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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.

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.


  • 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.


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.

Student 1 jennifer

According to Shrestha et al. (2020), Generalized Anxiety Disorder (GAD) is one of the most common mental health disorders in older adults fifty-five years and older, and when symptoms of anxiety are overlooked or not adequately treated, the number of unmet  mental health needs increases. According to the American Psychiatric Association (2020), GAD is defined as an excessive amount of worry and anxiety about different events of everyday life that occurs on more days than not for a minimum of six months. In GAD, the individual finds it hard to control the worry, and the anxiety is accompanied by other symptoms including restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, and sleep disturbance. These symptoms causes a significant impairment in the life of the individual, and it is not better explained by another mental health illness, medical illness or abuse of substance (American Psychiatric Association, 2022).

According to Flint (2005) the most frequent comorbidity with GAD in older adults is major depression so a medication with both anxiolytic and anti-depressive qualities is recommended for first-line treatment of GAD in older adults. Citalopram which is a Selective Serotonin Re-uptake Inhibitors (SSRIs), and Venlafaxine which is a Serotonin Norepinephrine Re-uptake Inhibitors (SNRIs) are the first-line recommended medications for older adults as they do not have sedative effects like Benzodiazepines, and are more efficacious with minimal side effects when compared to non-benzodiazepine anxiolytics (Flint, 2005).

According to Stahl (2021), Citalopram is a Federal Drug Administration (FDA) approved drug for the treatment of Generalized Anxiety Disorder in older adults, and it takes about two to four weeks for therapeutic effects to be seen. The benefits of Citalopram is that it is typically well tolerated by older adults, it is efficacious when used treat symptoms of anxiety, and to prevent relapses by using it for maintenance treatment. It also helps with treating a comorbidity of depression and sleep disturbance which is commonly seen in most older adults dealing with anxiety, and the medication also helps reduce the risk of suicidality. The risks of Citalopram includes side effects if sexual dysfunction, decreased sexual desire, gastrointestinal symptoms like diarrhea, nausea and decreased appetite, hyponatremia seen mostly in older patients, and renal impairment in special populations all of which can be reversed when the medication is discontinued (Stahl, 2021).

Bupropion is a medication that is not FDA approved for treating anxiety and used off-label, and has shown good efficacy as a mono therapy when used to treat GAD, and when compared to Citalopram. It is also sometimes used as an adjunct to treat the sexual dysfunction side effects caused by SSRIs (Garakani et al., 2020). According to Stahl (2021), the benefits of Bupropion includes; it works fairly fast taking two to four weeks for therapeutic effects, it is used to as a maintenance treatment to prevent relapses, it can also treat symptoms of Attention Deficit Hyperactivity Disorder, it also treats co-morbid symptoms of depression, it can be used for smoking cessation, and it can be added to SSRI treatment to help treat side effect of sexual dysfunction. The risks of Bupropion includes side effects of dry mouth, weight gain, insomnia, dizziness, headache, agitation, abdominal pain, and hypertension, so monitor for these side effects (Stahl, 2021).

One non-pharmacological treatment of GAD in older adults that has show good efficacy is Cognitive Behavioral Therapy (CBT) which it focuses on two principles including tackling the patients false beliefs which causes them to get anxious, and helping them balance them their anxiety when they do get anxious or panicked by informing them that it is time-limited and not life threatening (Boland & Verduin, 2022). Another approach in CBT in older adults is teaching guided self-help used to reduce the symptoms of anxiety, and has shown good results. Overall the best approach is use of medication and psychotherapy together to help get the best outcome for the patient (Gaudreau et al., 2015).

One of the rating scales used in risk assessment and treatment measurement of GAD is the GAD-7 which is a seven item questionnaire used by practitioners when diagnosing GAD, and to gauge the severity level of GAD. GAD-7 is used frequently when treating older adults with GAD because it has been shown to have good internal consistency, reliability and validity when used in risk assessment of GAD, and to measure the efficacy of treatment outcome (Shrestha et al., 2020).

Clinical practice guidelines exist for the treatment of GAD and they include adequate diagnosis of the condition using the DSM-5, risk assessment to corroborate and help guage severity level of GAD, treatment options augmenting pharmacology using SSRIs and SNRIs as FDA first-line treatment of GAD, along with psychotherapy with CBT being highly recommended as described above. SSRIs and SNRIs also have the added benefit of treating common co-morbid conditions like depression and insomnia seen in older patients with GAD (Boland & Verduin, 2022).


Student 2 nicoline

Alzheimer’s disease is a progressive irreversible degenerative neurological disease that result in the death of neurons. The underlying cause of the disease is still unknown. The disease is characterized by progressive memory loss, impaired thinking, neuropsychiatric symptoms such as hallucinations and delusions, and the inability to perform activities of daily living. According to Rosenthal & Burchum (2021), Alzheimer’s disease is the sixth leading cause of death in the United States with an annual cost of $277 billion. It is imperative to note that the significant risk factor of developing Alzheimer’s disease is advanced age, in which roughly 90% of patients develop onset at sixty-five years or older. This risk gets double after or every ten years until the patient reaches the ages 85 to 90, according to Wong, Min, Kranick, Ushasri, Trinh & Kwon (2022).


The FDA-approved drug, one off-label drug, and one nonpharmacological intervention for treating Alzheimer’s in older adults


The goal to treat Alzheimer’s disease is to improve the symptoms and reverse cognitive impairment. However, it is unfortunate that this goal cannot be attainable because the available drugs cannot perform that function. The least that the available drugs can do is slow the loss of memory and cognition; they promote independent function for some patients. The Food and Drug Administration recommend four drugs for treating Alzheimer’s disease or dementia these four drugs include Donepezil, memantine, rivastigmine and galantamine. According to Rosenthal & Burchum (2021) of all these four approved medications, no single one of them is more effective than the other so selection or choice of prescription is considered based on how easy the patient can use the medication, family preference, cost price of the drug and how the patient tolerated. For instance, if the patient has severe disease symptoms, the drug of choice will entail Donepezil, a cholinesterase inhibitor used to treat mild to severe AD. It will work by preserving and delaying destruction of the neuron that has not yet been destroy through transmission of the central cholinesterase neuron. When this action is delay, it helps the patient function better. It is important to note that cholinesterase does not cure the disease progression but slow the growth rate. On the other hand, if symptoms were mild to moderate, then the other three choices above could be prescribed.


With the treatment of Alzheimer’s Neuropsychiatric symptoms like aggression delusions agitation and hallucination often occur in more than 80% of the patients. Different classes of off label medications like antidepressants, antipsychotics, mode stabilizers have all proven to have limited benefits for these patients. However, others like Risperdal and Zyprexa are the only two proven to modestly reduce neuropsychiatric symptoms as they slightly improve mortality related to cardiovascular infections and evens Rosenthal & Burchum (2021). Risperidone in low dose is use for patients exhibiting psychosis.


When it comes to nonpharmacological treatment for patients with Alzheimer’s disease support group for patients and family is necessary. A support group will give the family a sense of how other families are dealing with similar situations and help them cope positively. In addition to group therapy, exercise routine exercise can help patients cope with restlessness or anxiety, occupational activities to keep them distracted and music that they like to listen to will help them cope, according to Sousa et al. (2023).


Explain the risk assessment to inform 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?

One risk assessment for patients with Alzheimer’s disease would include functional assessment instrument activities of daily living questionnaire. This test will provide a baseline on the patients functioning an area where the patient needs the most help, the need to assess the patient’s depression scale. For example, patients held questionnaires for the geriatric depression scale. Another test will be cognitive assessment test to determine the degrees and stage of Alzheimer’s. It is rather unfortunate that the FDA approved medications for Alzheimer’s disease only help to slow the disease progression and does not cure the disease. So eventually the condition will get worst. According to Rosenthal & Burchum (2021), these medications have no actual or definite cure benefit. The off-label medication is effective in reducing anxiety. Take for instance. The medication memantine is prescribed for patients with Alzheimer’s to help improve their thinking and functioning however, it does not work for all patients with Alzheimer’s, leaving it as a trial.

The risk factor associated with all cholinesterase inhibitors must be communicated to families is the risk of lightheadedness. Lightheadedness can result thus a risk for falls. If the patient notices any light headedness, it is important to sit down until the feelings go away and to change position and move slowly might help. Eat healthy to supplement weight lost that might occur as a result.

 Clinical guidelines for Alzheimer’s.

The clinical guidelines for treating Alzheimer’s disease fall into the disease progression stages. The first stage, the mild and early stage of Alzheimer’s, involves memory lapses and difficulties these patients face in performing the task including losing objects. In the second stage which is also the longest stage of Alzheimer’s, the patient experience confusion, anger, and frustration in the last stage, which is also the most severe, where the patient is not even aware of their environment. Based on these difficulties categories of issues, the guideline enforces the treatment care plan adjustment considering the patient’s preferences and needs. The provider should develop treatment goals that are realistic and meaningful for the patient and their family. The guideline also elaborates on the need to involve family and caregivers providing care for this patient with education, knowledge and support including helpful resources Parra-Anguita, Sánchez-García, del Pino-Casado & Pancorbo-Hidalgo (2019). Lastly, medication plans should incorporate affordability, easy to use and family preferences. Regarding treatment guidelines, cholinesterase inhibitors should be prescribed with caution, particularly for patients with raspatory diseases or peptic uncle disease. Caution should also be exercise when prescribing this medication for patients with bradycardia or history of first-degree heart blocks because the risk outweighs the benefits Rosenthal & Burchum (2021).


To sum up researchers continue to work hard to find a cure for this disease that claims the lives of Americans and people worldwide. The treatment to slow progression of the disease remain cholinesterase inhibitors and cognitive assessment for perceived benefit should be priority for patients taking these medications.


Choose one of the two following specific populations below and select specific disorder from the  DSM-5 to use.

Pregnant women

Older adults


Based on your selection for either pregnant women or older adults:

Recommend one FDA-approved drug (use a credible scholarly resource to support)

Recommend one off-label drug (use a credible scholarly resource to support)

Recommend one nonpharmacological intervention for treating (use a credible scholarly resource to support)


Based on your selection for either pregnant women or older adults:

Explain the risk assessment you would use to inform your treatment decision-making.

Explain the risks and benefits of the FDA-approved medicine

Explain the risks and benefits of the off-label drug


Based on your selection for either pregnant women or older adults:

Explain whether clinical practice guidelines exist for this disorder

If clinical practice guidelines exist for the diagnosis, use them to justify your recommendations.

If clinical practice guidelines  does not existfor the diagnosis, explain what information you would need to take into consideration.

Support your reasoning with at least three current, credible scholarly resources from the 2016-2021. I will accept 2015-2021 will be acceptable as well.


Respond to  at least two of your colleagues on  2 different days who selected different disorders. a.  Propose an alternative on-label

Propose an alternative off-label pharmacological treatment

Propose an alternative nonpharmacological treatment for the disorders

Justify your suggestions with at least two references to the literature


You are unable to get the max points without research validation.  However, some parts specifically request you to support your rationale with research.  To receive max points in any of the areas would require critical thinking=research validation


Last Updated on July 26, 2023

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