STUDENT 1: CHRISTINA
What additional considerations should be given when dosing medications for children and seniors and why?
Like geriatric patients, juveniles are vulnerable to the side effects of psychotropics due to the way their body processes the drug (Jacobson, 2014). Here are some things I learned what we should consider with prescribing medications to children and adolescents. When prescribing medications to geriatric patients, understand that adequate dosage may be reduce and adequate time may be longer for elderly patients, as opposed to younger patients. Elderly patients typically need one-third to one-half of the conventional dose for results. A prescriber should only make one medication adjustment at a time and assess periodically the response of the medication.
Medication use elderly patients require routine screening (Jacobson, 2014). Along with obtaining a medical history, a physical examination is important to perform to identify any evidence of hepatic, renal, neurological, or other medical diseases that may further increase the risk of side effects in elderly patients. Baseline laboratory studies need to be performed including basic chemistries, such as blood urea nitrogen, glucose, electrolytes including calcium, and creatine; complete blood count with platelets; cholesterol; triglycerides, thyroid-stimulating hormone, and electrocardiogram. The results of the history and physical exam along with the findings of the laboratory studies are important considerations when prescribing the most appropriate medication regime for elderly patients (Abdulah et al., 2018).
When considering prescribing psychotropic medications for geriatric patients there are various things to keep in mind, such as pharmacokinetics and pharmacodynamics (Amin et al., 2018). Pharmacokinetics involves the way the body process the drug including the absorption, distribution, metabolism, and elimination/clearance. Pharmacodynamics involves the effect the drug has on the body, such as the effects on enzymes or effects on receptors, presynaptic or postsynaptic and eventually targeted tissues. Due to the effects of the aging process, geriatric patients are more vulnerable to the effects of drugs and close monitoring of the body’s response to psychotropic medications is required for the most optimal patient outcomes.
Having knowledge in pharmacodynamics and pharmacokinetics is important in treating the geriatric population with psychotropics. (Jacobson, 2014). As individuals age, the way the body responds to drugs-pharmacodynamics, as well as how the body processes drugs-pharmacokinetics changes over time. Providers must know that in elderly patients, psychotropics last longer than in younger patients due to age related changes in absorption, distribution, and elimination (pharmacokinetic effects); in addition, greater drug effects are frequently seen in elderly patients due to having a greater pharmacodynamic sensitivity. Therefore, close monitoring of the body’s chemistry and drug reactions are vital to patient safety and optimal outcomes.
What is the Beers Criteria?
The American Geriatric Society (AGS) Beers Criteria may be utilized by nurses/providers to avoid potentially improper prescribing among older patients (Inocian et al., 2021). Providers should be guided by the most recent AGS Beers Criteria recommendations to avoid any potential of inappropriate medication use in older adults. The ASG Beers Criteria is a collection of medications to potentially avoid or administer with caution due to an unfavorable balance of harms and benefits for the geriatric population (American Geriatrics Society, 2021). The ASG Beers Criteria has five categories to follow when prescribing medications to geriatric patients to reduce drug related problems, exposure to inappropriate medications, medications to avoid in geriatric patients with certain conditions, drug-to-drug interactions and drugs that warrant extra caution in the geriatric population. Unnecessary prescriiption of drugs among the elderly population increases healthcare cost related to extended hospitalizations and poor outcomes. The utilization of the AGS Beers Criteria is for older adults aged 65 and older (American Geriatrics Society, 2019). The overall goal is to improve medication selection, education of caregivers, older adults, and interprofessionals, for improved outcomes while preventing unintended harms, such as adverse drug events and medications.
Your diagnosis and Reasoning
The patient is diagnosed with mild neurocognitive disorder with behavioral disturbance (American Psychiatric Association [APA], 2013). The patient meets criterion A, number one, B, C, and D from the diagnostic criteria on pages 605 to 606 of the diagnostic and statistical manual of mental disorders, fifth edition (DSM-5), for mild neurocognitive disorder with behavioral disturbance. The patient meets criterion A as evident by the patient and her spouse reporting a modest cognitive decline in memory, language, complex attention, perceptual-motor, and social cognition. The patient meets criterion number one as evident by the patient’s spouse, a knowledgeable informant expressing concern pertaining to the patient’s mild decline in cognitive function. The patient meets criterion B as evident by the patient having difficulty, forgetting, and making errors in the houses bookkeeping. The patient meets criterion C as evident by the case study does not report the patient is experience delirium. The patient meets criterion D as evident by the cognitive deficits are not explained better by another mental disorder. The patient meets the specifier of with behavioral disturbance due to the agitation and accusatory accusations over items being stolen from her house by the housekeeper and then returned instead of misplaced.
Any differential diagnoses
Differential diagnoses for this patient include normal cognition, delirium, and major depressive disorder (APA, 2013).
Any additional questions you would have asked
Do you drink alcohol (Cleveland Clinic, 2019)?
Do you have any problems with hearing or seeing?
Do you feel rested when you wake up?
Are you tired throughout the day?
Do you have an infection?
Do you take any medications?
What is your medical and psychiatric history?
What is your family’s medical and psychiatric history?
Are you allergic to any medications?
Do you feel like you are stressed, depressed, or anxious?
Do you have a plan to kill yourself, if so, what is the plan?
Do you have access to any weapons such as a firearm?
Have you attempted suicide in the past?
What is stopping you from killing yourself?
Do you have any social supports?
Medication recommendations along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
Supplements such as ginkgo and vitamin E have been suggested to assist in the prevention or delay the progression of mild cognitive impairment, although there is no supplement that has shown to be beneficial in a clinical trial (Mayo Clinic, 2020). There are no medications approved by the Food and Drug Administration to treat mild cognitive disorder, however, donepezil (Aricept) is used off-label to treat mild cognitive impairment (Stahl, 2021).
The patient will be prescribed donepezil, 5 milligram (mg) tablet by mouth nightly Stahl, 2021). Donepezil may slow the advancement of mild cognitive impairment to Alzheimer’s disease. The patient and her family should be informed that donepezil may take up to six weeks until improvement in behavior or baseline memory is evident (Stahl, 2021). It is also important to inform the patient and her family that donepezil may slow the progression and improve the symptoms of the disease, however, the medication does not reverse the degenerative process. Potential side effects of donepezil include sleep disturbances, nausea, vomiting, increased gastric acid secretion, dizziness, fatigue, depression, muscle cramps abnormal dreams, and weight loss. Dangerous or life-threatening side effects include syncope and seizures. The patient and her family need to be educated about not stopping donepezil abruptly to avoid withdrawal effects, the medication must be tapered. Additionally, discontinuation of donepezil may lead to a notable deterioration in behavior and memory that may not be regained with the drug is restarted.
Any labs and why they may be indicated
There are two blood test that may be used to test for Alzheimer’s disease, the Quest Alzheimer’s Disease- Detect and the Preclivity Alzheimer’s Disease (American Geriatrics Society, 2019). The Quest Alzheimer’s Disease- Detect is used to determine the risk for Alzheimer’s disease through idneitfying the levels of amyloid beta proteins. The Preclivity Alzheimer’s Disease Test that also measures amyloid proteins in the blood, in which a particular buildup of the proteins indicates an Alzheimer’s diagnosis. However, these tests are seeking approval by the Food and Drug Administration, and most insurance companies do not cover the cost.
Determining if there is a presence of thyroid dysfunction, electrolyte imbalances, and vitamin B12 deficiency is necessary when assessing and treating mild neurocognitive disorder (Mayo Clinic, 2020). The patient’s blood urea nitrogen, glucose, electrolytes including calcium, and creatine; complete blood count with platelets; cholesterol; triglycerides; thyroid-stimulating hormone; and electrocardiogram should be obtained (Abdulah et al., 2018). Additionally, a urinalysis, urine toxicology, and a blood alcohol test should be obtained (Cleveland Clinic, 2019).
Screener scales or diagnostic tools that may be beneficial
The AGS Beers Criteria can be used in combination with other criteria such as the Screening Tool to Alert Doctors to the Right Treatment (START criteria) and the Screening Tool of Older Persons Potentially Inappropriate Prescriiptions (STOP criteria), to best guide the prescribed through the medication decision-making process (American Geriatrics Society, 2019). The patient should be referred for formal neuropsychological testing (American Psychiatric Association, 2013). An evaluation of the patient’s medical history, a neurological exam, brain scans, and possibly genetic testing would be beneficial in determining a diagnosis, genetic testing is beneficial in identifying a propensity to developing dementia (Dementia Care Central, 2020). The Montreal Cognitive Assessment (MoCA) which includes the Clock Drawing Test assesses the ability to concentrate, the person’s short-term memory, and their understanding of time and place. Research shows that MoCA is reliable for identifying dementia, however, the assessment is better at identifying early-stage dementia and mild cognitive impairment. Ruling out reversible causes of mild cognitive impairment that can affect a person’s memory is important such as hypertension, depression, and sleep apnea is important (Mayo Clinic, 2020).
Additional resources to give (Therapy modalities, support groups, activities, etc.)
Lifestyle and home remedies can promote overall good health and may play a part in good cognitive health such as regular physical exercise, a diet rich in fruits and vegetables and low in fat, omega-three fatty acids, intellectual stimulation, social engagement, and memory training (Mayo Clinic, 2020). Cognitive behavioral therapy may be effective for individuals with mild cognitive impairment, in addition to early stages of dementia (Linnemann & Fellgiebel, 2017).
STUDENT 2: LALETHA
What additional considerations should be given when dosing medications for children and seniors and why? Dosing for a child is more of an art than a science. Children’s “small volume distribution suggests the use of lower doses than those used in adults.” However, children also have faster metabolisms than adults and may require a higher strength ratio of a drug compared to kilograms of body weight. It is acceptable to use adult doses for children if the dose is adequate and the adverse effects are tolerable. For elderly patients, there are two concerns: 1) geriatric patients are more susceptible to adverse effects, and 2) they may metabolize and excrete medication slower than middle-aged adults. With these considerations, clinicians should start with small initiation doses, approximately half the usual starting dose, and increase doses slowly until the clinical benefit is reached or unacceptable adverse effects. Elderly patients are more likely to take multiple medications; therefore, drug-drug interactions must be considered. Avoid medications that cause drowsiness, as they may increase the risk of falls (Boland & Verduin, 2021).
What is the Beers Criteria? The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults is a list of medications that clinicians should potentially avoid or proceed with caution because they are not the safest or most appropriate for geriatric patients. Medications on this list should be either 1) generally avoided by most geriatric patients, 2) avoided due to specific health conditions, 3) avoided because of drug-drug interactions, 4) used cautiously because of potentially harmful side effects, or 5) avoided or dosed differently due to reduced kidney function (American Geriatrics Society, 2019).
Your diagnosis and reasoning: This patient’s diagnosis is attention-deficit/hyperactivity disorder. He meets DSM-5 critieria A1-(b, c, d, e, h), A2-(a, b, e, f, g), B, C, D, and E. Inattentive symptoms include trouble sustaining attention in tasks, he wants to do something else after 15-20 minutes of watching TV. His father reports he does not seem to listen when spoken to and forgets to follow through on task within three minutes. He has difficulty organizing task such as cleaning his room and he is easily distracted by extraneous stimuli. Hyperactive and impulsive symptoms include fidgeting and difficulty staying in his seat at school or at home to complete his homework. He has a lot of energy, gets in trouble in school for talking excessively, and blurts out answers when it is not his turn. The symptoms present before age 12 and occur at home and at school. The symptoms interfere with home and school, and he cannot participate in extracurricular activities due to his inability to concentrate and follow directions. There is no evidence that these symptoms are part of another psychiatric disorder or medical illness. He meets the specifier for combined presentation and mild severity (American Psychiatric Association, 2013).
Any differential diagnoses:
Oppositional defiant disorder
Specific learning disorder
Disruptive mood dysregulation disorder
Any additional questions you would have asked:
It is reported that the patient talks back to and argues with adults. I would recommend screening this child for oppositional defiant disorder.
For a firm diagnosis of ADHD I would ask about:
Previous psychiatric treatment
Frustration tolerance
Ability to keep up with things necessary for tasks
Family history of psychiatric illness
Ability to engage in activities quietly
Personal and family history of cardiac disease
Family dysfunction
Social skills
Legal system involvement
Substance abuse (Wilkes, 2022)
Medication recommendations, along with your rationale. Note possible side effects or issues to address if attempting to obtain consent.
The medication recommendation for this patient is dextroamphetamine-amphetamine (Krull, 2022), immediate-release 5 mg twice daily (once in the morning shortly before rising and the second dose six hours later) for one week to assess tolerability and effectiveness. At follow-up in one week, if the medication is ineffective and the patient can tolerate it, the dose will be increased to 7.5 mg twice daily. Doses can be increased by 5mg per day weekly (Stahl, 2021). Once an effective dose is found, the patient will be switched to Adderall XR at the same dose for coverage that will last through the school day and into the evening for homework (Lexicomp, n.d.). This medication is chosen because it can be crushed; therefore, if the child cannot swallow the pill, it can be taken safely. Also, this medication is immediate release, so if the patient has any adverse reactions to the medication, it will metabolize out of his system quickly (Stahl, 2021), and it will wear off at lunchtime, and the patient will have an appetite (Puzantian & Carlat, 2020). This medication targets concentration, motor hyperactivity, and impulsiveness (Stahl, 2021). Side effects include insomnia, anorexia, dry mouth, exacerbation of tics, overstimulation, temporarily slow growth in children, and sexual dysfunction. Life-threatening side effects that require immediate medical attention are psychosis, seizure, and activation of mania (Stahl, 2021). Adderall carries the BlackBox warning for sudden death, severe cardiovascular adverse events, and a high potential for abuse (FDA, 2017).
Any labs and why they may be indicated
Liver function tests are performed if the patient has a history of hepatic dysfunction because amphetamines are metabolized in the liver (Wilkes, 2022). The patient’s blood pressure, weight, and height should be monitored regularly. Before prescribing the medication, the patient’s history, physical exam, and family history will be assessed for cardiac disease. (Stahl, 2021)
Screener scales or diagnostic tools that may be beneficial
There is not a single test for ADHD. Several psychometrics and education test are used in the diagnosis of ADHD. The Conners’ Parent and Teacher Rating Scale is used for children (Garcia-Rosales et al., 2021). The Conner’s Continuous Performance Test can test impulsivity and inattention (Shaked et al., 2020). Various testing for executive function and learning disabilities are needed (Wilkes, 2022).
Additional resources to give (Therapy modalities, support groups, activities, etc.)
School accommodations such as an individualized educational plan (IEP).
Local ADHD support groups
Reading: Smart but Scattered
Behavior modification and family therapy (Wilkes, 2022)
