Post-traumatic stress disorder (PSTD) among older adults

The assessment and diagnosis of a patient require the PMHNP to consider the special characteristics of the patient before determining a suitable course of treatment (Bodner et al., 2018). In cases where the pharmacological treatments have not been approved by the FDA, the PMHNP should consider using “off-label” drugs which he deems appropriate for the treatment of PSTD. However, these drugs are only preferred if the benefits outweigh their risks (Ehret, 2019). This discussion delves into the treatment of post-traumatic stress disorder (PSTD) among older adults by recommending one FDA-approved drug, one off-label drug, and one non-pharmacological intervention. It also provides an appropriate risk assessment plan that would inform decision-making as well as the existence of clinical practice guidelines for PSTD.

Currently, there are only 2 FDA-approved medications for the treatment of PSTD: 1) sertraline and 2) paroxetine, both of which are selective serotonin reuptake inhibitors (SSRIs). Although other pharmacological therapies like selective norepinephrine reuptake inhibitors (SNRIs) are used in PSTD treatment, they are hitherto approved by the FDA and may not be safe (Ehret, 2019). In older adults’ PSTD treatment, I would recommend the administration of Sertraline (Zoloft) because it is the most common medication prescribed for PSTD treatment. Compared to Paxil, Zoloft is slightly better tolerated by patients across all age groups and is easier to discontinue (Ehret, 2019). Elderly patients have a weaker immune response and may respond differently to pharmacological treatment (Bodner et al., 2018). However, they can easily tolerate it in their bodies and remain healthy even after it is withdrawn due to adverse side effects.

For off-label drugs, I would recommend benzodiazepines because they decrease neural firing and anxiety for the patient. Evidence-based research studies bring out BZDs as effective “off-label” therapies for use in the treatment of symptoms of anxiety disorders, including PSTD, are safe (Ehret, 2019). Although some BZDs are discouraged for use in geriatric patients due to their increased half-life caused by slower hepatic metabolism and decreased renal clearance (Ehret, 2019). I would use BZD’s with a shorter half-life like Brotizolam to help in relieving PSTD symptoms.

For non-pharmacological therapies, I would recommend prolonged exposure therapy. PE helps the older adult patient to confront things she/he has been avoiding because they keep reminding him/her of the traumatic event (Bodner et al., 2018). Prolonged exposure therapy involves 8 to 15 therapy sessions of 90 minutes each. In the initial stages, the therapist teaches the patient breathing techniques to relieve his anxiety level as he thinks about what happened. The patient would then list things she/he has been avoiding so that she/he may learn how to face them without fear (Bodner et al., 2018). The therapist would also ask the client to recount his traumatic experience and then go home and listen to a recording of self-narrating the experiences.

Before administering any pharmacological treatment to the PSTD older adult, it is critical to assess the benefits and risks of each drug. The benefits of Zoloft are innumerable and may include having a shorter half-life, being easy to discontinue, and high tolerability (Dent et al., 2019). The initial dose for older adults is usually 50 mg PO Day but can be increased by 75 mg from time to time depending on the patient’s tolerance and response. Zoloft is used in PSTD treatment due to its association with lesser adverse side effects than paroxetine (Dent et al., 2019). The medication helps the patient to stop thinking about and reacting to past traumatizing events like flashbacks and nightmares (Bodner et al., 2018). Moreover, BZDs are safe in treating PSTD symptoms and can help the patient get rid of symptoms like anxiety and others. However, they should be administered with caution in elderly patients due to increased half-life caused by slower hepatic metabolism and decreased renal clearance (Dent et al., 2019). Before administering BZDs, it is critical to assess for co-morbid medical illnesses like dementia, cancer, kidney failure, renal diseases, and others.

There are clinical guidelines for the treatment of PSTD in older adults. The current clinical guideline recommends cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), prolonged exposure therapy (PE), and cognitive therapy (CT) (Dent et al., 2019). The clinical practice guideline further recommends the integration of other therapies like brief electric psychotherapy (BEP), eye movement desensitization, and processing (EMDR). It also recommends pharmacological treatments like Zoloft (Bodner et al., 2018). Although pharmacological therapies are administered in PSTD treatment, non-pharmacological therapies like CBT and PE are primarily recommended as first-line therapies (Dent et al., 2019). FDA-approved medications like Zoloft and off-label drugs are only recommended where non-pharmacological therapies are deemed ineffective.

In conclusion, the treatment of PSTD is implemented using both pharmacological and non-pharmacological therapies. Some recommended pharmacological therapies among geriatric patients include Zoloft (FDA-approved) and Benzodiazepines like Brotizolam (off-label) with a shorter half-life. The treatment can also be in the form of non-pharmacological therapies like CBT, PE, and other therapies. Non-pharmacological therapies are the recommended first-line therapies for PSTD in older adults.

References

Bodner, E., Palgi, Y., & Wyman, M. F. (2018). Ageism in mental health assessment and treatment of older adults. International Perspectives on Aging, 241-262. https://doi.org/10.1007/978-3-319-73820-8_15

Dent, E., Morley, J. E., Cruz-Jentoft, A. J., Woodhouse, L., Rodríguez-Mañas, L., Fried, L. P., Woo, J., Aprahamian, I., Sanford, A., Lundy, J., Landi, F., Beilby, J., Martin, F. C., Bauer, J. M., Ferrucci, L., Merchant, R. A., Dong, B., Arai, H., Hoogendijk, E. O., … Vellas, B. (2019). Physical frailty: ICFSR international clinical practice guidelines for identification and management. The Journal of Nutrition, Health & Aging, 23(9), 771-787. https://doi.org/10.1007/s12603-019-1273-z

Ehret M. (2019). Treatment of post-traumatic stress disorder: Focus on pharmacotherapy. The Mental Health Clinician, 9(6), 373–382. https://doi.org/10.9740/mhc.2019.11.373

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