**THIS DISCUSSION IS DIVIDE IN TWO PARTS –

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MAIN DISCUSSION POST BY WEDNESDAY 01/25/2023 BEFORE 8:00 PM EST

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TWO REPLIES BY FRIDAY 01/27/2023 BEFORE 8:00 PM EST

PRESCRIBING FOR OLDER ADULTS AND PREGNANT WOMEN

After assessing and diagnosing a patient, PMHNPs must take into consideration special characteristics of the patient before determining an appropriate course of treatment. For pharmacological treatments that are not FDA-approved for a particular use or population, off-label use may be considered when the potential benefits could outweigh the risks.

In this Discussion, you will investigate a specific disorder and determine potential appropriate treatments for when it occurs in an older adult or pregnant woman. 

TO PREPARE:

· Choose one of the two following specific populations: either pregnant women or older adults. Then, select a specific disorder from the 
DSM-5-TR to use.

· Research evidence-based treatments for your selected disorder in your selected population (either older adults or pregnant women). You will need to recommend one FDA-approved drug, one non-FDA-approved “off-label” drug, and one non-pharmacological intervention for treating the disorder in that population.

Instructions

· Recommend one FDA-approved drug, one off-label drug, and one non-pharmacological intervention for treating your chosen disorder in older adults or pregnant women.

· Explain the risk assessment you would use to inform your treatment decision making. What are the risks and benefits of the FDA-approved medicine? What are the risks and benefits of the off-label drug?

· Explain whether clinical practice guidelines exist for this disorder, and if so, use them to justify your recommendations. If not, explain what information you would need to take into consideration.

· Support your reasoning with at least three current, credible scholarly resources, one each on the FDA-approved drug, the off-label, and a non-pharmacological intervention for the disorder.

Weekly Resources

· American Psychiatric Association. (2016). 


The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia Links to an external site.


. https://doi.org/10.1176/appi.books.9780890426807

· Agency for Healthcare Research and Quality. (2019). 

Maternal and fetal effects of mental health treatments in pregnant and breastfeeding women: A systematic review of pharmacological interventions Links to an external site.

. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/protocol-pharm-pregnant-women_0.pdf

Instructions:

Respond to your colleague. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature. 

**minimum of two (2) scholarly references are required for each reply cited within the body of the reply & at the end**

Reply # 1

Lauranne Elisa Brown

 

Depression in the Elderly

Depression is a significant concern in the elderly population due to multiple challenges.  According to Robertson et al. (2019), the elderly is susceptible to significantly more health problems in addition to experiencing life stressors that include financial challenges, social isolation, retirement, and the death of loved ones.  Suicide rates are also high in the elderly which account for 19% of all suicides even though older adults are only 13% of the population (Robertson et al., 2019). Moreover, depression the elderly is often overlooked and frequently coexists with many general illnesses (Robertson et al., 2019).  Robertson et al. (2019) indicated that depression is also perceived as an inevitable part of the aging process by some healthcare providers, and is therefore not treated effectively; nevertheless, it is crucial for clinicians to recognize this mental illness in older adults and intervene when depression is present.  In this discussion the treatments prescribed to treat major depressive disorder in older adults will be explored.

Assessment Tool

            The structured version of the Hamilton Depression Inventory (HAM-D) would be selected to detect depression in the elderly population (Carrozzino et al., 2020).  For many years this assessment tool has been the gold standard for detecting depression with good inter-rater and test-retest reliability in addition to sufficient sensitivity and internal reliability (Carrozzino et al., 2020).  Nevertheless, Carrozzino et al. (2020) cautioned that unstructured forms of this test should be avoided due to reduced reliability and sensitivity in these versions.

FDA Approved Drug for Depression in the Elderly-SSRIs

            The first line of treatment for older adults with major depressive disorder is selective serotonin reuptake inhibitors (SSRIs) such as sertraline, paroxetine, and fluvoxamine (Robertson et al., 2019). Although SSRIs have a lower rate of cardiotoxic and antimuscarinic side effects compared to tricyclic antidepressants which is a significant benefit, in the elderly they raise the risk of hemorrhagic strokes, insomnia, restless legs, hyponatremia, cholinergic blockade, and gastrointestinal bleeds (Robertson et al., 2019). SSRIs also increase the risk of dizziness due to hypotensive side effects that can led to falls in older adults and subsequent injuries (Robertson et al., 2019).

 

Off Label Drug for Depression-Ketamine

Ketamine is an anesthetic and dissociative drug which can change sensory perceptions which is similar to phencyclidine (PCP) (Di Vincenzo et al., 2021).  This drug has been researched by the psychiatric community and appears effective in alleviating treatment-resistant depression in both younger and older generations alike (Di Vincenzo et al., 2021).  Ketamine is considered safe treatment option for older adults and is generally well-tolerated in this population; however, side effects of ketamine can include confusion, disorientation, and feelings of detachment from the environment, and oneself (Di Vincenzo et al., 2021). Sensory changes that can include auditory and visual hallucinations in addition to vomiting, nausea, dizziness, and increased temperature, pulse, blood pressure and respiratory rates are also side effects of ketamine providers should be aware of (Di Vincenzo et al., 2021).

Nonpharmacological Treatments for Depression in the Elderly

Although cognitive behavioral therapy, interpersonal psychotherapy, and the group life-review are all recommended to treat depression in elderly patients, according to Wu et al. (2023) modified problem solving therapy that emphasized developing coping skills, obtaining information and self-efficacy showed promising results in treating depression in older adults. Moreover, modified problem solving therapy is a form of cognitive behavioral therapy that is specifically geared towards those experiencing depressive disorders (Wu et al., 2023).  In a randomized controlled study that compared treatment as usual to an 8-week intervention using modified problem-solving therapy, the intervention group showed significant improvements as compared to the control group when using this technique (Wu et al., 2023).  

Clinical Practice Guidelines

According to the American Psychiatric Association (2010), there are clinical guidelines for the treatment of depression in older adults.  These guidelines include the use of SSRIs, selective-norepinephrine-dopamine reuptake inhibitors (SNRIs), and norepinephrine dopamine reuptake inhibitors (NDRIs) in combination with psychodynamic therapy, behavioral therapy, or cognitive behavioral therapy to treat depressive symptoms. Moreover, the American Psychological Association (2019) states that empirically supported interventions include second generation antidepressants such as SSRIs and SNRIs in addition to the therapies described above.  Although ketamine is used off-label to medicate treatment-resistant depression and is not included in the guidelines, empirical research shows this drug is a promising medication that may stop suicidality and major depressive symptoms when other antidepressants have failed (Di Vincenzo et al., 2021).  Overall, the above recommendations of SSRI antidepressants and modified problem-solving therapy are in line with the guidelines for the treatment of depression in the elderly.

 

References

American Psychological Association. (2019). Clinical practice guidelines for the treatment of

     depression across three age cohorts. https://www.apa.org/depression-guidelines

American Psychiatric Association. (2010). Practice Guidelines-Major Depressive Disorder.

     https://psychiatryonline.org/guidelines

Carrozzino, D., Patierno, C., Fava, G., & Guidi, J. (2020). The Hamilton rating scales for

     depression: a critical review of clinimetric properties of different versions. Psychotherapy

     and Psychosomatics, 89(3), 133-150. 
https://doi.org/10/1159/000506879
Links to an external site.

Di Vincenzo, J., Siegal, A., Lipsitz, O., Ho, R., Teopiz, K., Ng, J., Lui, L., Lin, K., Cao, B.,

      Rodrigues, N., Gill, H., McIntyre, R., Rosenblat, J. (2021). The effectiveness, safety, and

     tolerability of ketamine for depression in adolescents and older adults: A systematic review.

     Journal of Psychiatric Research, 137, 232-241. doi:10.1016/j.jpsychires.2021.02.058

Robertson, L., Bertonini, F., Meader, N., Davies, S., Barbui, C., Gilbody, S., & Churchhill, R.

     (2019). Antidepressants for major depression disorder in older people: a network meta-

     analysis. The Cochrane Database of Systematic Reviews, 2019(9).

     doi:10.1002/14651858.CD013394

Wu, X., Li, J., Zhang, C., Zhou, X., Dong, X., Cao, H., Duan, Y., Wang, S., Liu, M., Zhang, Q.,

     & Xie, J. (2023). The effects of modified problem-solving therapy on depression coping, and

     self-efficacy in elderly nursing home residents. Frontiers in Psychology, 13(2023), 25-39.   

     doi:10.3389/fpsyg.2022.1030104

Instructions:

Respond to your colleague. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature. 

**minimum of two (2) scholarly references are required for each reply cited within the body of the reply & at the end**

Reply # 2

Myrlande Dessalines

Initial Post

FDA-Approved drug, Off-Label Drug, and Nonpharmacological Interventions

Major neurocognitive disorder due to Alzheimer’s disease (AD) with behavioral disturbance [331.0 (G30.9)] is the most common cause of dementia found in older adults. They experience evident decline in memory and learning and have a steady and progressive decline in cognition (American Psychiatric Association, 2013). Donepezil (Aricept) is FDA-approved for AD whether mild, moderate, or severe, where it inhibits acetylcholinesterase, and improves the availability of acetylcholine (Liu et al., 2022). Risperidone is utilized as an off-label drug for behavioral disturbances in dementias, where it is indicated for patients with AD receiving short-term treatment with symptoms with aggressive behavior (Oliveira et al., 2021). Nonpharmacological interventions include keeping individuals who are diagnosed with AD engaged with a set routine and schedule. It is important that they are provided with various trainings to assist with memory training utilizing memory aids, as well as music and dance therapy (Park & Cohen, 2019).

Risk Assessments to Inform Treatment Decision-Making. Risks and Benefits of FDA-Approved Medicine and Off-Label drug

Risk assessments that would be utilized in making an informed treatment plan would primarily involve the stage as to where patient is in the progression of AD. Safety is a priority when assessing patients, and ensuring that they receive adequate treatment that will assist in slowing the progression, versus promoting adverse treatments. Low doses of medications must be started and utilized with the older adults as it can eliminate harsh side effects that may be experienced. There are always risks involved when medications are prescribed—whether they are FDA-approved or used off-label. However, there is greater safety when using those which are FDA-approved as there has been extensive evidence-based research to support the benefits versus the risks. When using off-label drugs there is greater risk in harm as research has not fully developed or supported its use for disease process.

Clinical Practice Guidelines for Alzheimer’s Disease

There are clinical practice guidelines in place for Alzheimer’s disease. These guidelines have been established by the official Alzheimer’s Association which has partnered with a plethora of healthcare agencies and organizations. These clinical guidelines provide suggestions and clinical tips on safety, as well as research on differentiating between various forms of dementia from one another (Park & Cohen, 2019). The guidelines in place also provide education and direction on the rationalization of various pharmacological guidelines, as it relates to AD.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). DSM-5. 
https://doi.org/10.1176/appi.books.9780890425596
Links to an external site.

Liu, L., Zhu, Y., Fu, P., & Yang, J. (2022). A network pharmacology based research on the

mechanism of donepezil in treating Alzheimer’s disease. Frontiers in Aging Neuroscience, 14, 822480. 
https://doi.org/10.3389/fnagi.2022.822480
Links to an external site.

Oliveira, L. de F., Camargos, E. F., Martini, L. L. L., Machado, F. V., & Novaes, M. R. C. G.

(2021). Use of psychotropic agents to treat agitation and aggression in Brazilian patients with Alzheimer’s disease: A naturalistic and multicenter study. Psychiatry Research, 295, 113591. 
https://doi.org/10.1016/j.psychres.2020.113591
Links to an external site.

Park, J., & Cohen, I. (2019). Effects of exercise interventions in older adults with various types

of dementia: Systematic review. Activities, Adaptation & Aging, 43(2), 83–117. 
https://doi.org/10.1080/01924788.2018.1493897