By Day 7 of Week 8

Write a 1- to 2-page summary paper that addresses the following:

  • Briefly summarize the patient case study you were assigned, including each of the three decisions you took for the patient presented.
  • Based on the decisions you recommended for the patient case study, explain whether you believe the decisions provided were supported by the evidence-based literature. Be specific and provide examples. Be sure to support your response with evidence and references from outside resources.
  • What were you hoping to achieve with the decisions you recommended for the patient case study you were assigned? Support your response with evidence and references from outside resources.
  • Explain any difference between what you expected to achieve with each of the decisions and the results of the decision in the exercise. Describe whether they were different. Be specific and provide examples.



Alzheimer’s is one of the most common progressive neurological disorders among the elderly caused by dementia. Patients will present with mild to moderate cognitive signs and symptoms at the onset of the disorder, which will progress to severe memory loss with time, as they grow much older (Li et al., 2019). However, several treatment options have been proven to be effective in the management of Alzheimer’s disorder among the elderly. The purpose of this discussion is to illustrate the decision process in selecting the most effective drug, based on pharmacokinetic and pharmacodynamic factors, for treating an elderly patient diagnosed with Alzheimer’s disease.

Patient Case Study Summary

The assigned case study demonstrates a 76-year-old Iranian male with symptoms of Alzheimer’s disorder. The patient displays strange behavior upon arrival at the clinic reporting symptoms of memory loss, forgetfulness, confusion, and diminished interest in religious activities for the last 2 years. Pharmacokinetic and pharmacodynamic patient factors which contributed to the selection of drugs for this patient include his advanced age, male gender, Iranian race, and presenting symptoms in addition to the mini-mental exam results of moderate dementia. the patient’s diagnosis of Alzheimer’s disorder will also be considered.

Treatment Decisions

Based on the patient history and the pharmacokinetic and pharmacodynamic factors mentioned above, the most appropriate intervention is to initiate Exelon 1.5mg twice daily. Exelon (rivastigmine) is an FFDA-approved drug for treating mild to moderate Alzheimer’s disease (Fish et al., 2019). Previous studies support great effectiveness, and safety profile for use of the drug among the elderly diagnosed with Alzheimer’s (Khoury et al., 2018). The second decision was to increase the dose of Exelon to 4.5 mg twice daily as recommended by most clinical practice guidelines for patients who have displayed great tolerance but with minimal effectiveness. The last decision was to increase the dose further to 6mg twice daily, to promote optimal effectiveness as the patient still displayed limited remission of symptoms with the previous intervention.

Expected Outcome

Studies show that Exelon when administered appropriately takes between 8 to 12 weeks to completely manage symptoms of Alzheimer’s among elderly patients. As such, with the initial intervention of 1.5mg Exelon twice daily, the patient was expected to display approximately 50% remission of symptoms (Nguyen et al., 2021). The dose was however to be titrated to obtain the optimum outcome, not exceeding 6mg twice daily. The same results were expected with the second and third interventions with no side effects expected.

Difference Between Expected Outcome and Actual Outcome

Just like expected, the patient displayed a minimal reduction of symptoms of Alzheimer’s with no side effects reported with the first intervention. After the dose was increased in the second intervention, the patient reported further remission of symptoms, but at a slow rate, hence increasing the dose in the last intervention, which led to optimal remission of Alzheimer’s symptoms just as expected (Huang et al., 2020).


Alzheimer’s is a common disorder among the elderly compromising their quality of life and well-being. For the patient in the provided case study, it was necessary to administer Exelon at a starting dose of 1.5 mg which was titrated to 4.5mg then 6.5mg twice daily. The patient displayed great effectiveness with this medication in the management of his Alzheimer’s symptoms, with no side effects reported.


Fish, P. V., Steadman, D., Bayle, E. D., & Whiting, P. (2019). New approaches for the treatment of Alzheimer’s disease. Bioorganic & medicinal chemistry letters29(2), 125-133.

Huang, L. K., Chao, S. P., & Hu, C. J. (2020). Clinical trials of new drugs for Alzheimer’s disease. Journal of biomedical science27(1), 1-13.

Khoury, R., Rajamanickam, J., & Grossberg, G. T. (2018). An update on the safety of current therapies for Alzheimer’s disease: focus on rivastigmine. Therapeutic Advances in Drug Safety9(3), 171-178.

Li, D. D., Zhang, Y. H., Zhang, W., & Zhao, P. (2019). Meta-analysis of randomized controlled trials on the efficacy and safety of donepezil, galantamine, rivastigmine, and memantine for the treatment of Alzheimer’s disease. Frontiers in neuroscience13, 472.

Nguyen, K., Hoffman, H., Chakkamparambil, B., & Grossberg, G. T. (2021). Evaluation of rivastigmine in Alzheimer’s disease. Neurodegenerative Disease Management11(1), 35-48.




The case study depicts a 43-year-old white male who presents with a complaint of pain. He uses a set of clutches when ambulating. The patient reports that he has been referred for psychiatric assessment by his family doctor since the doctor perceived that he had psychological pain (Laureate Education, 2016). The pain began seven years ago after sustaining a fall and landed on the right hip. Four years ago, it was revealed that the cartilage around the right hip joint had a 75% tear. 

However, no surgeon was willing to perform a total hip replacement since they believed that there would be tissue repair over time (Laureate Education, 2016). He reports having severe cramping of the right extremity. A neurologist diagnosed him with complex regional pain syndrome (CRPS). He states that he gets low moods at times but denies being depressed.  He had been prescribed with Hydrocone but used it in low doses due to drowsiness and constipation, and the drug does not manage pain effectively (Laureate Education, 2016). The mental status exam is unremarkable.  


Decision Point One: Savella 12.5 mg orally once daily on Day 1, followed by 12.5 mg BD on Day 2 and 3, then 25 mg BD on days 4-7 and then 50 mg BD after that.

Reason: Savella is a serotonin-norepinephrine reuptake inhibitor that has NMDA antagonist activity, which brings analgesia at the nerve endings (Cording et al., 2015). It is indicated for fibromyalgia and thus effective for this client (Cording et al., 2015). I prescribed Savella to help in pain management and improve the overall mood.

Expected Result: I anticipated that Savella would lower the degree of pain. However, it was expected that the client would experience adverse effects such as nausea, constipation, headache, hot flushes, and insomnia.

Expected Vs. Actual Results: The client returned to the clinic after for weeks without using crutches but with a bit of limping. He states that the pain has been more manageable. The pain is severe in the morning but improves throughout the day (Laureate Education, 2016). On a scale of 1-10, the client rates the pain at four and states that he gets to a point on most days where he does not need crutches. Nevertheless, he reported having increased sweating, sleeping difficulties, nausea, and palpitations (Laureate Education, 2016). His BP was 147/92, and the pulse at 110. He denied having suicidal ideations and was still future-oriented.

Decision Point 2: Continue with Savella but lower dose to 25 mg twice a day.

Reason: I selected this decision to lower the severity of the adverse effects of Savella, which include nausea, constipation, headache, hot flushes, and insomnia (Cording et al., 2015).

Expected Result: Reduction in the dose of Savella would help control the side effects but lower the degree of pain control.

Expected Vs. Actual Results: The client returned to the clinic in four weeks using crutches and rates his current pain at 7/10. He reports that his condition has declined since the previous month (Laureate Education, 2016). He states that he sleeps at night but frequently wakes up due to pain in the right leg and foot. The BP is at 124/87 and pulse at 87. He denies having palpitations and suicidal ideations but is discouraged by the slip in pain management and seems sad.

Decision Point 3: Change Savella to 25 mg in the morning and 50 mg at Bedtime.

I reduced the dosage in the morning since the pain is mostly under control and increased the dose at Bedtime when there is less control (Resmini et al., 2015).

Expected Result: By lowering the morning dose and increasing the bedtime dose, I expected that the client’s pain symptom would improve while at the same time controlling the side effects of Savella (Resmini et al., 2015).

Expected Vs. Actual Results: The client reported an improvement in the pain with a rate of 3/10 denied having any side effects from the drug.  


Cording, M., Derry, S., Phillips, T., Moore, R. A., & Wiffen, P. J. (2015). Milnacipran for pain in fibromyalgia in adults. Cochrane Database of Systematic Reviews, (10).

Laureate Education. (2016). Case Study: A Caucasian man with hip pain. Baltimore, MD: Author.

Resmini, G., Ratti, C., Canton, G., Murena, L., Moretti, A., & Iolascon, G. (2015). Treatment of complex regional pain syndrome. Clinical cases in mineral and bone metabolism: the official journal of the Italian Society of Osteoporosis, Mineral Metabolism, and Skeletal Diseases12(Suppl 1), 26–30.



Integrating Evidence-Based Practices in Complex Pain Management: A Case Study Analysis


Complex Regional Pain Syndrome (CRPS), a challenging neurological condition, demands a nuanced and evidence-based approach to alleviate suffering and enhance patients’ quality of life. This in-depth analysis delves into the intricate case of a 43-year-old white male diagnosed with CRPS in his right hip. Through a series of carefully considered decisions, this patient’s journey sheds light on the complexities of managing CRPS while balancing medication side effects and therapeutic outcomes.

Patient Summary

The patient’s ordeal commenced seven years ago, following a fall at work resulting in significant right hip injury. Despite extensive diagnostic tests, he faced skepticism from healthcare professionals, leading to delays in appropriate treatment. The decisions taken included initiating amitriptyline at 25 mg, titrating to 125 mg at bedtime, and later reducing the dosage to 100 mg daily. These decisions were geared towards mitigating pain, enhancing functionality, and minimizing side effects such as grogginess and weight gain.

Evidence-Based Support for Decisions

The initiation of amitriptyline aligns with studies demonstrating its efficacy in managing neuropathic pain, particularly CRPS (Neyama et al., 2020). Amitriptyline, a tricyclic antidepressant, modulates pain perception through multiple pathways, making it a cornerstone in neuropathic pain management (Solomon et al., 2022). The decision to maintain the dose despite minor weight gain is substantiated by research indicating that the benefits of pain control often outweigh modest side effects (Naguib et al., 2021). Additionally, the avoidance of Qsymia was prudent, considering its potential cardiac risks and the patient’s BMI falling below the recommended threshold for its use (Lei et al., 2021).

In addition to pharmaceutical interventions, exploring alternative therapies such as neuromodulation techniques has gained significant attention. A comprehensive study by Sivanesan, & Goebel (2021) delves into the effectiveness of spinal cord stimulation and peripheral nerve stimulation in managing Complex Regional Pain Syndrome, providing valuable insights into diverse treatment modalities.

Goals and Outcomes

The overarching goal was to reduce the patient’s pain levels to an acceptable threshold (around 3 on the scale) and restore his ability to perform daily activities without crutches. The outcomes were remarkably positive; the patient’s pain diminished from a debilitating 9 to a manageable 4. This reduction facilitated enhanced mobility and daily functioning, marking a significant improvement in his overall well-being. Despite minor weight gain, the patient’s improved quality of life underscored the success of the interventions.

Discrepancies Between Expectations and Results

In this case, the outcomes closely mirrored the expectations. The patient experienced a substantial reduction in pain, improved functionality, and minimal side effects, including manageable weight gain. The decisions made successfully struck a delicate balance between therapeutic benefits and potential drawbacks, ensuring the patient’s optimal quality of life. The minor weight gain, while a concern, was overshadowed by the vast improvements in pain control and functionality, aligning with the patient’s stated preferences.


CRPS management necessitates a holistic and individualized approach, integrating evidence-based practices, patient preferences, and vigilant monitoring of outcomes. This case study underscores the pivotal role of healthcare providers in navigating the complexities of CRPS treatment. By employing a comprehensive understanding of available therapies and their potential effects, clinicians can significantly enhance the lives of individuals afflicted with this debilitating condition.


Lei, X., Ruan, J., Lai, C., Sun, Z., Yang, X., Lei, X.-G., & Ruan, J.-Q. (2021). Efficacy and Safety of Phentermine/Topiramate in Adults with Overweight or Obesity: A Systematic Review and Meta-Analysis. Obesity (19307381)29(6), 985–994.

Naguib, I. A., Ali, N. A., Elroby, F. A., & Elghobashy, M. R. (2021). Green HPLC-DAD and HPTLC Methods for Quantitative Determination of Binary Mixture of Pregabalin and Amitriptyline Used for Neuropathic Pain Management. Journal of Chromatographic Science59(6), 536–547.

Neyama, H., Dozono, N., Uchida, H., & Ueda, H. (2020). Mirtazapine, an α 2 Antagonist-Type Antidepressant, Reverses Pain and Lack of Morphine Analgesia in Fibromyalgia-Like Mouse Models. The Journal of Pharmacology and Experimental Therapeutics375(1), 1–9.

Sivanesan, E., & Goebel, A. (2021). Complex regional pain syndrome: developing diagnostic tools and treatments from sympathetic nervous system, neuroimmune and neuromodulation discoveries in neuropathic pain. Regional Anesthesia & Pain Medicine46(3), 193–195.

Solomon Tesfaye, Gordon Sloan, Jennifer Petrie, David White, Mike Bradburn, Tracey Young, Satyan Rajbhandari, Sanjeev Sharma, Gerry Rayman, Ravikanth Gouni, Uazman Alam, Steven A Julious, Cindy Cooper, Amanda Loban, Katie Sutherland, Rachel Glover, Simon Waterhouse, Emily Turton, Michelle Horspool, … Dinesh Selvarajah. (2022). Optimal pharmacotherapy pathway in adults with diabetic peripheral neuropathic pain: the OPTION-DM RCT. Health Technology Assessment26(39).