Assignment

Lau Har

PLEASE RESPOND to the following Discussions #1

Prescribing Considerations for the Older Adult: Bipolar Disorder

According to Ljubic et al (2021), bipolar I and II affects approximately as many as 1% of the elderly population. Compared to patients with an onset of bipolar disorder in their younger years, the older onset patients have more symptoms of depression, a difference in co-morbidities, and a difference in the course of the illness as well. Psychopharmacological options also need to be considered carefully, considering the age-related changes, with possible off-label treatment options proposed. Non-pharmacological treatment options may also be available to help reduce symptoms (Ljubic et al, 2021). Clinical guidelines for older adults diagnosed with bipolar disorder are the same as the guideline recommendations for younger patients diagnosed with bipolar, but the provider must consider the age related changes and other influences, such as poly pharmacy, that might affect safe prescribing (Tampi and Tampi, 2022).

Treatment Considerations

When considering medications to prescribe the older adult diagnosed with bipolar I or II, the provider should consider the many differences in the elderly such as reduced enzyme activities, diminished metabolic pathway, decreased protein binding, and impairment to thermoregulation. Also consider co-morbidities and current states of blood pressure, glycemic control, lipid control (Ljubic et al, 2021).

FDA-Approved Medication

Lithium is FDA-approved for the treatment of manic episodes, acute mania/mixed mania, maintenance for bipolar disorder with mania history, and bipolar maintenance (Stahl, 2021).

Off-Label Use Medication

Oddly enough, Lithium is also used off-label to treat bipolar depression and major depressive disorder. Lithium can be used as monotherapy or adjunctive therapy (Stahl, 2021). This student feels like she is cheating by using the same medication for each category! According to Stahl (2021), aripiprazole is a mood stabilizer that can be prescribed, off-label, for bipolar depression.

Things to Consider with FDA-Approved and Off-Label Medications

Therapeutic levels of lithium can be reached at lower levels and lower doses may also be required to reach a significant reduction in symptoms. Even though lower doses may be prescribed and lower serum levels may be present, it is critical for the provider to be aware that medications such as thiazides, ACE Inhibitors, and NSAIDS, all of which many elderly patients are prescribed, can increase plasma serum levels in patients (Stahl, 2021). Additionally, it is critical to assess renal, thyroid, and cardiac functions prior to starting treatment with lithium in the elderly population (Tampi & Tampi, 2022).

Aripiprazole is a third generation antipsychotic used off-label for bipolar depression. It shares similar prescribing concerns as lithium. The provider will want to ensure diabetes status, as well as track BMI, and lipid values. Monitor blood pressure, smoking status, and white blood cell count. Monitor for TD. Assess risk for CV events. Lower doses may be better tolerated (Torrico et al, 2020).

Non-Pharmacological Treatment Options

According to Tampi and Tampi (2022), there are several psychotherapy methodologies that have been shown to be beneficial to older patients with bipolar disorder. Medication adherence skills training (MAST-BD) is designed to improve adherence to medications, ability to manage medications, symptoms of depression, and also to improve certain aspects of health‐related quality of life among older patients with bipolar disorder (Tampi & Tampi, 2022).

 

References

 Ljubic, N., Ueberberg, B., Grunze, H. et al (2021). Treatment of bipolar disorders in older adults:

A review. Annals of General Psychiatry, 20, 45. https://doi:org.10.1186/s12991-021000367-x

Stahl, S. (2021) Stahl’s essential psychopharmacology: Prescriber’s guide (7th ed). Cambridge

University Press

Tampi, R, Tampi, D. (2022) Management of patients with older age bipolar disorder. Psychiatric

Times. Retrieved on January 25, 2022 from https://psychiatrictimes.com/view/managent/of/patients/with/older/age/bipolar/disorder  

Torrico, T., Kiai, N., Meza, C. et al. (2020) Suspected Aripiprazole-induced neutropenia in

geriatric patient: a case report. BMC Geriatrics 20, 179 Retrieved on January 23, 2023 from  https://doi.org/10.1186/s12877-020-01514-x

Mar Ander
PLEASE RESPOND to the Discussions #2

Week 9 Discussion: Prescribing for Older Adults and Pregnant Women

Proper risk assessment and the consideration of the unique patient characteristics constitute a patient-centered approach vital in determining the right course of treatment that would yield rational health outcomes. For this discussion, the population of focus includes older adults, and the disorder of interest is delirium. Delirium is a neurocognitive disorder induced by brain dysfunction due to structural or metabolic impairment. It affects attention causing patients to find it challenging to focus, maintain, or shift their attention (Huang, 2022). It tends to be more common in geriatric patients.

Treatment Approaches

Pharmacological and non-pharmacological therapies are viable options when deciding the treatment approaches for geriatric patients. However, multi morbidity and reduced immune function are among the unique considerations that clinicians should keep in mind. Treatment approaches for older adults with delirium are as follows:

FDA-Approved Medicine 

Generally, there are no FDA-approved medications for delirium (Thom et al., 2019). 

Off-Label Drug

Even though the FDA has not approved any drugs for delirium, antipsychotics are commonly used off-labels. For instance, Dexmedetomidine has been identified to have a better cost-benefit profile for agitation secondary to delirium (Wilson et al., 2020). On the other hand, Haloperidol is commonly used as an off-label medication in inpatient palliative care units for treating delirium and insomnia. Antipsychotics have the potential benefit of decreasing the incidence of delirium. The risk, however, is that drugs with anticholinergic properties like diphenhydramine could exacerbate delirium.

Non-pharmacological Intervention

There exist multiple non-pharmacological interventions that have been identified to be useful in reducing incidences of delirium episodes. These interventions include re-orientation, sleep hygiene, cognitive stimulation, proper nutrition, hydration, oxygenation, and bowel and bladder care (Burton et al., 2021). 

Clinical Practice Guidelines

There exist clinical practice guidelines (CPG) for delirium. The CPG by the Indian Psychiatric Society, for instance, recommends the management of delirium based on the underlying etiology (Grover & Avasthi, 2018). It justifies and prioritizes the use of multimodal non-pharmacological strategies like re-orientation and only recommends pharmacological treatment using antipsychotics when there is no response to non-pharmacological measures. 

References

Burton, J. K., Craig, L. E., Yong, S. Q., Siddiqi, N., Teale, E. A., Woodhouse, R., … & Quinn, T. J. (2021). Non-pharmacological interventions for preventing delirium in hospitalised non‐ICU patients. 
Cochrane Database of Systematic Reviews, (7).

Grover, S., & Avasthi, A. (2018). Clinical practice guidelines for management of delirium in elderly. 
Indian Journal of Psychiatry, 60(Suppl 3), S329–S340. 

Huang, J. (2022). 
Delirium. MSD Manual Professional Version. https://www.msdmanuals.com/professional/neurologic-disorders/delirium-and-dementia/delirium?query=delirium

Thom, R. P., Levy-Carrick, N. C., Bui, M., & Silbersweig, D. (2019). Delirium. 
American Journal of Psychiatry, 
176(10), 785-793.

Wilson, J. E., Mart, M. F., Cunningham, C., Shehabi, Y., Girard, T. D., MacLullich, A. M., … & Ely, E. (2020). Delirium. 
Nature Reviews Disease Primers, 
6(1), 1-26.

ERI Mar PLEASE RESPOND to the Discussions #3

Insomnia Disorder in Older Adults

The number of Americans that are over sixty five years of age is increasing rapidly. Sadock et al. (2015) report that by the year 2050 that twenty percent of the population will be greater than sixty five. Thus, it is imperative as future psychiatric providers one must be aware of potential medication interactions and possible side effects when treating older adults. Many older adults complain about sleep issues and they seek assistance to help their sleeping issues. I will discuss one FDA medication that is approved to treat insomnia in older adults, one off-label medication used to treat insomnia, and a non pharmacological intervention that an older adult can use to help alleviate their insomnia symptoms. 

The APA (2022) reports that the Insomnia Disorder (F51.01) is a disorder when a patient complains of discontent with the amount of sleep one is getting or the quality of their sleep. Additionally, the patient must have either difficulty falling asleep, difficulty maintaining sleep, and early morning awakenings with unable to return to sleep. Many older individuals will report sleep issues affecting their quality of life. An FDA approved medication to use in older adults is Doxepin. In a study by Sys et al. (2020) they report that Doxepin is a medication that is FDA approved to treat insomnia in older adults. Furthermore, the dosages of 1 mg, 3 mg, and 6 mg were all effective in treating insomnia. Additionally, this study found that there were no impairments in memory, daytime alertness, and psychomotor function. This study is great because it compared many medications for insomnia in older adults head to head. Usually, sedating medications, benzodiazepines, or Z-drugs are prescribed to adults with sleep issues. However, these classes potentially have higher side effects. Thus, this study was manifested to help decrease the risk of adverse reactions in this growing population class.

An off label drug not approved by the FDA commonly used in older adults is Trazodone. This medication does have sedative properties. In a study by Lavinge et al. (2020) report that Trazodone is a commonly prescribed sleep medication despite poor evidence of insomnia improvement. Furthermore this study also exhibits that Trazodone may increase suicidal ideations in patients taking this medication. The aim of this study by Lavinge et al. (2020) was to demonstrate that commonly prescribed medications for sleep that are not FDA approved carry an increase risk of suicidal ideation. What the study found that indeed Trazodone caused an increase risk in suicide and this medication should be discouraged to treat insomnia. However, this medication does have great benefits and one would be that it does treat depression. Thus, it is imperative that as a provider one must screen and assess what is the main reason why the patient is visiting you. If the patient has mostly depression and a symptom of depression one is having is insomnia, one could consider this medication. However, I would make sure the patient is well aware of the risks and side effects of the medication. 

Lastly, one nonpharmacological intervention in treating older adults with insomnia is using cognitive behavioral therapy. In a study by Cassidy-Eagle et al. (2022) they report that CBT is the gold-standard treatment option to treat insomnia based upon its results and how it is cost-effective. What the study demonstrates and reports is that firstly, the patient in CBT with insomnia will be given a background on psychoeducation and facts about sleep. Next, Cassidy-Eagle et al. (2022) discuss that sleep restriction is imperative as well. This concept is limiting the amount of time in bed when it is close to sleep. Additionally, behaviors reinforced is setting a daily routine when to sleep and wake. Also, avoiding napping is recommended and avoiding lying down in bed throughout the day is encouraged. Lastly, relaxation methods are stressed to help the older adult unwind before the nights end.

The risk assessment I would use to inform my treatment decision is multifocal. I would want to first assess what brought the patient in to seek my services. Is the patient having difficulties falling asleep? Are they sleeping too much during the day? Do they have comorbid conditions such as GERD, BPH, HTN, DM, ANXIETY, or DEPRESSION that are causing sleep complications. I would want to fully listen to their chief complaint and use shared-decision making in formulating the plan of care. With using an FDA-approved medication, I know that the medication has undergone rigorous research in clinical studies that actually provide evidence of the efficacy of the medication. However, there could still be risks using the medication that is FDA approved.  Perhaps, the patient does not tolerate it well and has serious side effects to the medication. One would have to thoroughly consider what medication to use in certain patient scenarios. With using non-FDA medication, again, one would have to consider the benefits versus the risks. Possible benefits would be a placebo effect or cost effect. Imagine as a provider you prescribe a medication that is not FDA because the patient wants the medication due to a family member or a close friend is taking a certain medication with great success. Also, some non FDA medications are more cost-effective and thus compliance would have a better outcome rather than an expensive medication a patient cannot afford. Risks using an non-FDA medication are that it does not meet certain requirements and the results are mixed. Furthermore, if the patient has serious side effects or health issues on the medication, a provider can be held liable in prescribing the medication due to lack of evidence of its efficacy. 

There are some clinical practice guidelines for this disorder but the guidelines are used more as recommendations rather than guidelines. I would justify and change my recommendations to prescribe less benzodiazepines and Z-drugs in older adults due to Beers criteria and the increased risk of falls. I would also counsel the use of benzodiazepines and Z-drugs are only used for short term usage. Also, I would explain that using these drugs are highly addictive and it is hard to wean off these medications. Lastly, I would stress non-pharmacological agents first, such as cognitive behavioral therapy, and the patient must first demonstrate good sleep hygiene before exploring other avenues to help with sleep. In the end, I would listen to the patient, and provide my recommendations, and try to help the patient improve their sleep quality and prevent insomnia. 

                                                                                           References

 

American Psychiatric Association. (2022). 
Diagnostic and statistical manual of mental disorders (5th ed., text rev.).

Cassidy-Eagle, E. L., Siebern, A., Chen, H., Kim, H. (Monica), & Palesh, O. (2022). 

Cognitive-Behavioral Therapy for Insomnia in Older Adults. 
Cognitive and Behavioral Practice, 
29(1), 146–160. https://doi.org/10.1016/j.cbpra.2021.04.002

Lavigne, J. E., Hur, K., Kane, C., Au, A., Bishop, T. M., & Pigeon, W. R. (2019). Prescription Medications for the Treatment of Insomnia and Risk of Suicide Attempt: a Comparative Safety Study. 
JGIM: Journal of General Internal Medicine, 
34(8), 1554–1563. https://doi.org/10.1007/s11606-019-05030-6

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). 
Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Sys, J., Van Cleynenbreugel, S., Deschodt, M., Van der Linden, L., & Tournoy, J. (2020). Efficacy and safety of non-benzodiazepine and non-Z-drug hypnotic medication for insomnia in older people: a systematic literature review. 
European Journal of Clinical Pharmacology, 
76(3), 363–381. https://doi.org/10.1007/s00228-019-02812-z

Den LesPLEASE RESPOND to the Discussions #4

Many women need to take medicine to stay healthy during pregnancy, including medicine for

mental health conditions. Anxiety symptoms can develop or worsen during pregnancy. It is estimated

that over 50% of women experience worsen anxiety or depression during pregnancy. And if anxiety is left

untreated during pregnancy, it can raise the risk of low birth weight and preterm delivery. This means a

baby is born smaller or earlier than expected, (CDC, 2020). Lexapro (escitalopram) is an FDA approved

medication for anxiety that can be used during pregnancy. There are many antidepressants available.

Two of the most common classes of antidepressants used for anxiety in pregnancy are selective

serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs),

(CDC, 2020).  clinicians may prescribe off-label medications to help treat anxiety symptoms, especially

when traditional anti-anxiety meds don’t work. Healthcare professionals often prescribe off-label

medications for anxiety disorders.  Research suggests that up to 40% of people with anxiety disorders

don’t respond to current treatments for these conditions. Pregabalin is also prescribed off-label as an

anti-anxiety medication, (Marchesi et al, 2016).  Experts believe that pregabalin lowers anxiety by

reducing the release of excitatory neurotransmitters, such as glutamate, (Marchesi et al, 2016). A non-

pharmaceutical intervention would be to start psychotherapy. Studies have shown that psychotherapy is

an effective treatment for a wide range of psychological disorders, (Zhang et al, 2019).

 GAD-7 is a diagnostic tool used to diagnosed Generalized Anxiety Disorder. It is an 8-question

assessment and based on the scoring, I would decide the appropriate medication to prescribe my

pregnant patient. Treatment concerns Including factors of black box warning and evidence-based

knowledge would also play an important role in the treatment plan. Some risk and benefits of using FDA

approved medicine is that it will provide legal support if something was to happen to the pregnant

patient or the fetus because of the medication prescribed. A risk of prescribing an off-label drug to a

pregnant woman is that clinicians are more vulnerable to malpractice lawsuits. The American College of

Obstetricians and Gynecologists (ACOG) has developed empirically based guidelines for how to diagnose

and treat perinatal depression. ACOG recommends that pregnant women with a history of major

depressive disorder who are being maintained on an antidepressant should be encouraged to continue

medication, and women who choose to discontinue medication ought to be taper off and carefully

monitored, (Rayburn, 2015).

 

Center for Disease Control and prevention. (2020). Pregnant Women Report Taking Medicines for Anxiety and Other Mental Health Conditions. Retrieved from https://www.cdc.gov/pregnancy/meds/treatingfortwo/features/pregnant-women-taking-anxiety-meds.html

Marchesi, C., Ossola, P., Amerio, A., Daniel, B. D., Tonna, M., & De Panfilis, C. (2016). Clinical management of perinatal anxiety disorders: A systematic review. Journal of Affective Disorders, 190, 543–550. 

https://doi.org/10.1016/j.jad.2015.11.004
Links to an external site.

Rayburn, W. (2015). Off label prescribing during pregnancy. Retrieved from https://pubmed.ncbi.nlm.nih.gov/9266573/

Zhang, A., Franklin, C., Jing, S., Bornheimer, L. A., Hai, A. H., Himle, J. A., Kong, D., & Ji, Q. (2019). The effectiveness of four empirically supported psychotherapies for primary care depression and anxiety: A systematic review and meta-analysis. Journal of Affective Disorders, 245, 1168–1186. https://doi.org/10.1016/j.jad.2018.12.008