1. ALZHEIMER’S DISEASE
Clerkship
Arjan Aryal
5th year Pharm. D

2. DEMOGRAPHIC DATA
NAME X
Age 76
Sex Male
IP No. 384952
Department Psychiatric
Ward Male Psychiatric Ward
Unit I
Weight 98 kg
Height 5’11’’ cm
BMI 30.13
DOA 14/12/2015
DOD 30/12/2015
LOS 16 days.

3. SUBJECTIVE DATA
PATIENT COMPLAINTS
 Memory loss and blackouts (during driving).
 Increased forgetfulness , insidious in onset , slowly
progressive ( forgets appointments, phone calls).
 Problems in walking ( uses cane to walk around
house).
 Confused and easily becomes lost.
 Difficulty in sleeping.
 Aggression shown few times.

4. SOCIAL HISTORY
Smoker: Yes (45 Years)
Alcoholic: No , occasional.
Occupation: Company Owner, looked after by his
son currently.
Diet: High Protein diet , mostly non vegetarian.
Education: MBA
Marital status: Married
Allergy: No Known allergies
NO FAMILY HISTORY

5. PAST MEDICAL HISTORY:
H/O Asthma (15 Years)
No h/o head injury, strokes.
PAST MEDICATION HISTORY :
Neb Duolin+Budecort (20/100 mcg+ 200 mcg) (1-1-1)
Tab Theophylline 400 mg/day (1/2-0-1/2)

6. PHYSICAL EXAMINATION
 Patient was confused and not oriented to time.
 Aphasia
 Apraxia
 CNS: NAD
 P/A: Soft, Non tender.
 RS: NVBS
 CVS: S1S2 positive
 PMA: decreased.
 Mood: Anxious, Depressed.

7. OBJECTIVE DATA
VITALS 14-16 17-20 21-25 26-29 30
BP 170/110
mmHg
160/110
mmHg
160/100
mmHg
150/90mmHg 140/80
mmHg
RR 19 b/m 20 b/m 22 b/m 20 b/m 20 b/m
Pulse 95 b/m 92 b/m 97 b/m 90 b/m 90 b/m
Temp 98.6°F 98.6°F 98.6°F 98.6°F 98.6°F

8. LAB INVESTIGATIONS
TEST Normal 14 22
Blood Sugar
Fasting 70-110 mg/dl 120 82
Post Prandial 110-140 mg/dl 145 113
Hematology
Hb% 12-18 g/dl 14.2 16
PCV 32-47% 38% -
WBC Count 5000-11000
cells/cumm
6500 8000
Neutrophils 40-75% 66 65
Lymphocytes 20-50% 33 41
Platelets 1.5-4.5 lakh/cumm 1.6 2.3
ESR 0-20 mm/hr 22 17

9. LAB INVESTIGATIONS
TEST Normal 14 22
Urea and
Creatinine
Serum Urea 20-50 mg/dl 52 50
Serum Creatinine 0.9-1.1 mg/dl 1.1 1.1
Electrolytes
Sodium 136-145 mEq/L 136 139
Potassium 3.5-4.5 mEq/L 4.2 4.0

10. LAB INVESTIGATIONS
LIPID
PROFILE
TEST
Normal 14 22
Triglycerides Upto 150
mg/dl
200 160
Total
Cholesterol
Upto 200
mg/dl
421 336
HDL
Cholesterol
30-60 mg/dl 48 52
LDL
Cholesterol
Upto 100
mg/dl
191 156
VLDL
Cholesterol
Upto 20 mg/dl 30 20

11. Urine analysis
Urine Analysis 16
Volume 10 ml
Colour Pale Yellow
Turbidity Clear
Albumin +2
Sugar Nil
Pus Cells 2-3
Ep Cells 1-2

12. Liver Function Test
LFT Normal Range Result (14)
Total Bilirubin 0.3-1.2 mg/dl 0.8
Direct Bilirubin 0-0.2 mg/dl 0.3
Indirect Bilirubin 0.3-1 mg/dl 0.5
SGOT Upto 35 IU/L 32
SGPT Upto 45 IU/L 13
ALP 53-128 IU/L 78
Protein Analysis
Total Protein 6.4-8.3 mg/dl 8.2
Albumin 3.5-5.2 mg/dl 5.5

13. Diagnostic Tests.
 CBC: ruled out potential causes of memory loss
and confusion such as thyroid disorder or vitamin
deficiencies. (14th, 22nd )
 MRI showed no shrinkage of brain, ruled out
Multi infarct vascular dementia. (14th)
 Renal Function test done that reported GFR of
92 ml/min which ruled out renal impairment.(16th)
 Lipid Profile test showed hyperlipidaemia. (14th,
22nd)
 MMSE score of 16 resulting in Moderate
Alzheimer’s Disease. (14th) .

14. Diagnosis
ALZHEIMER’S
DISEASE

15. TREATMENT GOALS
 To maintain functioning of brain as long as possible.
 To treat psychiatric and behavioral symptoms.

16. DRUGS PRESCRIBED
TRADE NAME GENERIC NAME DOSE FREQ. 14 15 16 17 18
-
30
Tb Aricept Donepezil 5 mg 0-0-1 √ √ √ √ √
Neb Duolin
+Budecort
Ipratropium
Bromide+Levosalbutamol+
Budesonide
20/50 mcg+
200 mcg
(60/150+600
mcg)
1-1-1 √ √ √ √ √
Tb Aten Atenolol 50 mg 1-0-0 √ √ √ √ √
Risperdal Risperidone 0.5 mg
(1 mg)
1-0-1 √ √ √ √ √
Tb Atorva Atorvastatin 40 mg 0-0-1 √ √ √ √ √
Tb Pan Pantoprazole 40 mg 1-0-0 √ √ √ √ √
Tb Sartine Sertraline 50 mg 0-0-1 √ √ √ √ √

17. Discharge Medication.
Medication Dose Frequency QTY/Duration
Tb Aricept 5 mg 0-0-1 3 months
Neb Duolin
+Budecort
20/50 mcg+ 200 mcg 1-1-1 Further orders
Tb Aten 50 mg 1-0-0 Further orders
Risperdal 0.5 mg 1-0-1 3 months
Tb Atorva 20 mg 0-0-1 Further orders
Tb Pan 40 mg 1-0-0 Continue
Tb Sartine 25 mg 0-0-1 3 months
FOLLOW UP – 3 Months

18. CARE TAKER EDUCATION
 Educate about the disease to the patient’s care
taker such as environmental modification, task
simplification for the patient.
 Discuss in detail about the diagnosis, progression
and treatment choices.
 Discuss about basic legal and financial planning
with the care taker related to the disease.
 Give constant care to the patient.
 Referral to social service agencies or support
organization incase of uncontrollable progression
of disease.

19. PATIENT EDUCATION
 Adhere to medication.
 Avoid Stress.
 Quit Smoking.
 Take diet such as fish, food rich in antioxidants
(berries), green vegetables like spinach, cabbage,
food rich in Vit E, Vit D avoid salty and fried foods.
 Engage yourself in some works, go for walks (with
caregiver).
 Check your blood sugar level frequently . (
risperidone, Atorvastatin).
 Do ECG to check if any irregular heart beat rhythm
persists. (sertraline + risperidone).

20. Patient Counselling
O Do not do strenuous exercise like running or
lifting weights as it can worsen your condition.
O Avoid animal furs as it acts as a source for
spreading allergen.
O Go for vacations, and relax.
O Do not take grape fruit juice along with
atorvastatin.
O Adhere to same medication ( in case of signs
of improvement).

21. References.
O http://shp.missouri.edu/vhct/case1299/references.htm
O http://shp.missouri.edu/vhct/case2400/behavior.htm
O http://www.alz.org/alzheimers_disease_steps_to_diagnosis.asp#brain
O http://www.alz.org/socal/images/professional_natlguideline.pdf
O http://www.medscape.org/viewarticle/420328
O https://www.nice.org.uk/guidance/ta217/chapter/4-Evidence-and-
interpretation
O https://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-
medications-fact-sheet
O http://www.aafp.org/afp/2011/0615/p1403.html
O http://www.alzheimer-europe.org/Dementia/Alzheimer-s-disease/How-
is-Alzheimer-s-disease-diagnosed#fragment3
O http://www.mayoclinic.org/diseases-conditions/alzheimers-
disease/diagnosis-treatment/diagnosis/dxc-20167109
O http://www.medicaldaily.com/smoking-cocaine-and-3-other-ways-you-
can-kill-your-brain-cells-325920
O Joseph T.DiPiro, Pharmacotherapy handbook.
O Drugs.com