Mental Health Issues with the Elderly and what is within the role of the FNP regarding - PowerPoint Presentation

Slide1

Mental Health Issues with the Elderly and what is within the role of the FNP regarding diagnosing and prescribing

Kaley M. Brennen, MSN FNP-CSlide2

Mental Health and Neurocognitive Issues Common in the Elderly

Depression

Suicide

Anxiety

Dementia

DeliriumSlide3

Depression, Suicide and Anxiety

Caucasian males >85 years with a recent loss have highest suicide rate (Kaplan & Sadock, 2007)

Many mental health diagnoses coexist and overlap, contributing to worsening symptoms and difficulty of treatment

Depression

Both

Anxiety

Depressed Mood

Sleep Disturbance

Palpitation

Anhedonia

Psychomotor Agitation

Muscle Tension

Appetite Disturbance

Concentration Difficulty

Sweating

Worthlessness

Irritability

Dry Mouth

Suicidal Ideation

Fatigue

NauseaSlide4

Risk factors for Suicide

Psychiatric illness diagnosis

Substance abuse disorder

Hopelessness

Previous attempt

Caucasian, Male, >85

Relationship status (single or recently lost relationship)

Unemployment

Poor health

Childhood trauma/abuse/neglect

Family history of suicide

Use of antidepressants (age <24)

Significant loss

LGBT community

(Kaplan &Sadock, 2007)Slide5

Depression Screening

SIGE CAPS

S

uicidal thoughts 

I

nterests decreased 

G

uilt 

E

nergy decreased 

C

oncentration decreased 

A

ppetite disturbance (increased or decreased) 

P

sychomotor changes (agitation or retardation) 

S

leep disturbance (increased or decreased)

5 or more in two weeks (major depressive episode)

(American Psychiatric

Association, 2013)Slide6

Anxiety Screening

Generalized anxiety disorder

WATCHERS

W

orry 

A

nxiety 

T

ension in muscles 

C

oncentration difficulty 

H

yperarousal (or irritability) 

E

nergy loss 

R

estlessness 

S

leep disturbance

3 or more, most days, for 6 months or longer

(American

Psychiatric Association, 2013)Slide7

Depression Treatment in Primary Practice

Selective serotonin reuptake inhibitor (SSRI)- first choice in mood disorders and anxiety disorders, improves mood

Fluoxetine (

P

rozac), Sertraline (Zoloft), Citalopram (

Celexa

), Escitalopram (Lexapro), Paroxetine (Paxil)

Selective serotonin norepinephrine reuptake inhibitor (SNRI)-Improves mood, energizing, increases focus, used with anxiety and resistant depression

Venlafaxine (Effexor), Duloxetine (Cymbalta),

Desvenlafaxine

(

Pristiq

)

Selective dopamine reuptake inhibitor (SDRI)-usually and add on with and SSRI, lifts mood, less sexual adverse effects that SSRI or SNRI

Bupropion (Wellbutrin)

Http://psychiatryonline.org/guidelines

Slide8

Dosing for Antidepressant Medications

Prozac 20mg daily increased up to 80mg daily until therapeutic

Zoloft 25mg daily increased to 50mg daily after one week

Celexa

20mg daily increased to 40mg daily (if needed) after one week

Lexapro 10-20 mg daily

Paxil 10mg daily starting dose, increased in 10mg increments up to 50mg daily

Effexor 37.5-75mg daily with a maximum dose of 225mg daily

Cymbalta 40-60 mg daily, can be given in 2 divided doses, 20mg BID or 30mg BID

Pristiq

10mg daily, increased to 50mg daily for most therapeutic effect

Wellbutrin 100mg twice daily-150mg twice daily, maximum dose of 450mg daily

(Collins-Bride & Saxe, 2013)Slide9

Depression Treatment in P

rimary Practice

Start with lowest dose

Allow 4-6 weeks for therapeutic effect

Provide education

Encourage compliance

Frequently reassess

Do not abruptly stop medication, taper over 6 weeks

Antidepressant

D

iscontinuation Syndrome (

FINISH

)

F

lu like symptoms,

I

nsomnia,

N

ausea,

I

mbalance,

S

ensory disturbances,

H

yperarousal/

H

eadacheSlide10

Anxiety Treatment in Primary Practice

SSRI is the gold standard treatment for anxiety

Other treatments include SNRI, Benzodiazepine, and anxiolytic medications

Benzodiazepine

Alprazolam (

X

anax), Diazepam (Valium), Lorazepam (Ativan)

Fast acting

Often used as needed

Sedating

Potential for dependence

Anxiolytic

Buspirone (

Buspar

)

L

ess sedating than benzodiazepine medications

Requires consistent compliance, dosing multiple times daily, and several weeks to begin to have a therapeutic effect

(Collins-Bride & Saxe, 2013)Slide11

Dosing for Anti-anxiety Medications

Xanax 0.25-0.5mg TID, increased as needed for therapeutic effect, every 3-4 days, to a maximum daily dose of 4mg divided

Valium 2-10mg doses 2-4 times daily as needed

Ativan 0.5, 1, or 2mg doses up to 3 times daily as needed

Buspar

15mg daily, divided in 2-3 doses, increased up to 60mg daily in 2-3 divided doses as needed for therapeutic effect

(Collins-Bride & Saxe, 2013)Slide12

Considerations for the E

lderly Patient

Pharmacokinetics change, pharmacodynamics do not

Decreased kidney function, hepatic blood flow, metabolic rate, and hydration

Choose medication with the shortest half life

Longest to Shortest half life-Prozac (84h),

Celexa

(33h), Lexapro (27-32h), Zoloft (26h), Paxil (21h)

CYP450 Isoenzyme Inhibition (Medication interactions)

Most to Least interactions-Zoloft, Paxil, Prozac,

Celexa

, Lexapro (NO CYP isoenzyme interactions)

Level of sedating properties of medication

Most to Least sedating-Paxil, Lexapro,

Celexa

, Zoloft, Prozac

(

Collins-Bride & Saxe, 2013)Slide13

Dementia

Slowly developing impairment of intellectual or cognitive functioning

Insidious onset, months-years

Symptoms:

Memory loss, especially short term

Disturbed sleep wake cycle (day and night reversal)

Psychomotor and perceptual disturbances seen late in disease

Word searching>sparse speech>mute

No identifiable underlying cause

Chronic, progressive and irreversibleSlide14

Delirium

S

udden, rapid changes in brain function

Abrupt onset, hours-days

Symptoms:

Confusion

Change in cognition, activity, level of consciousness, psychomotor activity, sleep wake cycle (sun-downing)

Perceptual disturbances (hallucinations)

Speech issues (incoherent, confused, using inappropriate words)

Acute underlying cause

Reversible with treatment of underlying cause

Delirium can coexist with dementia (can occur in patient with dementia)Slide15

DELIRIUMS Mnemonic

D

rugs (medication added or adjusted/anticholinergics, antipsychotics, opioids, benzodiazepines, ETOH)

E

motional/

E

lectrolyte (hyponatremia)

L

ow PO2/

L

ack of drugs (withdrawal)

I

nfection (UTI, CAP

MOST COMMON DELIRIUM ETIOLOGY

)

R

etention of urine or feces/

R

educed sensory input (deaf/blind)

I

ctal or postictal state (ETOH withdrawal seizures common)

U

ndernutrition (malnutrition/vitamin deficiency)

M

etabolic/

M

yocardial (DM, Thyroid, MI, Heart failure, dysrhythmia)

S

ubdural hematomaSlide16

Delirium diagnosis and Treatment

Full diagnostic workup including:

BUN, Cr

CMP (Glucose, Calcium, Sodium)

Hepatic enzymes

B12 and Folate

TSH

Syphilis testing (RPR/VDRL)

CBC with WBC differential

Urinalysis with C&S

ECG

CT/MRI, PET scan, Toxicology screen, CXR, ESR, HIV or additional testing may be ordered based on patient presentation and risk factorsSlide17

Delirium diagnosis and Treatment

Treatment, both pharmacological and nonpharmacological, is based on the underlying cause of the delirium

Treat the underlying cause according to current guidelines and recommendations and follow up frequently to assess for reversal of deliriumSlide18

Dementia

Alzheimer-type

50-80% (30% also have Vascular dementia)

Vascular (Multi-infarct)

20%

Parkinson disease

5%

Miscellaneous cause

HIV, dialysis, encephalopathy,

neurosyphilis

, normal-pressure hydrocephalus, Pick’s disease, Lewy body disease (normal cognition/vivid hallucinations), frontotemporal dementia, otherSlide19

Alzheimer-type Dementia Treatment

Pharmacological interventions have been approved to slow the progression of dementia and to promote optimal functioning in patients throughout the stages of this progressive disease. Dementia is not reversible, so intervention aims to improve cognitive function and memory, treat coexisting symptoms such as depression, agitation and psychosis, and to slow the progression of the disease process.Slide20

Alzheimer-type Dementia Treatment

Early treatment to slow the decline associated with Alzheimer-type dementia

Vitamin E 1,000 IU BID OR

Selegiline

5mg BID

AntioxidantsSlide21

Alzheimer-type Dementia Treatment

Mild-moderate stage disease, cholinesterase inhibitors are the gold standard of treatment

Cholinesterase inhibitors work to increase availability of acetylcholine by slowing its breakdown, which has shown clinically significant, however minor and time-limited benefits in this stage of the disease.

Donepezil (Aricept) 5-10mg daily, in the evening,

R

ivastigmine

(Exelon) 3-6mg daily, with meals,

Galantamine

(

Razadyne

) 8mg daily, increased to 16mg initial maintenance dose after 4 weeks

Side effects include GI symptoms, anorexia and weight loss

Contraindicated with bradycardia

Baseline ECG needed if coexisting cardiovascular condition exists

Rivastigmine

(Exelon) has been shown to have fewer side effects

(Collins-Bride & Saxe, 2013)Slide22

Alzheimer-type Dementia Treatment

Moderate-severe stage disease, N-methyl-D-aspartate receptor antagonist is indicated for treatment, and can be combined in earlier stages of the disease with cholinesterase inhibitors. (Mini Mental Status Exam score 15 or less)

N-methyl-D-aspartate receptor

antagonists work by reducing glutamate-mediated excitotoxicity, helping to maintain or increase storage and retrieval of information

Mamentine

(Namenda) starting dose 5mg daily, increased in 5mg increments weekly

Week 2- 5mg twice daily, Week 3- 5mg three times daily, and maintained at 10mg twice daily, totaling 20mg/day starting the fourth week of dosing

Side effects include constipation, dizziness and headache

Contraindicated with renal impairment

(Collins-Bride & Saxe, 2013)Slide23

Alzheimer-type Dementia Treatment

Psychosis and agitation treatment

Psychotropic medications-second generation antipsychotics (

Risperdone

(Risperdal),Quetiapine (Seroquel)) increased risk of stroke with these medications, so always weigh risk vs benefit. Avoid with alcohol. Avoid use with vascular dementia or vascular risk factors

40% of dementia patients have coexisting depression/anxiety

Treat depression and anxiety with standard recommended treatment

Carefully assess for non-cognitive issues that may be contributing to behavioral issues (not dementia), which are common in elderly patients, and treat appropriately

Pain, infection, sensory Slide24

Alzheimer-type Dementia Treatment

Promote improvement in functional performance

Strong evidence-behavior modification, scheduled toileting, prompted voiding

Good evidence-graded assistance, practice and positive reinforcement

(American Academy of Neurology, 2016)Slide25

Referral Indications and resources for Elderly Mental Health Patients

Any new, sudden, rapidly progressing or atypical presentation of mood disorder or neurocognitive disorder should be referred to neurology/psychiatry, as appropriate for evaluation and collaborative approach to treating these patients in primary care.

Worsening symptoms or symptoms resistant to standard treatments should be referred to neurology/psychiatry, as appropriate.Slide26

References

American Association of Neurology. (2016). AAN Guideline Summary for Clinicians: Detection, Diagnosis and Management of Dementia. Retrieved from http://tools.aan.com/professionals/practice/pdfs/

dementiaguideline.pdf

.

American Psychiatric Association. (2013).

Diagnostic and statistical manual of mental disorders

, 5

th

ed., text revision: DSM-IV-TR. Washington, D.C.: American Psychiatric Association.

American Psychiatric Association. (2018). Practice Guidelines for the Treatment of Patients with Major Depressive Disorder.

http://psychiatryonline/guidelines

.

Collins-Bride, G. M., Saxe, J. M. (2013).

Clinical Guidelines in Advanced Practice Nursing: An Interdisciplinary Approach

. (2

nd

ed.) Burlington, MA: Jones and Bartlett Learning.

Kaplan, H., Sadock, B. (2007).

Kaplan &

Sadock’s

Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry

, (10

th

Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.