NRNP 6675 PMHNP Across the Life Span II: Prescribing for Older Adults and Pregnant Women

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Title: NRNP 6675 PMHNP Across the Life Span II: Prescribing for Older Adults and Pregnant Women

NRNP 6675 PMHNP Across the Life Span II Prescribing for Older Adults and Pregnant Women

FDA-approved drug, off-label drug, and one nonpharmacological intervention for treating GAD in older adults.

Anxiety disorders are among the most prevalent mental health issues in the elderly. Antidepressants are the first-line treatment for anxiety disorders. Escitalopram is FDA-approved for the treatment of generalized anxiety disorder (GAD) and has demonstrated improvement in anxiety symptoms when compared with placebo in older adults (Subramanyam et al, 2018). One off-label drug for treating GAD in older adults is propranolol (Szeleszczuk and Frączkowski, 2022). Lifestyle modification is a recommended nonpharmacological intervention for treating GAD in older adults. This includes sleep, diet, exercise, and socialization. These activities provide some stimulation and interaction with the environment and give a sense of control (Subramanyam et al, 2018).

Risks and benefits of Escitalopram and Propranolol.

A proper risk assessment for hypersensitivity reactions to other medications, possible QT prolongation, risk of bleeding, and serotonin syndrome is indicated for patients, before prescribing escitalopram is essential (Landy et al, 2022). Escitalopram is contraindicated for patients with a history of hypersensitivity reactions to escitalopram or citalopram. Recently, liver enzyme CYP2C19 activity has been deemed by pharmacogenetics as a determinant for contraindicating escitalopram use (Landy et al, 2022). Patients on escitalopram should be monitored for mood or behavioral changes, including suicidality (Landy et al, 2022). Escitalopram is well tolerated and found to be significantly more effective than comparators in treatment effect (Landy et al, 2022).

Benefits of propranolol include minimal effects on cognition, compared to Lorazepam. It also significantly relieved other symptoms including shortness of breath, chest pains, and weakness. Risks associated with the use propranolol include bradycardia, gastrointestinal issues, abdominal pain, nausea, erectile dysfunction, and wheezing/bronchospasms (Shahrokhi and Gupta, 2022). Propranolol is a lipophilic drug that is also metabolized by the liver, which is an important consideration in elderly patients with comorbid heart or liver conditions as it can increase their circulating levels (Crocco et al, 2017).

Clinical practice guidelines for treating anxiety in older adults.

Clinical guidelines include a comprehensive assessment of severity of symptoms and impairment in functioning because of symptoms

(Subramanyam et al, 2018). The Geriatric Anxiety Inventory has become the gold standard for assessment in elder anxiety (Subramanyam et al, 2018). Differentials that must be ruled out as these commonly will be the underlying cause of anxiety include side effects of medication use, drug and alcohol use, medical conditions, and other psychiatric disorders (Subramanyam et al, 2018). The choice of treatment setting is also considered. While most anxiety disorders can be treated in an outpatient setting, inpatient management is recommended when there is severe depression, poor social support, presence of chronic stressor, and concurrent medical illnesses requiring evaluation, treatment, and management (Subramanyam et al, 2018).

NRNP 6675 PMHNP Across the Life Span II: Prescribing for Older Adults and Pregnant Women References

Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological Management of Anxiety Disorders in the Elderly. Current treatment options in psychiatry, 4(1), 33–46. https://doi.org/10.1007/s40501-017-0102-4

Links to an external site.

Landy, K., Rosani, A., & Estevez, R. (2022). Escitalopram. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557734/#article-60.s6

Links to an external site.

Shahrokhi, M & Gupta, V. (2022). Propranolol. In StatPearls. StatPearls Publishing. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557801/#article-27818.s2

Links to an external site.

Subramanyam, A. A., Kedare, J., Singh, O. P., & Pinto, C. (2018). Clinical practice guidelines for Geriatric Anxiety Disorders. Indian journal of psychiatry, 60(Suppl 3), S371–S382. https://doi.org/10.4103/0019-5545.224476

Links to an external site.

Szeleszczuk, Ł., & Frączkowski, D. (2022). Propranolol versus Other Selected Drugs in the Treatment of Various Types of Anxiety or Stress, with Particular Reference to Stage Fright and Post-Traumatic Stress Disorder. International journal of molecular sciences, 23(17), 10099. https://doi.org/10.3390/ijms231710099

Links to an external site.

Hello Adeyiri, I appreciate your post on anxiety disorder among the elderly. I agree with you that anxiety disorders are among the most prevalent mental health issues among the elderly. However, I would like to highlight that there are several types of anxiety disorders, hence a need to narrow down one when exploring the pharmacological and non-pharmacological approaches for treatment (Martin, 2022). You did excellently by focusing on generalized anxiety disorder and the use of Escitalopram as an FDA-approved medication for individuals with generalized anxiety disorder. I believe that apart from the lifestyle modifications of socialization, exercise, diet, and sleep as non-pharmacological approaches, psychotherapy approaches can also be key in relieving the symptoms associated with a generalized anxiety disorder (Bandelow et al.,2022). You also did well by looking at the risk and benefits of both the FDA-approved and off-label medications for generalized anxiety disorder. Did you find any adverse reactions of either Escitalopram or Propranolol?

NRNP 6675 PMHNP Across the Life Span II: Prescribing for Older Adults and Pregnant Women References

Bandelow, B., Michaelis, S., & Wedekind, D. (2022). Treatment of anxiety disorders. Dialogues In Clinical Neuroscience.

Martin, P. (2022). The epidemiology of anxiety disorders: a review. Dialogues In Clinical Neuroscience. https://doi.org/10.31887/DCNS.2003.5.3/pmartin. https://doi.org/10.31887/DCNS.2017.19.2/bbandelow

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Hello Brenda, I appreciate a lot your discussion on prescriptions for the elderly population. I agree with you that It is estimated that by 2040 the older adult population will reach 80.8 million. The elderly are at risk of experiencing life-changing events, serious illnesses, and losing a loved one, which can cause feelings of grief, depression, and anxiety. The implication is that their levels of depression need appropriate management. Your choice of the FDA-approved medication for depression in the elderly is perfect. Indeed, sertraline has shown its propensity over the years to reduce depressive symptoms (Feng et al.,2018). I am also impressed that you have identified the medication class and a brief overview of its mechanism of action. You are also spot on by discussing ketamine as a current off-label drug for treating depression. I concur with you that the mechanism of action of this medication is currently unclear hence a need for further research. From your discussion, it is evident that the benefits of the medications outweigh the risks and hence should be used.

NRNP 6675 PMHNP Across the Life Span II: Prescribing for Older Adults and Pregnant Women References

Corriger, A., & Pickering, G. (2019). Ketamine and depression: a narrative review. Drug Design, Development, and Therapy, 3051-3067. Doi: 10.2147/DDDT.S221437

Feng, R., Wang, P., Gao, C., Yang, J., Chen, Z., Yang, Y., … & Wang, S. (2018). Effect of sertraline in the treatment and prevention of poststroke depression: A meta-analysis. Medicine, 97(49). https://doi.org/10.1097%2FMD.0000000000013453

Prescribing for Older Adults

The population of adults who are 65 years and older represent 54.1 million people or 16% of the United States population (CDC, 2023). It is estimated that by 2040 the older adult population will reach 80.8 million. Elderly are at risk of experiencing life changing events, serious illnesses, losing a loved one, that can cause feelings of grief, depression and anxiety. Warning signs can present as noticeable changes in moods, difficulty sleeping, irritability, misuse of alcohol or drugs, feelings of hopelessness, suicidal thoughts and engaging in behaviors that may be concerning to others (National Institute of Mental Health, 2023). With the concern for our older population’s mental health and importance of treatment a provider must manage this population with a realm of caution.

FDA-approved

An FDA approved medication for depression in the elderly is sertraline. Sertraline is a selective serotonin re uptake inhibitors (SSRIs) that targets the inhibitory effects of the pre-synaptic serotonin re uptake, resulting in an increase in serotonin (Singh & Saadabadi, 2023). Sertraline is considered a first -line treatment for MDD. This medication is prescribed once a day, if a patient experiences drowsiness, the dose may be taken prior to bedtime. The analogy of “start low and slow” is a good practice when prescribing to the older population, with starting doses of 25mg and depending on response may increase weekly.

Risk-Benefit of FDA-Approved

When prescribing any medications to the elderly risk factors will present. They may have chronic diseases such as diabetes, heart failure, chronic obstructive pulmonary diseases, brain disease, thyroid diseases, renal or hepatic impairments. Any chronic illness will have an impact on the effects, excretory or metabolism of medications. Sertraline side effects but not limited to dizziness, diarrhea, nausea, xerostomia, hallucinations, tremors, rhinitis, and fatigue. It can cause a prolong QT interval and may inhibit platelet aggregation resulting in a bleeding risk and serotonin syndrome when combined with another serotonergic agent (Singh & Saadabadi, 2023).

Benefits of prescribing an FDA approved agent is accessing the already studied and proven knowledge. This information can be used as a guideline to prescribing for an age specific population. Medications indicated by FDA as labeled “first line” can be an indication that this is suggested treatment for a specific disorder. Indications has been provided for specific areas that have a required monitoring to prevent adverse effects.

Off Label Drug

Off label is an atypical use of a repurposing of a drug other than their intended FDA approved use. One off label drug that has become the “hottest trend” is ketamine. The exact mechanism of action is unclear although it is a noncompetitive antagonist of the glutamate receptors (Skanland & Pobuda-Cieslar, 2019). Some studies have shown a gradual improvement in depression symptoms in the elderly and a sustained response, with no adverse reactions noted and no discontinuations due to adverse effects, but it was noted limited studies (Journal of Psychiatric Research, 2021).

Risk-Benefit of Off Label Drugs

The risk of using off label drugs can be a concern since possible studies have not been shown the safety and effectiveness of the medication. This can result in a possible worsening of a disorder, risk of medication interactions is a questions and long term affects needs to be part of the consideration. In using off label drugs, a provider must weigh the benefits and risks before prescribing.

A benefit of using a off label medication is it may fulfill the unmet needs of an FDA approved medication. One such example is the use of Trazodone, a medication for depression, has been successful in the use of treating insomnia (Rusz, et al., 2021). Off-label medications has the advantage that it may meet the unmet needs of a conventional approach and possibly increasing the accessibility of a drug.

Non pharmacological Interventions

With the treatment choice for depression factors that come into play is what severity they present with and how their lie is affected. There are many non pharmacological approaches that are available to the elderly. They can range from encouraging physical exercise to psycho-dynamic therapies. Using complementary and alternative medicine (CAM) may be what the patient is interested in lieu of medications. Example of CAM therapies are dietary supplement, herbal remedies, and acupuncture. The clinician will need to balance the interest of a client to the responsibility of choosing the treatment that is supported by evidence-based science (Gsrtiehner, et al., 2017)

Risk Assessment

Risk assessments for this population will encompass areas of chronic illness, family history and risk vs benefits. Using assessment tools such as the Beck Depression Inventory (BDI) can be used from ages 13 to 80 to measure behavioral and severity of depression. Assessing depression in the elderly can be seen as a result of a chronic illness or a metabolic symptom from a disease process or medication interactions. Determining these will depend on a thorough assessment and evaluation.

Clinical Practice Guidelines for Major Depressive Disorder

Depression among the elderly population can present with psychological issues such as fear, loneliness or depression which can have a serious impact on their daily lives (Zhang, Xiang, Li, & Pan, 2021). According to the DSM-5-TR a specific set of criterion are required for a diagnosis of major depressive disorder, (MDD). Five or more symptoms must be present during the same 2-week period and cause a change in previous functioning and at least one symptom is either depressed mood or loss of pleasure/interest (Association, 2022). The symptoms include and are not attributed to a medical condition are:

1.Depressed mood most of the day, nearly every day, subjective- feels sad, empty, hopeless or observed by others.

Diminished interest or pleasure most of the days or nearly every day.
Weight loss or gain, decrease or increase in appetite.
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation.
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt.
Diminished ability to think, concentrate or indecisiveness, nearly every day.
Recurrent thoughts of death, recurrent suicidal idealization without a plan or a suicide attempt or plan to committing suicide(Association, 2022).

Using the DSM-5-TR as a clinical guideline will be the first step in determining diagnosis. Furthermore, determining the severity of any disorder will be a guide in determining the treatment plan what is most beneficial for a client.

NRNP 6675 PMHNP Across the Life Span II: Prescribing for Older Adults and Pregnant Women References

Association, A. P. (2022). DSM-5. Washington DC: American Psychiatric Association Publishing.

(2023, April). Promoting Health for Older Adults. Retrieved from Center for Disease Control and Prevention: https://www.cdc.gov/chronicdisease/resources/publications/factsheets/promoting

Gartiehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., . . . Lohr, K. (2017, April 27). Pharmacological and non pharmacological treatments for major depressive disorder: review of systematic reviews. Retrieved from BMJ Open: https://bmjopen.bmj.com/content/bmjopen/7/6/e014912.full.pdf

Journal of Psychiatric Research. (2021, May). The effectiveness , safety and tolerability of ketamine for depression in adolescents and older adults: A systematic review. Retrieved from Journal of Psychiatric Research: https://www.sciencedirect.com/science/article/pii

National Institute of Mental Health. (2023). Older Adults and Mental Health . Retrieved from National Institute of Mental Health: https://www.nimh.nih.gov/health/topics/older-adults-and-mental-health

Rusz, C.-M., Osz, B.-E., Jitca, G., Mikios, A., Batrinu, M.-G., & Imre, S. (2021, October 18). Off-Label Medications: From a Simple Concept to Complex Practical Aspects. Retrieved from National Library of Medicine: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8508135/

Singh, H. K., & Saadabadi, A. (2023, February 13). Sertraline. Retrieved from Stats Pearls Publishing: https://www.ncbi.nlm.nih.gov/book

Skanland, S., & Pobuda-Cieslar, A. (2019, December 15). Off-label uses of drugs for depression. Retrieved from European Journal of Pharmacology: https://www.sciencedirect.com/science/article/pii/S0

Zhang, S., Xiang, K., Li, S. L., & Pan, H.-F. (2021). Physical Activity and depression in older adults : the known and unknowns. Retrieved from Psychiatry Research: https://reader.elsevier.com/reader/sd/pii/

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Please note that GCU Online weeks run from Thursday (Day 1) through Wednesday (Day 7).

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Discussion questions:

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