Discussion: Therapy with Older Adults
Clients who are older have often times been dealing with their mental health disorder their entire lives, whiles other disorders may be brought on through the aging process or the trauma of losing a lifelong partner. Treatment can be challenging for both the client and the therapist. For this Discussion, you will focus on therapeutic approaches for an older adult presented in a case study.
Respond to 2. people Maria and Kindra in the following way. Respond to at least two of your colleagues by providing one alternative therapeutic approach. Explain why you suggest this alternative and support your suggestion with evidence-based literature.
Maria M (Two citations and references for Maria)
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Treatment Plan for a 69-year-old Patient with Depression and anxiety
Timely recognition and adequate management of depression among the elderly can lead to an improvement in the quality of life, maintaining optimal levels of function and independence, reduction in morbidity and mortality due to suicide, development of medical illnesses, and treatment costs. The treatment plan discussed below is geared at meeting these goals. As individuals age, they may experience physical as well as cognitive decline. Depression and other mood disorders are common with the elderly, but they are not the normal aging processes. The rate of remission of depression may be impacted by the chronicity, comorbid psychiatric, and somatic illnesses (Wheeler, 2014).
Patient information: A 69-year-old, widowed African American male.
Diagnosis: Major depressive disorder single episode moderate with anxious distress 296.22 (F32.1).
Differential diagnosis includes:
1. Adjustment disorder with depressed mood due to the imminent death of his father
2. Sadness: Based on APA (2013) criteria, periods of sadness are an inherent part of the human experience and must not be diagnosed as a major depressive episode unless criteria are met for severity that is five out of nine symptoms, the duration that is most of the day, nearly every day for at least 2 weeks, and clinically significant distress or impairment. These are findings with the patient’s symptoms.
Tests or tools considered to help identify the correct diagnosis?
There are several tools that can be used to accurately diagnose this patient including the geriatric depression scale which is described by Wheeler (2014), as the most widely used screening tool for depression. Also, the Montgomery-Asberg’s depression rating scale can be used to measure symptom severity over time and the impact of psychotherapy (Wheeler, 2014).
In addition to checking the patients’ blood pressure, other tests will include baseline CBC and CMP to ensure there is no renal or hepatic impairment and rule in or out of any organic cause. According to Stahl (2013), the impaired renal or hepatic function can result in increased drug concentration. The patient is obese and has tried several antidepressants with negative responses. A thyroid function tests, vitamin B12 and folate levels, lipid profile will be performed. According to Stahl (2013), thyroid dysfunction has been associated with some mental disorders.
The rationale for the diagnosis?
According to APA (2013), the essential feature of a major depressive episode is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. The patient must also experience at least four additional symptoms including appetite or weight, sleep, and psychomotor activity, decreased energy, feelings of worthlessness or guilt, difficulty thinking, concentrating, or making decisions, or recurrent thoughts of death or suicidal ideation or suicide plans or attempts. Also, for the patient’s diagnosis to be considered a major depressive episode the symptom must either be newly present or must have worsened compared with the patient’s pre-episode status. Furthermore, the symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks and associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning. Finally, a stressful life events such as the imminent death of his father, and his cancer diagnosis are well recognized as precipitants of major depressive episodes.
This is a 69-year-old, widowed African American male who expressed the need for help with depression and anxiety. He reports worsening of depression and anxiety symptoms over the past few months. His mood is depressed and anxious due to the imminent death of his father. The patient does not enjoy being with his family and has stopped his volunteer job at the nursing home. This is an indication of a loss of interest in the things he likes to do. He suffers from insomnia, decreases concentration when reading, and fatigue. Laying on the couch all day. There is evidence of guilt and rumination which are indicative of depressive symptoms. The patient is extremely anxious with a feeling of “moving in slow motion.” when lying on the couch and expresses thoughts of sadness, and frustration. He reports the fear of losing his father who is his main support and appears depressed and anxious. He has a history of anxiety due to prostate cancer diagnosis and was treated with psychotherapy.
In the above description of the patient, the diagnosis is incongruent with the symptoms reported by the patient. Reporting depression and anxiety for the past few months is more than the two weeks recommended for a diagnosis of major depression. Secondly, he reported sadness and loss of interest which are the core symptoms that must be present for a patient to have the diagnosis of major depression. In addition to the two core symptoms, he suffered from four other symptoms including insomnia, lack of concentration, fatigue, evidence of guilt, and rumination. He described the episode to be worsened and has significantly impaired his social functioning such as not wanting to be with his family.
The patient has been prescribed many antidepressants over the years meaning that he has suffered from depression for years. According to APA (2013), for an episode to be considered recurrent, there must be an interval of at least 2 consecutive months between separate episodes in which criteria are not met for a major depressive episode and for the severity to be considered moderate the patient must have three symptoms or moderate to severe, if four to five symptoms are present without psychomotor involvement such as fast-talking, restlessness, etc. The severity of his symptoms is moderate to severe. Though, he has more than five depressive symptoms, the psychomotor activity involvement is absent. The explanation, therefore, justifies the diagnosis for the patient as written above.
· Lorazepam 1 mg by mouth BID
· Bupropion 150 mg PO Q12hrs
The patient has taking SSRI’s (Prozac, Zoloft, Lexapro) and SNRI’s (Effexor, Duloxetine) with a partial or negative response. Based on the case presentation, there is no indication that he is currently taking any antidepressant. Also, the specific negative or partial responses while taking the SSRI’ or SNRI’s are not available. With the assumption that he cannot take SSRI’s or SNRI’s due to the side effects, the patient can be started on another treatment or class of drugs with a different mechanism of action from SNRI and SSRI such as norepinephrine-dopamine reuptake inhibitor (bupropion). When choosing an antidepressant for the patient the neuropharmacological mechanism are chosen to eliminate the symptoms. If symptoms persist or patient experience side effects, treatment with a different mechanism of action is added or switched. According to Stahl (2013), symptoms are matched with the brain circuits involve and neuropharmacological regulation of the circuits by neurotransmitters. For example, a patient with decreased concentration, lack of interest, and fatigue will benefit from a treatment approach that target norepinephrine, and dopamine with a first line antidepressant plus an augmenting agent that acts on the these neurotransmitters (Stahl, 2013).
· Neuroimaging maybe considered in this case because of the treatment-resistant. He has been treated over the years for depression with different pharmacologic agents without response. According to Avasthi, and Grover (2018), about 30% of elderly patients with depression do not respond to first-line treatment with an antidepressant and if there is no improvement following 4–8 weeks of pharmacotherapy, a thorough review must be done for a re-evaluation of diagnosis, treatment adherence, and pharmacokinetic/pharmacodynamic factors which may be affecting treatment. The treatment plan is then revised by maximizing the initial medication treatment, switching to another antidepressant medication, augmenting antidepressant medications with other agents, psychotherapy, or electroconvulsive therapy (ECT). Therefore, ECT can be an option for this patient.
· Also, a baseline EKG will be obtained to rule out any cardiac abnormality or use as a baseline comparison tool if any cardiac changes occur as treatment proceed. According to Stahl (2013), there is evidence of rising in supine blood pressure when taking Bupropion.
Recommended treatment strategy:
Avasthi and Grover (2018), points to the treatment options for the management of depression to include antidepressants, somatic treatments, and psychosocial intervention categories.
· The treatment strategy will include incorporating the findings from the comprehensive assessment into the therapy
· Establishing a therapeutic alliance with the patient. Depression is a chronic disease that requires the patient to actively participate and adhere to treatment for a long period and maintaining a good alliance with the patient is especially important.
· Providing education to the patient and if appropriate to the family. Educating them about symptoms of depression, available treatment modality, course of the disorder, and time to respond to treatment. Informing the patient about the lag period of onset of action of antidepressants and stressing the need to adhere to treatment will help with compliance issues. According to Avasthi, and Grover (2018), providing the patient with information will help the patient to make informed decisions, anticipate side effects, and adhere to treatments.
· Use pharmacological agents that are safe given his age. For example, antidepressants are associated with side effects like hypotension, and those with highly sedating properties will be avoided (Avasthi & Grover, 2018). Also, the patient is 69 yrs. old with no cognitive decline. Medical history includes GERD, HTN and hyperlipidemia and prostate cancer. He has an unsteady gait and uses a walker. Any pharmacologic agent prescribed must take into consideration his age, comorbidities, and current medication to avoid drug-drug interaction. According to Rosenthal and Burchum (2018), the following factors genetics, gender, ethnicity, age, or behavior can affect the pharmacokinetics and the pharmacodynamics processes in patients. Therefore, the choice of medication and doses must take into consideration these factors to ensure the patient’s safety. Apart from ensuring that the medications are safe, the patient will be closely monitored for any significant changes in his condition, the emergence of new symptoms, or destructive impulses towards self or others which may warrant a diagnostic re-evaluation of the patient and a revised treatment plan.
· Provide psychotherapy. Randomized control trials have shown that a combination of pharmacologic and psychotherapy interventions especially interpersonal therapy (IPT) is more effective than either intervention alone in treating patients with major depression. Therefore, the patient will be treated with pharmacologic agents and psychotherapy (Wheeler, 2014). According to wheeler (2014), to support successful aging, psychotherapy intervention must include information to support informed decision making, strengthen coping strategies, and promote meaningful activities, social engagement, and social support.
The treatment prescribed and the rationale:
Psychopharmacological treatment as well as cognitive behavior therapy (CBT) treatment will be prescribed for the patient. Cognitive behavior therapy will address the patient’s thoughts, feelings, or behaviors that are affecting his mood. It will also assist to identify and change distorted or negative thinking patterns and teaches him skills to respond to life’s challenges in a positive way. Psychotherapeutic medications should be used as part of a comprehensive psychotherapeutic approach to treat this patient. When choosing an antidepressant for the patient the neuropharmacological mechanism is chosen to eliminate the symptoms. According to Stahl (2013), symptoms are matched with the brain circuits and neuropharmacological regulation of the circuits by neurotransmitters. Both treatments can change the brain circuits and combining them may be therapeutically synergistic. Psychotherapy can induce epigenetic changes in the brain circuits that enhance efficient information processing in the malfunctioning neurons to improve the symptoms. The drugs may improve the neurotransmission in the brain circuits by increasing neurotransmitters at the synapses. As such, a good memory formed during psychotherapy may alter the same brain circuit targeted by the drugs thereby influencing the efficiency of information processing and eventually relieving the symptoms (Stahl, 2013).
Standard Guidelines used to treat or assess this patient:
Guidelines to treat depression provide a broad framework for assessment, management, and follow-up of elderly patients presenting with depression. However, they do not substitute professional knowledge and clinical judgment. The guidelines from the American Association for Geriatric Psychiatry, American Psychological Association for the treatment of depression is used for the treatment of this patient.
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorder (5th edition). Washington, DC: Author. Retrieved from https://dsm-psychiatryonline-org.ezp.waldenulibrary.org/doi/book/10.1176/appi.books.9780890425596
Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474
Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). Cambridge University Press *Preface, pp. ix–x
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
Kindra L (Two citations and references for Kindra)
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Case Study: 69 year old with depression and anxiety
When diagnosing any client, we must carefully consider the presenting clinical manifestations along with the context and timeline in which the symptoms began in order to determine an accurate diagnosis. The client in this case study revealed he has been struggling with depression and anxiety symptoms since his father has been ill and is faced with losing his primary source of support. There are several diagnoses that come to mind based on the situation provided by the case study. I would consider major depression and generalized anxiety disorders, however since they both presented around the same time and seem to correlate with each other, I think major depression with anxious distress would be an appropriate diagnosis for this client. Therefore, major depression and generalized anxiety disorders would be differential diagnoses. Based upon the DSM criteria, this client meets criteria due to five or more presenting symptoms which evidenced by feeling depressed for more than two weeks and loss of interest. This client also exhibits fatigue, sleep disturbances, psychomotor retardation, diminished ability to concentrate and social withdrawal from his family (American Psychiatric Association, 2013). Being that the anxiety occurred in conjunction with the depressive symptoms already evidenced by the DSM-V, I think major depression, severe with anxious distress is appropriate. The DSM-V coding for this diagnosis is Major Depression, recurrent, severe with anxious distress specifier 296.23 (F32.2) (American Psychiatric Association, 2013).
Assessment tools are frequently utilized to aid in diagnosing psychiatric disorders. When considering diagnostic screening tools, not all are geared for every population. Being that this client is 69 years old, it would be preferred to utilize assessment tools specifically designed for the geriatric population. The Geriatric Depression Scale or the GDS is an assessment tool that is widely used to screen for depression in the aging population, which would make this specific tool appropriate for this client (Wheeler, 2014, pg. 631). Another assessment tool that we can use to rule out generalized anxiety in favor of meeting criteria for an anxious distress specifier would be the Penn State Worry Questionnaire, which is a 16-item inventory to measure anxiety in older adults (Wheeler, 2014, pg. 631).
Among utilizing assessment screening tools, it is important to complete a physical assessment and diagnostic testing to rule out medical etiology especially in the older adult due to medical concerns being more prevalent due to advanced aging. Common lab values and tests that may be conducted that can mimic symptoms of depression if left untreated are vitamin D levels, thyroid, and anemia.
Treatment Plan and Psychotherapy
When meeting with a client to obtain a psychiatric diagnosis, it is critical to conduct a thorough psychiatric assessment; along with physical examinations, mini-mental status, and diagnostic testing to rule out medical etiology. After these steps are completed, we can infer an appropriate diagnosis. Based upon the diagnosis, we can begin a treatment plan for this client addressing needs tailored to the client. For this client, psychotherapy would be a beneficial treatment along with pharmacological intervention. According to Wheeler (2014), there are several psychotherapeutic models that are viable for the older adult suffering from depression which include cognitive behavioral therapy, and interpersonal psychotherapy (pg. 632). Other alternatives are group therapies such as reminiscence therapy or group CBT (Depression Treatments for Older Adults, 2020).
Psychopharmacology and Safety
When considering psychopharmacological interventions, safety comes to mind. Second-generation antidepressants or otherwise known as SSRS’s, SNRIs or NDRIs can be safely used in the older adult to treat depression. However, it is important to combine pharmacological interventions with psychotherapy for the best possible expected outcome. This client has tried many different medications, but there are still many to choose from that may still provide him symptom relief. Safety plays in an important role when prescribing medication to the geriatric patient. We must consider the clients lifestyle when determining appropriate medication and outweigh the risks and benefits of using medication. Second-generation antidepressants can be used safely due to reduced side effects and a safer overall medication profile. When thinking about safety and medications, this client is currently prescribed a benzodiazepine; the safety of the client must be considered as benzodiazepines often pose a safety risk for geriatric patients due to sedation leading to a risk for falls (Benzodiazepines: Uses, Side Effects, Interactions & Warnings, 2020).
Psychoeducation is an important part of any treatment planning process. Psychoeducation provides the client with information necessary relative to their diagnosis, safety, symptom management, treatment adherence, medication compliance, sleep hygiene, healthy diet and overall health maintenance strategies (Wheeler, 2014, pg. 633). Among psychoeducation, adhering to standard guidelines can also impact the expected outcome. When developing a treatment plan in addition to providing psychoeducation it is imperative to follow standard guidelines for treating depression which include medication and a combination of psychotherapy.
Depression and other psychiatric disorders are not a normal part of aging so therefore must be taken seriously when any individual is exhibiting psychiatric symptoms of any kind. It is important to rule out medical etiology due to advanced aging. Once medical etiologies are ruled out, we must determine a diagnosis in order to begin the treatment planning process. Assessment tools are beneficial in this process. Treatment planning strategies typically includes medication in combination with psychotherapy; since it has been proven successful (Wheeler, 2014). As with any treatment plan, we must provide psychoeducation to address medication compliance, treatment adherence, safety, lifestyle and other factors that may impact the clients expected outcome.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Benzodiazepines: Uses, Side Effects, Interactions & Warnings. Drugs.com. (2020). https://www.drugs.com/article/benzodiazepines.html .
Depression Treatments for Older Adults. (2020). https://www.apa.org/depression-guideline/older-adults .
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.
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