Kaley M. Brennen, MSN FNP-C

1. Mental Health Issues with the Elderly and what is within the role of the FNP regarding diagnosing and prescribing Kaley M. Brennen, MSN FNP-C

2. Mental Health and Neurocognitive Issues Common in the Elderly • Depression • Suicide • Anxiety • Dementia • Delirium

3. Depression, Suicideand 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

4. 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)

5. Depression Screening

6. Anxiety Screening • Generalized anxiety disorderWATCHERSWorry Anxiety Tension in muscles Concentration difficulty Hyperarousal (or irritability) Energy loss Restlessness Sleep disturbance • 3 or more, most days, for 6 months or longer (American Psychiatric Association, 2013)

7. Depression Treatment in Primary Practice • Selective serotonin reuptake inhibitor (SSRI)- first choice in mood disorders and anxiety disorders, improves mood • Fluoxetine (Prozac), 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

8. 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)

9. Depression Treatment in Primary 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 Discontinuation Syndrome (FINISH) • Flu like symptoms, Insomnia, Nausea, Imbalance, Sensory disturbances, Hyperarousal/Headache

10. Anxiety Treatment in Primary Practice • SSRI is the gold standard treatment for anxiety • Other treatments include SNRI, Benzodiazepine, and anxiolytic medications • Benzodiazepine • Alprazolam (Xanax), Diazepam (Valium), Lorazepam (Ativan) • Fast acting • Often used as needed • Sedating • Potential for dependence • Anxiolytic • Buspirone (Buspar) • Less 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)

11. 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)

12. Considerations for the Elderly 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)

13. 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 irreversible

14. Delirium • Sudden, 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)

15. DELIRIUMS Mnemonic • Drugs (medication added or adjusted/anticholinergics, antipsychotics, opioids, benzodiazepines, ETOH) • Emotional/Electrolyte (hyponatremia) • Low PO2/Lack of drugs (withdrawal) • Infection (UTI, CAP MOST COMMON DELIRIUM ETIOLOGY) • Retention of urine or feces/Reduced sensory input (deaf/blind) • Ictal or postictal state (ETOH withdrawal seizures common) • Undernutrition (malnutrition/vitamin deficiency) • Metabolic/Myocardial (DM, Thyroid, MI, Heart failure, dysrhythmia) • Subdural hematoma

16. 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 factors

17. 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 delirium

18. 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, other

19. 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.

20. 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 • Antioxidants

21. 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, Rivastigmine (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)

22. 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)

23. 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

24. 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)

25. 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.

26. 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, 5th 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. (2nd ed.) Burlington, MA: Jones and Bartlett Learning. Kaplan, H., Sadock, B. (2007). Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, (10th Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.