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Please reply to the two-discussion post
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Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature.
Discussion post reply # 1
Treatment of major depressive disorder (MDD) in older adults usually involves a combination of pharmacological and nonpharmacological interventions. According to the DSM-5-TR, MDD involves persistent sadness and loss of interest in activities that one used to enjoy. This condition in older adults has an approved drug by FDA as Sertraline, a selective serotonin reuptake inhibitor (SSRI). As stated by Lewis et al. (2019), Sertraline is an effective antidepressant with a good safety profile, hence suitable for geriatric patients. But side effects, especially gastrointestinal disturbances and a higher risk of falls, need to be closely monitored.
While treating elderly MDD patients, an alternative off-label drug option is Trazodone. However, although primarily employed as a sedative, Trazodone has been proved in depression therapy especially comorbid insomnia. According to Fagiolini et al. (2023), Trazodone is an effective sleep pattern enhancer for older adults with MDD as they can have sleeping disorders. Although Trazodone poses risks such as an orthostatic hypotension, which could be a serious concern especially among older population that is likely to fall and sustain injuries.
CBT is highly recommended for a nonpharmacological intervention. CBT is effective in treating depression among the elderly and is non-pharmacological, as Gautam et al. (2020) note. It is important in controlling depression disorder because it changes negative patterns of thoughts and behaviors. Second, CBT can be adapted for use with age-related cognitive changes and physical limitations thus making it a suitable treatment option for the elderly.
For MDD treatment in older adults, clinicians provide few clinical practice guidelines that combine pharmacological and nonpharmacological treatments. As stated by Karrouri et al. (2021), according to the APA guidelines, SSRIs such as Sertraline are recommended as first-line treatment because of their safety profile and efficacy. These guidelines also support psychotherapy including CBT especially when case medications are inappropriate due to adverse effects or patient preference. In spite of the fact that second-line treatment drugs are classified as off label drugs like Trazodone, they are however considered in certain cases when insomnia is a major symptom. It is thus necessary to account for the medical history of an individual patient, potential side effects, and particular symptoms of depression when making treatment-based decisions that aim at producing personalized and effective treatment plans.
Cristele Y
Discussion post reply #
2
Enhancing pharmacological treatment is a crucial element of geriatric care to mitigate drug-related problems. Nevertheless, other aspects contribute to the complexity of prescription medicine for the elderly. Prior to addressing other factors, it is essential to note that the probability of experiencing adverse effects from medication is more significant in older individuals. This is because, in comparison to younger individuals, the elderly are more prone to having many medications prescribed to them as a result of various long-term health conditions. A further concern arises from excluding elderly people in pre-market research trials for new medications. Hence, the pharmaceuticals and dosages lawfully provided to the aged often do not represent the optimal choices. It is crucial to exercise caution while selecting prescription choices for the elderly due to age-related alterations in pharmacodynamic and pharmacokinetic characteristics. This research aims to provide one pharmacological therapy, one nonpharmacological treatment, and one non-FDA-approved “off-label” medicine for the treatment of schizophrenia in elderly persons. After that, we will review the risk assessment that will guide our selection. The last thing we will do is review the availability of clinical practice guidelines for this condition.
FDA Approved Drug Benefits and Side effects: Quetiapine
Disruptions in thought processes and altered perceptions are hallmarks of the long-term mental disorder known as schizophrenia (Iqbal et al., 2019). Pharmacological antipsychotics are the cornerstone of schizophrenia therapy. One of the antipsychotics used to treat schizophrenia is quetiapine. Typically, quetiapine IR is used orally twice a day to treat schizophrenia. The typical effective dosing range is between 300 and 450 mg daily (Iqbal et al., 2019). Atypical antipsychotics come in a range of dosages, and there is a recommendation that adults with schizophrenia take 25–50 mg of Seroquel IR daily or 50 mg of Seroquel ER daily, with 50 mg increments (Maan, Ershadi, et al., 2023).
Due to its impact on serotonin, olanzapine’s benefits are alleviating unpleasant side effects such as lack of interest, alogia, avolition, and flat affect (Tollens et al., 2018). An adverse effect of quetiapine prescription that is not as well publicized is the possibility of its abuse. Of all the SGAs, quetiapine has the highest rate of misuse and market value on the street (Klein et al., 2017). The street calls this drug “Susie-Q,” “baby heroin,” and “quell.” Quetiapine with heroin or cocaine makes a “Q-ball .”Quetiapine may boost recreational heroin and cocaine euphoria while relieving withdrawal symptoms. It even neutralizes stimulants (Curry & Richards, 2022). In addition to abuse as adverse effects, there is also dizziness, hypotension, blurred vision, dry mouth, urinary retention, constipation, paralytic ileus, abdominal pain, and tachycardia (Stahl, 2020, p. 669).
Off-Label Drug benefits and side effects: Carbamazepine
Some mood stabilizers can be used off-label to treat schizophrenia. A further study found that mood stabilizers reduced the likelihood of psychosis rehospitalization, a symptom of relapse in schizophrenia, by 12% when administered as adjuvant therapy for schizophrenia (Puranen et al., 2022). For the treatment of geriatric schizophrenia, I opted for the off-label usage of carbamazepine. Even though it is not officially approved for this usage, antiepileptic medicines, mainly carbamazepine, are often prescribed to people with schizophrenia (Grunze, 2008/2022).
Resistant schizophrenia is an off-label usage of carbamazepine. Patients with schizoaffective disorder, violent episode schizophrenia, and schizophrenia with abnormal EEGs have all shown improvement in simple, well-designed studies. In those with schizophrenia, carbamazepine alleviates both good and bad symptoms (Maan et al., 2023).
Carbamazepine often causes the following adverse effects: lightheadedness, lethargy, nausea, and vomiting. Carbamazepine raises the incidence of delirium in the elderly because of its weak anticholinergic action. Additionally, diarrhea, elevated intraocular pressure, and urine retention may result from this impact (Maan et al., 2023).
Non-pharmacological Intervention: Psychoeducation
Although medication is the first line of defense against schizophrenia, most treatment guidelines now endorse the use of nonpharmacological approaches, such as psychosocial interventions and different forms of psychotherapy like CBT and family therapy (Ventriglio et al., 2020). As an alternative to pharmaceuticals, I opted for psychoeducation while caring for elderly patients. As a recommended part of schizophrenia therapy, psychoeducation has many benefits, including lowering relapse and hospital readmission rates, increasing functioning and quality of life, and improving satisfaction with mental health services and treatment adherence (Herrera et al., 2023). A small body of research suggests that patients with schizophrenia who were using little or no antipsychotic medication might benefit just as much from nonpharmacological therapy as those who took the total recommended dosage of pharmaceuticals (Cooper et al., 2020).
Risk Assessment. In clinical practice,
risk assessment is often defined as gathering data to determine the probability of future hazardous behavior (Nathan & Bhandari, 2022). For quite some time, risk assessment has been acknowledged as an essential part of psychiatric treatment. The decision-making process around the treatment and suicide risk of older individuals with schizophrenia requires special attention to this aspect. The primary aim of risk assessment will be to obtain facts on adherence to medication and screen patients for suicide risk. Schizophrenic people are at greater risk of experiencing suicide risk. This is due to medication noncompliance (Warriach et al., 2021).
Clinical practice guidelines.
This guideline aims to enhance the quality of care for individuals with schizophrenia (Keepers et al., 2020). This endeavor aims to address the psychological impacts of the illness, as well as its rates of death and morbidity. The primary intended recipients of these proposals are psychiatrists who provide therapy or supervision for schizophrenia as a comprehensive condition. As to the APA recommendation, individuals diagnosed with schizophrenia who have not shown improvement with other therapies and those who present a significant suicide risk or have already tried suicide should be prescribed antipsychotic medication (Keepers et al., 2020, Table BOX 1. Guideline Statements). It is essential to monitor the medicine’s adverse effects and efficacy regularly. Patients who have seen amelioration of their symptoms should persist in taking their medicine and Psychosocial Intervention (Grover & Avasthi, 2019).
