Discussion: Prescribing for Older Adults and Pregnant Women

NRNP 6675 Discussion: Prescribing for Older Adults and Pregnant Women

Peripartum Depression occurs during pregnancy or after childbirth. This new term acknowledges depression that surrounds having a baby can have an onset during pregnancy.

Treatment includes:

APA guidelines for treating women with major depressive disorder who are pregnant, or breastfeeding recommend psychotherapy without medication as a first-line treatment for mild depression with a pregnant or breastfeeding mother. For moderate or severe depression antidepressants such as SSRIs, SNRIs, etc. can serve as primary treatment (American Psychiatric Association, 2020).

FDA Approved Drug

Brexanolone is an IV aqueous β-cyclodextrin-based formulation that produces stable serum levels Brexanolone is thought to be connected to GABA-A receptor activity. To compensate for the decline in allopregnanolone that follows childbirth, Brexanolone increased doses of allopregnanolone ( a horomone that rises in

Discussion Prescribing for Older Adults and Pregnant Women

Discussion Prescribing for Older Adults and Pregnant Women

childbirth but then quickly depletes after childbirth. It is thought to be a precipitating factor for PPD). like what the mothers’ levels are in the 3rd trimester (Fadden and Citrome ,2020).

Off-Label Drug

In a double-blind randomized trial of sertraline for peripartum depression, Sertraline produced a remarkably larger response rate (59 %) than placebo (26 %) and a more than twofold increased remission rate (53 % vs. 21 %) (Psychopharmacology, 2014).

 

Nonpharmacological Interventions

Interventions include physical therapy, kinesitherapy, music therapy and acupuncture. Cognitive behavioral therapy

Discussion Prescribing for Older Adults and Pregnant Women

Discussion Prescribing for Older Adults and Pregnant Women

and interpersonal psychotherapy are 2 of the most common interventions with strong clinical efficacy for treating peripartum depression. Physical therapies such as repetitive transcranial magnetic stimulation and light therapy are also effective. rTMS has been shown to last 6 months or more. Light therapy targets sleep and circadian rhythms which can heavily influence PPD (Medicine, 2020).

References

Faden, J., & Citrome, L. (2020). Intravenous Brexanolone for postpartum depression: what it is, how well does it work, and will it be used?. Therapeutic advances in psychopharmacology, 10, 2045125320968658. https://doi.org/10.1177/2045125320968658

Hantsoo, L., Ward-O’Brien, D., Czarkowski, K. A., Gueorguieva, R., Price, L. H., & Epperson, C. N. (2014). A randomized, placebo-controlled, double-blind trial of sertraline for postpartum depression. Psychopharmacology, 231(5), 939–948. https://doi.org/10.1007/s00213-013-3316-1

Torres, Felix. (2020). What is Peripartum Depression (formerly Postpartum)? American Psychiatric Association.  https://www.psychiatry.org/patients-families/postpartum-depression/what-is-postpartum-depression

Wang, Y., Li, H., Peng, W., Chen, Y., Qiu, M., Wang, J., Hao, Q., Tu, Y., Liu, Y., & Zhu, T. (2020). Non-pharmacological interventions for postpartum depression: A protocol for systematic review and network meta-analysis. Medicine, 99(31), e21496. https://doi.org/10.1097/MD.0000000000021496

Older adults and depression
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Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: Discussion: Prescribing for Older Adults and Pregnant Women

As people grow older, they are likely to encounter physical and mental changes. They may experience diseases that are commonly seen in the older population such as diabetes, high blood pressure, and degenerative diseases. In addition to all these changes, they may also experience other changes such as children moving out of the house, causing them to be empty nesters, or loved ones getting ill and passing. These changes may precipitate mental health disorders such as depression. According to Csajbók, Kagstrom, and Cermakova, (2022) third of older adults experience a mental health disorder like depression. Mental health clinicians need to properly understand the variations in older adults, their comorbidities, lifestyle changes, order of medications being administered, and their pharmacodynamics in relation to any medications they prescribe for depression.

According to Chen et al., (2021) music, physical exercise, and massage have been shown to improve depressive symptoms in older adults. Depending on the severity of depressive symptoms, it will be beneficial to initiate nonpharmacological options. Patients should be educated on the goals of each treatment option. Patients who already have multiple medications should also attempt nonpharmacological options first to avoid potential side effects and interactions with other medications.

According to Glass, Hermida, Hershenberg, and Schwartz, (2020) many medications have been approved for the treatment of depression in the elderly. However, SSRI and SNRI are more preferred compared to tricyclics due to more favorable side effects.  Citalopram is most frequently used due to its limited interaction in the liver

Before starting any antidepressant for an older adult, It is important to take into consideration the drug-drug interaction, family history, and other comorbidities since antidepressants may also treat other depressive-related disorders, start with the lowest possible dose and titrate while monitoring for any drug interaction or adverse effect (Glass, Hermida, Hershenberg, and Schwartz, 2020).

 

Reference

 

Csajbók, Z., Kagstrom, A., & Cermakova, P. (2022). Season of birth has no effect on symptoms of depression and anxiety in older adults. Scientific Reports, 12(1), 1–9. https://doi.org/10.1038/s41598-022-10892-8

 

Chen, Y.-J., Li, X.-X., Pan, B., Wang, B., Jing, G.-Z., Liu, Q.-Q., Li, Y.-F., Bing, Z.-T., Yang, K.-H., Han, X.-M., & Ge, L. (2021). Non-pharmacological interventions for older adults with depressive symptoms: A network meta-analysis of 35 randomized controlled trials. Aging & Mental Health, 25(5), 773–786. https://doi.org/10.1080/13607863.2019.1704219

 

Glass, O. M., Hermida, A. P., Hershenberg, R., & Schwartz, A. C. (2020). Considerations and Current Trends in the Management of the Geriatric Patient on a Consultation-Liaison Service. Current Psychiatry Reports, 22(5), 1–12. https://doi.org/10.1007/s11920-020-01147-2

 

Vijay, A., Becker, J. E., & Ross, J. S. (2018). Patterns and predictors of off-label prescription of psychiatric drugs. PloS One, 13(7), e0198363. https://doi.org/10.1371/journal.pone.0198363

 

Week 9 Forum
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The selected disorder is Post Traumatic Stress Disorder

It can be both seen in the geriatric and pregnant populations.

One FDA-approved drug:

The drugs approved by the FDA are serotonin reuptake inhibitors like paroxetine and sertraline, both used for the post-traumatic disorder. These are the primary drugs of choice for treating that condition (Kelmendi et al., 2017).

Risks associated with that drug are platelet inhibition which can induce bleeding. By that drug, the QT interval can also be prolonged. It can also produce serotonin syndrome, so the risk assessment while prescribing it in terms of dose and management should be considered. It is contraindicated in patients with hypertension and also produces toxicity with monoamine oxidase inhibitors, so contraindicated with that disorder, too. According to the FDA-approved criteria, the drug helps reduce the symptoms of the post-traumatic disorder, panic disorder, and social anxiety disorders (Singh et al., 2019).

Off-label drug:

Ketamine is used as an off-label drug to treat the post-traumatic disorder. Other drugs used as the off-label treatment are serotonin-norepinephrine reuptake inhibitors (SNRIs), like venlafaxine. It reduces the disorder’s symptoms (Liriano et al., 2019). The risk associated with ketamine is neurotoxicity, cognition impairment, and slow mental functioning. Cardiovascular functioning can also be affected by chronic use of ketamine (Zhu et al., 2016).

 

Non-Pharmacological Intervention:

Psychotherapy is a type of non-pharmacological treatment for that disorder. Interpersonal and cognitive behavioral therapies are used for psychotherapy in that disorder, and these techniques are most effective in treating the disorder. In the clinical practice guidelines for the post-traumatic disorder, psychotherapy treatment is one of the non-pharmacological interventions (Schnurr, 2017).

The recommended options are according to the given guidelines for post-traumatic disorder treatment in the pregnant and geriatric population. The purpose behind the FDA-approved drugs is to measure the risks associated with medications, their interaction, benefits and treatment power, etc., are considered thoroughly and then recommended the physician prescribes doses in safe measure after proper evaluation, other drug interactions, and needs of the patients.

References:

Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults. (n.d.). Https://Www.apa.org. https://www.apa.org/ptsd-guideline

Kelmendi, B., Adams, T. G., Southwick, S., Abdallah, C. G., & Krystal, J. H. (2017). Posttraumatic stress disorder: An integrated overview of the neurobiological rationale for pharmacology. Clinical Psychology: Science and Practice, 24(3), 281.

Liriano, F., Hatten, C., & Schwartz, T. L. (2019). Ketamine as treatment for post-traumatic stress disorder: a review. Drugs in context, 8.

Singh, H. K., & Saadabadi, A. (2019). Sertraline.

Schnurr, P. P. (2017). Focusing on trauma-focused psychotherapy for posttraumatic stress disorder. Current opinion in psychology, 14, 56-60.

Zhu, W., Ding, Z., Zhang, Y., Shi, J., Hashimoto, K., & Lu, L. (2016). Risks associated with misuse of ketamine as a rapid-acting antidepressant. Neuroscience bulletin, 32(6), 557-564.

Week 9 Discussion
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Generalized Anxiety Disorders in the Geriatric Population

 

Having had the predominance of my experience in geriatric psych, I chose to research this discussion on the elderly population. The disorder I chose was Generalized Anxiety Disorder (GAD). Unfortunately, GAD is a diagnosis you see all too often in the geriatric population oftentimes as a comorbidity with major depressive disorder. As a clinician, one FDA-approved drug I would recommend for GAD is Lexapro. The first line of treatment for GAD in the elderly is an SSRI. According to Crocco et al., “escitalopram may be a better tolerated first line treatment over SNRIs in the elderly” (Crocco et al., 2017). An off-label medication I would choose for an elderly patient with GAD would be Lyrica. According to Montgomery et al., “the anxiolytic efficacy of pregabalin had an early onset (by 2 weeks) and significantly improved both psychic and somatic symptoms of anxiety” (Montgomery et al., 2008). Finally, a non-pharmacological intervention I would use for GAD would be cognitive behavioral therapy as it is a known beneficial approach with positive results.

 

Risk Assessment

 

The risk assessment tool I would use when assessing geriatric patients for GAD would be the Geriatric Anxiety Scale. Depending on the score of the assessment, I would determine the route of my treatment plan. If the score was lower, the patient may benefit from only cognitive behavioral therapy. However, a higher score would indicate a need for pharmacological intervention in conjunction with cognitive behavioral therapy. When discussing the risks versus benefits of the use of Lexapro I would discuss the side effects in the elderly, that being, confusion, headache, memory problems which are all indicative of low sodium. Conversely, the benefits are a decrease in the feelings of anxiety. When it comes to risks associated with Lyrica, studies have shown that Lyrica is an overall safe drug to give to the eldery, however, they are more likely to experience side effects such as dizziness, blurred vision and confusion.

 

Clinical Practice Guidelines

 

Gradual dose reductions are required by the Centers of Medicare and Medicaid Services (CMS) for patient’s of long term care facilities who are on psychotropic medications. Gradual dose reductions assure that the patients are on the lowest possible dose of psychotropic medication possible with the best possible effects. Gradual dose reductions must occur at least quarterly according to CMS but some facilities may require sooner.

 

 

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

Department of Health and Human Services. (2016, March 25). Center for Clinical Standards and Quality/Survey & Certification Group. Psychosocial Harm In Nursing Homes. Retrieved July 28, 2022, from https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-16-15.pdf

 

Mayo Foundation for Medical Education and Research. (2022, February 1). Pregabalin (oral route) side effects. Mayo Clinic. Retrieved July 28, 2022, from https://www.mayoclinic.org/drugs-supplements/pregabalin-oral-route/side-effects/drg-20067411?p=1

 

Montgomery, S., Chatamra, K., Pauer, L., Whalen, E., & Baldinetti, F. (2008). Efficacy and safety of pregabalin in elderly people with generalised anxiety disorder. British Journal of Psychiatry, 193(5), 389–394. https://doi.org/10.1192/bjp.bp.107.037788

RE: Week 9 Discussion
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Hi Julianna,

This is an informative site for older adults with anxiety issues. In middle-aged and elderly individuals, major depressive disorder (MDD) and generalized anxiety disorder (GAD) are among the most frequent mental illnesses. According to a comprehensive study, the primary predictors of depressive disorders and symptoms in the elderly include female gender, somatic illness, cognitive impairment, functional handicap, absence of or loss of close social connections, and clinical history of depression. These investigations revealed that the risk factors for anxiety are comparable to those for depression, while biological components seemed more significant in predicting depression than anxiety (Domènech-Abella et al., 2019). 

The off-label use of pregabalin in a dosage range of 150–600 mg/day is a safe and effective therapy for generalized anxiety disorder in the elderly, independent of the severity of generalized anxiety disorder or the degree of subsyndromal depression. Pregabalin’s anxiolytic effectiveness began early (within two weeks) and considerably alleviated psychological and bodily anxiety symptoms (Montgomery et al., 2008).

I believe escitalopram is a good choice for the elderly and is FDA-approved for treating generalized anxiety disorder (GAD). This has been shown to reduce anxiety symptoms in older individuals compared to placebo(Crocco et al., 2017). In addition, escitalopram inhibits the return of symptoms. When cognitive behavioral treatment (CBT) is combined with medication, recent research, including older individuals with social anxiety, showed that the effectiveness and tolerability of escitalopram were compared to placebo (Crocco et al., 2017). Thank you for your post.

Michelle

References

Montgomery, S., Chatamra, K., Pauer, L., Whalen, E., & Baldinetti, F. (2008). Efficacy and safety of pregabalin in elderly people with generalized anxiety disorder. British Journal of Psychiatry, 193(5), 389–394. Retrieved July 28, 2022, from https://doi.org/10.1192/bjp.bp.107.037788

Week 9 Discission post
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Week 9

Discussion

Initial Post

Prescribing for Older Adults and Pregnant Women

Older adults and pregnant women are vulnerable populations that providers must take precautions when prescribing for this population. The intensity, chronicity, and co-morbidity of the mental disease, disorder, or condition should be considered together with the possibility of unfavorable medication-related outcomes when making decisions about drug selection, dosage, and duration(Rishabh, Parveen, Ravinder & Malika,2021). This paper aims to discuss about prescribing FDA-approved, off-label, and non-pharmacological interventions for depression in older adults.

Prescribing for Depression in Older Adults

Major depressive disorder, a DSM-5 diagnosis that affects older persons is the selected disorder of choice. Due to its serious consequences, late-life depression is an important public health issue and it is associated with worsened physical, cognitive, and social functioning, increased self-neglect, and an increased risk of illness, all of which are associated with an increased risk of mortality (Gabriel et al., 2020).

     FDA-approved, Off label, and non-pharmacological interventions

Sertraline is a drug that has FDA approval for treating elderly patients with severe depression. A selective serotonin reuptake inhibitor (SSRI) called sertraline has antidepressant and anxiolytic effects. According to the results of several well-designed trials, sertraline (50-200 mg/day) is effective in the treatment of major depressive disorder in elderly patients (> or =60 years of age) (Gartlehner et al., 2017). The off-label drug chosen is fluoxetine, which is effective in treating dementia and depressive symptoms in elderly patients. According to Gabriel et al.,(2020), cognitive-behavioral therapy (CBT) is an effective and long-lasting treatment for late-life depression. While there is little data, CBT is also regarded to be helpful for elderly persons with anxiety issues and it is a successful and beneficial method of treating insomnia.

Risk and Benefit Assessment

Several antidepressants have shown promise in treating older people with MDD who do not exhibit psychotic symptoms. It is suggested that the optimal side effect profile and the lowest likelihood of drug-drug interactions be considered while choosing an antidepressant. Sertraline, for instance, is well tolerated by persons with cardiovascular disease because it has fewer anticholinergic effects than earlier antidepressants. Common side effects of SSRIs include nausea, dry mouth, insomnia, somnolence, agitation, diarrhea, excessive sweating, and, less frequently, sexual dysfunction (Gabriel et al., 2020). One month after starting SSRI therapy, it is crucial to check sodium levels, especially if the patient is also taking other medications that might result in hyponatremia, including diuretics (Gartlehner et al., 2017). The withdrawal symptoms associated with other SSRIs have not been described with fluoxetine. In the elderly population, fluoxetine should not be avoided and, in some circumstances, maybe the drug of choice. The SSRI fluoxetine may not be as effective in treating older patients with MDD as it is in treating younger ones.

                                                                                Clinical Guidelines

As people get older, older persons experience significant losses such as losing a companion or spouse, their jobs, their social status, and their physical and mental abilities (Ruberto, Jha & Murrough,2020). Due to physiological changes brought on by advancing age, the elderly may be more susceptible to drug therapy. Patients who are older are more vulnerable to medication and may need more cautious dose adjustments. The elderly is routinely prescribed medication for a variety of causes, and drug interactions are a problem.

Tricyclic antidepressants are no longer advised as first-line treatments for older people due to the likelihood of adverse effects such as postural hypotension, which can result in falls and fractures, abnormal cardiac conduction, and anticholinergic effects(Ruberto, Jha & Murrough,2020). These latter symptoms include delirium, frequent urination, dry mouth, retention, and constipation. Tricyclic antidepressants have the potential to exacerbate a number of common medical disorders affecting the elderly, including dementia, Parkinson’s disease, and cardiovascular problems and Nortriptyline and desipramine are the best alternatives if tricyclic is used as a second-line treatment since they are less anticholinergic(Ruberto, Jha & Murrough, 2020).

When an antidepressant is chosen for an elderly patient, the first dose should be half that of a younger adult in order to minimize side effects. Elderly antidepressant side effects are probably brought on by aging-related changes in hepatic metabolism, co-occurring medical conditions, and drug-drug interactions. Instead, the intention should be to increase the dose gradually at 1- to 2-week intervals until it reaches an average therapeutic level (Gartlehner et al., 2017). Furthermore, it is now known that there are many individual variations even though the average therapeutic dose is frequently lower than that recommended for younger individuals due to how aging affects hepatic metabolism. Some patients will require a therapeutic dosage that is greater than usual.

Assume that a typical therapeutic dosage is used for 2 to 4 weeks, and no appreciable improvement is observed. The dosage should be raised until there is a clinical improvement, serious adverse effects, or until the maximum dosage is achieved (Gabriel et al., 2020). Therefore, it is essential to schedule frequent follow-up consultations to monitor therapy response, assess side effects, and modify dose as necessary. Additionally, it’s critical to watch out for any indications of depression getting worse, agitation, or anxiety, as well as the risk of suicide, particularly in the beginning stages of therapy. (Gartlehner et al., 2017). There is no evidence that antidepressant usage in the elderly causes an increase in suicidal ideation.

References

Rishabh Sharma, Parveen Bansal, Ravinder Garg, & Malika Arora. (2021). Potentially inappropriate medication prescribing in older adults: American geriatric society updated beers criteria journey. Journal of the Indian Academy of Geriatrics, 17(1), 28–35. https://doi.org/10.4103/jiag.jiag_2_21

Gabriel, F. C., de Melo, D. O., Fráguas, R., Leite-Santos, N. C., Mantovani da Silva, R. A., &Ribeiro, E. (2020). Pharmacological treatment of depression: A systematic review comparing clinical practice guideline recommendations. PloS one, 15(4), e0231700.

https://doi.org/10.1371/journal.pone.0231700

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., Greimel, J., Lux, L., Gaynes, B. N.,Viswanathan, M., Patel, S., & Lohr, K. N. (2017). Pharmacological and nonpharmacological treatments for major depressive disorder: a review of systematic reviews. BMJ Open, 7(6), e014912. https://doi.org/10.1136/bmjopen-2016-014912

Ruberto, V. L., Jha, M. K., & Murrough, J. W. (2020). Pharmacological Treatments for Patientswith Treatment-Resistant Depression. Pharmaceuticals (Basel, Switzerland), 13(6), 116. https://doi.org/10.3390/ph13060116