The case study involves an elderly Iranian man, Mr. Akkad, who is exhibiting symptoms of dementia such as confusion, memory loss, and changes in behavior. The PMHNP sees Mr. Akkad and his son and performs a mental status exam, diagnosing Mr. Akkad with probable Alzheimer's disease. The PMHNP must make three decisions about medication to treat Mr. Akkad: initiating a cholinesterase inhibitor, adjusting the dose, or adding another medication. The PMHNP selects options that gradually increase the dose of Exelon while counseling the family on the progression and treatment of Alzheimer's disease.

1. Chapter 5 Case Study
The following case study provides you with an ethical dilemma
which will allow leaders to use the ethical tools provided in this
chapter (e.g., codes of ethics, ethical paradigms, ethical
decision-making models), to analyze and find a resolution to the
case. Pay particular attention to analyzing the case study from
multiple ethical paradigms (e.g., ethic of justice, critique, care,
profession).
Mark G. Edelstein, President Lakes Region Community College
Laconia, New Hampshire
The Problem Student
Background-
McClain Community College (MCC) is a large suburban
institution with a long-standing reputation for academic quality
and high transfer rates. ← 119 | 120 → Because of its
reputation, it draws a diverse student body from throughout the
region. In fact, many students drive by other colleges to attend
MCC. The college offers its 25,000 students a broad array of
technical and liberal arts programs and is especially known for
its outstanding programs in science and math. The proximity of
a major urban center and a large, prestigious research university
has enabled the college to attract a particularly talented and
well-qualified faculty. The college employs almost 300 full-
time faculty and hundreds of additional part-timers. Faculty
members have a tradition of strong leadership and extensive
involvement in college decision making. However, this
involvement has not led to a particularly “collegial”
environment. Many faculty members are suspicious of college
administrators and believe that the role of administration should
be extremely limited. The large faculty senate and the faculty

2. union work very closely together to maintain the faculty’s sense
of empowerment. A new president was appointed to MCC five
years ago and a new academic vice president four years ago.
Both have attempted to move the college, which has become
very traditional in its outlook, into a more innovative mode. The
introduction of new technologies, the expansion of distance
education, and the development of a more flexible and varied
course schedule have all raised concerns among the faculty.
Talk about the need for change in higher education has
threatened some of the faculty and made them feel that their
current efforts are not sufficiently appreciated. Statement of the
Problem You are the college president and have recently been
informed by your academic vice president of a case in which a
member of the math department has inappropriately changed the
final grade she awarded to a student in the previous semester.
The faculty member, Dr. Simms, is the former chair of the math
department and a very highly regarded teacher. Her reason for
changing the student’s grade from a “C” to an “A” is that she
felt harassed and intimidated by the student and believed that
the only way she could get him to stop contacting her was to
accede to his demands for a better grade. The academic vice
president reviewed the student’s quiz and test ← 120 | 121 →
scores for the semester, and it was clear that he had not earned a
grade higher than a “C.” The student, David, is a young man in
his early twenties, who has come to the attention of the vice
president for student services on several occasions. While some
faculty members have been able to work quite well with David,
others, particularly women, have complained about his odd
intensity and erratic behavior. This is the second course that
David has taken with Dr. Simms. Dr. Simms has spoken on a
number of occasions with the vice president for student services
about her discomfort with this student. David has monopolized
her office hours, written, emailed, and called her frequently
both in her office and at her home. While he has not physically
threatened nor sexually harassed her, Dr. Simms has complained
about his obsessiveness and other behaviors she considers

3. “paranoid.” The vice president has called David into her office
twice and warned him about inappropriate contacts with Dr.
Simms. After each discussion, his behavior improves for a time
but eventually reverts. The vice president believes that David
has “psychological problems,” but that he has broken no rules
or regulations and can no more be excluded from a particular
class than could a person with a physical disability. She
believes that a large, open-access institution such as MCC will
always have a certain number of people with psychological or
behavioral problems and that the college needs to be as tolerant
as possible. Dr. Simms, on the other hand, feels that the college
has not fulfilled its responsibility to protect her from what she
perceives as a threat. The president of the Faculty Senate and
the president of the Faculty Union have both dropped by your
office to discuss the issue of the grade change, which has
become public knowledge. They advise you that any type of
disciplinary action against a respected senior faculty member
would be received quite badly. The current math chair informs
you that a letter is being drafted by the department in
unanimous support of Dr. Simms. The academic vice president
is sympathetic to Dr. Simms, but feels that he must reverse her
grade change and that the college must take some formal action
to point out that the change of grade was a lapse of professional
ethics. He believes that the academic integrity of the institution
requires that some action be taken.
The Assignment
Examine Case Study: An Elderly Iranian Man with Alzheimer’s
Disease. You will be asked to make three decisions concerning
the medication to prescribe to this client. Be sure to consider
factors that might impact the client’s pharmacokinetic and
pharmacodynamic processes.
· At each decision point stop to complete the following:

4. Also include how ethical considerations might impact your
treatment plan and communication with clients.
BACKGROUND
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.
SUBJECTIVE
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 the PMHNP performs 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

5. 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 the
PMHNP 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)
RESOURCES
§ Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2002).
Mini-Mental State Examination (MMSE). Lutz, FL:
Psychological Assessment Resources.
DECISION POINT ONE
Select what the PMHNP should do first
Begin Exelon (rivastigmine) 1.5 mg orally BID with an increase
to 3 mg orally BID in 2 weeks.
Begin Aricept (donepezil) 5 mg orally at bedtime
Begin Razadyne (galantamine) 4 mg orally BID
Selection Point One
· Which decision did you select?
· Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this decision?
Support your response with evidence and references to the
Learning Resources.

6. · Explain any difference between what you expected to achieve
with Decision #1 and the results of the decision. Why were they
different?
I will select to begin Exelon (rivastigmine) 1.5 mg orally BID
with an increase to 3 mg orally BID in 2 weeks.
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· The client is accompanied by his son who reports that his
father is “no better” from this medication. He reports that his
father is still disinterested in attending religious
services/activities, and continues to exhibit disinhibited
behaviors
· You continue to note confabulation and decide to administer
the MMSE again. Mr. Akkad again scores 18 out of 30 with
primary deficits in orientation, registration, attention &
calculation, and recall
Decision Point Two
What should the PMHNP do next
· Increase Exelon to 4.5 mg orally BID
· Increase Exelon to 6 mg orally BID
· Discontinue Exelon and begin Namenda (memantine) 10 mg
orally BID
Selection Point Two
I will select to increase Exelon to 4.5 mg orally BID
· Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this decision?
Support your response with evidence and references to the
Learning Resources.

7. · Explain any difference between what you expected to achieve
with Decision #2 and the results of the decision. Why were they
different?
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client’s son reports that the client is tolerating the medication
well, but is still concerned that his father is no better
· He states that his father is attending religious services with
the family, which the son and the rest of the family is happy
about. He reports that his father is still easily amused by things
he once found serious
Decision Point Three
What should the PMHNP do next
· Increase Exelon to 6 mg orally BID
· Maintain current dose of Exelon
· Add Namenda (memantine) 5 mg orally per day
Selection Point Three
I will select that The PMHNP should increase Exelon to 6
mg orally BID
· Why did you select this decision? Support your response with
evidence and references to the Learning Resources.
· What were you hoping to achieve by making this decision?
Support your response with evidence and references to the
Learning Resources.
· Explain any difference between what you expected to achieve
with Decision #3 and the results of the decision. Why were they
different?
Result of the Decision Three as
Guidance to Student
At this point, the client is reporting no side effects and is
participating in an important part of family life (religious

8. services). This could speak to the fact that the medication may
have improved some symptoms. The PMHNP needs to counsel
the client’s son on the trajectory of presumptive Alzheimer’s
disease in that it is irreversible, and while cholinesterase
inhibitors can stabilize symptoms, this process can take months.
Also, these medications are incapable of reversing the
degenerative process. Some improvements in problematic
behaviors (such as disinhibition) may be seen, but not in all
clients.
At this point, the PMHNP could maintain the current dose until
the next visit in 4 weeks, or the PMHNP could increase it to 6
mg orally BID and see how the client is doing in 4 more weeks.
Augmentation with Namenda is another possibility, but the
PMHNP should maximize the dose of the cholinesterase
inhibitor before adding augmenting agents. However, some
experts argue that combination therapy should be used from the
onset of treatment.
Finally, it is important to note that changes in the MMSE should
be evaluated over the course of months, not weeks. The absence
of change in the MMSE after 4 weeks of treatment should not be
a source of concern.
Also include how ethical considerations might impact your
treatment plan and communication with clients.