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UTRGV Tricyclic Antidepressant Toxicity in Geriatric Patient Case Study

UTRGV Tricyclic Antidepressant Toxicity in Geriatric Patient Case Study

Question Description

I have researched the articles and attached the abstracts to make it easy

Your Annotated Bibliography assignment is the evidential foundation for your Case Study Presentation assignment. In this assignment, students will pick a case study, diagnose the patient, and present a plan for treatment options.

Select at least six current original research articles published within the last five years to support your treatment plan. For each article, place each article reference in APA format and write a summary that includes a) the purpose of the research, b) sample information, c) statistical significant or trustworthy results related to your practice change, d) recommendations made by the author(s), and e) your personal comments about the quality of the article. Submit this assignment using the respective link by the due date in Black.

Further Explanation:


An annotated bibliography is a list of citations to books, articles, and documents. Each citation is followed by a brief (usually about 150 words) descriptive and evaluative paragraph, the annotation. The purpose of the annotation is to inform the reader of the relevance, accuracy, and quality of the sources cited.


Abstracts are the purely descriptive summaries often found at the beginning of scholarly journal articles or in periodical indexes. Annotations are descriptive and critical; they expose the author’s point of view, clarity and appropriateness of expression, and authority.


Creating an annotated bibliography calls for the application of a variety of intellectual skills: concise exposition, succinct analysis, and informed library research.

First, locate and record citations to books, periodicals, and documents that may contain useful information and ideas on your topic. Briefly examine and review the actual items. Then choose those works that provide a variety of perspectives on your topic.

Cite the book, article, or document using the appropriate style, APA.

Write a concise annotation that summarizes the central theme and scope of the book or article. Include one or more sentences that (a) evaluate the authority or background of the author, (b) comment on the intended audience, (c) compare or contrast this work with another you have cited, or (d) explain how this work illuminates your bibliography topic.

Use the Same Topic as your Case Presentation and Professional paper (Don’t re-invent the wheel)

Khalid, M. M., & Waseem, M. (2020). Tricyclic Antidepressant Toxicity. In StatPearls. StatPearls Publishing.

Tricyclic antidepressants (TCAs) were introduced in the late 1950s for the treatment of depression. However, with the advent of selective serotonin reuptake inhibitors (SSRIs) and other new antidepressants, the use of TCAs has become limited, although it is still used to treat depression that has not responded to treatment with less toxic agents. In adults, TCAs are also used in migraine headache prophylaxis, treatment of neuralgic pain, including the pain associated with Ciguatera poisoning, and obsessive-compulsive disorder. In children, TCAs have been used to treat nocturnal enuresis. Despite the current limited use of TCAs, the curve for TCA-overdose associated hospitalization and fatality is on the rise.

Clark, S., Catt, J. W., & Caffery, T. (2015). Rapid diagnosis and treatment of severe tricyclic antidepressant toxicity. BMJ case reports, 2015, bcr2015211428. https://doi.org/10.1136/bcr-2015-211428

A woman in her mid-50s contacted her social worker and expressed intent to commit suicide by ingesting prescription medications. On arrival of emergency responders, the patient was found unconscious with an empty bottle of amitriptyline. Time of ingestion was estimated using the social worker’s contact with local authorities. The patient’s presentation at the emergency department (ED) exemplified tricyclic antidepressant toxidrome with a poor prognosis, based on measurable criteria and physical findings. Respiratory and cardiovascular collapse was managed emergently. Haemodynamic status and EKG findings responded in a stepwise fashion with therapy in the ED and intensive care unit. Full clinical recovery took 7 days, and the patient was subsequently transferred to an in-patient psychiatric facility for further evaluation. Eight days later, she was discharged home with no neurological sequelae.

von Düring, S., Challet, C., & Christin, L. (2019). Endoscopic removal of a gastric pharmacobezoar induced by clomipramine, lorazepam, and domperidone overdose: a case report. Journal of medical case reports, 13(1), 45. https://doi.org/10.1186/s13256-019-1984-0

Introduction: Gastric pharmacobezoars are a rare entity that can induce mechanical gastric outlet obstructions and sometimes prolong toxic pharmacological effects. Certain medications, such as sustained-release forms, contain cellulose derivatives that may contribute to the adhesion between pills and lead to the creation of an aggregate resulting in a pharmacobezoar. Case reports are rare, and official guidelines are needed to help medical teams choose proper treatment options.

Case presentation: Our patient was a 40-year-old Caucasian woman with borderline personality disorder and active suicidal thoughts who was found unconscious after a massive drug consumption of slow-release clomipramine, lorazepam, and domperidone. On her arrival in the emergency room, endotracheal intubation was preformed to protect her airway, and a chest x-ray revealed multiple coffee grain-sized opaque masses in the stomach. She was treated with activated charcoal followed by two endoscopic gastric decontaminations 12 h apart in order to extract a massive gastric pharmacobezoar by manual removal of the tablets.

Conclusion: This case demonstrates that in the case of a massive drug consumption, a pharmacobezoar should be suspected, particularly when cellulose-coated pills are ingested. Severe poisoning due to delayed drug release from the gastric aggregate is a potential complication. Detection by x-ray is crucial, and treatment is centered on removal of the aggregate. The technique of decontamination varies among experts, and no formal recommendations exist to date. It seems reasonable that endoscopic evaluation should be performed in order to determine the appropriate technique of decontamination. Care should be patient-oriented and take into account the clinical presentation and any organ failure, and it should not be determined solely by the suspected medication ingested. Thus, serum levels are not sufficient to guide management of tricyclic antidepressant intoxication.

Colijn MA, Nitta BH, Grossberg GT. Psychosis in Later Life: A Review and Update. Harv Rev Psychiatry. 2015;23(5):354-367. doi:10.1097/HRP.0000000000000068

Psychosis is relatively common in later life and can present in a wide variety of contexts, including early-onset and late-onset schizophrenia, delusional disorder, mood disorders, and various dementias. It can also occur as the result of numerous medical and neurological diseases and from the use of certain medications. Although identifying the cause of psychosis in older patients can be challenging, the unique clinical features associated with the different disorders can help in making the diagnosis. Accurate diagnosis of psychosis in older populations is essential, as its treatment varies depending on the context in which it appears. Despite the safety concerns regarding the use of antipsychotics in older patients, certain pharmacological treatments appear to be both efficacious and reasonably safe in treating psychosis in older populations. Additionally, although research is limited, numerous psychosocial therapies appear promising. This review summarizes the literature on the epidemiology, clinical characteristics, neuroimaging, and treatment of psychosis in later life, and serves as an update to past reviews on this topic.

Fournier JP, Wilchesky M, Patenaude V, Suissa S. Concurrent Use of Benzodiazepines and Antidepressants and the Risk of Motor Vehicle Accident in Older Drivers: A Nested Case-Control Study. Neurol Ther. 2015;4(1):39-51. doi:10.1007/s40120-015-0026-0

Introduction: Aging of the population results in an increase in senior drivers. Elderly are frequently treated with benzodiazepines and antidepressants. The objective of this study was to determine whether the concurrent use of benzodiazepines and antidepressants is associated with motor vehicle accidents (MVAs) in the elderly.

Methods: This was a nested case-control study within a cohort of drivers aged 67-84 years between 1990 and 2000, identified from the Société de l’Assurance Automobile du Québec and the Régie de l’Assurance Maladie du Québec databases. First cases of MVAs during follow-up were matched with up to ten controls from the cohort. Odds ratios (ORs) for the association between MVA and the use of benzodiazepines and antidepressants were estimated using conditional logistic regression.

Results: The cohort included 373,818 drivers, with 74,503 MVA cases matched with 744,663 controls. The risk of MVA was higher in current users of long-acting benzodiazepines [OR 1.23; 95% confidence interval (CI) 1.16-1.29] than in current users of short-acting benzodiazepines (OR 1.05; 95% CI 1.02-1.08). The risk of MVA was increased in current users of selective serotonin reuptake inhibitors (SSRIs; OR 1.13; 95% CI 1.04-1.22), while it was not in current users of tricyclic antidepressants (TCAs; OR 1.04; 95% CI 0.96-1.14). The highest ORs of MVA were observed in long-acting benzodiazepines users concurrently using SSRIs (OR 1.37; 95% CI 1.07-1.77, P value for interaction = 0.964) or TCAs (OR 1.54; 95% CI 1.21-1.95, P value for interaction = 0.077).

Conclusion: Use of long-acting benzodiazepines is associated with an increased risk of MVA in the elderly, particularly in those concurrently using SSRIs or TCAs.

Keywords: Aged; Antidepressants; Automobile driving; Benzodiazepines; Drug interactions.

Eizadi-Mood, N., Sabzghabaee, A. M., Saghaei, M., Gheshlaghi, F., & Mohammad-Ebrahimi, B. (2012). Benzodiazepines co-ingestion in reducing tricyclic antidepressant toxicity. Medicinski arhiv, 66(1), 49–52.

Aim: Tricyclic antidepressant (TCA) overdose is generally associated with central nervous system (CNS) and cardiovascular toxicity manifested by seizure, electrocardiographic (ECG) abnormalities and arrhythmia. The objective of this study was to determine whether TCA toxicity would be reduced in patient where benzodiazepine (BDZ) was co-ingested with TCA.

Design: Patients who were diagnosed to be poisoned by ingestion of both a tricyclic antidepressant and benzodiazepine (TCA-BDZ), and patients intoxicated solely by a TCA were assessed, provided that they had one or more clinical signs of toxicity (anticholinergic, cardiovascular or CNS findings) and no underlying cardiac disease. TCA poisoned patients who had ingested any drugs other than benzodiazepines were excluded. Patients transferred from elsewhere and those admitted after the first 24 hours were also excluded. The clinical manifestations of TCA toxicity and outcome of the patients poisoned only with TCA (N = 60) were compared with those of the patients who had co-ingested TCAs and BDZs (N = 60).

Main results: The frequency distribution of sinus tachycardia, “QRS more than 100 ms, R/S aVR equal or more than 0.7, RaVR equal or more than 3 mm”, arrhythmia, and generalized tonic colonic seizure was less in patients who had co-ingested BDZ with TCA. Evaluating the relationship between ingested TCA dosage and electrocardiographic findings (duration of QRS, QT and PR intervals, the amplitude of R wave in lead aVR and right axis deviation) in both study groups, demonstrated that there was a strong relationship between TCA dosage and QRS duration in the TCA group. This was significantly different from the same correlation in the TCA-BDZ group (r, 0.50 in TCA group versus r, 0.04 in TCA and BDZ group, P < 0.05). No significant differences were found in complications (aspiration pneumonia, non-cardiac pulmonary oedema and death) between the two groups.

Conclusions: cardiovascular toxicity and seizure may be less in TCA-BDZ poisoned patients compared with patients intoxicated with TCA-alone.

Romanov, D. V., Lepping, P., Bewley, A., Huber, M., Freudenmann, R. W., Lvov, A., Squire, S. B., & Noorthoorn, E. O. (2018). Longer Duration of Untreated Psychosis is Associated with Poorer Outcomes for Patients with Delusional Infestation. Acta dermato-venereologica, 98(9), 848–854. https://doi.org/10.2340/00015555-2888

We examined the association between the duration of untreated psychosis and outcome for patients with delusional infestation. This multi-centre international study included 211 consecutive patients. Illness severity was evaluated at first presentation and outcome was measured with the Clinical Global Impression scale (CGI) at baseline and follow-up. A regression analysis showed a clear clinical and statistically significant association between shorter duration of untreated psychosis and better outcome at follow-up. Patients with a duration of untreated psychosis of less than one year showed a CGI-S change from 5.37 to 2.07; those with a duration of untreated psychosis of 1-5 years a change from 5.48 to 2.59, and those with a duration of untreated psychosis of >5 years a change from 5.59 to 3.37. This difference of 1.1 CGI points between the groups resembles a clinically relevant difference in patient outcome. Our results suggest that longer duration of untreated psychosis in patients with delusional infestation is associated with significantly less favour-able clinical outcomes.

Subramaniam, M., Abdin, E., Vaingankar, J., Picco, L., Shahwan, S., Jeyagurunathan, A., Zhang, Y., Verma, S., & Chong, S. A. (2016). Prevalence of psychotic symptoms among older adults in an Asian population. International psychogeriatrics, 28(7), 1211–1220. https://doi.org/10.1017/S1041610216000399

Background: Psychotic symptoms are common among older adults and are seen in a wide range of conditions. Most studies examining the prevalence and correlates of psychotic symptoms among older adults have been conducted in Western populations. To address this gap the current study was undertaken to establish the prevalence and correlates of psychotic symptoms and paranoid ideation within a community sample of older adults without dementia in an Asian population.

Methods: The Well-being of the Singapore Elderly (WiSE) study was a comprehensive single phase, cross-sectional survey. All respondents were assessed using the Geriatric Mental State examination (GMS). Specific questions of the GMS were then used to establish the prevalence of hallucinations and persecutory delusions.

Results: A total of 2,565 respondents completed the study giving a response rate of 65.6%. The prevalence of any psychotic symptoms in this population of older adults was 5.2%. The odds of hallucinations and any psychotic symptoms were significantly higher among those of Malay ethnicity, and those who had no formal education. Older adults aged 75-84 years were significantly associated with lower odds of having hallucinations (vs. older adult aged 60-74 years), while homemaker status was significantly associated with lower odds of having any psychotic symptoms.

Conclusions: The prevalence of psychotic symptoms among older Asian adults without dementia was higher than that reported from Western countries. Psychotic symptoms were associated with Malay ethnicity, poor cognitive performance and fewer years of schooling, visual and hearing impairment as well as depression and irritability.

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