Erica C. Garcia-Pittman

Family and Community

Non-pharmacological interventions can positively impact the aging process. These interventions include community involvement through age-friendly cities, disaster preparedness, as well as addressing the impact aging can have on the caregiver. Caregiving can expose family members to a unique set of stressors that are often not anticipated or addressed appropriately. This chapter discusses these interventions as well as the effects caregiving can have on family members and the benefit of providing resources for family members to better cope and provide care.

Development of oral candidiasis following initiation and rechallenge of extended-release bupropion in a geriatric patient

Objective: To report a case of oral candidiasis that developed in a 70-year-old white female both upon initiation and rechallenge of extended-release bupropion therapy. Case Summary: A 70-year-old female with a past medical history of osteoarthritis, degenerative joint disease, and polycythemia vera developed oral candidiasis on 2 occasions following initiation of extended-release bupropion for the treatment of recurrent depression. During both instances, the reaction occurred with an increased dose of the medication, suggesting the adverse event may have been dose-related. The patient had no risk factors for oral candidiasis aside from dry mouth at baseline that reportedly worsened on bupropion. Discussion: Though there are no other reports to our knowledge describing the development of oral candidiasis with bupropion, the likelihood of this having been an adverse reaction in this patient is probable as indicated by a calculated score of 8 from the Naranjo Algorithm. The adverse event appeared following bupropion administration and improved over time following its discontinuation. The adverse event reappeared following readministration of the agent, and no alternative causes were able to be identified. Additionally, the reaction occurred following an increase in the dose on both occasions, with the lower dose having only resulted in worsening dry mouth. Conclusion: This case demonstrates that an additional adverse event to screen for with bupropion treatment is the development of oral candidiasis. This adverse event may be more likely to occur in the older adult population.

Lithium rechallenge after renal transplant

Mrs B is a 65-year-old, married, white woman with long-standing history of bipolar disorder type I who achieved mood stability with chronic lithium treatment. She developed end-stage renal disease, which was suspected to be the result of chronic lithium exposure in the context of medical comorbidity, and subsequently required renal transplantation. Following transplantation and discontinuation of lithium, Mrs B was unable to achieve mood stability with multiple medication trials and required more than 40 medical and psychiatric hospitalizations with eventual transition to skilled nursing care. After much discussion among the psychiatric treatment team, the patient, and her husband, primary care provider, nephrologist, and renal transplant surgeon, the decision was made to restart the patient on lithium given her previous treatment success. The purpose of this case report is to discuss the use of lithium following renal transplantation. In this case, a multidisciplinary approach was used to assist the patient in carefully weighing the risks and benefits of her treatment decisions. The consensus of the patient, her husband, and her providers was that the benefit of mood stabilization outweighed the potential risks of renal toxicity. Although treatment with lithium after renal transplant is not a first-line treatment option, this case illustrates that lithium could be considered in certain cases.

Venous thromboembolism following initiation of atypical antipsychotics in two geriatric patients

Background Although not formally highlighted as a risk factor in current practice guidelines, several observational studies have reported a possible association between antipsychotic use and development of venous thromboembolism (VTE). However, it is unclear to what extent the risk is elevated. Case Report Described are 2 cases of VTE following recent initiation of second-generation antipsychotics in elderly patients. Ms A was a 65-year-old woman with newly diagnosed bipolar I disorder who was hospitalized for acute mania and psychosis. She was treated with risperidone along with traditional mood stabilizers and developed a pulmonary embolism shortly after treatment initiation. Ms B was a 77-year-old woman with newly diagnosed bipolar I disorder who was hospitalized for depression and psychosis. She was treated with quetiapine and electroconvulsive therapy and developed a pulmonary embolism and deep vein thrombosis within 2 months of starting treatment. Risk assessment tools were not able to definitively predict the VTEs that developed in our patients. Conclusion The association between antipsychotic medication and VTE has shown the highest risk with atypical antipsychotics, high dosages, and initiation within the past 3 months. Risk assessment tools may assist in assessing the risk of VTE in patients on antipsychotic therapy, although patients who are deemed by these tools to have minimal risk can still develop a VTE. Discussing VTE risk with patients when considering antipsychotic usage may help clinicians and patients safely determine the most appropriate treatment for their psychiatric illnesses while mitigating potential adverse effects.