Pharmacology
Dementia/Alzheimer’s Disease
Case Study
Patient Profile
Name: Jan White
Age: 70 years old
Gender: female
Current Medications
Centrum Silver daily multivitamin
History of Present Illness
J.W. is a 70-year-old woman presenting for her annual well visit. She is a retired widow. Jan presents with her supportive son who is reporting on her behalf that he is concerned about the fact that she has been missing medical and social appointments and has fallen behind on her bills over the past year. Her son visits her every day. He has no evidence that she has been wandering outside the house. She expresses fear of going out on her own and states she would prefer to go out with her son. Overall, she endorses that she has been experiencing some feeling of anxiety throughout the day that she has not experienced prior to the past year in her life.
The patient has not been sexually active for multiple years. She has otherwise been healthy and all routine immunizations and cancer screenings are up to date.
Relevant Assessment
Neurological Exam
Speech is clear and appropriate. Alert and oriented to person, place, time, and purpose. Gait and coordination are normal. 5/5 strength in all extremities.
Montreal Cognitive Assessment Screening Tool Score: 22 (25 and below is abnormal and supports cognitive impairment).
Psychological Exam
Normal range of affect. Judgement/competence is appropriate.
No other expanded review of system (subjective data) or examination (objective data) has an impact on the diagnosis reviewed in this case.
Differentials
Alzheimer’s disease, other dementia, delirium, depression, sleep disorder, thyroid disorder, vitamin B12 deficiency
Diagnosis
Alzheimer’s disease
Diagnostic Testing
Complete blood count with differential (CBCdiff), complete metabolic profile (CMP), vitamin B12, thyroid stimulating hormone (TSH), brain magnetic resonance imaging (MRI)
Results
All labs are within the normal range. MRI reveals generalized atrophy and white matter lesions supportive of Alzheimer’s disease.
Referrals
None at this time
Patient/Provider Collaborative Goals
Jan will experience no or minimal decline in cognitive function by follow-up visit.
Therapeutic Interventions
- Describe a first-line pharmacologic treatment: Include drug name, dose and formulation, frequency, and length of treatment at this dose.
Answer:
One option is donepezil (Aricept) 5 mg tablet by mouth at bedtime for one week.
- Drug Mechanism of Action:
Answer:
Donepezil is a cholinesterase inhibitor. Inhibition of cholinesterase, which breaks down acetylcholine, means there is more acetylcholine available to be transmitted via synapses into the central nervous system. Higheracetylcholine levels in the brain improve communication between synapses.
- Contraindications if applicable:
Answer:
Known sensitivity to donepezil or any of its components, piperidine derivatives, or, for the transdermal formulation, known history of contact dermatitis with transdermal delivery of the method.
- Drug Mechanism of Action:
- Therapeutic advisement and monitoring: (include any specific instructions that apply, such as when to take the medication, if there are foods to avoid, storage issues, etc; include what laboratory/other (i.e., EKG) test monitoring to expect and how often and monitoring for adverse effects both common and serious)
Answer:
Specific Instructions: Advise the patient that this medication does not cure dementia. Educate the patient and family to seek emergency care if they feel like they are going to pass out or that their heartbeat is too slow or beating abnormally. Note that nausea, diarrhea, and anorexia usually dissipate in one to three weeks. Tell the patient to take the medication at bedtime; this helps minimize common side effects in the morning. If the patient experiences vivid dreams that are bothersome to them, then they can change their dosing to the morning.
Donepezil can be taken with or without food. Instruct the patient to drink lots of non-caffeinated non-alcoholic beverages. If the patient misses a dose, skip it and get back on schedule, do not double doses. Patients should also be advised to report any serious adverse effects listed below.
- Therapeutic Monitoring: Assess cognitive function at baseline, one to two weeks post initiation of treatment, one month after that, and then every three months thereafter. The NP may extend it out to every six months if this patient does not have/develop comorbidities that make more frequent monitoring necessary; this concept always applies to follow-up visits with any diagnosis management. Sometimes it is not comorbidities that drive the monitoring decision, but an elderly person or younger person with mental health concerns may also impact your decision about length of time to the next follow-up appointment.
- Monitor side/adverse effects at one to two weeks post initiation of treatment, one month after that, and then every three months thereafter. The most common issues may include weight loss due to gastrointestinal (GI) effects, diarrhea, nausea, and anorexia. Assess for symptoms/signs of active or occult GI bleeding, insomnia and accidental injury, secondary to effects of bradycardia, syncope, or dizziness. The agent is associated with QT-prolongation. The NP should order an EKG at baseline, then with any cardiac complaint such as chest pain, palpitations, or lightheadedness. Also, consider EKG if there are multiple medications in use that are associated with QT-prolongation.
- Serious Adverse Effects:
- Neuroleptic malignant syndrome (NMS) is a potential adverse effect; signs and symptoms include hyperthermia, irregular pulse or blood pressure, cardiac arrhythmia or dysrhythmia, diaphoresis, muscle rigidity, mental status changes, elevated creatinine phosphokinase, and unexplained fever without additional symptoms. If NMS occurs, the nurse practitioner should immediately discontinue therapy, and the patient should be hospitalized for stabilization as necessary.
- Rhabdomyolysis is another rare but serious adverse effect. It can lead to acute renal failure, which is one reason the NP should see the patient within one week. This is rare, but it can occur within a few days. If a patient shows up looking ill but never called to report feeling ill, this could be the issue. If you don’t see the patient in person in one week, the NP can call the patient or family to check on them. When there is a high level of concern, the NP can also send the police to check the welfare of patients if they are not reachable. The NP should discontinue therapy for marked elevation of creatine phosphokinase (CPK) and/or signs and symptoms suggesting rhabdomyolysis.
- Planned follow-up should consider adverse effect monitoring, dose adjustment considerations, and decisions about continuing versus discontinuing. In this case, planned follow-up would be:
Answer:
Follow-up in one week and check for adverse reactions. Instruct the patient to contact the office if there are any concerns sooner than the scheduled follow-up.
Review Questions
Click the arrow to expand the section and view the correct answers.
- Which class of medications is an appropriate first-line medication for mild Alzheimer’s disease?
- Cholinesterase inhibitors
- Serotonin norepinephrine reuptake inhibitors
- N-methyl-D-aspartate (NMDA) receptor agonist
- Second generation antipsychotics
Answer:
A. Cholinesterase inhibitors
Feedback: Cholinesterase inhibitors such as donepezil, galantamine, and rivastigmine are first-line treatments for Alzheimer’s disease. These agents can be utilized for mild to moderate symptoms. For moderate to advanced dementia, the N-methyl-D-aspartate (NMDA) receptor agonist memantine can be considered. Serotonin norepinephrine reuptake inhibitors are used to treat depression and anxiety. Second generation antipsychotics are used for conditions such as schizophrenia, bipolar disorder, and major depressive disorder with psychotic features, as well as managing agitation and irritability that may be associated with dementia or other conditions. An additional class available are monoclonal antibodies; however, this is not routinely recommended and would be an intervention managed by neurology, not nurse practitioners in primary care.
- Which medication is NOT a cholinesterase inhibitor?
- Donepezil
- Galantamine
- Rivastigmine
- Diphenhydramine
Answer:
D. Diphenhydramine
Feedback: Donepezil, galantamine, rivastigmine are cholinesterase inhibitors. Diphenhydramine is a first-generation antihistamine.
- Which statement represents the mechanism of action of cholinesterase inhibitors?
- Cholinesterase inhibitors address the cholinergic deficiency in the cortex and basal forebrain that contributes to cognitive deficits in Alzheimer’s disease.
- Cholinesterase inhibitors address the cholinergic excess in the cortex and basal forebrain that contributes to cognitive deficits in Alzheimer’s disease.
- Use of cholinesterase inhibitors results in decreased concentrations of acetylcholine available for synaptic transmission in the central nervous system.
- Use of cholinesterase inhibitors results in increased protein binding of acetylcholine limiting acetylcholine available for synaptic transmission in the central nervous system.
Answer:
B. Cholinesterase inhibitors address the cholinergic deficiency in the cortex and basal forebrain that contributes to cognitive deficits in Alzheimer’s disease.
Feedback: Cholinesterase inhibitors address the cholinergic deficiency in the cortex and basal forebrain that contributes to cognitive deficits in Alzheimer’s disease. These agents reversibly, noncompetitively inhibit acetylcholinesterase while interfering with hydrolysis of acetylcholine increasing concentrations of acetylcholine transmitted to the central nervous system.
- True/False: The goal of pharmacotherapy for Alzheimer’s disease is to enhance quality of life and cure patients.
- True
- False
Answer:
B. False
Feedback: Pharmacotherapy for Alzheimer’s disease slows loss of memory and overall cognitive decline and extends the patient’s ability to function independently. Pharmacotherapy does not cure Alzheimer’s disease.
- When initiating pharmacotherapeutic treatment for a patient with Alzheimer’s disease, the nurse practitioner should include education about avoiding throw rugs, having good lighting and changing positions slowly. The rationale for this education is:
- All classes of medication used in the treatment of Alzheimer’s disease may cause orthostatic hypotension.
- All classes of medication used in the treatment of Alzheimer’s disease may cause dizziness.
- All classes of medication used in the treatment of Alzheimer’s disease may cause polyuria.
- All classes of medication used in the treatment of Alzheimer’s disease may cause bradykinesia.
Answer:
B. All classes of medication used in the treatment of Alzheimer’s disease may cause dizziness.
Feedback: Cholinesterase inhibitors, N-methyl-D-aspartate (NMDA) receptor agonists, and monoclonal antibodies used to treat Alzheimer’s disease all have the potential adverse effects of dizziness. Therefore, educating the patient and caregivers to mitigate fall risks in advance in the home may prevent injuries resulting from dizziness and falls.
- Patient monitoring of Alzheimer’s patients on pharmacotherapy at each routine follow-up office visit includes:
- ECG to rule out adverse effects of QT interval prolongation
- Urine for specific gravity to test for dehydration due to diarrhea
- Order radiographs to ensure there are no broken bones from unwitnessed falls
- Assess orientation, cognition, and functional status with a reliable tool
Answer:
D. Assess orientation, cognition, and functional status with a reliable tool
Feedback: The goal of pharmacotherapy for Alzheimer’s disease is to slow cognitive decline, slow memory loss, and preserve independence. Assessing orientation, cognition, and functional status allows the nurse practitioner to compare the patient’s functioning to baseline. Examples include the mini mental status examination and the Montreal Cognitive Tool.
- An option for pharmacotherapy for mild to moderate Alzheimer’s disease for a patient with a history of esophageal strictures includes a transdermal patch. Which of these statements is accurate?
- Rivastigmine transdermal patches are changed every 24 hours.
- Rivastigmine transdermal patches are associated with fewer adverse effects than oral agents used to treat Alzheimer’s disease.
- Rivastigmine transdermal patches reach a steady state faster than oral agents used to treat Alzheimer’s.
- Rivastigmine transdermal patches work best if the patient keeps the old patch on for the first few hours of the new patch being placed
Answer:
A. Rivastigmine transdermal patches are changed every 24 hours.
Feedback: Rivastigmine transdermal patches are changed every 24 hours, are associated with fewer adverse effects, and have lower doses compared to oral preparations, and the old patch should be removed prior to the new patch being placed.
- Your primary care patient who has Alzheimer’s presents for an annual well-being visit with her spouse. The patient has been on maximum recommended memantine therapy for the past year. The patient had labs drawn as requested prior to the appointment. Cognitive screening is the same as it was at the previous quarterly office visit. The creatinine clearance is noted to be 48, previously 60. You ordered a re-draw to confirm the results. The results are accurate. What action will you take regarding memantine dosing?
- Maintain the same memantine dose
- Increase the memantine dose
- Decrease the memantine dose
- Discontinue the memantine therapy
Answer:
C. Decrease the memantine dose
Feedback: If using memantine therapy, creatinine clearance between 30 and less than 50 requires reduced dosing. Creatinine clearance of less than 30 requires further dose reduction. The dosing recommendations are different for immediate release versus extended release, be sure to check package labeling or other sources like Up To Date®.
References
Condina Leik, M. T. (2025). Common disorders in geriatrics. In FNP Certification Intensive Review (pp. 493–512). Springer Publishing.
Rosenthal, L. D., & Burchum, J. R. (2026). Drugs for Alzheimer Disease. In Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (3rd ed., pp. 144–151). Elsevier.
Trinh N., Hoblyn J., Mohanty S., & Yaffe, K. Efficacy of cholinesterase inhibitors in the treatment of neuropsychiatric symptoms and functional impairment in alzheimer disease: A meta-analysis. JAMA. 2003;289(2):210–216. doi:10.1001/jama.289.2.210
Up To Date® (2025). Donepezil: Drug information. Lexidrug™. Retrieved June 9, 2025 from https://www.uptodate.com/contents/donepezil-drug-information
expression of emotional state
decreased appetite
An adverse medication reaction that is potentially life-threatening. Its symptoms and signs include high fever, rapid respirations, rigid muscles, abnormally low or high blood pressure, sweating, and altered mental status.
A condition that causes rapid skeletal muscle breakdown and kidney damage which may ultimately result in kidney failure. It can be a medication adverse effect or from traumatic injury to muscle. Its symptoms and signs include muscle pain, weakness, vomiting, confusion, and dark urine.
