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please follow the directions. Cite each paragraph. Attachment below. Apaformat and peer review articles with 5 years of publication
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DB1: 300 words without references page include. 2-3 references APA format. Peer review
articles within 5 years of publication only in U.S.A.
Discuss and differentiate the pharmacological treatments used for dementia. Are there any
contraindications?
There are several subtypes of neurocognitive disorders, and depending upon the cause, these subtypes
are either applied to younger, or older populations affected. They are listed as either mild, or major,
when making a determination of proper coding, according the DSM-5. The patient may present with
certain features related to the disorder, and the practitioner must be aware of the criteria which places
the patient within the appropriate subtype. Alzheimer’s subtle progression of diminishing memory
problems, and inability to perform normal function cognitively, and physically. Since there may be many
aspects of the cause, it will be up to the practitioner to ascertain whether diagnostic features are mild,
or major. Most likely there is a genetic component, such as family history, as well as environment, with
internal, and external factors (American Psychiatric Association, 2013). Dementia is a global term for
disorders related to a decline in memory functional, and physical decline. Since there are many stages,
obtaining a family history is crucial, due to the insidious succession of these stages. Aside from genetics,
or an inherited APOE ɛ4 gene,increasing age is considered a risk factor for Alzheimer’s. A disconnection
of certain neurons, or deficit with cholinergic functioning is believed to be related to interference with
memory problems, specifically short term memory. Cholinesterase inhibitors, like Donepezil,
Rivastigmine, and Galantamine inhibit AChE in certain areas of the brain, by enhancing access in the
deficient areas of the brain. A drug such as Memantine, (an NMDA antagonist), works as an open
channel antagonist, to prevent a stream of glutamate during neurotransmission. It should also be noted
that these drugs are more effective with early stages of Alzheimer’s (Stahl, 2013).
Obtaining a family history of mental health disorders is vital, as dementia with psychotic features
requires vigilant judgement with regard to treatment with antipsychotics. According to Jacobson (2014)
“When benefits of treatment outweigh the risks, and the decision is made to use an antipsychotic, it is
critically important to determine the probable etiology of dementia, because this determines
treatment” (p. 85). Typical and Atypical drugs have a death rate in geriatric patients which have
rendered them to come with black box warnings for this population. If a decision has been made to
place a patient on drugs, such as Quetiapine, Risperidone, or Aripiprazole, these are started at the
lowest doses. These medications should be scheduled, and not used on an as needed basis, or PRN, to
prevent over sedation (Jacobson, 2014). There should also be constraint in the use of an anxiolytic with
an antipsychotic. The warnings for these type of medications to control behaviors are not taken lightly,
due to increased risks of death, and CVA events. Contraindications also include patient with cardiac,
kidney, and liver problems (Stahl, 2017). Medications which may cause dizziness, also places the patient
as a high fall risk, and closer observation is warranted in this situation.
Discuss pharmacological treatments used for Autism Spectrum Disorder. What are the target
symptoms?
According to Preston, O’Neal, and Talaga (2015) “There is no effective medication specific to any of the
autism spectrum disorders” (p. 96). Treatment with certain medications are targeted at behavioral,
cognitive, and emotional regulation, so that rehabilitation might improve. SSRI’s, stimulants, mood
stabilizers, antipsychotics, beta-blockers, and opioid antagonist are common medications for certain
aspects of autism. Symptoms, and behaviors reported, or observed indicates proper treatment, and
involvement of a care team, and the family of the patient for continuity of care (Preston, O’Neal, and
Talaga, 2015). Optimal functioning is the goal for treatment, therefore; prescribing any of these
medications requires a family history, to rule out any differential diagnoses. A history of cardiac,
respiratory, sleep problems, and epilepsy should be included. Negative behaviors that have otherwise
become coping skills for patients require restoration through ongoing therapeutic intervention. When
these behaviors get in the way of psychotherapy, then this is where medications mentioned above may
be useful. A disorder, like Rett’s comes with cardiac, and respiratory problems, therefore; prescribing
any medications which might harm, rather than help, requires careful consideration.
Question for the class: For patient with dementia with psychotic features, we understand that
anxiolytics should not be used in conjunction with antipsychotics. What are some of the ways you might
have managed behaviors where you work, while patients are being stabilized?
References
American Psychiatric Association (2013). DSM-5: Diagnostic and statistical manual of mental disorders:
Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease. Arlington, VA: American Psychiatric
Publishing.
Jacobson, S. A. (2014). Clinical Manual of Geriatric Psychopharmacology (2nd ed.). Arlington, VA:
American Psychiatric Publishing
Preston, J. D., O’Neal, J. H., & Talaga, M. C. (2015). Child and Adolescent Clinical
Psychopharmacology Made Simple (3rd ed.). Oakland, CA: New Harbinger Publications.
Stahl, S. M. (2013) Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical
Applications. New York: Cambridge University Press.
DB2: 300 words without references page include. 2-3 references APA format. Peer review articles
within 5 years of publication only in U.S.A.
Discuss and differentiate the pharmacological treatments used for dementia. Are there any
contraindications?
Several medications are being used for dementia patients, but no medication has been found to slow or
reverse dementia. The goal of treatment for dementia is to provide symptomatic relief. Alzheimer’s
disease makes up about 60-70 percent of all dementia and is marked usually by a loss of cholinergic
neurons in the brain (Preston & Johnson, 2014). Most medications used for Alzheimer’s disease are
cholinesterase inhibitors, which boosts acetylcholine by inhibiting the enzyme that breaks down
acetylcholine Stahl, 2017). Cholinesterase inhibitors approved for Alzheimer’s are Donepezil,
Galantamine, and Rivastigmine. These medications inhibit cholinesterase not just in the brain but in
other parts of the body. The increase in acetylcholine results in cholinergic effects such as diarrhea,
nausea, gastrointestinal upset, and muscle cramps. Another medication used for Alzheimer’s disease is
Memantine, which is an NMDA receptor agonist. Memantine is helpful for moderate and severe cases
of Alzheimer’s disease (Preston & Johnson, 2014). The side effects of Memantine include, confusion,
constipation, cough, diarrhea, dizziness, and head pain, but these occur less frequently than the side
effects of cholinesterase inhibitors (Stahl, 2017). To get additive results in patients, Memantine may be
used at the same time as cholinesterase inhibitors because the mechanism of actions of the two classes
of medication are different (Stahl, 2017). Antipsychotics such as Olanzapine, Risperidone, Haloperidol,
and Quetiapine have also been used for Alzheimer’s disease. These medications are not anti-dementia
medications but are being used to treat behavioral dysregulation common with the disease (Preston &
Johnson, 2014). Although these medications may be partially effective in decreasing neuropsychiatric
symptoms, they must be used cautiously because they pose a safety risk to these patients. Citalopram is
an antidepressant that has been shown to be effective in reducing agitation in dementia patients
(Preston & Johnson, 2014). However, the medication does carry the risk of QTC prolongation and
patient’s EKG must be closely monitored.
Other types of dementia are: vascular, Lewy Bodies, frontotemporal, and pseudo dementia. Vascular
dementia is caused by several mini strokes. Cholinesterase inhibitors and Memantine are not effective
for this type of dementia. Rather, ACE inhibitors and statins may be helpful in treating the underlying
risk factors of strokes (Preston & Johnson, 2014). Dementia with Lewy Bodies frequently manifests with
recurrent visual hallucinations and progresses more quickly than other forms of dementia. Antipsychotics are contraindicated as they can cause severe extrapyramidal side effects, confusion,
catatonia, and neuroleptic malignant syndrome. Quetiapine is tolerated the best, if antipsychotic
medication must be used in these patients. Frontotemporal dementia is a result of increase damage to
the frontal and temporal lobes of the brain. Since this type of dementia does not involve loss of
cholinergic neurons, cholinesterase inhibitors have no effect. Frontotemporal dementia may be
managed as a last resort with SSRIs and atypical anti-psychotics. usually contraindicated in patients with
this type of dementia. In pseudo dementia, symptoms of depression present as dementia in elderly
patients. These patients can be treated like any other patients with depression (Preston & Johnson,
2014).
Discuss pharmacological treatments used for Autism Spectrum Disorder. What are the target
symptoms?
Autism Spectrum Disorder (ASD) shows dysfunction in four primary areas: social interaction,
communication, emotional regulation, and repetitive behaviors. Signs of ASD usually are seen by age of
two and each child may have a unique pattern of behavior and level of severity, ranging from low
functioning to high functioning (Mayo Clinic, 2019). There is no cure for ASD, but there are treatment
options for associated symptoms of the pervasive neurodevelopmental disorders (PNDs) (Preston,
O’Neal & Talaga, 2015). Medications that are indicating for treating or controlling PNDs include
serotonin medications, antipsychotics, beta-blockers, alpha-2 agonists, mood stabilizers, and stimulants.
SSRIs and clomipramine are effective in reducing aggression, agitation, ritualistic behavior, and anxiety
(Preston, O’Neal & Talaga, 2015). Second generation antipsychotics are helpful in decreasing aggression
and agitation, and improving social relatedness(Preston, O’Neal & Talaga, 2015). However, these must
be used cautiously given that children may be more sensitive to side effects of antipsychotics, including
extrapyramidal, cardiac, and weight gain. Beta-blockers and alpha-2 agonists have been indicated to
reduce aggression, impulsivity, and self-injurious behavior. Clonidine is indicated to provide a calming
effect (Preston, O’Neal & Talaga, 2015). Lithium, Depakote, and Tegretol may be effective in controlling
agitation, aggression, and self-harm. Stimulants may be used cautiously to treat attention problems, but
only when the distractibility is generalized and not related to some type of ritualistic behavior (Preston,
O’Neal & Talaga, 2015). Results are inconsistent in the use of naltrexone to reduce restlessness and to
improve focus (Preston, O’Neal & Talaga, 2015).
References
Mayo Clinic (2019. Autism spectrum disorder. Retrieved from https://www.mayoclinic.org/diseasesconditions/autism-spectrum-disorder/symptoms-causes/syc-20352928
Preston, J.D. & Johnson, J (2014). Clinical psychopharmacology made ridiculously simple. 8th edition.
MedMaster, Inc.
Preston, J.D., O’Neal, J.H. & Talaga, M.C. (2015) Child and adolescent clinical psychopharmacology made
simple. 3rd edition. New Harbinger Publications, Inc.
Stahl, S. M. (2017). Stahl’s essential psychopharmacology: The prescriber’s guide. 6th edition. Cambridge
University Press.
DB 3: 300 words without references page include. 2-3 references APA format. Peer review articles
within 5 years of publication only in U.S.A.
Discuss the difference that may appear in child therapies with your chosen therapy style?
The style of therapy that I chose was existential therapy. Existential therapy can be used for both
adults and children. There are similarities and differences in the approaches used by providers for each
age group. According to Sá Pires (2016), an event will present itself differently in each different age
group and the content may be shared with the use of different materials. A small child may express
themselves better by using toys such as dolls, where an adolescent may express themselves or discuss
personal experiences using a collage or pictures. No matter what age a client is, the provider usually
uses the same techniques to explore the content that comes up in therapy, such as active listening,
experimental validation, experimental immediacy, or existential challenge (Sá Pires, 2016).
How would you alter your techniques when treating children?
Prior to initiating therapy with a young child, a PMHNP may suggest a current physical by a
pediatrician to rule out any unknown medical problems that may be impacting the child’s behavior or
development. When providing therapy to a child it is important to keep in mind that the family or care
giver plays a large role in the child attending therapy sessions. A provider must actively listen to the
family’s concerns about the child and must also keep the family informed of how therapy sessions are
going. Another thing to take into consideration when providing therapy to children or adolescents is that
they did not choose to attend therapy, that decision was made by their care giver. With this being said,
it can be beneficial for the provider to take a strength-based approach by pointing out the client’s strong
points (Wheeler, 2014). When treating children, it is also important to not just focus on the child’s
behavioral issues but to also pay attention to the developmental level of the child and how the child
organizes their experiences. The provider should take note of how the child shares information, how
attentive the child is during the session, how the child uses hand gestures, and how the child reflects on
his or her ideas and feelings. When providing care to a child, it is important that the provider collaborate
with the parents and school or day care staff, as well as with the child, in order to get consistent
information about the child’s behaviors. Upon setting goals for the child, the provider should attempt to
include the family’s ideas into the treatment goals and both the parents and the child should be
involved in the setting of goals (Wheeler, 2014).
Discuss the needs of senior adults and how therapy may need a different delivery than other adults.
When providing care to an older adult the provider must remember that the patient’s general
practitioner plays an important role in their health care. It is essential to communicate with the client’s
general practitioner and establish contact with the family or residential institution as needed (Conell &
Lewitzka, 2018). According to Wheeler (2014), some important accommodations for the provider’s
office to offer are wheelchair accessibility, client materials with at least a 14-point font, and bathrooms
that are easily accessible. Some older adults may not have a good opinion of attending therapy and may
require education about the process of therapy. It is important to talk to the client about setting
appropriate goals, how therapy works to improve symptoms, how the client should behave during
sessions, the length, number, and cost of sessions, and the expected outcome of the therapy provided
(Wheeler, 2014).
Common therapies provided to older adults are Cognitive Behavioral Therapy (CBT), Relaxation
Therapy, Interpersonal Psychotherapy (IPT), and Reminiscence (RT) and Life Review (LRT). According to
Wheeler (2014), when providing CBT to a senior adult, extended sessions may be required in
comparison to that of younger adults to allow the client the time they need to process their thoughts
and feelings. Other modifications that may be required when providing CBT to a senior is changing the
focus to bettering physical and memory abilities in order to be successful with CBT. If a provider uses IPT
for a senior, it is common to make changes to therapy in order to support the client’s physical and
cognitive abilities and to center therapy on bereavement, role transitions, and role conflict. Some
modifications that may be required are allowing the client extra time to look at materials that are
provided, repeating new materials or skills from one session to the next, and allowing extra time for the
client to process information and answer questions (Wheeler, 2014).
RT and LRT are provided for senior adults and are typically not used in younger clients. Using these
forms of therapy allows the provider to take a different approach with the elderly client. When caring
for the elderly adult it is important for the provider to review the client’s family’s origin, educational
experiences, time spent in the military, sexual development, and religious history (Wheeler, 2014).
Are there senior adults that would not benefit from therapy?
I believe that all senior adults can benefit from therapy, but the provider must know what type of
therapy the client will thrive with. For instance, not all elderly clients will benefit from group therapy,
but some will enjoy meeting new acquaintances and will gain a new meaning of life after meeting new
people (Conell & Lewitzka, 2018). Originally, I thought that clients who have Alzheimer’s Disease or
profound memory loss may not benefit from psychotherapy because it may just agitate them if they do
not understand what is going on. After reading Wheeler (2014), I became further educated that these
patients can benefit from attending psychotherapy when initiated early in their diagnoses and that
psychotherapy can help reduce the level of disability that the patient acquires, therefore reducing early
institutionalization. Do you agree or disagree, that all seniors can benefit from the right form of therapy?
References
Conell, J., & Lewitzka, U. (2018). Adapted psychotherapy for suicidal geriatric patients with depression.
BMC Psychiatry, 18(1), 1–5. Retrieved from
https://search.ebscohost.com/login.aspx?direct=true&db=eoah&AN=45858855&site=ehost-live
Sá Pires, B. (2016). Therapy with Children and Adolescents in The Phenomenological-Existential
Tradition: Community-Based Clinical Interventions. Existential Analysis: Journal of the Society for
Existential Analysis, 27(1), 93–106. Retrieved from
https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=118733849&site=ehost-live (Links
to an external site.)
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for
evidence- based practice. Springer Publishing Company.
DB 4: 300 words without references page include. 2-3 references APA format. Peer review articles
within 5 years of publication only in U.S.A.
Discuss the difference that may appear in child therapies with your chosen therapystyle?
My chosen therapy style is EMDR trauma therapy. Research has shown that EMDR is effective in the
treatment of children and adolescents who have experienced trauma (Lewey, Smith, Burcham,
Saunders, Elfallal, & OToole, 2018). When initiating EMDR in a child or adolescent I would need to take
into account the developmental level of the patient. It is important to take into account what the
patient understands and how they understand the world. Secondly, it is important to take the patient’s
family into consideration, whatever the family system looks like. Family is involved in treatment and
treatment decisions and their level of understanding and engagement is key. Finally, I would need to
consider the systems that promote the patient’s development including school, peers and community
(Wheeler, 2014).
How would you alter your techniques when treating children?
I would alter my techniques depending on the 3 factors above and would need to consider the
differences between child/adolescent and adult therapy situations from initial contact on. Frequently,
the patient is not the one to initiate therapy and it is important to understand the reasoning of the
person who did, be it family or school, etc., and the reaction of the patient. Engaging and assessing the
patient individually and in the context of their family and the systems they operate in are key. When
implementing EMDR making sure to explain in a way the patient and their family can understand at the
appropriate developmental level and then using the same type of language during the therapy itself is
very important (Wheeler, 2014).
Discuss the needs of senior adults and how therapy may need a different delivery than other adults.
As with all our patient populations, assessment is key for working with older adults. It is important to
know what to look for that makes this population unique and, even more important, to know that aging
does not just mean decline. An APRN must assess cognitive, affective, functional, and behavioral status
as well as the patient’s family situation, not unlike assessments for other clients. With senior adults an
APRN should focus on ongoing growth and not just decline. This requires a good knowledge of the
normal aging process and an understanding that mental decline and illness may occur but are not
forgone conclusions as we age. Once an assessment is complete it is important to be prepared to assist
patients with developmental transitions and note that “senior” does not mean “ending”. The text points
out that the senior period of life can be a time when people develop as individuals and pursue dreams
and activities they might not have when they were younger because of the demands and responsibilities
they had at those times (Wheeler, 2014).
When assessing the senior adult, it is important for an APRN to look closely at functional status and
other things that may play a part in bringing about symptoms that are associated with mental illness.
This includes physical ailments and medication side effects that can promote or mimic depression or
other symptoms. When a senior adult appears depressed or anxious, it is inappropriate to assume it is a
mental health disorder for many reasons not the least of which is the medications for these disorders
will not work if there is an underlying physical reason for the symptoms. By the same token, an APRN
should never assume that, because there are physical issues or cognitive decline that there are not
coexisting mental health issues to be addressed. A thorough picture of the patient’s situation and
differential diagnoses are necessary (Wheeler, 2014).
If an APRN feels a patient is a good candidate for psychopharmacologic intervention he or she must
look at the medications closely for their known effects on senior adults as there may be a possibility of
paradoxical reaction. The senior population may also experience more severe side effects to
psychotropic medications which should be explained and monitored carefully (Williams, 2017).
When preparing for therapy an APRN should consider how the patient views mental illness and
therapy. Some generations see a lot of stigma in mental health issues and therapy and are not as open
to intervention. In addition, it may be difficult for a patient who is much older than the therapist to
develop the therapeutic alliance because they may have had fewer experiences with therapy. Education
and open communication about the patient’s paradigms and feelings may mediate these feelings. If
there are cognitive deficits, therapy is not precluded but it may be necessary to have shorter sessions,
use memory aids, take notes, and/or recap the last session before beginning a new one. From a practical
perspective the APRN should make sure that the office is set up so that patients can easily get in and out
and have furniture that they are comfortable in. The APRN should be aware that transference and
counter-transference may come from many stages of life and should be monitored for and there should
be clinical supervision and support. Ending the therapeutic relationship can be challenging as well as it
may feel like the patient may not have anyone else to share feelings or thoughts with and should be
planned for at the beginning of therapy to prevent boundary crossing (Wheeler, 2014).
Are there senior adults that would not benefit from therapy?
Senior adults that would not benefit from therapy are similar to other populations. If they cannot
participate related to cognitive impairment or physical impairment then therapy may not be the best
choice. If the stigma of mental illness is insurmountable for the patient and family or they are not able
or prepared to delve into what could be decades old trauma or issues it may be more appropriate to try
to treat with medications and continue to prompt therapy when appropriate (Wheeler, 2014)
References
Lewey, J., Smith, C., Burcham, B., Saunders, N., Elfallal, D., & OToole, S. (2018). Comparing the
effectiveness of EMDR and TF-CBT for children and adolescents: a meta-analysis. Journal of Child and
Adolescent Trauma, 11(4), 457-472.
Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for
evidence-based practice. New York: Springer Publishing Company.
Williams, S. (2017). Psychotropic medications in older adults: Pearls and pitfalls [Powerpoint slides].
Retreived November 19. 2019 from https://www.oacns.org/resources/Pictures/06-Williams-EvansPsychotropic%20Medications%20in%20Older%20Adults.pdf (Links to an external site.)
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