Sciences (2005) Antidepressants. Available at http://www.ncl.ac.

uk/nnp/teaching/
management/drugrx/antdep.html [Accessed on 2 April 2007].
NICE (National Institute for Health and Clinical Excellence) (2004a) Eating disorders full
guideline. Available at www.nice.org.uk/CG009fullguideline [Accessed 1 July
2008].
NICE (2004b) Anorexia nervosa, bulimia nervosa and related eating disorders. Under-
standing NICE guidance: a guide for people with eating disorders, their advocates
and carers, and the public. Available at www.nice.org.uk/CG009NICE guideline
[Accessed 1 July 2008].
NICE (2004c) Depression. Available at www.nice.org.uk/CG023NICEguideline [Accessed
1 July 2008].
Winstead NS and Willard SG (2006) Gastrointestinal complaints in patients with eating
disorders. Journal of Clinical Gastroenterology 40: 678682.
Case study level 3 A case of dementia, Alzheimers type
Learning outcomes
Level 3 case study: You will be able to:
I interpret clinical signs and symptoms
I evaluate laboratory data
I evaluate treatment options
I state goals of therapy
I describe a pharmaceutical care plan to include advice to a clinician
I describe the prognosis and long-term complications
I describe the social pharmacy issues which could include supply (e.g.
complex treatments at home, concordance and compliance) and lifestyle
issues.
Scenario
The wife of Mr EF, a 68-year-old black Caribbean male, is asking for some advice
from the village pharmacist because she is concerned about the changes in
behaviour her husband has been showing over the last few months. In contrast
with Mr EFs 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 rst time in his life he is now
using words and language expressions that are both rude and vulgar. The assess-
ment carried out by the local old age psychiatrist showed that Mr EF was mildly
confused, with both a decrease in blood pressure (100/65 mmHg) and a sodium
level of 155 mmol/L. He was nally diagnosed with Alzheimers type dementia.
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Sample chapter from Pharmacy Case Studies, Dhillon, S; Raymond, R (Pharmaceutical Press, 2009)
Questions
1 What are the Alzheimers type dementia clinical signs and symptoms?
2 Expand briey on the neuropathological changes observed in Alzheimers
dementia; comment on Mr EFs clinical and laboratory data.
3 What are the suitable treatment options for Mr EF?
4 Outline a pharmaceutical care plan for Mr EF. What are the goals of therapy in
Alzheimers dementia?
5 Expand on the monitoring of long-term treatment with antidementia medication.
6 Describe the prognosis and long-term complications of Alzheimers dementia.
7 What are the social pharmacy issues related to the case of Mr EF?
References
Alzheimers Society (2006) Anger as NICE says no to Alzheimers appeal. Available at
http://www.alzheimers.org.uk/News_and_Campaigns/News/10102006nice_says_
no.htm [Accessed 1 July 2008].
NICE (National Institute for Health and Clinical Excellence) (2006) NICE announces
Alzheimers disease drug appeal outcome and NHS guideline to support patients
and carers. Available at http://www.nice.org.uk/page.aspx?o=373237 [Accessed
1 July 2008].
General references
Newcastle University School of Neurology, Neurobiology & Psychiatry, Faculty of Medical
Sciences (2005) Atypicals. Available at http://www.ncl.ac.uk/nnp/teaching/
management/ drugrx/antpsych.html [Accessed 1 July 2008].
Schifano F (2002) Pharmacokinetic and pharmacodynamic considerations in old age
psychopharmacology. In: Copeland JRM, Abou-Saleh M and Blazer DG (eds)
Principles and Practice of Geriatric Psychiatry. Chichester: John Wiley & Sons Ltd,
pp. 6164.
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Case study level 3 A case of dementia, Alzheimers type see
page 83
1 What are the Alzheimers type dementia clinical signs and symptoms?
Alzheimers disease is a neurodegenerative disease characterised by progressive
cognitive deterioration accompanied by neurological, psychiatric and
behavioural disorders. It is characterised by loss of short-term memory (amne-
sia), accompanied by a relative integrity of older memories. As the disorder pro-
gresses, cognitive impairment extends to the domains of language (aphasia),
skilled movements (apraxia), recognition (agnosia), decision-making and plan-
ning. Either disinhibition and outbursts of violence, or excessive passivity, can
be frequently observed. The onset of Alzheimers disease is insidious and slow,
often making diagnosis difcult.
2 Expand briey on the neuropathological changes observed in Alzheimers
dementia; comment on Mr EFs clinical and laboratory data.
Typical Alzheimers disease pathological processes include neuronal loss or
atrophy at the temporoparietal and frontal cortex, together with an inammat-
ory response and the deposition of amyloid plaques and neurobrillary tangles.
Functional neuroimaging studies can provide a supporting diagnostic role.
However, Alzheimers disease remains a primarily clinical diagnosis based on the
presence of characteristic neurological features and the absence of alternative
diagnoses; there are no typical biochemical markers.
For measurement of cognitive outcomes in Alzheimers disease, the MMSE
(Mini Mental State Examination) instrument, scored out of 30 (best), is used.
Mild Alzheimers disease is usually associated with an MMSE of 2126. Moderate
Alzheimers disease is usually associated with an MMSE of 1020 (NICE, 2006).
Hypotension, increase in sodium levels and confusion found here might
suggest a moderate level of dehydration, which must be corrected.
3 What are the suitable treatment options for Mr EF?
Based on costbenet reasons, NICE (2006) recommendations state that:
I donepezil, galantamine and rivastigmine should be used as a treatment for
moderate stages of Alzheimers disease only (i.e. those with an MMSE score of
between 10 and 20 points) and
I memantine, previously used to treat more severe stages of the disease, has
been withdrawn from the NHS.
4 Outline a pharmaceutical care plan for Mr EF. What are the goals of therapy in
Alzheimers dementia?
People with dementia may at some point in their illness develop symptoms such
as depression, restlessness, aggressive behaviour and psychosis (delusions and
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hallucinations). Possible medications to be prescribed include atypical anti-
psychotics, although some of these drugs (risperidone and olanzapine) have
been determined to be unsuitable for use in people with dementia because of the
high risk of stroke. Furthermore, prescription of these drugs might be associated
with accelerating rates of decline and disease progression in people with demen-
tia. Sodium valproate and carbamazepine are sometimes also used to reduce
aggression and agitation. Antidepressants may be helpful not only in improving
persistently low mood but also in controlling both the irritability and the rapid
mood swings that often occur in dementia. Tricyclic antidepressants, such as
amitriptyline, imipramine or dothiepin, are likely to increase confusion in those
who suffer from dementia. They might also cause dry mouth, blurred vision,
constipation, difculty in urination and hypotension, which may lead to falls
and injuries. Newer antidepressants are preferable as rst-line treatments for
depression in dementia. SSRIs are likely to be better tolerated by older people.
Sleep disturbances can be distressing for the person with dementia and disturb-
ing for carers. Hypnotics are often best used intermittently.
5 Expand on the monitoring of long-term treatment with antidementia medication.
Patients who continue to be prescribed on a long-term basis with one of the
above antidementia medication should be reviewed by MMSE score and global,
functional and behavioural assessment every six months. The drug should
normally only be continued while their MMSE score remains above 10 points,
and clients global, functional and behavioural condition remains at a level
where the drug is considered to be having a suitable effect. When the MMSE
score falls below 10 points, patients should not normally be prescribed any of
the above antidementia medication (NICE, 2006). Any review involving MMSE
assessment should be undertaken by an appropriate specialist team.
6 Describe the prognosis and long-term complications of Alzheimers dementia.
People with Alzheimers disease eventually lose the ability to carry out routine
daily activities such as dressing/undressing; toileting; travelling and handling
money. As a result, many people with Alzheimers disease require a high level
of care.
7 What are the social pharmacy issues related to the case of Mr EF?
Whenever possible, the client should be helped to lead an active life, with inter-
esting and stimulating daily activities. By minimising distress and agitation it is
sometimes possible to limit the use of sedative drugs. The NICE guidelines
(NICE, 2006) regarding the use of antidementia drugs have proved to be very
controversial (Alzheimers Society, 2006).
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