Posted: December 25th, 2022

Treating Insomnia Disorder in the Elderly

Week 9: Special Considerations Related to Vulnerable Populations

The psychiatric mental health nurse practitioner assumes probably no greater responsibility than the responsibility of prescribing medications. While someone can be harmed by psychotherapy, the level and intensity of the harm generally does not come to the same level of harm that can occur from improper prescribing. The PMHNP must understand his/her responsibility both at a state and federal level when it comes to prescribing medications. It is of critical importance to understand the risks and benefits of the medications prescribed and their varying potential effects on special populations such as children/adolescents, pregnant women, or older adults.

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This week, you examine the special considerations when prescribing for pregnant women and older adults.
Learning Objectives

Students will:

Recommend psychopharmacological and nonpharmacological interventions for older adults and pregnant women in mental health settings
Evaluate the risks and benefits of pharmacological treatment for older adults and pregnant women
Justify clinical decision making related to pharmacological treatment of older adults and pregnant women in mental health settings

Learning Resources

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Required Readings (click to expand/reduce)

American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. https://doi.org/10.1176/appi.books.9780890426807

Agency for Healthcare Research and Quality. (2019). Maternal and fetal effects of mental health treatments in pregnant and breastfeeding women: A systematic review of pharmacological interventions.

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https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/protocol-pharm-pregnant-women_0.pdf

Hardy, L. T., & Reichenbacker, O. L. (2019). A practical guide to the use of psychotropic medications during pregnancy and lactation. Archives of Psychiatric Nursing, 33(3), 254–266. https://doi.org/10.1016/j.apnu.2019.04.001

National Library of Medicine. (2006–2020). Drugs and lactation database (LactMed). https://www.ncbi.nlm.nih.gov/books/NBK501922/

The LactMed® database is a peer-reviewed, evidence-based resource on drugs that may be used by breastfeeding mothers. It includes possible effects on nursing infants and offers drug alternatives where possible.

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Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry (11th ed.). Wolters Kluwer.

Chapter 27, “Psychiatry and Reproductive Medicine”
Chapter 33, “Geriatric Psychiatry”

Stewart, J. G., & DeNisco, S. M. (2019). Role development for the nurse practitioner (2nd ed.). Jones & Bartlett Learning.

Chapter 3, “Vulnerable Populations”
Chapter 4, “Mental Health and Primary Care: A Critical Intersection”
Chapter 5, “Cultural Sensitivity and Global Health”

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Required Media (click to expand/reduce)

American Psychiatric Association. (2020). Geriatric telepsychiatry [Video]. https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/geriatric-telepsychiatry

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.

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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.

Photo Credit: Getty Images/Blend Images

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 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.

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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.

Read a selection of your colleagues’ responses.
By Day 6 of Week 9

Respond to at least two of your colleagues on 2 different days 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.

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Note: For this Discussion, you are required to complete your initial post before you can view and respond to your colleagues’ postings. Begin by clicking on the "Post to Discussion Question" link, and then select "Create Thread" to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
Prescribing for older adults with Bipolar disorder
COLLAPSE

Progress is driven by innovation, and the development of new therapeutic biological products and drugs is critical. Every step process is supported by FDA in the pharmaceutical industry. Science is vital in creating understanding and creating new products, manufacturing, and testing procedures. One of the approved FDA drugs for adults patient with bipolar disorder includes quetiapine or Seroquel used by itself for treating bipolar depression in older adults (Rose & Kass, 2019). They are mood-stabilizing drugs effective for treating future depression in bipolar disorder. Olanzapine or Zyprexa is used as off-label to reduce behavioral and agitation disturbances for people with dementia. Bipolar disorder can also be treated by a non-pharmacological intervention that includes cognitive-behavioral therapy that offers strong efficacy regarding relapse prevention. For instance, comorbidities as complex situations are helped by cognitive and behavioral therapy for bipolar disorder. There is a positive impact shown by the evaluations, which are evidence-based and help improve mental health care for adults with bipolar conditions.

Risk assessment for treating bipolar disorders in older adults may first include the benefits and risks associated with the drugs. If the risks exceed benefits, the treatment cannot be informed for patients. Also, there are precautions that need to be undertaken for both FDA-approved and off-label use. Patients with allergic reactions may be affected, so medical history has to be carried out.

The FDA-approved drug is used to treat bipolar disorder by helping restore some balance for the brain's neurotransmitters. Seroquel helps improve concentration and decrease hallucinations (Rose & Kass, 2019). Additionally, it helps older adults think more positively and clearly by themselves, be more active in their life and stay less nervous. More benefits include decreasing severe and more often mood swings. Quetiapine may have its risks if the medication leads to more side effects risks than the benefits. It may lead to serious side effects like mood or mental changes like suicidal thoughts, depression, and anxiety. Effects like tiredness, drowsiness, constipation, and weight gain may occur.

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Off-label use of Olanzapine has its benefits. It helps many older individuals with mental health illnesses that lack FDA-approved options (Khorassani & Saad, 2019). For instance, it helps older people with dementia-related behavioral complications. However, for the off-label drug, there are risks associated with Olanzapine for older adults with dementia. It may increase their risk of stroke. Also, for older adults using olanzapine, there is the risk of cardiovascular problems and cognitive problems. The drug can have side effects like dry mouth and sleepiness for most people using the drug. Also, there is weight gain triggered by the drug.

Bipolar disorder is characterized by depression episodes, with many patients experiencing significant life changes. Thus, the disorder includes some clinical practice guidelines for its assessments. Patients need comprehensive assessments with complete information on their medical history.

References

Khorassani, F., & Saad, M. (2019). Intravenous olanzapine for the management of agitation: review of the literature. Annals of Pharmacotherapy, 53(8), 853-859.

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Dyrberg, H., Juel, A., & Kragh, M. (2021). Experience of Treatment and Adherence to Cognitive Behavioral Therapy for Insomnia for Patients with Depression: An Interview Study. Behavioral Sleep Medicine, 19(4), 481-491.

Rose, R. V., & Kass, J. S. (2019). Prescribing antipsychotic medications to patients with dementia: boxed warnings and mitigation of legal liability. CONTINUUM: Lifelong Learning in Neurology, 25(1), 254-259.

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Treating Insomnia Disorder in the Elderly

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The DSM-5 characterizes insomnia as dissatisfaction with either the quality or quality of sleep that is associated with one or more of the following: difficulty falling to sleep, difficulty staying asleep that is related to frequent awakenings, or problems returning to sleep after awakenings and early morning awakening with incapacity to return to sleep. The sleep disruptions cause clinically substantial distress or functional impairment that occurs at least three nights per week for at least three months despite adequate occasion to sleep. And symptoms are not related to other sleep-wake disturbances, illegal substance use, or comorbid medical or psychiatric disorders. Studies have concluded that 93% of the elderly population has a coexisting illness contributing to insomnia such as depression, chronic pain, cancer, cardiovascular disease, chronic obstructive pulmonary disease, mediation use, and other significant aging factors such as retirement, caregiving, and inactivity. The prevalence of insomnia in the elderly population is 30% to 48%. Insomnia has been linked to significant morbidity if left untreated with 23% increase of developing depression, anxiety, cardiovascular risks, and increased tedencies for suicide (Patel, Steinberg & Patel, 2018).

FDA-approved Pharmacological agent to treat Insomnia

Clinicans have several pharmacological treatment options to treat insomnia in the elderly population such benodiazepine, nonbenzodiapine, antidepressants, melatonin receptor agonists, and orexin receptor antagonists. The FDA approved Ramelteon (Rozerem) for treatment of insomnia a melatonin receptor agonist. Studies of adults age 65 years or older showed tht Rozerem reduced sleep latency after five weeks with not substantial rebound insomnia or withdrawal effects (Patel, Steinberg & Patel, 2018).

Benefits of Rozerem are that it is not linked to memory disturbances, dependence, and nocturnal gait instablility in the elderly (Patel, Steinberg & Patel, 2018). The usual dosage is 8 mg at bedtime, but may be titrated up to 160 mg before determining lack of efficacy.

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Risk of associated with Rozerem are dizziness, fatigue, headache, respiratory depression and rare angioedema. If adverse effect recommendation are to lower the dose (Stahl, 2017).

“Off-label” Pharmacological agent to treat Insomnia

Low dose Mirtazapine 7.5-15 mg has been prescribed off-label for insomnia for a decade; an atypical antidepressant used largely for major depressive disorder. Mirtazapine has a sedative, anxiolytic, antiemetic and appetite stimulat effect; however, it is used off-label to treat insomnia, post-traumatic stress disorder, panic disorder, general anxiety disorder, obsessive-compulsive disorder, fibromyalgia, headaches and migraines(Jilani, Gibbons, Faizy, & Saadabadi, 2021).

Benefits of Mirtazapine after only two weeks of treatment patient will have improvements in sleep onset latency, sleep efficiency and reduced awakenings during the night. Mirtazapine may be preferred over other pharmacological agents since it produces sedative effects solely through histamine receptor antagonism (Patel, Steinberg & Patel, 2018).

Risk of Mirtazapine in elderly patients with renal impairment or severe hepatic disease Mirtazapine clearance is significantly reduced; therefore, adjust dose accordingly and monitor drug levels. Abrupt cessation of Mirtazapine can cause depression,restlessness, vertigo, decreased appetite, nausea, insomnia, panic attacks, tinnitus, diarrhea, vomiting and rarely hypomania or mania (Jilani et al., 2021).

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Nonpharmacological intervention for Insomnia

Cognitive-behavior therapy for insomnia (CBT-I) is internationally considered the first-line treatment for insomnia. CBT-I improves sleep outcomes and reduces risks associated with hypnotics;however, rarely do providers refer patients for CBT-I. Evidence-based CBT-I utilizes behavior interventions to regulate sleep cycles and address maladaptive thoughts about sleep, reducing the need for pharmacolgical therapy. Cognitive-behavior therapy employing a combination of stimulus-control, structured exercise, sleep restriction, educational intervention such as sleep hygiene demonstrated moderate to large positive outcomes on sleep efficiency and insomnia severity. CBT-I delivery can occur as web-based programs, telehealth-delivery, self-help management by utilizing books and mobile phone applications to allow patients to eliminate the need for treaval and time barriers (Koffel, Bramoweth, & Ulmer, 2018).

Clinical practice guidelines for insomnia

The American College of Physicians (ACP) developed guideline to manage chronic insomnia disorder in adults. CBT-I improved remission, sleep latency, staying asleep, sleep efficiency and quality of sleep.The ACP recommended adult patient with insomnia to receive cognitive behavior therapy as the initial treatment. The second recommendation by ACP was provider use a shared decision-making approach, discussion risk, benefits and cost of short-term use of pharmacological therapy and to decide if pharmacological therapy should be added if CBT was ussuccessful. Hypnotic drugs have been associated with serious adverse effects such as dementia, fractures from falls, cognitive and behavioral changes, possible driving while impair and motor vehicle accidents. Therefore, especially with the elderly population my professional perference is not the use of hypnotic, and benzodiazepines, but rather melatonin receptor agonist and atypical antidepressant to reduce adverse side effects such as memory disturbances, dependence, nocturnal gait instablility, cognitive and behavioral changes (Qaseem, Kansagara, Forciea,Cooke, & Denberg, 2016).

References

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Jilani, T. N., Gibbons, J. R., Faizy, R. M., & Saadabadi, A. (2021). Mirtazapine. StatPearls [Internet].

Koffel, E., Bramoweth, A. D., & Ulmer, C. S. (2018). Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. Journal of General Internal Medicine, 33(6), 955-962.

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024.

Stahl, S. M. (2017). Prescriber's guide: Stahl's essential psychopharmacology. Cambridge University Press.

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Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 165(2),

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