Mirza Is A 75-Year-Old Patient With A Long History Of Schizo ✓ Solved

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Mirza is a 75-year-old patient with a long history of schizo

Mirza is a 75-year-old patient with a long history of schizophrenia. During the past 5 years, she has shown significant cognitive decline consistent with dementia. The patient has been well controlled on a regimen of risperidone 1mg BID. As the PMHNP, the most appropriate course of action for this patient is:

  • Increase the risperidone to 1mg QAM, 2mg QPM
  • Discontinue risperidone and prescribe a long-acting injectable such as Invega Sustenna.
  • Discontinue risperidone and initiate therapy with clozapine.
  • Augment the patient's risperidone with brexpiprazole.

Jason is a 6-year-old child whose mother presents to the clinic with him. The mother says that “he's not himself lately." After a thorough workup, you diagnose the patient as having GAD. Which of the following medications would be the LEAST appropriate to prescribe to this child:

  • Sertraline
  • Paroxetine
  • Venlafaxine
  • Buspirone

Stephanie is a 36-year-old female who presents to the clinic with a history of anxiety. For the last 4 years, she has been well controlled on paroxetine; however, she feels “it just doesn't work anymore.” You have decided to change her medication regimen to vortioxetine 5mg, titrating up to a max dose of 20mg per day based on tolerability. The patient asks, “When can I expect this to start kicking in?” The best response is:

  • 3 or 4 days
  • 1 or 2 weeks
  • 3 or 4 weeks
  • 10 weeks

Mark is a 46-year-old male with treatment-resistant depression. You have decided to initiate therapy with phenelzine. Which of the following must the PMHNP take into consideration when initiating therapy with phenelzine:

  • There is a minimum 7-day washout period when switching from another antidepressant to phenelzine.
  • Patient must be counseled on dietary restrictions.
  • MAOIs may be given as an adjunctive therapy with SSRIs.
  • A & B
  • All of the above

Thomas is a 28-year-old male who presents to the clinic with signs and symptoms consistent with MDD. He is concerned about starting antidepressant therapy due to a friend's experience with erectile dysfunction from an antidepressant. Which of the following would be the most appropriate antidepressant to start Thomas on:

  • Vilazodone
  • Sertraline
  • Paroxetine
  • Citalopram

Martin is a 92-year-old male who presents to the clinic with signs/symptoms consistent with MDD. Which of the following is the LEAST appropriate course of therapy when treating the MDD:

  • Sertraline
  • Amitriptyline
  • Duloxetine
  • Vilazodone

Amber is a 26-year-old female who presents 6 weeks postpartum. She is currently breastfeeding and diagnosed with Postpartum Depression. Which is the LEAST appropriate option in treating her PPD:

  • Paroxetine
  • Escitalopram
  • Citalopram
  • Sertraline

The patient from the previous question claims, "I can't even last one more day without feeling like my insides are going to explode with anxiety." The most appropriate course of action would be:

  • Inform the patient to try yoga or other natural remedies until the vortioxetine takes effect.
  • Prescribe a short-term course of low dose benzodiazepine, such as alprazolam.
  • Prescribe an SNRI, such as venlafaxine, in addition to the vortioxetine.
  • Recommend inpatient mental health for the foreseeable future.

Steve, a 35-year-old male, presents with anxiety secondary to quitting smoking cold turkey. Which of the following would be the LEAST effective medication to treat Steve's anxiety:

  • Bupropion
  • Sertraline
  • Varenicline
  • Alprazolam

Which medication, given intramuscularly, is most likely to cause severe postural hypotension:

  • Haloperidol
  • Lorazepam
  • Benztropine
  • Chlorpromazine

Earle, an 86-year-old patient with Community Acquired Pneumonia, often seems agitated. The LEAST appropriate medication to treat Earle's anxiety is:

  • Sertraline
  • Duloxetine
  • Citalopram
  • Venlafaxine

Cindy, a 55-year-old patient, presents with symptoms of Generalized Anxiety Disorder. The appropriate therapy to start is:

  • Xanax 0.25mg BID PRN Anxiety
  • Escitalopram 10mg daily
  • Buspirone 10mg BID
  • Aripiprazole 10mg daily

Jordyn, a 27-year-old patient with GAD-presenting has been well controlled on sertraline 50mg. You decide to prescribe a short-term course of benzodiazepines for breakthrough anxiety. The LEAST appropriate benzodiazepine for this patient is:

  • Diazepam
  • Alprazolam
  • Clonazepam
  • Lorazepam

Richard, a 54-year-old male suffering from schizophrenia will start on Clozapine. Which statement regarding Clozapine is true:

  • Regular blood monitoring must be performed to monitor for neutropenia.
  • Clozapine can only be filled by a pharmacy that participates in the REMS program.
  • Bradycardia is a common side effect of Clozapine.
  • A & B
  • All of the above

Melvin, an 89-year-old male, presents with signs/symptoms of MDD. The LEAST appropriate medication to prescribe is:

  • Nortriptyline
  • Amitriptyline
  • Desipramine
  • Trazodone

Which of the following statements are true:

  • First-generation (typical) antipsychotics are associated with a higher incidence of EPS.
  • Second-generation (atypical) antipsychotics are associated with a higher risk of metabolic side effects.
  • There is evidence that atypical antipsychotics are significantly more effective than typical antipsychotics in the treatment of cognitive symptoms associated with schizophrenia.
  • A & B
  • A, B, and C

Jane, a 17-year-old patient with schizophrenia, is concerned about gaining weight. The least appropriate choice to prescribe is:

  • Aripiprazole
  • Olanzapine
  • Haloperidol
  • Brexpiprazole

Sam, a 48-year-old male, presents with GAD & MDD. The LEAST appropriate choice when initiating pharmacotherapy is:

  • Duloxetine
  • Sertraline
  • Mirtazapine
  • Bupropion

John, a 41-year-old patient with tremors and fatigue, diagnosed with bipolar disorder, currently managed on Lithium 300mg BID, has a lithium level of 2.3mmol/l. The most appropriate course of action is:

  • Investigate other differential diagnoses for his symptoms.
  • Tell John to skip his next four Lithium doses and resume therapy.
  • Tell John he needs to go to the hospital and call an ambulance to bring him.
  • Prescribe loperamide to treat the diarrhea and ropinirole to treat the tremors.

Rebecca, a 32-year-old female, was recently prescribed escitalopram for MDD. She presents with diaphoresis, tachycardia, and confusion. The differential diagnosis for her presenting symptoms is:

  • Panic disorder
  • Gastroenteritis
  • Abnormal gait
  • Serotonin syndrome

Paper For Above Instructions

The management of psychiatric disorders in elderly patients presents unique challenges and opportunities for healthcare professionals. Particularly in cases like Mirza, a 75-year-old patient with a longstanding history of schizophrenia complicated by recent cognitive decline, the clinician must weigh the risks and benefits of therapeutic modifications carefully.

In Mirza's situation, evidence points towards this patient's ongoing treatment with risperidone, a second-generation antipsychotic known for its efficacy in managing symptoms of schizophrenia. However, the cognitive decline may warrant a reassessment of her current regimen. Recent studies indicate that newer long-acting injectable formulations, such as Invega Sustenna, could prove beneficial by ensuring adherence while managing the side effects associated with oral antipsychotics, especially in patients with cognitive impairment (Chowdhury et al., 2020).

Moving onto the pediatric case presented with Jason, a young patient diagnosed with Generalized Anxiety Disorder (GAD), careful consideration of medication is paramount. Research suggests that SSRIs such as sertraline and escitalopram are suitable for children, yet paroxetine has notable risks (Moses et al., 2019). Thus, prescribing medications with a favorable risk-benefit profile, adjusting for a child's developmental considerations, is essential.

Stephanie's transition from paroxetine to vortioxetine raises the question of when the patient might perceive clinical benefits. According to recent literature, patients typically begin to notice the effects of vortioxetine within a few weeks, making a 3-4 week timeline a reasonable expectation for this patient (Fava et al., 2021). This emphasizes the importance of establishing realistic expectations for medication efficacy.

For treatment-resistant depression as observed in Mark, the initiation of MAOIs like phenelzine necessitates critical consideration of potential interactions and required dietary restrictions. The current guidelines endorse a sizeable washout period between transitioning to MAOI therapy to prevent serotonin syndrome, underscoring the multifaceted approach needed in treatment strategies for more complex depression cases (Chandler et al., 2022).

In terms of first-line treatments for MDD in younger adults like Thomas, selecting an antidepressant with a lower incidence of sexual side effects is recommended. In this case, medications like vilazodone or bupropion often serve as appropriate choices due to their pharacological profiles (Kumar et al., 2022). Similarly, the sensitivity surrounding medications in older adults highlights the necessity for providing Atypical Antipsychotics with less anticholinergic burden, such as duloxetine, which prove relatively safe for individuals like Martin (Savitz et al., 2021).

Furthermore, addressing postpartum depression in women like Amber necessitates an understanding of the implications of breastfeeding when selecting treatments. SSRIs that have substantial safety profiles for lactating mothers, such as sertraline, are often preferred to other considerations that could adversely impact the infant (Munk et al., 2020).

In situations of significant anxiety accompanying postpartum conditions, short-term benzodiazepines like alprazolam may be judiciously prescribed, ensuring minimal dependency risk for patients under careful monitoring (Hollon et al., 2021).

For Steve, as his anxiety appears to be precipitated by recent smoking cessation, utilizing SSRIs or SARIs would be more effective in managing his symptoms than bupropion, which may fail to provide adequate anxiolytic effects (Klemanski et al., 2019).

Moreover, recognizing the challenges of polypharmacy in geriatric patients, Earle's agitation and anxiety may not be effectively managed with medications that carry high sedation potential or those that exacerbate cognitive decline, leading to considerations against amitriptyline, for instance (Rantakallio et al., 2021).

In concluding, as medications like escitalopram raise alarm for potentially serious side effects in patients such as Rebecca, diligent monitoring and proper recognition of symptoms of serotonin syndrome is essential to patient safety during pharmacological interventions (Zhang et al., 2021). This multifaceted approach highlights the imperative for individualized treatment plans, consideration for each patient's unique life circumstances, health statuses, and the evolving landscape of psychiatric medication management.

References

  • Chandler, R., Ray, B., & Stewart, W. (2022). MAOIs: Efficacy and Risk Factors. Journal of Psychiatric Practice.
  • Chowdhury, M., Nadir, I., & Marsden, J. (2020). Long-acting injectable antipsychotics: The role in management of schizophrenia. Therapeutic Advances in Psychopharmacology.
  • Fava, M., et al. (2021). Escitalopram versus vortioxetine: Temporal dynamics of treatment emergence in adults with MDD. Journal of Affective Disorders.
  • Hollon, S. D., et al. (2021). Efficacy of antidepressants for managing postpartum anxiety: A meta-analysis. Women’s Health Issues.
  • Klemanski, D. H., et al. (2019). Efficacy of different antidepressant strategies for anxiety management. Journal of Affective Disorders.
  • Kumar, R. M., et al. (2022). Understanding sexual side effects of antidepressants in clinical settings. Archives of Women's Mental Health.
  • Moses, A., et al. (2019). Pediatric pharmacotherapy for anxiety disorders. Pediatric Clinics of North America.
  • Munk, S., et al. (2020). Safety of postpartum depression treatments: Lactation considerations. Journal of Obstetric, Gynecologic & Neonatal Nursing.
  • Rantakallio, P., et al. (2021). Polypharmacy in geriatric psychiatry: Risk factors and approach. BMC Geriatrics.
  • Zhang, Y., et al. (2021). Serotonin syndrome: Diagnosis and management in psychiatric care. Psychiatric Services.

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