Patient Name __KL__________________________
Pharmacist Name__EB________________________
Date__March 4____________
Medical
Desired Outcomes / Goals
Drug Therapy Problems
Therapeutic Alternatives
Recommendation
Monitoring Parameters
Condition /
of Therapy
(Pharmacologic and Non-
with Justification
Indication
pharmacologic)
Parameter Value
Parameter
Frequency
Timeframe
Who
1)
S low
p rogression
o f
KL
i s
e xperiencing
n ausea
Alzheimer’s
Discontinue rivastigmine
Hold Rivastigmine
disease
alzheimer’s
d isease
,abdominal
d istension,
Hold rivastigmine then lower
Adverse
e ffects
a re
Efficacy
*Decrease
p rogression
o f
increased
b owel
s ounds,
a nd
dose
dose
d ependent
a nd
Change to another alternative
more
l ikely
t o
o ccur
i n
Resolution
o f
n ausea,
d iarrhea,
memory
l oss
a nd
m aintain
diarrhea
,
a n
a dverse
e ffect
abdominal
d istention,
a nd
r ebound
MMSE
e qual
t o
o r
g reater
of
t aking
r ivastigmine
such as donepezil or
the
e arly
t itration
galantamine
tenderness
i n
2
d ays
t o
b e
f ollowed
u p
than
1 7
w ithin
2 4
w eeks
phase,
o n
a n
e mpty
2)Resolve
s igns
a nd
stomach,
a nd
w ith
f ast
by
t he
p harmacist
symptoms
titration.
*Ensure
p atient
i s
a ble
t o
Cognitive
f unction
i ncluding
( ADAS-‐
Cog,
M MSE,
C IBIS-‐Plus
S cale)
I nitially
remember
g roceries,
a ttend
bridge
c lub
a nd
c omplete
at
4 -‐6
w eeks
t o
a ssess
f or
n eed
t o
titrate
d ose
t hen
e very
3
m onths
b y
other
a ctivities
o f
d aily
l iving
the
g eriatrician
within
2 4
w eeks
Forgetting
t o
a ttend
b ridge
c lub
a nd
3)
I mprove
q uality
o f
l ife
4)
M inimize
a dverse
d rug
pick
u p
g roceries
a t
s ame
f requency
as
c ognitive
f unction
b y
p harmacist
events
*No
d iarrhea,
n ausea,
abdominal
d istension,
Toxicity
increased
b owel
s ounds
within
4 8
h ours
5)
M inimize
c ost
CNS:
H eadache
a nd
d izziness,
f atigue,
insomnia,
a gitation,
a nxiety,
parkinsonism
s ymptoms,
d epression
RESP:
R hinitis
CVS:
b radycardia
( HR),
s yncope,
H TN
(BP)
GI:
N ausea,
v omiting,
d iarrhea,
anorexia,
a bdominal
d istension
a nd
rebound
t enderness,
w eight
Assess
a ll
t he
a bove
A DRs
i nitially
every
1 -‐2
w eeks
a nd
i f
t olerating
t hen
every
3
m onths
w ith
e ach
f ollow
u p
visit
b y
t he
p harmacists
Clinical
C are
P lan
T emplate
–
A Y
1 3
1