Treating Geriatric Clients With Mood Disorders
Treating Geriatric Clients With Mood Disorders
To prepare for this Assignment:
- Review this week’s Learning Resources. Consider how to assess and treat adult and geriatric clients requiring antidepressant therapy Treating Geriatric Clients With Mood Disorders.
The Assignment
Examine Case Study: An Elderly Hispanic Man with Major Depressive Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
- At each decision point stop to complete the following:
o Decision #1
Which decision did you select?
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
o Decision #2
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
o Decision #3
Why did you select this decision? Support your response with evidence and references to the Learning Resources.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
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Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
- Also include how ethical considerations might impact your treatment plan and communication with clients.
Note: Support your rationale with a minimum of three (3) academic resources. While you may use the course text to support your rationale, it will not count toward the resource
Major Late-life depression is a serious illness accompanied by medical morbidity, cognitive decline, and risk of suicide. Antidepressant medications are a cornerstone of treatment for depressed elders. Although they are optimally provided in conjunction with psychotherapy, in many cases they are used alone. In recent years concerns have developed about modern antidepressant medications, including concerns about their ultimate efficacy and particular risks that may be seen in older adult populations. Ultimately antidepressant medications are effective for many individuals and continue to play an important role in treating depressed elders, although the potential risks must be weighed with the patient and their families. Current data do not support restriction of their use and untreated depression has serious negative health consequences. Our patients need treatments with better efficacy and safety, including new pharmacological options and better access to and dissemination of nonpharmacological treatment Treating Geriatric Clients With Mood Disorders.
Keywords: Depressive disorder, aging, geriatrics, antidepressant, adverse events, side effects, suicide, treatment, psychotropic medications
Depressive disorder in adults and geriatrics is an increasing debilitating mental problem associated high morbidity, declined cognitive functions, dementia, caregiver burden, suicide, and mortality. It is a problem that significantly affects patients, their family, and overall economic status of a country (Taylor WD, 2014). Antidepressant therapy and regular follow-up are important in treatment and maximizing remission. Assessment of adult and geriatric patient requiring antidepressant therapy is done to be able to select safe antidepressant medication with the best pharmaco-therapeutic effect, best reaction profile and low risk of drug interaction. Failure of remission necessitates addition of other treatments and psychotherapy or electroconvulsive therapy severe cases. Though, majority of elderly patients with depression receive antidepressant therapy only. The paper examines a case of a 32 years old Hispanic man With Major depressive disorder and his treatment options. The medication prescriptions decision is carefully made and outcomes considered for proper management of the geriatric patient. Patient’s age and other factors likely to affect the pharmacokinetic and pharmacodynamic processes are considered.
Decision Point One
Selected Decision
Begin Zoloft 25 mg orally daily.
Reason for Selection
Zoloft (sertraline) is a selective serotonin reuptake inhibitors first-generation antidepressantswith fewer side effects, wide therapeutic index and low rates of drop-out. It’s a drug of choice for severe depression as it has the best efficacy, tolerability and safety in adults. The patient had severe depression with Montgomery-Asberg depression scale (MADRS) score of 51. Though serotonin-norepinephrine reuptake inhibitor (SNRIs) such as Effexor XR (Venlafaxine) is used in the treatment of severe depression, it has a lower efficacy and safety with numerous side effects (Thorlund K et al, 2015). Escitalopram is another good option. Therefore, Zoloft is the best option for management of this patient.
Expected Results
Zoloft is an effective SSRI with effects of improvement in remission of depressive symptoms in two weeks (Wolfgang N &Andreas E, 2017). The patient had expected results after four weeks of therapy. He reported a 25% decrease in depressive symptoms. Thus the patient had interest in engaging in usual activities, reduced feelings of being an outsider, reduced insomnia and improved concentration.
Differences between Expected Results and Actual Results
Despite a 25% improvement in the depressive symptoms, the patient had side effect of a new onset of erectile dysfunction. This was not a desired effect though expected because it is among the side effects of Zoloft. The others include headaches, dizziness, dry mouth, nervousness, sleep disturbance, and loss of appetite (Wolfgang N &Andreas E, 2017) Treating Geriatric Clients With Mood Disorders.
Decision Point Two
Selected Decision
Augmentation with mirtazapine 15mg daily and decrease Zoloft dosage to 12.5 mg orally daily
Reason for Selection
Zoloft has been effective in reducing the depressive symptom though with a side effect of sexual dysfunction .In such cases, various strategies are employed in management of sexual dysfunction induced by SSRI such as Zoloft. These strategies are reduction in dosage, drug holidays, substitution with another antidepressant, and augmentation .Therefore, Zoloft will be maintained with reduced dosage but augmented with mirtazapine which is beneficial in SSRI-induced sexual dysfunction (Pratap R. & Jeffrey R. ,2017). Introduction of mirtazapine and gradual withdrawal of Zoloft ensures continued remission of depressive symptoms and correction of erectile dysfunction.
Expected Results
Zoloft and mirtazapine, a tetracyclic antidepressant work together to further deduce symptoms of depression. Mirtazapine is a serotonin modulator and enhances therapeutic effects of the antidepressant. It has high tolerability and efficacy because its postsynaptic 5-HT2 and 5-HT3receptor blockade provides antidepressant effects early and without sexual dysfunction. Therefore, the patient will likely report an improvement in the depressive symptoms and normal sexual function (Pratap R. & Jeffrey R., 2017).
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Differences between Expected Results and Actual Results
After four weeks of therapy, the patient reports that the depressive symptoms had worsened though the erectile dysfunction had subsided. This was not expected especially after introducing an augmenting drug. This likely meant that reducing the patient’s Zoloft dosage and augmenting with mirtazapine was not appropriate.
Decision Point Three
Selected Decision
Change to Paxil 20 mg orally daily
Reason for Selection
Paxil is more effective SSRIs with fewer side effects on sexual functions compared to Zoloft. When sexual dysfunction side effects occur at first, it tends to reduce with continued therapy. Returning the patient to the initial dose of 25mg may improve the depressive symptoms but still present the side effects of erectile dysfunction. This bothersome sexual side effect may lead to non-compliance and cessation of treatment. Switching to another antidepressant in the same class presents lower drug interactions and discontinuation effects (Keks, N., Hope, J., & Keogh, S.2016).Therefore, it would be appropriate to change from Zoloft augmented with mirtazapine therapy to Paxil 20mg.Zoloft and Paxil are antidepressant in the same class of SSRIs Treating Geriatric Clients With Mood Disorders.
Expected Results
Paxil is indicated for prevention of relapse and further recurrence of depressive episodes because of its high efficacy. Also, it has a better therapeutic value in patients who do not respond to the first line antidepressant therapy ( Keks, N., Hope, J., & Keogh, S.2016). Therefore, the patient will have reduced depressive symptoms that are more than 25 % reduction compared to when using Zoloft. This includes improved concentration and relationships.
Differences between Expected Results and Actual Results
Switching antidepressant therapy within the same class is one way of dealing with unwanted side effects and reduced response to the initial therapy. This is to ensure adherence and continued remission of depressive symptoms respectively. Though the use of paxil may have some sexual dysfunction at first, its continued use resolves it ( Keks, N., Hope, J., & Keogh, S.2016).
Impact of Ethical Considerations on Treatment Plan
The purpose of antidepressant therapy is to do good to the patient and avoid harm. In regard to this PMHN seeks to help the patients get well by the use of antidepressant. At the same time these antidepressants have side effects .One of the common and serious side effect is suicidal tendencies. The PMHN should be cautious in prescribing the antidepressants with high suicidal tendencies and avoid if possible or closely monitor the patient. Also, depression greatly affects the cognitive functioning. This makes the patient unable to consent to treatment posing the ethical and moral issue of forced treatment .the PMHN have the responsibility of involving the family members and caregiver at the initial of treatment. Adoption of medication plan involves a complete thorough evaluation of the patient to come up with evidence based treatment option with less side effects and barriers to its adherence. Also, the treatment plan should be closely monitored and follow up of the patient done regularly (Taylor WD, 2014 Treating Geriatric Clients With Mood Disorders.
Conclusion
Major Late-life depression is a serious illness accompanied by medical morbidity, cognitive decline, and risk of suicide. Antidepressant medications are a cornerstone of treatment for depressed elders. Although they are optimally provided in conjunction with psychotherapy, in many cases they are used alone. In recent years concerns have developed about modern antidepressant medications, including concerns about their ultimate efficacy and particular risks that may be seen in older adult populations. Ultimately antidepressant medications are effective for many individuals and continue to play an important role in treating depressed elders, although the potential risks must be weighed with the patient and their families. Current data do not support restriction of their use and untreated depression has serious negative health consequences. Our patients need treatments with better efficacy and safety, including new pharmacological options and better access to and dissemination of nonpharmacological treatment.
Keywords: Depressive disorder, aging, geriatrics, antidepressant, adverse events, side effects, suicide, treatment, psychotropic medications
Depressive disorder is a prevalent debilitating mental problem among the adults and geriatrics. It is mainly managed by antidepressant therapy condition .Careful evaluation of the patient is required so as to adopt antidepressant medications that are effective and safe. Initiation of treatment should involve the patient, family and caregivers to ensure adherence. Also, decision on increasing or reducing the dosage or changing antidepressants should be made carefully to prevent relapse, drug interactions or treatment failures.
References
Jesús López-Torres, Ignacio Párraga, José M Del Campo, Alejandro Villena.(2013).
Keks, N., Hope, J., & Keogh, S. (2016). Switching and stopping antidepressants. Australian Prescriber, 39(3), 76–83. http://doi.org/10.18773/austprescr.2016.039
Pratap R. Chokka and Jeffrey R. Hankey.(2017). Assessment and management of sexual dysfunction in the context of depression. Published online . doi: 10.1177/2045125317720642
Taylor WD. (2014).Clinical practice. Depression in the elderly. N Engl J Med.371:1228 1236. [PubMed]
Thorlund K et al. (2015). Comparative efficacy and safety of selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors in older adults: A network meta-analysis. J Am Geriatr Soc; 63:1002. (http://dx.doi.org/10.1111/jgs.13395)
Wolfgang Novak &Andreas Erfurth. (2017). Treatment of depressive disorders with selective serotonin reuptake inhibitors (SSRI). psychopraxis. neuropraxis 20:1, 28-41 Treating Geriatric Clients With Mood Disorders.
