Prescribing for Older Adults and Pregnant Women Discussion Paper

Prescribing for Older Adults and Pregnant Women Discussion Paper

Prescribing for Older Adults and Pregnant Women Discussion Paper

The geriatric population is on the rise in the US due to improvements in diagnostic and interventional approaches with the implementation of healthcare technology. However, with aging, most of the body functions including hepatic and renal function decline. Similarly, geriatric patients are prone to comorbidities and chronic conditions (Barrio-Cortes et al., 2021). Consequently, prescribing for older adults presents a challenge to clinicians due to the increased risk of toxicity, comorbidities, and potential drug-drug interactions. The subsequent paragraphs will discuss FDA-approved and off-label drugs for treating a major depressive disorder in older adults including the risks, benefits, and clinical practice guidelines.

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FDA-Approved Drug

Major depressive disorder is a devastating condition characterized by anhedonia and depressed mood for at least two weeks. Although the peak age of onset is the third decade, depression is common in the elderly. Its etiology is multifactorial encompassing both psychological and biological factors. It is primarily a clinical diagnosis based on the DSM-5 criteria. Treatment involves pharmacotherapy with antidepressants and psychotherapy. Escitalopram, an SSRI approved by the FDA for the management of depression shall be discussed below.

Escitalopram is an SSRI approved by the FDA on the 14^th of August 2002 for the management of depression and generalized anxiety disorder (Landy et al., 2022). The drug selectively inhibits the reuptake of serotonin in the CNS. The antidepressant effect occurs within 1 to 4 weeks. Food does not affect absorption, is cost-effective, and a smaller dose is required in the elderly due to a fifty percent increase of the area under the curve (AUC). The drug is contraindicated in hypersensitivity and individuals on concurrent MAO inhibitor or pimozide therapy (Landy et al., 2022). However, it should be used cautiously in individuals with a history of mania, seizures, renal and hepatic impairment, lactating mothers, and pediatric patients. Dose reduction is mandatory in geriatric patients. Risks attributable to the drug include the risk of suicide, neuroleptic malignant syndrome, insomnia, diarrhea, nausea, syndrome of inappropriate antidiuretic hormone, serotonin syndrome, erectile dysfunction, withdrawal effects, abnormal bleeding, and increased appetite (Landy et al., 2022).

Clinical guidelines recommend assessment for mood changes and levels of anxiety, suicidal tendencies, serotonin syndrome, and sexual dysfunction prior to and during therapy (Strawn et al., 2021). Follow-up exams are also recommended as well as tapering of the dose to avoid withdrawal effects. Finally, a dosage of 10 mg once daily is recommended for the elderly (Strawn et al., 2021).

Off-label Drug

Off-label prescribing is legal in the United States. Surprisingly, this practice cannot be declared ethical or nonethical. Modafinil is an FDA-approved drug for the treatment of sleep disorders due to narcolepsy, obstructive sleep apnea, or shift work sleep disorder (Hashemian & Farhadi, 2020). However, it is commonly prescribed for the treatment of major depressive disorder (Vaccarino et al., 2019).  It produces CNS stimulation, rapidly absorbed, moderately plasma protein bound, and well distributed. It is contraindicated in hypersensitivity and cardiac disorders such as arrhythmias, mitral valve prolapse, and left ventricular hypertrophy. Adverse effects include suicidal ideation, headache, rhinitis, Steven Johnson syndrome, nausea, arrhythmias, hypotension, hallucinations, insomnia, and elevated liver enzymes (Vaccarino et al., 2019).

Guidelines recommend dose reduction in geriatric patients, periodic liver function tests, monitoring for changes in behavior, signs, and symptoms of angioedema or anaphylaxis, documentation of narcoleptic episodes, and periodic assessment for rash (Hashemian & Farhadi, 2020). Finally, the dosage for geriatric patients with depression is initiated at 50 mg PO once daily and titrated over 4 weeks to 200 mg once daily (Vaccarino et al., 2019).

Cognitive Behavioral therapy

Cognitive behavioral therapy (CBT) is an effective pharmacotherapy for major depressive disorder. The therapy relies on both behavioral modifications and cognitive restructuring to alter disruptive thought patterns (Gautam et al., 2020). The entire treatment duration is approximately 16 weeks. The first 4 weeks require two sessions per week while one session per week is adequate for the remaining 12 weeks (Gautam et al., 2020). CBT aims to enhance patients’ control over their emotions and the capability to deal with depression.

Conclusion

The geriatric population is considered special during pharmacotherapy. Subsequently, caution should be taken and necessary dose adjustments made. The selection of the appropriate pharmacotherapy should be based on risk-benefit analysis as well as the current guidelines. Off-label prescribing is legal in the United States although it may not always be safe.

References

Barrio-Cortes, J., Castaño-Reguillo, A., Beca-Martínez, M. T., Bandeira-de Oliveira, M., López-Rodríguez, C., & Jaime-Sisó, M. Á. (2021). Chronic diseases in the geriatric population: morbidity and use of primary care services according to risk level. BMC Geriatrics, 21(1), 278. https://doi.org/10.1186/s12877-021-02217-7

Gautam, M., Tripathi, A., Deshmukh, D., & Gaur, M. (2020). Cognitive behavioral therapy for depression. Indian Journal of Psychiatry, 62(Suppl 2), S223–S229. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_772_19

Hashemian, S. M., & Farhadi, T. (2020). A review on modafinil: the characteristics, function, and use in critical care. Journal of Drug Assessment, 9(1), 82–86. https://doi.org/10.1080/21556660.2020.1745209

Landy, K., Rosani, A., & Estevez, R. (2022). Escitalopram. https://pubmed.ncbi.nlm.nih.gov/32491666/

Strawn, J. R., Poweleit, E. A., Mills, J. A., Schroeder, H. K., Neptune, Z. A., Specht, A. M., Farrow, J. E., Zhang, X., Martin, L. J., & Ramsey, L. B. (2021). Pharmacogenetically guided escitalopram treatment for pediatric anxiety disorders: Protocol for a double-blind randomized trial. Journal of Personalized Medicine, 11(11), 1188. https://doi.org/10.3390/jpm11111188

Vaccarino, S. R., McInerney, S. J., Kennedy, S. H., & Bhat, V. (2019). The potential procognitive effects of modafinil in major depressive disorder: A systematic review: A systematic review. The Journal of Clinical Psychiatry, 80(6). https://doi.org/10.4088/JCP.19r12767

 

Discussion: 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.
Use the Walden Library to 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 nonpharmacological intervention for treating the disorder in that population.
By Day 3 of Week 9
Recommend one FDA-approved drug, one off-label drug, and one nonpharmacological 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 nonpharmacological intervention for the disorder.