Respond to at least two of your colleagues who selected different disorders. Propose an alternative on-label, off-label, or nonpharmacological treatment for the disorders. Justify your suggestions with at least two references to the literature. 

Peer 2 

Erika Cepero

Medications Used in the Geriatric Population for Sleep

In older adults, Ramelteon is a melatonin receptor agonist that is FDA-approved for treating insomnia. It is similar to melatonin, which is available over the counter (Jaqua et al., 2023). Trazodone is a medication that can be used off-label by older adults to treat insomnia, although it is used mainly for anti-depressive properties. This drug is classified as a serotonin modulator and functions by boosting serotonin levels in the brain to enhance mood and alleviate anxiety. In addition to its antidepressant properties, trazodone is also used to treat insomnia and can help older adults who have difficulty sleeping. It is used for sleep at low levels, and at higher levels, it has anti-depressive properties (Fagiolini et al., 2023).  Insomnia, a common sleep disorder, can be distressing and affect a person's overall quality of life. While medication is the most straightforward approach for treating insomnia, non-pharmacological interventions such as cognitive behavioral therapy (CBT) are to be tried first if appropriate. CBT is a form of talk therapy that helps individuals address the thoughts, behaviors, and emotions that may contribute to their sleep difficulties. It is a safe and effective approach that can help people establish healthy sleep habits and improve their overall sleep quality (Camino et al., 2022). Recent studies have provided evidence that the use of ramelteon is a safe and low-risk option for the treatment of older adults. This medication has been proven to have minimal risks of side effects and adverse reactions such as headaches, dizziness, or nausea. These findings make ramelteon a viable option for older adults who may be at a higher risk of experiencing negative side effects from other sleep medications (Jaqua et al., 2023).  Compared to other medications, trazodone is known to cause more severe side effects. These side effects may include QT prolongation (a heart condition that can be life-threatening), hypotension (low blood pressure), anticholinergic effects (symptoms such as dry mouth, blurred vision, and difficulty urinating), torsades de pointes (an abnormal heart rhythm), and an increase in suicidal thoughts. Despite the potential for these side effects, trazodone can be beneficial for older adults who struggle with insomnia. The medication is known to induce sedation, which can help clients fall asleep and stay asleep throughout the night. Additionally, trazodone has been shown to alleviate depressive symptoms, which can often contribute to sleep disturbances. Overall, while trazodone may come with some risks, its benefits can outweigh the potential downsides for certain individuals (Fagiolini et al., 2023).  Clinical practice guidelines are available for the treatment of insomnia, which recommend CBT for patients diagnosed with insomnia. Concerning medications, the guidelines do not recommend one medication over another but do give a recommendation and evidence for specific drugs that can be used. Based on the guidelines, in the elderly population, the efficacy of ramelteon compared to no therapy in adult patients is limited, and similarly, the efficacy of trazodone compared to no treatment is also limited (Sateia et al., 2017).  

References

Camino, M., Satorres, E., Delhom, I., Real, E., Abella, M., & Meléndez, J. C. (2022). Mindfulness-based Cognitive Therapy to Improve Sleep Quality in Older Adults with Insomnia. Psychosocial intervention, 31(3), 159–167. https://doi.org/10.5093/pi2022a12

Fagiolini, A., González Pinto, A., Miskowiak, K. W., Morgado, P., Young, A. H., & Vieta, E. (2023). Trazodone in the Management of Major Depression Among Elderly Patients with Dementia: A Narrative Review and Clinical Insights. Neuropsychiatric disease and treatment, 19, 2817–2831. https://doi.org/10.2147/NDT.S434130

Jaqua, E. E., Hanna, M., Labib, W., Moore, C., & Matossian, V. (2023). Common Sleep Disorders Affecting Older Adults. The Permanente journal, 27(1), 122–132. https://doi.org/10.7812/TPP/22.114Links to an external site.

Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med, 13(2):307–349.

Peer 1

Faustina Keke

Main Post

Prescribing for Older Adults with Schizophrenia

FDA-Approved Drug for Schizophrenia in Older Adults

Antipsychotic prescription drugs are crucial for treating schizophrenia in every age category, and effectiveness in older adult can often be comparable to younger patients (Zolk et al., 2022). One of the FDA-approved drugs for the treatment of schizophrenia in older adults is aripiprazole, an atypical antipsychotic.

Off-Label Drug for Schizophrenia in Older Adults

In broad terms, antipsychotic drugs are approved for the medical management of schizophrenia, and several possess been recommended for the treating of at least one phase of bipolar disorder. An off-label drug for the treatment of bipolar disorder in older adults with schizophrenia is risperidone, which is a second-generation antipsychotic medication (Wang et al., 2021). The approved starting dose is 0.25 to 0.5 mg. Novel or enhanced adverse reactions of off-label indications have been identified, and the FDA has authorized three new atypical (iloperidone, asenapine, and paliperidone) for the treatment of schizophrenia and bipolar disorder. The FDA additionally approved the formerly off-label functions for on-label use: For example, risperidone and aripiprazole were licensed to treat behavioral disturbances associated with autism spectrum disorders (Wang et al., 2021).  

Nonpharmacological Intervention

Alternatively, a combination of pharmacotherapy and psychosocial modalities is more likely to treat psychotic symptoms while carrying the lowest risk of major side effects when compared to pharmacological therapy alone. Nonpharmacological treatment of schizophrenia includes family therapy, cognitive-behavioral therapy, and psychoeducation (Tampi et al., 2019). Psychosocial interventions, for example cognitive behavioral social skills training (CBSST), may prove effective. CBSST, for instance, employs group therapy to enhance cognition and behavior coping skills, capacity for problem-solving, and interpersonal functioning with the goal to cater for neurocognitive shortcomings. Patients can also be empowered with coping skills (Stevović et al., 2022).

Risk Assessment to Inform Treatment Decision-Making

Older adults are at a higher risk of adverse effects of antipsychotics due to age-related alterations in pharmacokinetics that raise the distributed volume and half-life of antipsychotic drugs (Zolk et al., 2022). Therefore, lower starting drug doses are recommended for older adults. Aging alters the permeability of the blood-brain barrier, which increases the availability of the drug in the brain. Aging also causes pharmacodynamic changes that lower the number of dopaminergic neurons as well as D2 receptor density in the brain. Advanced age elevates the risk for adverse effects like tardive dyskinesia, metabolic syndrome, parkinsonism, and falls, which means that older adults should be monitored for drug side effects (Tampi et al., 2019).

Risks and Benefits of Aripiprazole

Aripiprazole is effective in treating schizophrenia because it improves negative and positive symptoms. The risks associated with aripiprazole include interaction with allergy medications, drowsiness, an elevated risk of hyperglycemia, fainting, difficulties cooling off the body, an increased risk of compulsive behaviors such as gambling, headaches, weight, and appetite changes, and increased production of saliva, among others (Preda & Shapiro, 2020). The tablets also contain phenylalanine and sugar, which may not be ideal for patients with phenylketonuria and diabetes. It may also take at least two weeks before the full effects of the medication are felt.

Risks and Benefits of Risperidone

Risperidone is beneficial in treating the positive and negative symptoms of schizophrenia. Risks associated with risperidone include increased appetite that causes weight gain. Risperidone is contraindicated in older adults with dementia because it may cause stroke, pneumonia, a fast or irregular heartbeat, and heart failure (Correll & Kane, 2020).

Clinical Practice Guidelines for Schizophrenia

The American Psychiatric Association has published clinical practice guidelines for the treatment of schizophrenia, which recommend that schizophrenia should be treated with pharmacological and nonpharmacological interventions such as psychoeducation and CBT (Keepers et al., 2020). Patients should be monitored for side effects, and effectiveness of treatment. Patients who respond well to medications should continue using them. Medication-related side effects warrant a reduction in drug dosage.

References

Correll, C. U., & Kane, J. M. (2020). Ranking antipsychotics for efficacy and safety in schizophrenia. JAMA Psychiatry, 77(3), 225-226. https://doi.org/10.1001/jamapsychiatry.2019.3377Links to an external site.

Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., Servis, M., Walaszek, A., Buckley, P., Lenzenweger, M.F., & (Systematic Review). (2020). The American Psychiatric Association practice guideline for the treatment of patients with schizophrenia. American Journal of Psychiatry, 177(9), 868-872. https://doi.org/10.1176/appi.ajp.2020.177901Links to an external site.

Preda, A., & Shapiro, B. B. (2020). A safety evaluation of aripiprazole in the treatment of schizophrenia. Expert Opinion on Drug Safety, 19(12), 1529-1538. https://doi.org/10.1080/14740338.2020.1832990Links to an external site.

Stevović, L. I., Repišti, S., Radojičić, T., Sartorius, N., Tomori, S., Kulenović, A. D., Popova, A., Kuzman, M.R., Vlachos, I.I., Statovci, S., & Jovanović, N. (2022). Non-pharmacological interventions for schizophrenia—analysis of treatment guidelines and implementation in 12 Southeast European countries. Schizophrenia, 8(1), 10. https://doi.org/10.1038/s41537-022-00226-yLinks to an external site.

Tampi, R. R., Young, J., Hoq, R., Resnick, K., & Tampi, D. J. (2019). Psychotic disorders in late life: a narrative review. Therapeutic Advances in Psychopharmacology, 9, 2045125319882798. https://doi.org/10.1177/2045125319882798Links to an external site.

Wang, J., Jiang, F., Yang, Y., Zhang, Y., Liu, Z., Qin, X., Tao, X., Liu, T., Liu, Y., Tang, Y. L., Liu, H., & Cotes, R. O. (2021). Off-label use of antipsychotic medications in psychiatric inpatients in China: a national real-world survey. BMC Psychiatry, 21(1), 375. https://doi.org/10.1186/s12888-021-03374-0Links to an external site.

Zolk, O., Greiner, T., Schneider, M., Heinze, M., Dahling, V., Ramin, T., Grohmann, R., Bleich, S., Zindler, T., Toto, S., & Seifert, J. (2022). Antipsychotic drug treatment of schizophrenia in later life: Results from the European cross-sectional AMSP study. The World Journal of Biological Psychiatry: the official journal of the World Federation of Societies of Biological Psychiatry, 23(5), 374–386. https://doi.org/10.1080/15622975.2021.2011403Links to an external site.