Description
. Provide a response to at least 2 of 3 discussion prompts that your colleagues provided in their video presentations. You may also provide additional information, alternative points of view, research to support treatment, or patient education strategies you might use with the relevant patient.
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Week 9: Special Considerations Related to Prescribing to Older Adults
Courtney Whitaker, RN
College of Nursing-PMHNP, Walden University
PRAC 6675: PMHNP Care Across the Lifespan II
Dr. Brown
January 24, 2024
NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Subjective:
CC (chief complaint): “I’ve been a little down and more anxious lately.”
HPI:
The patient is an 81-year-old Caucasian male with GAD, MDD, and PTSD presenting for
follow-up. He reports multiple stressors over the last three months, with the death of his brotherin-law, his wife’s declining health, being a full-time caregiver to his spouse, and having to take
on all of the household chores. He reports a depressed mood, daytime somnolence, increased
anxiety, and memory issues, stating, “I sometimes can’t find the words.” He states he has been
using Lorazepam more frequently due to his recent stressors and feeling like he is going to have
a panic attack at various times for unknown reasons. He reports feeling guilty and helpless
because he cannot spend time with his sister and recognizing that he is in the “last chapter” of his
life. He reports broken sleep with middle-of-the-night awakenings and trouble going back to
sleep. He reports that before his recent stressors, he slept through the night and felt rested upon
awakening with the supplemental oxygen ordered at bedtime by his primary care physician. He
states he tried over-the-counter melatonin once, which was effective, but he had some anxiety
about interaction with his other medications. He currently denies suicidal ideations, homicidal
ideations, intrusive thoughts, nightmares, flashbacks, auditory or visual hallucinations, and
mania symptoms. He reports that his appetite is good.
Past psychiatric hx:
Per chart review: The patient reports that he began outpatient behavioral health services in 2014
when he divorced his wife of 39 years; he reports experiencing increased anxiety, frequent panic
attacks, depressed mood, feelings of hopelessness, and insomnia. He reported a history of
nightmares and flashbacks of trauma experienced while working at a manufacturing job he had
over 60 years ago and has had ego dystonic intrusive homicidal ideations towards former
coworkers. He was started on Paxil for depressive symptoms, Clonazepam, and eventually
Lorazepam for panic attacks and insomnia by a former psychiatrist who retired. He continued
these medications for many years with his PCP. He denies any inpatient hospitalizations or
behavioral health services prior to 2014. He denies suicidal ideations, suicide attempts, selfinjurious behaviors, auditory and visual hallucinations, and mania. His therapist referred him to
his current PMHNP office for medication management one year ago.
Psychotherapy:
Currently participates in biweekly therapy since 2014.
Psychosocial Hx:
Per chart review: The patient is a retired heterosexual male living with his current spouse and
adult stepson for nine years. He has no biological children; he adopted a child with his first wife.
He completed high school. He denies any family substance use. His mother (deceased) had a
history of hypertension (HTN). His father (deceased) had a history of CVA and prostate cancer.
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
He had one brother (deceased) with HTN and MI and one younger sister with HTN. He reports
that his son (adopted) has an alcohol use disorder (AUD) and bipolar disorder (BPD),
Substance Current Use:
He denies any current or prior illicit substance, tobacco, nicotine, or vaping. He reports being a
social drinker in the past. He states that he quit drinking alcohol in 1980.
Medical History:
Coronary Artery disease (CAD), Chronic kidney disease (CKD)-Moderate, Gastric polyps,
Gastroesophageal reflux disease (GERD), Hypertension (HTN), Hyperlipidemia, Sensorineural
hearing loss-Bilateral
Current Medications: Paroxetine 40mg 1 tab daily- MDD,GAD, Lorazepam 0.25 mg 1 tab
daily prn panic attacks, Atenolol 50mg 1 tab daily HTN, Pantoprazole 40mg 1 daily GERD,
Atorvastatin 20mg 1 tab at bedtime-Cholesterol, Metoclopramide 10mg 1 tab daily GERD,
Sucralfate 1 g/10mL QID (with meals and at bedtime) GERD, Clopidogrel 75mg 1 tab daily,
Calcium with Vit D 1 daily, Oxygen @1-2L at bedtime prn, Ondansetron 4mg 1 q 4hr, prn N/V,
Melatonin 5mg OTC prn insomnia
Medication trials- Zoloft- reported GI upset, nausea/vomiting, Lexapro- reported increased
anxiety, Clonazepam-tapered off when Lorazepam initiated
Allergies: Codeine- hives, itching, Adhesive bandages
Reproductive Hx: No reported symptoms, per chart review. PT met all developmental
milestones; PT has no biological children.
ROS:
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GENERAL: Denies weight loss, fever, weakness
HEENT: Head: no complaints. Eyes: No visual loss, blurred vision, double vision, yellow
sclerae observed; hx of amaurosis fugax. Ears: Bilateral hearing aids, no observed
changes in hearing. Nose, Throat: No sneezing, congestion, runny nose, or sore throat.
SKIN: No rash was noted on the exposed skin.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No
palpitations; hx of hypertension, coronary artery stent.
RESPIRATORY: No shortness of breath, respirations even and unlabored, use of
supplemental oxygen at bedtime as needed
GASTROINTESTINAL: No abdominal pain, anorexia, diarrhea, nausea, vomiting, hx of
GERD, appendectomy, cholecystectomy, partial gastrectomy, hernia repair.
GENITOURINARY: No enuresis, no burning on urination, urgency, hesitancy; hx of
prostate cancer, prostatectomy.
NEUROLOGICAL: No headaches, no dizziness, syncope.
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
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MUSCULOSKELETAL: No muscle or back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising noted to exposed skin; low platelets
per recent laboratory results.
LYMPHATICS: No enlarged nodes were observed; no complaints were voiced.
ENDOCRINOLOGIC: No polyuria or polydipsia.
Objective:
BP 128/73 P- 72, R- 20 Temp. 36.8 SpO2: 94% Wt: 59.42 kg; 131 lbs Ht: 160.02 cm; 5ft 3 in.
BMI: 22.91
Diagnostic results:
Laboratory results completed by PCP 11/2023
CBC- This is utilized for screening or evaluating disease situations and determining if the
patient’s symptoms can be attributed to a medical condition (Pagana et al., 2017). This patient’s
Platelets are 133,000 per microliter. Adults’ normal platelet count ranges between 150,000 and
450,000 per microliter (Pagana et al., 2017). The 133,000 is indeed below the normal range but
not severely low. He has a history of gastric polyps and GERD, which could cause ulcers.
CMP- This is utilized for screening or evaluating disease situations to see if the disease can
account for the patient’s symptoms (Pagana et al., 2017). The patient’s results showed a
Creatinine Level of 1.5 HIGH. Creatinine levels typically rise slightly with age as muscle mass
naturally decreases. Consistently elevated creatinine levels are consistent with his CKD. This
patient has GFR 48 LOW. He has a diagnosis of moderate CKD. Generally, it would fall within
the 45-59 ml/min/1.73 m² range, aligning with the eGFR range for stage 3a CKD.
Lipids- The procedure aims to identify patients who may be at risk for coronary and vascular
disease (Pagana et al., 2017). He is currently taking medication for hyperlipidemia and has a
family history of cardiovascular issues. This testing is important to assist in making medication
choices; certain antipsychotic medications have the potential to increase lipid levels. Regular
monitoring of lipid levels is crucial when prescribing antipsychotic medications, as it helps to
identify potential risks. The patient’s results were within normal range. Total Cholesterol 104,
Triglycerides- 81, HDL-36, LDL-52
Vit D – Vitamin D can influence the production and activity of neurotransmitters like serotonin
and dopamine, which are crucial for mood regulation. This patient’s vitamin D levels are
acceptable at 36.0ng/mL.
Urinalysis- This test can detect issues such as urinary tract infections or conditions beyond the
kidneys (Pagana et al., 2017). The patient results are within an acceptable range.
GAD7: 10- A score of 10 on the GAD-7 suggests moderate anxiety. Screen tools are reliable and
efficient instruments for identifying anxiety in older adults (Carlucci et al., 2021).
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
PHQ9: 5- A score of 5 on the PHQ-9 suggests mild depression. Screening tools help identify
bothersome symptoms reported by the patient. A comprehensive assessment is required to
diagnose (Carlart, 2017).
Assessment:
Mental Status Examination:
He is an 81-year-old Caucasian male who looks the stated age. He presents himself politely and
pleasantly, appropriately dressed and groomed for the occasion. The individual demonstrates a
cooperative and polite demeanor, although there are indications of unease through fidgeting and
limited eye contact, which may suggest an underlying anxiety. He exhibited a variety of
emotions, ranging from tearful concern to anxious unease, fueled by his worries about his wife’s
deteriorating health and his realization of mortality. The individual’s thoughts are wellstructured; however, there seems to be a slight tendency towards distraction. This is evident in
his occasional difficulty maintaining focus and expressing his thoughts, which can be observed
in delayed speech. He seems restless, as evidenced by his rocking in his chair. However, there
are no indications of delusions or hallucinations, and no signs of self-harm or suicidal thoughts
were observed during the interview.
Diagnostic Impression:
1. F41.1 Generalized Anxiety Disorder (GAD)- GAD was considered due to the supporting
evidence of excessive worry, difficulty focusing, irritability, sleep problems, and somatic
complaints. DSM-5-TR criteria for GAD that are met include excessive worry, difficulty
controlling worry, and significant distress and impairment. Pertinent positives: Excessive worry,
impending doom, distractability, and sleep problems. A GAD-7 score of 10 suggests moderate
anxiety and was taken into consideration and used in conjunction with an assessment to confirm
GAD. His current symptoms and generalized worry about various issues align with GAD.
2. F32.2 Major Depressive Disorder (MDD): MDD was taken into consideration. In order to
receive a diagnosis of depression, according to the DSM-5-TR, an individual must experience
five symptoms that persist for a minimum of two weeks and significantly impact their normal
functioning. One may experience feelings of sadness or a loss of interest/pleasure. Common
signs of depression include experiencing daily sadness or emptiness, frequent crying, and a
decrease in overall activity level. Other symptoms may include a loss of enjoyment in most
activities, sudden weight gain or loss, changes in appetite, excessive sleepiness, noticeable
anxiety or slowed movement, persistent fatigue, feelings of worthlessness or excessive shame,
difficulty with concentration or focus, frequent thoughts of death or suicide attempts, significant
distress or impairment in daily life. It is important to note that these symptoms should not be
caused by drugs, medical conditions, or grief alone, as these factors may contribute to some
symptoms but cannot fully explain them (APA, 2022). There was no indication of psychosis or
bipolar disorder, and no signs of mania or hypomania were present (APA, 2022). There are
indications of potential Major Depressive Disorder based on sleep issues and feelings of sadness,
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
guilt, and helplessness. This patient’s presentation suggests a lower likelihood of Major
Depressive Disorder, as the predominant theme appears to be anxiety and lack of anhedonia,
with only some depressive symptoms present.
3. F51.01 Insomnia- The DSM-5-TR criteria for diagnosing insomnia states a predominant
complaint of dissatisfaction with sleep quantity or quality (APA, 2022). One may experience
challenges in falling asleep, staying asleep throughout the night, and waking up early in the
morning without being able to fall back asleep. A consistent pattern of sleep disturbance is
happening regularly, occurring at least three nights per week for at least three months. The sleep
disturbance results in significant distress or impairment in social, occupational, or other
important areas of functioning. These symptoms may manifest as excessive daytime sleepiness
or fatigue, impaired concentration or memory, and decreased motivation or productivity.
Experiencing mood disturbances such as irritability or anxiety, facing challenges in social or
occupational functioning, and finding it difficult to maintain relationships. The sleep disturbance
is not caused by any other medical condition or mental disorder (APA, 2022). The key factor that
currently rules out this diagnosis as the primary is that his sleep disturbance could be related to
other factors, and this patient’s sleep issues have not been occurring for the required three
months.
4. F43.1 Post-traumatic Stress Disorder (PTSD) Experiencing the loss of a loved one can be a
highly traumatic event that meets the criteria for PTSD (Unterhitzenberger et al., 2020). PTSD
was considered due to this supporting evidence: Pt has a history of nightmares and flashbacks of
his previous job. One notable aspect of PTSD is the disturbance of sleep, often caused by
recurring memories or dreams (APA, 2022). This patient is not reporting flashbacks,
hypervigilance, or nightmares that would support PTSD; therefore, it is ruled out at this time.
Reflections:
If I could conduct this session again, I would spend more time building rapport. Given his age
and complex medical conditions, establishing a strong therapeutic alliance might have taken
more time than initially allotted. Building trust and rapport could have allowed for a deeper
exploration of his difficulties and, potentially, better intervention engagement.
I would also want to focus more on coping skills for sleep difficulties. While we discussed
general stress management, specific sleep hygiene strategies and relaxation techniques might
have been more helpful for his immediate sleep concerns (Wuthrich et al., 2024). (Zhao et al.,
2019). The interaction between symptoms of insomnia and depression has a significant impact
on the quality of life (Zhao et al., 2019).
Case Formulation and Treatment Plan
Reviewed laboratory results from PCP. The risks and side effects of medications are discussed,
including the black box warning of increased suicidal thoughts and potential side effects, GI
upset, nausea, vomiting, increased anxiety, highly anticholinergic, sedating, and orthostatic
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
hypotension and currently being at maximum dosing for renal impaired patients for Paroxetine
(American Geriatrics Society, 2023). Discussed taking Paroxetine at bedtime due to this possibly
causing hypersomnolence. Potential for increased cognitive impairment and dependency with
benzodiazepines (American Geriatrics Society, 2023). Informed client not to stop the medication
abruptly due to withdrawal syndrome of headaches, vomiting, and weakness without discussing
it with the provider. Instructed to call and report any adverse reactions. He voiced understanding
of the discussion and agreed to the course of the treatment plan.
Continue current medications:
Paroxetine 40mg 1 tab at bedtime for MDD, GAD
Melatonin 5mg 1 tab at bedtime as needed for insomnia
Lorazepam 0.25mg 1 tab daily as needed for panic attacks
Provided supportive psychotherapy and discussed how current stressors can contribute to
anxiety, depressive symptoms, and sleep disturbance. Encouraged the use of guided breathing
exercises as an alternative intervention for anxiety and sleep disturbances to reduce the use of
Lorazepam for anxiety. Low-intensity psychological interventions (LIPI) offer a valuable
alternative or starting point for managing mental health problems (Wuthrich et al., 2024). They
are particularly beneficial for individuals with mild to moderate symptoms who desire
accessible, evidence-based, and empowering interventions. Considering his age and
capabilities, gentle exercises like guided chair yoga or breathing exercises could have been
incorporated into the session to address his physical and emotional well-being simultaneously
(Wuthrich et al., 2024). There is a need to prioritize elderly symptoms of sleep disturbance and
depression to improve their quality of life (Zhao et al., 2019).
Continue with biweekly psychotherapy with his therapist.
Continue to follow up with PCP management of CAD, CKD, HTN, Hyperlipidemia, GERD
Return to clinic in 1 month or sooner if needed.
PRECEPTOR VERIFICATION:
I confirm that the patient used for this assignment is seen and managed by the student at their
Meditrek-approved clinical site during this quarter’s learning course.
Preceptor signature: ____________________________Date: ________________________
© 2022 Walden University
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NRNP/PRAC 6665 & 6675 Comprehensive Focused SOAP Psychiatric
Evaluation Template
Objectives:
1. Colleagues will be able to analyze the complex correlation of comorbid conditions in an
older adult, considering potential medication interactions and exacerbating factors.
2. Colleagues will be able to critically evaluate the effectiveness of the patient’s current
medication regimen in light of his presenting symptoms and comorbidities.
3. Colleagues will be able to develop a comprehensive interdisciplinary treatment plan for
the patient, incorporating pharmacological and non-pharmacological interventions
tailored to his specific needs and geriatric considerations.
4. Colleagues will be able to propose evidence-based strategies for addressing ethical
considerations and potential barriers to treatment adherence in older adults with complex
mental health presentations.
Discussion Prompts
1. Given the patient’s multiple comorbidities and potential medication interactions, what
alternative or adjunctive medication options might be considered to address his primary
mental health symptoms while minimizing risks and side effects?
2. Considering his physical health limitations and geriatric factors, How can we effectively
integrate non-pharmacological interventions into this patient’s care plan?
3. What ethical considerations arise when treating an older adult with PTSD symptoms
related to a past traumatic event, and how can we ensure culturally competent and
patient-centered care in this context?
© 2022 Walden University
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Evaluation Template
References
American Geriatrics Society 2023 updated AGS Beers Criteria® for potentially inappropriate
medication use in older adults. (2023). Journal of the American Geriatrics Society, 71(7),
2052–2081. https://doi.org/10.1111/jgs.18372
Carlat, D.J. (2017). The psychiatric interview. (4th ed.). Wolters Kluwer.
Carlucci, L., Balestrieri, M., Maso, E., Marini, A., Conte, N., & Balsamo, M. (2021).
Psychometric properties and diagnostic accuracy of the short form of the geriatric anxiety
scale (GAS-10). BMC Geriatrics, 21(1), 401. https://doi.org/10.1186/s12877-021-023503
Pagana, K.D., Pagana, T.J., Pagana, T.N. (2017). Mosby’s diagnostic and laboratory test
reference. (13th ed.). Elsevier.
Wuthrich, V. M., Dickson, S. J., Pehlivan, M., Chen, J. T.-H., Zagic, D., Ghai, I., Neelakandan,
A., & Johnco, C. (2024). Efficacy of low intensity interventions for geriatric depression
and anxiety – A systematic review and meta-analysis. Journal of Affective
Disorders, 344, 592–599. https://doi.org/10.1016/j.jad.2023.10.093
Unterhitzenberger, J., Sachser, C., & Rosner, R. (2020). Posttraumatic stress disorder and
childhood traumatic loss: A secondary analysis of symptom severity and treatment
outcome. Journal of Traumatic Stress, 33(3), 208–217. https://doi.org/10.1002/jts.22499.
Zhao, X., Zhang, D., Wu, M., Yang, Y., Xie, H., Jia, J., Li, Y., & Su, Y. (2019). Depressive
symptoms mediate the association between insomnia symptoms and health‐related
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Evaluation Template
quality of life and synergistically interact with insomnia symptoms in older adults in
nursing homes. Psychogeriatrics, 19(6), 584–590. https://doi.org/10.1111/psyg.12441
© 2022 Walden University
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Week 9 Older Adult Case Study Presentation
Respond at least 2 times each to all colleagues who presented this week. The goal is for
the discussion forum to function as robust clinical conferences on the patients. Provide
a response to at least 2 of 3 discussion prompts that your colleagues provided in their
video presentations. You may also provide additional information, alternative points of
view, research to support treatment, or patient education strategies you might use with
the relevant patient.
Objectives
1. Colleagues will be able to analyze the complex correlation of comorbid conditions in an
older adult, considering potential medical interactions and exacerbating factors.
2. Colleagues will be able to critically evaluate the effectiveness of the patient’s current
medication regimen in light of his presenting symptoms and comorbidities.
3. Colleagues will be able to develop a comprehensive interdisciplinary treatment for the
patient, incorporating pharmacological and non-pharmacological interventions tailored to
his specific needs and geriatric considerations.
4. Colleagues will be able to propose evidence-based strategies for addressing ethical
considerations and potential barriers to treatment adherence in older adults with
complex mental health presentations.
Discussion Prompts
1. Given the patient’s multiple comorbidities and potential medication interactions, what
alternative or adjunctive medication options might be considered to address his primary
mental health symptoms while minimizing risks and side effects?
2. Considering his physical health limitations and geriatric factors, how can we effectively
integrate non-pharmacological interventions into this patient’s care plan?
3. What ethical considerations arise when treating an older adult with PTSD symptoms
related to a past traumatic event, and how can we ensure culturally competent and
patient-centered care in this context?
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