how to recognize side effects.
– **Care Team:** Collaborate with other healthcare providers, including geriatricians and neurologists, to ensure comprehensive care.
### Addressing Medication Nonadherence
**Assessment:**
– Identify potential barriers to adherence such as cognitive impairment, lack of understanding, or medication complexity.
– **Alternative Solutions:** Simplify the medication regimen, provide clear written instructions, and consider involving a caregiver to assist with medication management.
**New Treatment Plan:**
– **Plan:** If nonadherence persists, consider adjusting the treatment plan to include long-acting formulations or exploring other cognitive-enhancing therapies.
### Conclusion
In prescribing for patients with neurocognitive disorders, it is essential to choose medications that are both effective and appropriate for the patient’s specific condition. Memantine is the most suitable choice for the 82-year-old male with mild neurocognitive disorder due to its efficacy in managing cognitive decline and its favorable safety profile. By following a comprehensive treatment plan, including patient education and collaboration with the healthcare team, we can optimize treatment outcomes and enhance medication adherence.
### References
– Haddad, P. M. (2015). Benzodiazepine use in the elderly: A review. *Journal of Clinical Psychiatry, 76*(12), 1796-1804.
– Muench, J., & Hamer, A. M. (2010). Adverse effects of antipsychotic medications. *American Family Physician, 81*(5), 617-622.
– Sitsapesan, H., Green, M. S., & Verity, A. (2016). Memantine: A review of its efficacy in treating neurocognitive disorders. *Current Alzheimer Research, 13*(8), 879-889.
– Van Dyck, C. H. (2013). Anti-dementia drugs: Current status and new developments. *Journal of Clinical Psychiatry, 74*(7), 643-655.
– Zhao, Q., Li, Y., & Li, W. (2017). Memantine in the treatment of cognitive disorders: A systematic review and meta-analysis. *Neuropsychiatric Disease and Treatment, 13*, 613-621.
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Ensure that all references and in-text citations follow APA format, and remember to include a title page and summary in your final paper.
This week, you will dive more in depth into special patient populations. You will look at considerations for older adult clients, women of reproductive years, children and adolescents, and those who are most likely to struggle with medication adherence. You will also practice the act of prescribing.
The Practicum Assignment, due this week, is a requirement in order to progress from this course; however, no point value is associated with the assignment. An incomplete will be submitted as the final grade if the practicum assignment is not completed.
Assignment 1
To complete this Assignment, you will choose a case study for a patient population for special consideration during prescribing practices. You will consider the specific patient and determine the appropriate medication to prescribe, based on the patient specifics and medication attributes in various case studies. You will construct a 4- to 5-page paper in which you determine the medication, the dosing, necessary patient education, and potential side effects. You will also indicate why the other medications would not be appropriate, as well as any necessary labs or diagnostics that might be needed. You will develop a plan to enhance medication adherence for the nonadherent patient.
Construct a paper concerning your assigned vulnerable population patient case. In your paper include the following:
· Determine which medication would be most appropriate to prescribe from the assigned vulnerable population patient case medication choices.
· Explain your rationale for choosing this medication. Explain why the other medications listed are not appropriate for this patient.
· Explain the dosing schedule for the specific patient including the therapeutic endpoint.
· Provide necessary education to the patient to review risks, benefits, and potential side effects of the medication.
· Describe any necessary labs or additional diagnostics needed prior to prescribing this medication.
· Explain how you might monitor efficacy or side effects of the medication.
· Include any additional collaboration or education to others that would be necessary for this patient. Consider family members, home health care, primary care providers, etc.
· What would you need to include in your assessment for a patient who may become nonadherent with your prescribing plan for your scenario? What are alternative treatment solutions based upon how you assessed? Describe your new treatment plan.
This Assignment requires a minimum of five (5) peer-reviewed, evidence-based scholarly references outside of course resources.
Note: You will need to include the APA style formatting.
Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.
Special Considerations for Patient Population Cases:
· Patient 1: 82-year-old male presenting with cognitive decline. He had always been a very active individual. Over the past year, he has become less active in the community. Previously, he played cribbage weekly with friends at the local senior center but has been struggling with the math involved with the game and no longer attends the weekly card game. He had also volunteered as a crossing guard for the local public school. He quit doing that after he took the wrong turn to get home and drove around the town feeling lost. He acknowledges he is “sensitive” to this and can be irritable towards his children when they bring up these concerns. He was diagnosed with mild neurocognitive disorder after completing neuropsychological testing. Of the following medications, which would be the most appropriate to prescribe? Explain why you chose this medication. What would be the dosing schedule for this patient? Provide education to the patient and review risks, benefits, and potential side effects of the medication. In addition, explain why the other medications listed are not appropriate for this patient. Med List: lorazepam, olanzapine, memantine
· Patient 2: 76-year-old female who recently moved from her home to an assisted living. After 1 week of moving in, she has become extremely confused. Staff have attempted to re-orient her, and she struggles to focus on what they are saying. She is only oriented to self. She has become very agitated and has even thrown breakable objects in her room. Her family is concerned stating she is “out of it.” The PCP ordered labs and UA. Labs are unremarkable outside of mild leukocytosis and positive dipstick analysis for nitrite and red blood cells. Med List: valproate, alprazolam, trimethoprim
· Patient 3: A 33-year-old female that is 6 weeks postpartum. She presents with depressed mood, sadness, easily emotional, difficulties with sleep even when the infant is sleeping. She has lost weight and has a poor appetite. You note psychomotor retardation. She has limited interests in hobbies or bonding with the infant. Her partner is concerned and reports she is typically active and “bubbly” and enjoys the outdoors. She is diagnosed with major depressive disorder, with postpartum onset. She denies suicidal ideation, homicidal ideation, or infanticidal ideation. No psychotic symptoms are present. She is nursing the infant and wants to continue this hoping it will assist with bonding with the infant. Med List: lithium, paroxetine, sertraline
· Patient 4: 10-year-old male who comes in with his father. He has been diagnosed with generalized anxiety disorder. He has constant worries that he cannot control. He feels nervous and tense. He is easily irritable. He struggles to settle down or relax. He is also quite fidgety and restless. He and his father are interested in medications to manage these symptoms. Med List: quetiapine, duloxetine, fluoxetine
· Patient 5: 27-year-old male with a diagnosis of schizophrenia. He has been hospitalized three (3) times in the past 1 year due to symptoms. When symptomatic, he becomes disorganized and paranoid. He will respond to auditory hallucinations. He will scream out at night after seeing a shadow in his room. He has delusions that the CIA is poisoning food and will not eat for multiple days. He has unintentionally hurt his mother after “slapping” food out of her hand, as he did not want her to ingest the “poisoned food.” Symptoms are treated very well with paliperidone, but he struggles to remember to take it. Med List: paliperidone palmitate, clozapine, lamotrigine
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