NURS 6630 Discuss Treatment for a Patient With a Common Condition

Sample Answer for NURS 6630 Discuss Treatment for a Patient With a Common Condition Included After Question

NURS 6630 Discuss Treatment for a Patient With a Common Condition

 

Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.

NURS 6630 Discuss Treatment for a Patient With a Common Condition Reference: 

Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.

NURS 6630 Discuss Treatment for a Patient With a Common Condition
NURS 6630 Discuss Treatment for a Patient With a Common Condition

By Day 3 of Week 7

Post a response to each of the following:

  • List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
  • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
  • Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
  • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
  • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
  • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

Read a selection of your colleagues’ responses.

By Day 6 of Week 7

Respond to at least two of your colleagues on two different days in one of the following ways:

  • If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
  • If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

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SAMPLE 1

Questions and Rationale

The first question that I might ask the Patient is, “what brings you in today?”. By this question, you are forming a rapport with the Patient and making it for her to share his/her feelings openly. By asking an open-ended question, the Patient is more willing to share information with the provider (Stern, 2016). The second question that would be of beneficial knowledge during the interview is, “do you consume caffeine?” If so, how much caffeine do you consume in a day? Since caffeine consumption close to bedtime contributes significantly to insomnia. Lastly, “do you suffer from Gastro-Esophageal Reflux Disease (GERD)?”. GERD is a contributing factor to insomnia in elderly patients. The provider can rule out environmental factors by asking the above questions while assessing the Patient’s concerns with open-ended questions. (Farazdaq et al., 2018).

People in the Patient’s life, Questions, and feedback

The People in the Patient’s life that could help and give further information are her children or caretakers. Since they are in close contact with the Patient before admission to your office, questions that would be appropriate to ask the Patient’s children or caretaker would be, “Is there a recent decrease in her appetite, energy, mood, or interests?” By asking about these questions, external information will be provided, and further assessment that the Patient might be withholding or unaware of.

Appropriate Physical Examinations and Diagnostic Tests

A physical exam could be performed with the order of blood testing to rule out thyroid problems. Hyperthyroidism results in nervousness from the overactivity of this hormone, and insomnia is often a symptom. Administering the Hamilton Anxiety Rating Scale would assess the severity of the Patient’s anxiety. The HAM-A results would aid with further treatment of the Patient’s insomnia if related to anxiety. Also, insomnia relies heavily on self-report for a diagnosis (Levenson et al., 2015). Another appropriate scale to administer to this Patient is the Hamilton Depression Rating Scale. HDRS is an assessment that focuses on feelings of guilt, mood, suicidal ideation, activities, weight, various stages of insomnia, and many more critical areas (Hamilton, 1960) appropriate to the Patient’s condition.

Differential and Likely Diagnosis

The Patient has a previous diagnosis of depression. The differential diagnosis for this Patient is Generalized Anxiety Disorder (GAD), secondary to the husband’s death. There are many possible changes within the dynamics of life, such as financial stress, fear of being alone, fear of death, and sudden sleep alone. Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about several things. People with GAD may anticipate disaster and be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worries. They may worry more than seems warranted about actual events. This differential diagnosis fits the Patient given in the scenario. Changes within this Patient’s routine may be a cause of reported insomnia.

Appropriate Pharmacologic Agents

The two pharmacological agents appropriate for the Patient’s antidepressant therapy are Trazodone and Temazepam.

Trazodone is widely used for insomnia. It Is FDA approved for the treatment of major depression and used off-label for insomnia and anxiety. Trazodone inhibits serotonin reuptake, alpha-1 adrenergic receptor antagonist, and serotonin 5-HT2A and 5-HT2C receptor antagonist and is metabolized primarily through CYP3A4 to active metabolite mCPP, that is metabolized by 2D6, inducing P-glycoprotein. Trazodone, however, carries the side effect of daytime somnolence and dizziness (Cook et al., 2018).

Another good sleep aid choice is Temazepam. It is also FDA approved for insomnia and used off-label for anxiety disorders, acute mania, psychosis, and catatonia (Puzantian & Carlat, 2020). It is generally effective in the treatment of insomnia by enhancing the widespread inhibitory activity of GABA (Levenson et al., 2015). Temazepam is metabolized through the liver without CYP450. Temazepam is used to help people get to sleep. It is habit-forming and should not be used for more than seven to ten nights in a row but is safer in elderly patients, which suits the Patient in the scenario given. Although, trazodone is mainly used for its sleep-inducing effects (an off-label indication) rather than as an antidepressant. Only generic forms are available, which makes it a lot cheaper than some other sleep-inducing alternatives, and it is not classified as a controlled substance.

Contraindications and Patient Factors

The favorable medication for this Patient is Temazepam. Temazepam is a safer medication for elderly patients because of its lack of active metabolites, short half-life, and absence of drug interactions (Puzantian & Carlat, 2020). The Patient is currently taking Metformin, Januvia, Losartan, HCTZ, and Sertraline. The Patient is being treated for diabetes mellitus, hypertension, and depression based on the current medications. Adding Temazepam to the Patient’s medication regimen would not result in toxicity of other medications. Sleep is heritable and regulated by numerous genes. A genome broad association study found numerous single-nucleotide polymorphisms significantly associated with insomnia symptoms. The most significant SNPs occurred within genes involved in neuroplasticity, stress reactivity, neuronal excitability, and mental health.

Checkpoints and Therapeutic Changes.

The starting dose of Temazepam is lower in the elderly population (Puzantian & Carlat, 2020). The proper dose to begin with this Patient is Temazepam 7.5mg tab PO QHS. At the 4-week checkup, the expected outcome would be an increased ability to sleep and reduced anxiety. If these results have not been achieved, Temazepam 15mg tab PO Q HS would be ordered. Temazepam does have the risk of weakness and dizziness, so great care and caution would need to be taken when increasing the dose. There needs to be an evaluation of the effects at week 8, or sooner if needed. The maximum dose of Temazepam is 30mg PO Q HS, and even lower in the elderly (Cook et al., 2018).

Lessons Learned and Therapeutic Application

The lesson I’ve learned from the given case study is that depression and sleep have a bidirectional relationship. This means that poor sleep can contribute to the development of depression and that having depression makes a person more likely to develop sleep issues. Sleep problems often accompany most people who have experienced depression. At the same time, sleep problems can exacerbate depression, leading to a negative cycle between depression and sleep that can be challenging to break, not only to elderly patients but in all types of life development from kids to adolescents, adults up to elderly patients. Depression and sleep are closely intertwined and must be prioritized, and should not be taken lightly. I could apply this in my practice by giving health teachings, counseling, or educating patients about the basic knowledge on depression. Not to be scared to talk about their feelings to others, their healthcare provider, doctors, and families. Patients with this kind of situation are most likely to feel better after they open up their situation.

NURS 6630 Discuss Treatment for a Patient With a Common Condition References:

Cook, B., Creedon, T., Wang, Y., Lu, C., Carson, N., Jules, P., Alegría, M. (2018). Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse. Drug and Alcohol Dependence187, 29-34. DOI: 10.1016/j.drugalcdep.2018.02.011

Farazdaq, H., Andrades, M., & Nanji, K. (2018, December 31). Insomnia and its correlates among elderly patients presenting to family medicine clinics at an academic center. Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382090/

https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

Hamilton, M. (1960). Hamilton Rating Scale for Depression. PsycTESTS Dataset, 23, 56-62. https://doi.org/10.1037/t04100-000

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The Pathophysiology of Insomnia. Chest, 147(4), 1179-1192. https://doi.org/10.1378/chest.14-1617

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A Sample Answer For the Assignment: NURS 6630 Discuss Treatment for a Patient With a Common Condition

Title: NURS 6630 Discuss Treatment for a Patient With a Common Condition

Week 7 Discussion  

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Treatment for a Patient with a Common Condition 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. 

  1. Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?  

Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O’Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O’Callaghan et al., 2018). 

  1. How many hours of sleep are you getting each night?  

Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, leading to more anxiety and insomnia (Levenson et al., 2015). 

  1. Have you had any feelings of depression, hopelessness, or feeling down in the past month?  

Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and determine if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020). The patient’s husband died ten months ago in the given scenario. If the patient responds positively to this question, it is critical to also assess for suicide risk. 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. 

It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s daily life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask. 

Have you noticed a change in her interest in doing things? 

Have you she seemed down or hopeless? 

How has she been eating? 

Do you know if she is taking her medications or noticed any side effects from her medications? 

Have you noticed any anxiety or changes in memory? 

Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used. 

Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults with depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015). The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as many organic illnesses can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies. 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible. 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

The patient is currently taking Sertraline 100mg daily. If the patient takes the medication as prescribed, the patient should see improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia. At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can improve sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017). 

Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the anti-depressant to Bupropion. Studies have shown that in patients with diabetes, burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish et al., 2018). 

For the drug therapy, you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making? 

Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug’s effects may increase due to slow kidney or liver removal. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020). 

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone. 

References 

Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf 

Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03 

Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797 

Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033 

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617 

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404 

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493 

Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/ 

Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/ 

Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c 

Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4 

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Week 7 Discussion  

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Edwina Etienne 

07/12/2022 

 

 

Case: An elderly widow who just lost her spouse.  

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:  

  • Metformin 500mg BID  
  • Januvia 100mg daily  
  • Losartan 100mg daily  
  • HCTZ 25mg daily  
  • Sertraline 100mg daily  

Current weight: 88 kg 

Current height: 64 inches 

Temp: 98.6 degrees F 

BP:132/86  

Post a response to each of the following: 

  • List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.  
  • Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  
  • Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  
  • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.  
  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.  
  • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?  
  • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.  

      

 

According to the American Academy of Sleep Medicine, insomnia is defined as difficulty either falling or staying asleep that is accompanied by daytime impairments related to those sleep troubles (Balter & Uhlenhuth, 2017). Insomnia can be acute or chronic. Acute insomnia is common. Common causes include stress at work, family pressures, or a traumatic event. It usually lasts for days or weeks. Chronic insomnia lasts for a month or longer. Most cases of chronic insomnia are secondary (Stern et al, 2015). 

 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. 

 

 

I would ask the patient how long she has been taking the medication Sertraline, if her dose has ever been adjusted, and if she felt that it has helped her depression. The reason I am asking these questions is to determine if the medication is helping her depression and if it would benefit to increase them. 

I would ask about medication adherence and educate about the importance of taking her medication as prescribed and not skipping dosage. Finding out if the patient is compliant with her medications can help determine the next step in treatment (Stern et al, 2015). 

 

I would also ask about activities before sleep. For example, I would ask about activities such drinking alcohol beverages, or coffee before bed, smoking, exercising, and watching television. Since alcohol can reduce REM sleep and cause sleep disruptions, people who drink before bed often experience insomnia symptoms and feel excessively sleepy the following day. 

 

. This patient may need some “calming” exercises and suggestions on how to decrease her brain’s state of arousal. 

 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. 

            I would want to speak to this patient’s adult children if they are close to their mother and involved in her care.  I would ask if they have seen any changes in their mother recently and if they have any other input, concerns, or suggestions when it comes to their mother’s care.  I would also want to know if any of them or other family members has a history of insomnia. 

 

List Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  

             

Since the patient is in her 70’s it is important I would get a CBC and a BMP to check for any abnormal labs and for baseline values. I would also draw endocine related labs. For example, cortisol, adrenocorticotropic hormone, melatonin, noradrenaline, γ-Aminobutyric acid, and calcium (Stern et al, 2015). 

I would use the results of these labs to determine if the patient has any deficiencies or abnormalities that need treated that could be the cause of the patient’s insomnia. 

            I would also use the Hamilton or (DSM-5) depression scale with this patient to monitor the effects of the treatment on her depression symptoms. 

 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

            A differential diagnosis for this patient would be insomnia associated with situational depression. The patient stated she lost her husband less than one year ago.  This patient is more than likely still grieving her husband’s death and is unable to sleep due to her current situation. 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

      

For her depression I would start her on sertraline 50 mg daily, and then increase by 25 to 50 mg/day or the evening; may increase by 25 to 50 mg/day at intervals of at least 1 week to MAX 200 mg. Sertraline works by increasing the levels of a mood-enhancing chemical called serotonin in your brain. It helps many people recover from depression and has fewer unwanted side effects than older antidepressants (Stern et al, 2015). 

 

             I would also add trazadone for the insomnia, starting her at 25 mg at bedtime. The drug trazadone has been ‘approved for the treatment of depression, but the off-label use of this medication for insomnia has surpassed its usage as an antidepressant’ (McHorney et al,. 2019). Trazadone has reported sufficient sleep and has maintained sleep without causing daytime drowsiness (Stern et al, 2015). 

 

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities? 

            some ethnicities are more prone to be carriers ‘of CYP2D6/CYP2C19 (cytochromes responsible for antidepressant metabolism)’ (Simon, 2017).  This can cause problems with the metabolism of antidepressants, which can cause a buildup of toxic levels in the neurological system. 

 

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options choices. 

I would want to see this patient back in the office in about two to three weeks in the office setting, she can also call the office if she has any questions. IT will also be a good idea to ask her to keep a log of her sleep schedule activity.   

 

           

References 

 

               Balter, M. B., & Uhlenhuth, E. H. (2017). New epidemiologic findings about insomnia and its treatment. The Journal of clinical psychiatry. Vol 13.28 Pg 56-89. 

 

McHorney, C. A., Ware Jr, J. E., & Raczek, A. E. (2019). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical care, 247-263. 

Simon, G. E., & VonKorff, M. (2017). Prevalence, burden, and treatment of insomnia in primary care. American journal of psychiatry, 154(10), 1417-1423. 

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences. 

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Sandra Fernandez Arias  

Week 7 Discussion  

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Three possible questions meant for the client 

  1. Are you really compliant with the medications prescribed to you?  
  1. How often do you take caffeine drinks?  
  1. Over the last one month, did you feel hopeless, helpless, depressed or even had reduced pleasure to your day-day activities?  

Overly, in the case where a client is on medications, it is good to confirm whether the client is compliant to the prescribed medications. It also gives the reasons as to why the patient might present with a given chief complaint. In this case, the client complains about insomnia and is currently taking antihypertensive and even taking sertraline which is a selective serotonin reuptake inhibitor and it triggers insomnia as a side effect (Bickley et al., 2020). Additionally, it would be good to inquire whether the patient takes caffeinated drinks since they also cause insomnia. The last question is meant to assess the presence of depression and it is part of the mental health screening questions. 

People who could offer feedback about the patient in the case presentation 

 The patient currently stays with her children and would be closest people to offer feedback on whether the patient is compliant with the prescribed medications. The question would be important in identifying the differential diagnosis for the patient. In this case, the question would be whether the patient is compliant to the prescribed medications (Bickley et al., 2020). Additionally, the patient’s guardian can be questioned about whether he or she noted any changes on the patient’s speech, mood or attention as well as changes in memory, insight or orientation.  Lastly, the question could deduce observations made on patient’s phobias, ritualistic behavior, anxiety and panic. Others would confirm if the patient has dementia or delirium (Carlo et al., 2021).  

 

Diagnostics 

The patient Health questionnaire which has got nine questions is used to screen the patient. Some of the questions include whether the patient is depressed and whether in the past one month the patient has been feeling hopeless, helpless or depressed. overly, the given questions could achieve a sensitivity of 97% and a specificity rated as 67%. Others include Zung Self –Rating depression scale and the last one which would be performed by a qualified professional include the Hamilton Depression rating scale where a score above 20 would be regarded as moderately severe (Bickley et al., 2020). A normal score would fall within 0 to 7.  Since she is an older patient, a geriatric depression scale would also be viable. It has got 30 items. However, it has got a complex interpretation of the results. Lastly, to assess dementia, a Cornell Scale for Depression in Dementia would be used and it determine both the category as well as the severity. There are other useful laboratory studies that are done in cases of major depressive disorder such as alcohol levels in blood. arterial blood gas, dexamethasone suppression test meant for Cushing disease and cosynthropin stimulation test meant for Addison disease.  Neuroimaging is also done to assess the nature of the neurological illnesses that the patient presents with (Kopel, 2021). 

Differential diagnoses 

Major Depressive disorder. This is the most possible condition in this case since the patient indicates that her depression worsened when her husband died.  Therefore, the assessment should be focused on identifying the symptoms of depression such as hopelessness, helplessness and having depressive episodes (Hogan-Quigley & Palm, 2021). The patient has altered sleep pattern or insomnia which might be as a result of major depression.  

Schizophrenia: This is a possible diagnosis where the patient presents with compulsive behavior, delusions, slowness in activities, depression, frenzied kind of thinking as well as memory impairment (Hogan-Quigley & Palm, 2021). Patients might also be active and have insomnia.  In this case, however, the patient only has insomnia and does not meet the exact criteria used to diagnose schizophrenia.  

Illness anxiety disorder:  this is also referred to as hypochondria. It usually develops mostly during adulthood and would be characterized by intense fear that they have got some serious condition and at times get worried when they present with minor symptoms (Hogan-Quigley & Palm, 2021). 

Pharmacological treatment 

Zyprexa (Olanzapine): It is an atypical antipsychotic that is mostly used to manage patients with bipolar symptoms or schizophrenia. It is also used to manage patient who have had depression that is resistant to treatment. The dosage includes 10 mg per day given orally.  It is metabolized through the liver and would be interfered with if the liver is affected (Carlo et al., 2021).  

Buspirone: It is regarded as an antianxiety drug but also has got antidepressant effects. Its dosage is given as 45mg per day. However, the dosage may increase if combined with selective serotonin reuptake inhibitors or Tricyclic antidepressants especially among patient who have treatment-resistant depression. Its anxiolytic effects usually last for two to three weeks (Kopel, 2021).  

Any contraindications to use or alterations in dosing 

Monitor the patient closely since she is elderly and would be at a higher risk of having hyponatremia (Bickley et al., 2020). This is triggered by use of SSRIs especially among the elderly and other possible factors that need to be assessed include tumors, low body weight, smoking, central nervous system illness or any previous episodes of hyponatremia that the patient states.  

Check points 

A two-week follow up is necessary to rule out any drug interactions especially anti-depressant induced hyponatremia as well as stroke which may occur as a result of use of depression among patients with hypertension.  

References 

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins. 

Carlo, A. D., Basu, A., & Unützer, J. (2021). Associations of common depression treatment metrics with patient-centered outcomes. Medical Care, 59(7), 579-587. https://doi.org/10.1097/mlr.0000000000001540 

Hogan-Quigley, B., & Palm, M. L. (2021). Bates’ nursing guide to physical examination and history taking. Lippincott Williams & Wilkins. 

Kopel, J. (2021). Zyprexa. Encyclopedia of Autism Spectrum Disorders, 5256-5257. https://doi.org/10.1007/978-3-319-91280-6_102100 

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1 month ago  

Leilani Davis  

RE: Week 7 Discussion Peer Response #2  

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Hello Sandra,  

Thank you for your post.  I agree that compliance with antidepressant therapy is a barrier to effective treatment.  There are multiple factors behind lack of adherence to treatment of depression with insight into need for treatment being high on the list (Ho & Tangiisuran, 2017).  I also agree that it is essential to obtain an accurate assessment of the patients’ compliance with her current treatment.  If the patient is not currently compliant, it is important to assess factors related to non-compliance, including presence of bothersome side effects, lack of relief of symptoms, and lack of knowledge regarding treatment.  Adjusting the dose of current medication or making changes in current treatment regimen are dependent on these factors. 

Regarding the use of Zyprexa in the treatment of depression, I would like to provide some additional information.  Zyprexa is classified as an atypical antipsychotic medication and is used in the treatment of agitation associated with schizophrenia and/or mania associated with bipolar disorder (Thomas & Saadabadi, 2022).    It is also used as an adjunct therapy in the treatment of bipolar depression and in treatment resistant depression.  Side effects associated with Zyprexa include weight gain that may lead decreased insulin sensitivity which must be carefully considered in this case due to established obesity and uncontrolled diabetes in the patient (Thomas & Saadabadi, 2022).  There is also a black box warning for Zyprexa related to risk of dementia related psychosis and should not be used in the elderly who display symptoms associated with dementia (Thomas & Saadabadi, 2022).       

References 

Ho, S. C., Jacob, S. A., & Tangiisuran, B. (2017). Barriers and facilitators of adherence to antidepressants among outpatients with major depressive disorder: A qualitative study. PloS one, 12(6), e0179290. https://doi.org/10.1371/journal.pone.0179290 

Thomas K, Saadabadi A. Olanzapine. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532903/ 

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1 month ago  

Edwina Etienne  

RE: Week 7 Discussion  

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Hello Sandra 

Insomnia is a common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep (Simon & VonKorff , 2017). You may still feel tired when you wake up. Insomnia can sap not only your energy level and mood but also your health, work performance and quality of life. 

Everyone sleeping pattern is different. At some point, many adults experience short-term insomnia, which lasts for days or weeks. It’s usually the result of stress or a traumatic event. But some people have long-term insomnia that lasts for a month or more. Insomnia may be the primary problem, or it may be associated with other medical conditions or medications (Stern et al, 2015). 

According to McHorney et al., (2019), it is suggested to keep these activities to help your sleeping pattern. Educate the patient to keep their bedtime and wake time consistent from day to day, including weekends. Regular activity helps promote a good night’s sleep. Check your medications to see if they may contribute to insomnia. Avoid or limit caffeine and alcohol, and don’t use nicotine. Avoid large meals and beverages before bedtime. 

                                                                         

                                                                                                  References 

McHorney, C. A., Ware Jr, J. E., & Raczek, A. E. (2019). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical care, 247-263. 

Simon, G. E., & VonKorff, M. (2017). Prevalence, burden, and treatment of insomnia in primary care. American journal of psychiatry, 154(10), 1417-1423. 

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences. 

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Insomnia 

Question 1: Three Questions I Might Ask Her If She Came to My Office 

Q1. What time does she take to sleep? How frequently does she wake up at night, and for her to fall back asleep lasts how long? The aim of asking her this question will be to know the severity and the frequency of her insomnia because most people take a normal time of 10 to 20 minutes at night to fall asleep (Patel et al.,2018). Q2. What is the frequency of her trouble sleeping? What time does it take for the trouble to end? My aim in asking her this question is to know the nature of her sleep pattern and the duration from the moment it is present. Acute insomnia normally is related to a stress event and lasts for a few days. Q3. Are there any of the members of her family with problems sleeping? To rule out the generic cause, I will ask her this question.  

Question 2: People in The Life of The Patient That I May Require to Talk to  

These people include her children and the specific questions I would ask them to include at what time does she wake up? Does she experience difficulty in sleeping? And does she suffer frequent mid-sleep wakening? Another group of people I may require to talk to are her relatives, and the questions I would ask include Has she experienced feelings of depression, hopelessness, and down feeling in the past month? How frequently does she speak to them? And What is the frequency at which they meet? Finally, I would require them to speak to her friends, and the questions I would ask include, have they realized any disturbance of mood or dysfunction of cognitivism in the past month? What is the frequency at which she socializes? And has she been under little pressure or interest in doing things?  

Question 3: Appropriate Diagnostic Tests and Physical Exams That Would Be Utilized 

Physical exams are likely to assist in that finding and provide hints about underlying medical problems that may cause insomnia and also facilitates insomnia classification and the differential diagnosis. The examination is done carefully for the neck and the head. Sleep disturbance or insomnia will be revealed by the large neck size, cardiac disease or hypertension, low-lying soft palate, and enlarged tonsils (Riemann et al.,2017). The diagnostic tests that would be carried out on her include polysomnography utilized in diagnosing sleep disorders, including recording blood oxygen level, brain waves, leg and eye movements, and breathing and heart rate. Other diagnostic tests include the multiple sleep latency test and the actigraphy used for characterizing sleep disturbances. 

Question 4: The Patient’s Differential Diagnoses 

The patient’s differential diagnosis includes circadian rhythm disorder and sleeplessness, restless legs syndrome, obstructive sleep apnea, periodic limb movement disorder, and social isolation, loneliness, or depression (Buysse et al.,2017). Among these, depression or loneliness is the most likely for this patient’s case because of the grief that the death of her husband could cause. The husband’s loss is a distressing thing to her. Further, changes in her status and lifestyle accompanied by freedom of action, reductions in financial security, and perceived personal safety may cause insomnia. 

Question 5: Appropriate Two Agents of Pharmacology and Dosing to Her 

Tricyclic and SNRI antidepressants are the two pharmacologic agents appropriate for therapy in pharmacodynamics and pharmacokinetics. Since this patient is already on an SSRI (Zoloft 100mg daily), I would start her on Mirtazapine 7.5 mg at bedtime to establish efficacy and tolerance. I chose Mirtazapine due to its effectiveness as an adjunct to the Zoloft, providing its sedation and antidepressant effects. Another medication I would use is Doxepin 3 mg daily at bedtime, as it has been found to help elderly patients with insomnia (Stahl, 2022). I would consider the SNRI instead of the tricyclic agent in this case because, unlike the SSRI, the TCA is related to higher significant cardiovascular risk, especially for patients with a heart problem (Deng et al.,2017). Additionally, compared to SNRIs, TCA is highly lethal in that an overdose of TCA can result in hallucinations, respiratory depression, hypertension, and cardiac arrhythmias for about five days or so. 

Question 6: SSRIs May Be Contraindicated or Not Suitable in Case the Patient Has Conditions Including: 

Type 2 diabetes or type 1 diabetes is one of the contraindications of SSRI dosing because SSRIs worsen glycemic control for individuals with diabetes. On the other hand, hyperinsulinemia and hyperglycemia are induced by tricyclic antidepressants. Another contraindication is epilepsy, whereby SSRIs should be taken only when epilepsy is controlled well and stopped if it worsens (Wang et al.,2018). The issue with this drug use in other people depending on the ethical guidelines of prescription or making of the decision include while concurrently suffering from greater adverse effects, the Hispanics respond to TCAs with lower dosages. Additionally, Asians experience more other side effects and anticholinergic. At lower dosages of these medications, the Asians experience adverse events. 

Question 7: Check Points” (I.E., Follow-Up Data at Week 4, 8, 12, etc.), And Changes of Therapy That May Make Depending on Possible Results That May Occur Include 

The psychological well-being and the improved functional status of health would reduce the expected sleep-related impairment of sleep-related life quality. It would further improve daytime performance and personal functioning domain. Depending on the possible outcomes, the therapeutic changes may include reducing SSRI and other drug doses, CBT modification, and later hypnotic step-by-stepwise approach. 

 

 

 

References 

Buysse, D. J., Rush, A. J., & Reynolds, C. F. (2017). Clinical management of insomnia disorder. Jama, 318(20), 1973-1974. 

Deng, L., Sun, X., Qiu, S., Xiong, Y., Li, Y., Wang, L., … & Liu, M. (2017). Interventions for managing post-stroke depression: A Bayesian network meta-analysis of 23 randomized controlled trials. Scientific reports, 7(1), 1-12. 

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024. 

Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., … & Spiegelhalder, K. (2017). European guidelines for the diagnosis and treatment of insomnia. Journal of sleep research, 26(6), 675-700. 

Wang, S. M., Han, C., Bahk, W. M., Lee, S. J., Patkar, A. A., Masand, P. S., & Pae, C. U. (2018). Addressing the side effects of contemporary antidepressant drugs: a comprehensive review. Chonnam medical journal, 54(2), 101-112. 

Stahl, S. M., Grady, M. M., & Muntner, N. (2021). Stahl’s essential psychopharmacology: Prescriber’s Guide. Cambridge University Press.  

 

 

 

1 month ago  

Lymarie Vilella  

Case: An elderly widow who just lost her spouse.  

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Three questions to ask the patient and a rationale for asking these questions. 

  1. Who do you live with now?  

I would like to know if she lives by herself, or if she is having company during this time when she is feeling depressed and unable to sleep.  I would be concerned for her if she wakes up in the middle of the night due to Insomnia, is probably tired or confused, and falls.  In addition, if someone helps her monitor her medication and make sure that she is taking it correctly. 

  1. Could you tell me your medications, and how are you taking them?  

In this way, I will know if she really knows each medication, dosage, and frequency or if she is forgetting any of them.  Maybe she is not taking sertraline correctly or forgetting to take it and therefore she is feeling depressed again. 

  1. Are you having negative thoughts or suicidal ideation?    

It is important to know how severe her depression is and if she needs to be monitored 24 hrs in a mental health facility to prevent any event until the medication works. 

 

People in the patient’s life to speak to or get feedback from to further assess the patient 

I would like to know if she has any children, caregivers, or any support system that she usually goes to (such as a Pastor, church, friend, etc)  I would like to know her living situation, socio-economic status, if she does her ADLs or if she needs help, if she is having company during the day and at night, how many hours she is sleeping, if her house is safe for her (no cables or rugs on the floor), and if she normally does any activity that she is not doing anymore. 

 

 

Physical and diagnostic tests 

CBC, CMP, HGA1C, EKG, hepatic function panel, and Polysomnography. I will know her renal function (GFR), electrolytes, B12, if she has any QT interval or any heart dysrhythmia, thyroid function, etc. before I start any medication. According to Gerstenslager & Slowik (2021), stated “Polysomnography is a sleep study to diagnose any sleep disorder and in addition may be used to help initiate or adjust treatment plan”.  Psychiatrists frequently prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for torsade de pointes (Funk ET al., 2018). 

 

Differential diagnoses for the patient 

1) Major depressive disorder (MDD) 

2) Sleep Apnea 

3) DM 

My first differential is MDD- according to Otte et al., (2016) “MDD is a debilitating disease that is characterized by depressed mood, diminished interests, impaired cognitive function, and vegetative symptoms, such as disturbed sleep and appetite. Occurs about twice as often in women than it does in men”. 

Pharmacologic agents and their dosing 

Trazodone- FDA approved for depression and insomnia.  I will use this medication for an add augmentation with Sertraline 100 mg.  I will start low and slow 25 mg first 2 -4 weeks, especially for her age.  This medication is metabolized CYP450, half-life.  The first phase is approximately 3-6 hours and the second phase is approximately 5-9 hours.  Blocks serotonin 2 A receptors potently, blocks serotonin reuptake pump.  Onset therapeutic actions in Insomnia are immediate if dosing is correct.  The onset of therapeutic actions in depression is usually not immediate, often delayed 2-4 weeks whether given as an adjunct to another anti-depressant or as a monotherapy (Stahl, 2017).   

            Lunesta- metabolized by CYP 450 3A4 and 2E1, terminal elimination half-life approximately 6 hours, heavy high fat meal slow absorption, which could reduce the effect on sleep latency.  FDA approved for insomnia.  May bind selectively, a subtype of the benzodiazepine receptor.  May enhance GABA inhibitory actions that provide sedative-hypnotic effects more selectively than other actions of GABA.  Inhibitory actions in sleep centers may provide sedative-hypnotic effects and generally takes less than an hour (Stahl, 2017).   

Drug therapy contraindications 

One of the contradictions of using Trazodone– Do not take it with MAOI, caution for patients with a history of seizures, and reports of increased and decreased prothrombin time in patients taking warfarin (Stahl, 2017).   

 

Checkpoints 

            Initial dosage 25-50 for 4 weeks.  If the symptoms are not improved, then I will increase the dosage as usually tolerated by 50-100 mg/day, but some patients may require up to the full antidepressant dose range.  However, I prefer to go low and slow due to her age (Stahl, 2017).   

 

 

 

References 

 

 

Funk, M. C.., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018).  Resources Document on QTc prolongation and psychotropic medications.  American Psychiatric Association.  https://content.waldenu.edu/content/dam/laureate/laureate-academics/wal/ms-nurs/nurs-6630/week-07/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf 

 

Gerstenslager B, Slowik JM. Sleep Study. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563147/ 

Stahl S. (2017).  Essential psychopharmacology prescribers guide. (6th eds).  Cambridge, United Kingdom.  

 

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1 month ago  

Maribel Morfi Caso  

RE: Case: An elderly widow who just lost her spouse.  

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Hello Vilella,  

Thank you for sharing your ideas on the discussion. First, your opinion of wanting to know who the patient lives with is excellent. This defines the patient’s safety while at home. If the patient lives by themselves, then the practitioner knows their safety might be at risk. Additionally, psychiatric mental health nurses must be alert to the possibility that an unsociable, depressed, or otherwise problematic patient is suffering from a mental disorder. Nursing care for a patient with mental illness may necessitate the use of the following tactics: Provide sensitive, patient-centered treatment by determining the mental health of your patients and maintaining open lines of communication and a personal connection with them. 

References 

Pusey, H., & Keady, J. (2017). Services for older people with mental health problems. Psychiatric and mental health nursing, 715-724. https://doi.org/10.1201/9781315381879-64 

 

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1 month ago  

Catherine Murad  

RE: Case: An elderly widow who just lost her spouse.  

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Good morning Lymarie, 

 

Great presentation. I’ve discovered an article on Trazodone that I would like to bring to your attention so that you may consider while prescribing Trazodone. Trazodone is indeed a second-generation atypical antidepressant with a specific inhibitory effect on serotonin transport. Thus, Trazodone is particularly effective in the treatment of depression, anxiety, and sleeplessness. (Drugs & Medications. n.d.). The majority of Trazodone adverse effects come with long-term usage at a daily dose of 150-200 mg. Furthermore, long-term Trazodone usage may result in parkinsonian symptoms. Greenhouse Treatment. (n.d.).  According to this study, acute extrapyramidal symptoms were reported when patients were given a modest dosage of 100mg of Trazodone, and sudden change in mental state with increased sleepiness and significant spasticity with cogwheel rigidity of the upper limbs were noted. (Sotto. M. et al., 2015). 

Catherine. M.  

References: 

Drugs & Medications. (n.d.). Www.webmd.com. https://www.webmd.com/drugs/2/drug-11188/trazodone-oral/details 

Sotto. M. et al., (2015). Trazodone in the elderly: risk of extrapyramidal acute events. BMJ case reports, 2015, bcr2015210726. https://doi.org/10.1136/bcr-2015-210726 

Greenhouse Treatment. (n.d.). Trazodone: Side Effects, Withdrawal & Long Term. https://greenhousetreatment.com/trazodone/long-term-effects/ 

 

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1 month ago  

Yvette Kamayou  

Peer Response #2  

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Hello Lymarie,  

Finding out about the patient’s compliance with her antidepressant drug would be very crucial. Non-compliance refers to the failure of a patient to take medication as per the directions given by a healthcare professional. Essentially, non-compliance is the biggest challenge in achieving the required outcome, especially for patients with psychiatric disorders. Besides, it is among the common causes of rebound symptoms and treatment failure. According to a study carried out by Tini et al. (2022), sertraline is among the antidepressants associated with non-compliance. The main reason behind non-compliance with Sertraline is the burden of the side effects. For this reason, the patient should be for the side effects of the drug, and adjustments are made if possible. Conversely, sertraline is FDA-approved as the first-line drug for the management of the major depressive disorder. According to Singh & Saadabadi (2021), sertraline is a serotonergic drug and sudden discontinuation may cause adverse reactions such as anxiety, sleep disorder, dysphoric mood, emotional liability, seizures, tremors, and diaphoresis among others. For this reason, it tapering of the dosage is recommended.   

 

References 

Singh, D., & Saadabadi, A. (2021). Venlafaxine. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK547689/  

Tini, E., Smigielski, L., Romanos, M., Wewetzer, C., Karwautz, A., Reitzle, K., … & Walitza, S. (2022). Therapeutic drug monitoring of sertraline in children and adolescents: A naturalistic study with insights into the clinical response and treatment of the obsessive-compulsive disorder. Comprehensive Psychiatry, 115, 152301. https://doi.org/10.1016/j.comppsych.2022.152301 

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shynetra jackson  

Discussion  

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Case: An elderly widow who just lost her spouse.  

 

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:  

 

  • Metformin 500mg BID   
  • Januvia 100mg daily   
  • Losartan 100mg daily   
  • HCTZ 25mg daily   
  • Sertraline 100mg daily   

 Current weight: 88 kg 

Current height: 64 inches 

Temp: 98.6 degrees F 

BP: 132/86  

 

According to the case study the patient did not have any prior history of depression but now she is currently being treated for depression, so my first question would be: 

  • How long have you been having insomnia?  
  • When did you get diagnose with depression?  
  • When did you start taking the Zoloft, the does have been taking and have your dose been recently changed?  

 

 I would ask these questions because sometimes medications can cause problems, for instance Zoloft can cause a patient to have trouble sleeping. I would also inquire about the patient living situation, for example; do the patient live alone, with family or in an ALF or long-term facility. 

 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  

 

I would ask for permission to request the patient medical record from the PCP and medical record from the provider who prescribed the Zoloft medication, I would request these records to get a better understanding of when and why the patient started this medication, it will also tell me if the patient dose of medication has recently changed. The records will also give me a baseline of the patient which will gives me pertinent information to help guide my treatment plan for the patient. The medical records will tell me if the patient had any type diagnostic exams that would be beneficial in adding with the patient treatment. For instance, any recent labs, images etc.  I would check to see if the patient has children or a caregiver that have more information as it relates to the patient medical wellbeing. 

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  

A complete work up of labs would be appropriate due to the patient being elderly, their bodies react differently to medication. The labs could show if the patient electrolytes are abnormal which could possible cause insomnia, for example if the potassium is low is can cause insomnia. A complete ROS is needed as well to ensure that nothing is missed during the assessment. I would also recommend a psych evaluation for the patient.  

 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

 

Subsyndromal depression, which can leaded to major depression if left untreated. This type of depression is seen in elderly which could be brought on due to death of a friends or family, chronic medical illness, facing mortality, isolation, or widowhood, just to name a few. These causes can put the patient at risk for thoughts of suicide, sleep problems, lack of concentration, fatigue and sadness.    

 

UTI- Sometimes with older adults they can have a UTI but have different signs and symptoms from the common one. For instance, common signs and symptoms in non-elderly maybe; burning when urinating, frequent urination, dark colored urine with an odor, abdominal cramps but with elderlies and UTIs, they can present with any type of symptoms that’s why it’s very important to check the patient urine regardless of the presenting symptoms.  

 

Polypharmacy- Polypharmacy is more common among older adults. Aging places individuals at risk of multi-morbidity (coexistence of 2 or more chronic health conditions) due to associated physiological and pathological changes and increases the chances of being prescribed multiple medications (Von Buedingen et al., 2018). 

 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.  

 

Late-life depression is one of the most common psychiatric disorder in the elderly population, affecting up to 30% of those 65 years and older and it has been associated with increased morbidity and mortality (Horackova K. et al., 2019). As it relates to medication for this patient, selective reuptake inhibitors (SSRIs) are the first choice of treatment for depression in elderly patients because they are said to be less sedating than Tricyclic antidepressants (TCA, TCAs can have an effect on the heart so they are not recommended for the elderly. 

 

Zoloft 50mg PO 1 time a day, this medication works by enhancing serotonin in the brain. I chose this medication over celexa due to fact that celexa is not recommended for elderly according to research because the adjustment in the dose is not possible with the available dose strength of this particular medication. Coupland et al., 2011, have previously reported the risk of adverse effects secondary to the use of antidepressants in the elderly. 

 

When it comes to prescribing medications to an elderly patient, the provider must be competent about what medication he or she is prescribing as some medication may work different on different people especially the elderly. For instance, in elderly their metabolism slows down which can cause the medication to take a long time to process through the body, another issue is their kidneys are not as active as a younger person therefore all the medication that Is not used by body will saying within the body and can continue to add up which interims causes an overdose for the patient because the kidneys are not excreting the excess. The provider must be aware of the patient current medication and understand if there are any contraindications. The provider must also me aware and willing listen to the patient when they give their way of treatment especially if its related to culture. The provider must also think about what other vitamins or medication the patient maybe taking already 

 

I would follow back up with patient in 4 to 6 weeks to see if there has been any improvement and then I would make my recommendation based on what the patient says. 

 

 

 

 

References 

 

  1. Coupland, P. Dhiman, R. Morriss, A. Arthur, G. Barton, and J. Hippisley-Cox, “Antidepressant use and risk of adverse outcomes in older people: population based cohort study,” BMJ, vol. 343, no. 2, p. d4551, 2011

 

 

Horackova K, Kopecek M, Machů V, Kagstrom A, Aarsland D, Motlova LB, Cermakova P. Prevalence of late-life depression and gap in mental health service use across European regions. Eur Psychiatry. 2019;57:19–25. 

 

 

von Buedingen F, Hammer MS, Meid AD, Müller WE, Gerlach FM, Muth C. Changes in prescribed medicines in older patients with multimorbidity and polypharmacy in general practice. BMC Fam Pract. 2018 Jul 28;19(1):131. 

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1 month ago  

Amancia Normil  

RE: Discussion  

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Reply to Shyntera 

I agree with your assessment of how important elderly people and their treatment is within long-term psychiatric care. Because of the high incidence of mental illness after the age of 65, it is important to manage the use of medication as well as psychotherapy. I agree with you that depression can be initially treated with ssris with this age group (Horackova et al., 2019). 

Since tricyclic antidepressants may have more force and more sedative effects, it is better to refrain from those at first. I also agreed with your use of Zoloft because of its use in brain chemistry regulation and stability. I think adjusting the dose as you suggested will be contingent on ongoing side effects. 

Hey slowing or aging metabolism can be of significant distress because of the limited effects that can be seen through continual prescription. The appearance of adverse outcomes as well as the severity of Christine symptoms are two factors  that must be carefully maintained (Coupland et al., 2011). 

You did touch on how the continual long-term management requires complementary systems and treatment mechanisms. In this light I further think that psychotherapy could substantially improve this patient’s lifestyle because of their ongoing problems and the limited social circle that is presently available. 

References 

  1. Coupland, P. Dhiman, R. Morriss, A. Arthur, G. Barton, and J. Hippisley-Cox, “Antidepressant use and risk of adverse outcomes in older people: population based cohort study,” BMJ, vol. 343, no. 2, p. d4551, 2011

Horackova K, Kopecek M, Machů V, Kagstrom A, Aarsland D, Motlova LB, Cermakova P. Prevalence of late-life depression and gap in mental health service use across European regions. Eur Psychiatry. 2019;57:19–25. 

von Buedingen F, Hammer MS, Meid AD, Müller WE, Gerlach FM, Muth C. Changes in prescribed medicines in older patients with multimorbidity and polypharmacy in general practice. BMC Fam Pract. 2018 Jul 28;19(1):131. 

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1 month ago  

Edwina Etienne  

RE: Discussion  

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Hello Synetra, 

 

I agree with your assessment of how important to detect the elderly clients with depression and people and their treatment.  

Since the patient is in her 70’s it is important I would get a CBC and a BMP to check for any abnormal labs and for baseline values. I would also draw endocrine related labs. For example, cortisol, adrenocorticotropic hormone, melatonin, noradrenaline, γ-Aminobutyric acid, and calcium (Stern et al, 2015). 

I will use the results of these labs to determine if the patient has ann older people, depression often goes along with other medical illnesses and disabilities and lasts longer. Depression in older adults is tied to a higher risk of cardiac diseases and of death from illness. At the same time, depression reduces an older person’s ability to (Simon, 2017). 

                                                References 

McHorney, C. A., Ware Jr, J. E., & Raczek, A. E. (2019). The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical care, 247-263. 

Simon, G. E., & VonKorff, M. (2017). Prevalence, burden, and treatment of insomnia in primary care. American journal of psychiatry, 154(10), 1417-1423. 

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2015). Massachusetts General hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences. 

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Week 7 Discussion  

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Week 7 Discussion/Main Post 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.  

  1. I would formally ask the patient about the start of using Sertraline, any adjustment to the dose, and if the dose affects her. By asking her this, I can determine whether increasing the current medication would be effective.    
  1. I would ask the patient if she follows the medication as authorized by the practitioner. By this, I will be able to establish the next step of treatment.  
  1. I would ask the patient about her activities before going to bed. By asking this, I can plot effective suggestions on recommendable exercises that may help reduce her anxiety.   

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  

            Depending on the medical history provided, I would first like to understand why the patient arrived at the hospital in a private car. The fact that she arrived in the hospital alone makes me doubt whether she lives alone or has settled in a hotel facility. I would also like to know whether she has children, family friend, or guardian to take care of her. If any exists, I would question them about the Patient’s living situation, socioeconomic status, and social life. According to Moscrop et al. (2019), living situation, socioeconomic status, and social life are additional factors essential in determining a patient’s health conditions. I would also ask about her sleeping habits, whether she takes a nap during the day, and what she does before and after bed.  

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  

            According to her medical history, the patient only visits PCP once or twice a year. Thus, it would be appropriate to assume that the patient has visited the facility for the first time. Thus, I would use this opportunity to gather thorough health information about the patient, including her medical, demographics, social, and family history. Second I would conduct a physical and mental health test. I would use an HGBA1C to examine her glycemic control. I would look into the patient’s use of HCTZ because her frequent urination while taking it could be contributing to her insomnia and uncontrolled diabetes. Notably, unmonitored use of HCTZ can lead to uncontrolled levels of diabetes (Orrange, 2018). From the evaluation, effective adjustments can be made to regulate the administration of HCTZ.   

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.  

I would decide to keep the patient on her current Sertraline 100 mg and boost it with another medication. I decided against adding another SSRI as it may intensify or result in adverse effects on the patient. 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.  

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making? Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.  

            The patient’s history indicates that she is currently taking Sertraline for her major depressive disorder. However, the patient reports that her depression has increased since the death of her husband 10 months ago. The increased symptoms of depression affect her sleeping habits. As a psychiatric nurse practitioner, I recommend changing her current therapy and boosting her medication with second-line treatment. As mentioned earlier, I would advocate for the continuous use of Sertraline 100mg. However, I would augment the treatment using Benzodiazepines. Benzodiazepines are considered effective in treating anxiety disorders and making it easier for the patient to sleep (Tibrewal et al., 2021). Particularly, Benzodiazepines improve patients’ outcomes from a major depressive disorder. Also, Benzodiazepines are beneficial as they increase the treatment’s overall speed (Bhatt, 2019).  

            I would use Alprazolam (Xanax) as a type of Benzodiazepine. The patient is to start with a small dose of 0.25mg TID. Also, I would set a 4-week follow-up appointment to evaluate her progress. Alprazolam has a quick onset of action and is the ideal drug for anxiety and insomnia (George & Tripp, 2021). The patient will be educated on a diet. Specifically, she will be educated on her intake of grapefruit and alcohol as they affect the proper functioning of the drug (Palaniappan, 2022).  

References 

Bhatt, N. V. (2019, March 27). What is the role of benzodiazepines in the treatment of anxiety disorders? Medscape. Retrieved July 12, 2022, from https://www.medscape.com/answers/286227-14594/what-is-the-role-of-benzodiazepines-in-the-treatment-of-anxiety-disorders 

George, T. T., & Tripp, J. (2021). Alprazolam. StatPearls Publishing LLC. https://www.ncbi.nlm.nih.gov/books/NBK538165/#_NBK538165_pubdet_ 

Moscrop, A., Ziebland, S., Roberts, N., & Papanikitas, A. (2019). A systematic review of reasons for and against asking patients about their socioeconomic contexts. International Journal for Equity in Health, 18(1), 1-15. https://doi.org/10.1186/s12939-019-1014-2 

Orrange, S. (2018, December 8). High Blood Sugar? It Could Be a Side Effect of These Medications. GoodRx Health. Retrieved July 12, 2022, from https://www.goodrx.com/drugs/side-effects/high-blood-sugar-medication-side-effect 

Palaniappan, M. (2022). Alprazolam interaction with food, herbs and alcohol. Medindia. Retrieved July 12, 2022, from https://www.medindia.net/drugs/drug-food-interactions/alprazolam.htm 

Tibrewal, P., Looi, J. C., & Bastiampillai, T. (2021). Benzodiazepines for the long-term treatment of anxiety disorders? The Lancet Journal, 398(10295), 119-120. https://doi.org/10.1016/S0140-6736(21)00934-X 

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1 month ago  

Rose Butler  

RE: Week 7 Discussion: Response 1  

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Greetings, Aleksander, 

Congratulations on sharing your informative posts on this week’s discussion. I have been pleased with how you organized your work as it can be easily understood. In addition to the identified question, the patient should be asked to describe her sleeping pattern. The question helps in understanding the number of hours the patient sleeps. While assessing the time when the medication was started, it is important to evaluate her level of compliance with the drugs. In addition to the identified individuals having a relationship with the patient, her primary care provider should be questioned. The evaluation helps in understanding the patient’s disease management process. In addition to the medical diagnostic test, the patient must undergo psychiatric and mental health conditions. Diagnostic scales for depression, anxiety, and sleep quality should be administered to the patient. 

The differential diagnosis for the patient can be generalized anxiety disorder and depression. Depression is the most likely diagnosis. I agree with you that the patient should be continued on sertraline 100 mg following the depression (Liu et al., 2021). To help relieve insomnia, the patient can be started on a medication such as trazodone. Trazodone is associated with minimal side effects and improves patient insomnia (Wang et al., 2020). 

References 

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on Sleep Quality and Cognitive Function in Arteriosclerotic Cerebral Small Vessel Disease Comorbid With Chronic Insomnia. Frontiers in Psychiatry, 11. https://doi.org/10.3389/fpsyt.2020.00620 

Liu, W., Li, G., Wang, C., Wang, X., & Yang, L. (2021). Efficacy of sertraline combined with cognitive behavioral therapy for adolescent depression: a systematic review and meta-analysis. Computational and Mathematical Methods in Medicine, 2021. 

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1 month ago  

Sandra Fernandez Arias  

RE: Week 7 Discussion  

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Hello Milian, 

Your post is interesting and educating. Anxiety is a condition that can affect an individual’s capability to work, study and take part in other interests. However, recovery is achievable with the right treatment. Therefore, it is imperative for the healthcare provider to determine if the patient is consistent with the medication. A patient who is following a medication regimen is more likely to manage anxiety symptoms better and improve his/her emotional wellbeing. Secondly, a patient’s preparedness to take medication signifies confidence in the whole treatment process and the development of skills needed in recovery. On the other hand, poor medication adherence will compromise the patient result. When a patient is non-compliant, the provider should investigate factors influencing adherence such as medication cost, side effects, frequency of dosing, and the patient’s beliefs then educate and counsel the patient accordingly. A patient will probably shirk taking medication he/she thinks to be ineffective, or one with complex dosage requirements. 

References 

National Library of Medicine (2011). Medication Adherence: WHO cares? Retrieved July 16, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3068890 

National Library of Medicine (2013). The influence of symptoms of anxiety and depression on medication nonadherence and its causes: a population-based survey of prescription drug users in Sweden Retrieved July 16, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3751505/ 

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1 month ago  

Marianela Chinea  

RE: Week 7 Discussion  

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Hello Alexander, 

Reading your post, really opened my eyes to interventions I’d yet to think about. I really appreciate your post. In adding to what you’ve already mentioned. When faced with insomnia as well as addition co-morbidities as this week’s client face, the practitioner should always be cautions of symptoms, especially symptoms that are now chief complaints that are known to be exaggerated by certain disease process. The less you sleep, the higher your blood pressure may go. People who sleep six hours or less may have steeper increases in blood pressure. If you already have high blood pressure, not sleeping well may make your blood pressure worse (Lopez-Jimenez, 2021, para. 2). 

        Insomnia is a prevalent sleep disorder that is associated with a multitude of health consequences. Insomnia has also been associated with cardiovascular disease and its precursors, such as hypertension and blood pressure non-dipping (Jarrin et al., 2018). For this client, assessing for compliancy with care for her other comorbidities are important. 

References 

Jarrin, D. C., Alvaro, P. K., Bouchard, M.-A., Jarrin, S. D., Drake, C. L., & Morin, C. M. (2018). Insomnia and hypertension: A systematic review. Sleep Medicine Reviews, 41, 3–38. https://doi.org/10.1016/j.smrv.2018.02.003 

Lopez-Jimenez, F. (2021, January 6). Sleep deprivation: A cause of high blood pressure? Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/high-blood-pressure/expert-answers/sleep-deprivation/faq-20057959 

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Keyana Hobdy  

Week 7 Discussion  

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Discussion Post Week 7 

For this discussion, a patient presents to your primary care office today with chief complaints of insomnia. Patient is a 75 y/o with PMH of DM, HTN and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideation. Patient arrived at the office today by private vehicle. 

Questions for Patient 

  1. Have you been taking your daily medications as directed? The patient is noted to be on Zoloft along with other medications for HTN and DM. Sertraline is medication is and antidepressant used as a first-line treatment of major depressive disorder. (Singh & Saadabadi, 2022) Before we try to distinguish if the medication is working, we must first have a direct conversation with the patient to ensure that the patient is adhering to the medication as directed.  
  1. Prior to your spouse’s death, have you ever suffered from anxiety or depression? The provider must first establish if the patient is still in the stages of grief, or if the patient is experiencing true MDD. While assessing the elderly patient for depression, it is important to remember that elderly patients often under-report their depressive symptoms and they may not acknowledge being sad, down, or depressed. (Avasthi & Grover, 2018) if the patient has been adhering to the medication, and the medication is found not to be effective, this could indicate that the patient is still experiencing grief.  
  1. Can you tell me about your bedtime routine? It is important that if the patient does not already have a bedtime routine that one gets established to help the patient achieve the best outcomes. Sleep disorders are among the most common disorders of aging; however, they are often overlooked by both clinicians and researchers as mere symptoms of other “primary” disorders. (Dzierzewski & Dautovich, 2018)  

                                Questions for the family/friends of the patient 

  1. Although the case description does not state whether the patient has family, I would want to inquire to the patient’s family or caregivers about her daily routine. Does the patient perform her daily routines? How is the patient eating? Has the patient been more withdrawn recently? Have they noticed any changes in the patient’s behavior? Symptoms of depression may be different or less obvious in older adults, such as memory difficulties, personality changes, physical aches or pains, fatigue or loss of appetite and often wanting to stay home instead of socializing. Suicidal thinking or feelings could also be present. (Depression (Major Depressive Disorder) – Symptoms and Causes – Mayo Clinic, n.d.)  
  1. Does the patient attend church? Does the patient have a social routine? Has she been attending these functions? The provider needs to understand the type of life both before the patient lost her husband, and after she lost her husband to gauge what the psychosocial needs may be for this patient. Psychosocial support should be allocated to individuals at higher DL stages because of their greater mental health needs. (Na & Streim, 2017)  Lack of a social network can have an impact on the patient’s physical health.  

                                                  Diagnostic Testing 

I would begin with a Head-to-toe assessment of the patient while in my office. Upon completion of that, I would administer the Geriatric Depression Scale 15 (GDS-15) at this time. The 15-item GDS is a short form of the GDS and is used to screen, diagnose, and evaluate depression in elderly individuals. (Shin et al., 2019) This would help to determine where the patient is in terms of her depression. I would also consider drawing some lab work such as a CBC w/diff, and a BMP to rule out any infection. Because the patient is a diabetic, I would also want to draw a Hemoglobin A1C to ensure that the patient’s blood glucose is within normal limits, and this will also help to see if the patient is adhering to her medications. An MRI may be warranted based on the patient’s head to toe assessment, and the answers received from family and caregivers of the patient. This would only be necessary if there were to be notable changes in the patient’s moods, mannerisms, or memory. 

                                                Differential Diagnosis 

  1. Major Depressive Disorder MDD is medical condition that includes abnormalities of affect and mood, neurovegetative functions, (such as appetite and sleep disturbances), cognition, (such as inappropriate guilt and feelings of worthlessness), and psychomotor activity (such as agitation or retardation). (Fava & Kendler, 2000)  
  1. Insomnia Sleep onset or initial insomnia is manifested by difficulty falling asleep that occurs at the start of the sleep period. (Brewster et al., 2018) If the patient is having trouble sleeping, I would encourage and teach the patient the importance of a bedtime routine or ritual to prepare the patient for bed and to encourage a healthy sleep routine.  

                                         Treatment Recommendation 

 

After carefully reviewing all the information provided at this visit, at this time my treatment recommendation would consist of beginning the patient on a bedtime routine and consider changing the medication to Trazadone. Trazadone is an established medication that is efficacious for the treatment of a broad array of depressive symptoms, including symptoms that are less likely r respond to other antidepressants (e.g. SSRI) such as insomnia. (Cuomo et al., 20190701) by changing the medication, it would allow the patient to be treated for both the depression and the insomnia and would offer the patient a better patient outcome than that which was previously achieved by the Sertraline. 

                                           Ethical Considerations 

 Ethically, we would want to ensure that this patient has no previous history of suicidal ideation, and we would want to rule out the potential of any dementia to ensure that the patent would be able to achieve the desired effects of the new SSRI. We would also want to consider that in the elderly patient, hyponatremia can be a side effect in the patient being treated with an SSRI. Hyponatremia is an electrolyte disorder that can be caused by multiple factors, among which the syndrome of inappropriate antidiuretic home secretion is one of the most frequent causes. This effect was more significant in elderly patients. (Mazzoglio y Nabar et al., 2022) 

                                            Check Points 

 I would want the patient to return to the office in 4 weeks so we can re-evaluate how she is doing upon starting the Trazadone. I would want to draw a Na level at that visit as well to check for hyponatremia. If the symptoms have improved and the patient’s sodium level remained stable, then I would make no changes. If the medication was found to not be effective, at this check point, I would consider this being treatment resistant depression and would consider both CBT and alternative treatment. 

 

References 

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian Journal of Psychiatry, 60(7), 341. https://doi.org/10.4103/0019-5545.224474 

Brewster, G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the older adult. Sleep Medicine Clinics, 13(1), 13–19. https://doi.org/10.1016/j.jsmc.2017.09.002 

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (20190701). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria. https://doi.org/10.1708/3202.31796 

Depression (major depressive disorder) – symptoms and causes – mayo clinic. (n.d.). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007 

Dzierzewski, J. M., & Dautovich, N. D. (2018). Who cares about sleep in older adults? Clinical Gerontologist, 41(2), 109–112. https://doi.org/10.1080/07317115.2017.1421870 

Fava, M., & Kendler, K. S. (2000). Major depressive disorder. Neuron, 28(2), 335–341. https://doi.org/10.1016/s0896-6273(00)00112-4 

Mazzoglio y Nabar, M. J., Muniz, M. M., Montivero, C. A., Schraier, G., & Leidi Terren, E. E. (2022). Hyponatremia secondary treatment with ssri antidepressants in adults and elderly. CNS Spectrums, 27(2), 243–244. https://doi.org/10.1017/s1092852922000505 

Na, L., & Streim, J. E. (2017). Psychosocial well-being associated with activity of daily living stages among community-dwelling older adults. Gerontology and Geriatric Medicine, 3, 233372141770001. https://doi.org/10.1177/2333721417700011 

Shin, C., Park, M., Lee, S.-H., Ko, Y.-H., Kim, Y.-K., Han, K.-M., Jeong, H.-G., & Han, C. (2019). Usefulness of the 15-item geriatric depression scale (gds-15) for classifying minor and major depressive disorders among community-dwelling elders. Journal of Affective Disorders, 259, 370–375. https://doi.org/10.1016/j.jad.2019.08.053 

Singh, H., & Saadabadi, A. (2022). Sertraline. StatPearls. 

 

 

 

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Hope OKOROIGWE  

RE: Week 7 Discussion  

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Hi Keyana, 

Thanks for your interesting post, particularly the differential diagnosis you provided for insomnia. Insomnia is a sleep disorder. It makes it hard to sleep and function during the day. Insomnia affects about ten percent of the population and is usually associated with other mental or physical issues (Szelenberger, & Soldatos, 2018). For it to be called insomnia, the person must have difficulty sleeping even when there are numerous opportunities to sleep. Chronic insomnia is diagnosed when the symptoms appear at least three times per week for at minimum three months. However, there is short term insomnia, which is also known as intermittent or episodic insomnia and it has the same criteria of chronic insomnia, but it must last for less than three months. 

I was inspired by the way in which you posed the assessment questions to the patient and her support system. The questions you asked the patient were important in determining medication adherence, changes in sleeping patterns, and possible depressive symptoms following her husband’s death. Additionally, choosing to interview her family and the caregivers would aid in identifying behavioral and medication compliance changes as determined by her support system. I also agree with your selection of diagnostic tests and physical exams. The Geriatric Depression Scale and Sleep Study tests have been used to diagnose patients with symptoms similar to this patient in both inpatient and outpatient settings (Schenck, Mahowald, & Sack, 2019). 

 

References: 

Szelenberger, W., & Soldatos, C. (2018). Sleep disorders in psychiatric practice. World 

psychiatry: official journal of the World Psychiatric Association (WPA), 4(3), 186–190. 

Schenck, C. H., Mahowald, M. W., & Sack, R. L. (2019). Assessment and management of 

insomnia. JAMA, 289(19), 2475–2479. https://doi.org/10.1001/jama.289.19.2475 

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Amancia Normil  

RE: Week 7 Discussion  

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Reply to keyana 

Trazodone is a helpful treatment option as it is versatile and can be used to address multiple types of depression. It is also faster to respond and it will create better initial results when treating patients with comorbidities (Avasthi & Grover, 2018). 

As you mention, treating insomnia is just as important as depression in this case. Interruptions to The sleep cycle are difficult to overcome when handling multiple mental and physical health concerns. This is something that is noticeable both when handling elderly patients and those of average age (Brewster et al., 2018). Ultimately the use of different treatment options is effective only when handling the severity of symptoms and the overall scope of patient management (Cuomo et al.,2019). 

Another important component is the efficacy of depression treatment in the scope of mental health. Since this patient has fewer people that she depends on emotionally it can be challenging for her and Son alone to handle all the consequences of insomnia. Breaking the cycle of having two or more conditions as well as a limited set of outlets to engage with others are factors that will ultimately precipitate greater levels of depression or anxiety. It would be important to channel this elderly person’s interests and available time into straightforward and steadfast strategies that provide an outlet within the constraints of available time. Some of the ways to do this could be with talk therapy either with a social worker or a therapist. Feeling the patient out or feeling the family members out regarding the success of this would be important for further treatment to continue. 

References 

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian Journal of Psychiatry, 60(7), 341. https://doi.org/10.4103/0019-5545.224474 

Brewster, G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the older adult. Sleep Medicine Clinics, 13(1), 13–19. https://doi.org/10.1016/j.jsmc.2017.09.002 

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (20190701). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria. https://doi.org/10.1708/3202.31796 

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Sandra Fernandez Arias  

RE: Week 7 Discussion  

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Hello Keyana, 

Excellent post on week seven post! I enjoyed reading your post, and I agree with your differential diagnosis. Your post influenced my understanding of the concept. You helped to learn that arterial blood gas is an important test to perform for the patient. 

Insomnia poses significant challenges to public health (Krystal et al., 2019). Insomnia is a common condition that affects about 10% of the population. Insomnia remains one of the most common sleep disorders encountered in the geriatric population (Patel et al., 2018). Many times, insomnia co-occurs with psychiatric or physical conditions. Insomnia is a risk factor for major depression, anxiety disorders, substance use disorders, suicidality, hypertension, and diabetes (Krystal et al., 2019). Insomnia is associated with significant distress or impairment in functioning and daytime symptoms, including fatigue, daytime sleepiness, impairment in cognitive performance, and mood disturbances (Levenson et al., 2015). Insomnia is differentiated from sleep deprivation by difficulty sleeping despite having adequate opportunity to sleep; for example, I suffer from sleep deprivation because I work at night and do not have the time to sleep. Insomnia can also be evaluated by detailed history and thorough physical examination (Patel et al., 2018). 

References 

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: An update. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674 

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617 

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Keyana Hobdy  

Week 7 Discussion  

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Discussion Post Week 7 

For this discussion, a patient presents to your primary care office today with chief complaints of insomnia. Patient is a 75 y/o with PMH of DM, HTN and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideation. Patient arrived at the office today by private vehicle. 

Questions for Patient 

  1. Have you been taking your daily medications as directed? The patient is noted to be on Zoloft along with other medications for HTN and DM. Sertraline is medication is and antidepressant used as a first-line treatment of major depressive disorder. (Singh & Saadabadi, 2022) Before we try to distinguish if the medication is working, we must first have a direct conversation with the patient to ensure that the patient is adhering to the medication as directed.  
  1. Prior to your spouse’s death, have you ever suffered from anxiety or depression? The provider must first establish if the patient is still in the stages of grief, or if the patient is experiencing true MDD. While assessing the elderly patient for depression, it is important to remember that elderly patients often under-report their depressive symptoms and they may not acknowledge being sad, down, or depressed. (Avasthi & Grover, 2018) if the patient has been adhering to the medication, and the medication is found not to be effective, this could indicate that the patient is still experiencing grief.  
  1. Can you tell me about your bedtime routine? It is important that if the patient does not already have a bedtime routine that one gets established to help the patient achieve the best outcomes. Sleep disorders are among the most common disorders of aging; however, they are often overlooked by both clinicians and researchers as mere symptoms of other “primary” disorders. (Dzierzewski & Dautovich, 2018)  

                                Questions for the family/friends of the patient 

  1. Although the case description does not state whether the patient has family, I would want to inquire to the patient’s family or caregivers about her daily routine. Does the patient perform her daily routines? How is the patient eating? Has the patient been more withdrawn recently? Have they noticed any changes in the patient’s behavior? Symptoms of depression may be different or less obvious in older adults, such as memory difficulties, personality changes, physical aches or pains, fatigue or loss of appetite and often wanting to stay home instead of socializing. Suicidal thinking or feelings could also be present. (Depression (Major Depressive Disorder) – Symptoms and Causes – Mayo Clinic, n.d.)  
  1. Does the patient attend church? Does the patient have a social routine? Has she been attending these functions? The provider needs to understand the type of life both before the patient lost her husband, and after she lost her husband to gauge what the psychosocial needs may be for this patient. Psychosocial support should be allocated to individuals at higher DL stages because of their greater mental health needs. (Na & Streim, 2017)  Lack of a social network can have an impact on the patient’s physical health.  

                                                  Diagnostic Testing 

I would begin with a Head-to-toe assessment of the patient while in my office. Upon completion of that, I would administer the Geriatric Depression Scale 15 (GDS-15) at this time. The 15-item GDS is a short form of the GDS and is used to screen, diagnose, and evaluate depression in elderly individuals. (Shin et al., 2019) This would help to determine where the patient is in terms of her depression. I would also consider drawing some lab work such as a CBC w/diff, and a BMP to rule out any infection. Because the patient is a diabetic, I would also want to draw a Hemoglobin A1C to ensure that the patient’s blood glucose is within normal limits, and this will also help to see if the patient is adhering to her medications. An MRI may be warranted based on the patient’s head to toe assessment, and the answers received from family and caregivers of the patient. This would only be necessary if there were to be notable changes in the patient’s moods, mannerisms, or memory. 

                                                Differential Diagnosis 

  1. Major Depressive Disorder MDD is medical condition that includes abnormalities of affect and mood, neurovegetative functions, (such as appetite and sleep disturbances), cognition, (such as inappropriate guilt and feelings of worthlessness), and psychomotor activity (such as agitation or retardation). (Fava & Kendler, 2000)  
  1. Insomnia Sleep onset or initial insomnia is manifested by difficulty falling asleep that occurs at the start of the sleep period. (Brewster et al., 2018) If the patient is having trouble sleeping, I would encourage and teach the patient the importance of a bedtime routine or ritual to prepare the patient for bed and to encourage a healthy sleep routine.  

                                         Treatment Recommendation 

 

After carefully reviewing all the information provided at this visit, at this time my treatment recommendation would consist of beginning the patient on a bedtime routine and consider changing the medication to Trazadone. Trazadone is an established medication that is efficacious for the treatment of a broad array of depressive symptoms, including symptoms that are less likely r respond to other antidepressants (e.g. SSRI) such as insomnia. (Cuomo et al., 20190701) by changing the medication, it would allow the patient to be treated for both the depression and the insomnia and would offer the patient a better patient outcome than that which was previously achieved by the Sertraline. 

                                           Ethical Considerations 

 Ethically, we would want to ensure that this patient has no previous history of suicidal ideation, and we would want to rule out the potential of any dementia to ensure that the patent would be able to achieve the desired effects of the new SSRI. We would also want to consider that in the elderly patient, hyponatremia can be a side effect in the patient being treated with an SSRI. Hyponatremia is an electrolyte disorder that can be caused by multiple factors, among which the syndrome of inappropriate antidiuretic home secretion is one of the most frequent causes. This effect was more significant in elderly patients. (Mazzoglio y Nabar et al., 2022) 

                                            Check Points 

 I would want the patient to return to the office in 4 weeks so we can re-evaluate how she is doing upon starting the Trazadone. I would want to draw a Na level at that visit as well to check for hyponatremia. If the symptoms have improved and the patient’s sodium level remained stable, then I would make no changes. If the medication was found to not be effective, at this check point, I would consider this being treatment resistant depression and would consider both CBT and alternative treatment. 

 

References 

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian Journal of Psychiatry, 60(7), 341. https://doi.org/10.4103/0019-5545.224474 

Brewster, G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the older adult. Sleep Medicine Clinics, 13(1), 13–19. https://doi.org/10.1016/j.jsmc.2017.09.002 

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (20190701). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria. https://doi.org/10.1708/3202.31796 

Depression (major depressive disorder) – symptoms and causes – mayo clinic. (n.d.). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007 

Dzierzewski, J. M., & Dautovich, N. D. (2018). Who cares about sleep in older adults? Clinical Gerontologist, 41(2), 109–112. https://doi.org/10.1080/07317115.2017.1421870 

Fava, M., & Kendler, K. S. (2000). Major depressive disorder. Neuron, 28(2), 335–341. https://doi.org/10.1016/s0896-6273(00)00112-4 

Mazzoglio y Nabar, M. J., Muniz, M. M., Montivero, C. A., Schraier, G., & Leidi Terren, E. E. (2022). Hyponatremia secondary treatment with ssri antidepressants in adults and elderly. CNS Spectrums, 27(2), 243–244. https://doi.org/10.1017/s1092852922000505 

Na, L., & Streim, J. E. (2017). Psychosocial well-being associated with activity of daily living stages among community-dwelling older adults. Gerontology and Geriatric Medicine, 3, 233372141770001. https://doi.org/10.1177/2333721417700011 

Shin, C., Park, M., Lee, S.-H., Ko, Y.-H., Kim, Y.-K., Han, K.-M., Jeong, H.-G., & Han, C. (2019). Usefulness of the 15-item geriatric depression scale (gds-15) for classifying minor and major depressive disorders among community-dwelling elders. Journal of Affective Disorders, 259, 370–375. https://doi.org/10.1016/j.jad.2019.08.053 

Singh, H., & Saadabadi, A. (2022). Sertraline. StatPearls. 

 

 

 

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Hope OKOROIGWE  

RE: Week 7 Discussion  

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Hi Keyana, 

Thanks for your interesting post, particularly the differential diagnosis you provided for insomnia. Insomnia is a sleep disorder. It makes it hard to sleep and function during the day. Insomnia affects about ten percent of the population and is usually associated with other mental or physical issues (Szelenberger, & Soldatos, 2018). For it to be called insomnia, the person must have difficulty sleeping even when there are numerous opportunities to sleep. Chronic insomnia is diagnosed when the symptoms appear at least three times per week for at minimum three months. However, there is short term insomnia, which is also known as intermittent or episodic insomnia and it has the same criteria of chronic insomnia, but it must last for less than three months. 

I was inspired by the way in which you posed the assessment questions to the patient and her support system. The questions you asked the patient were important in determining medication adherence, changes in sleeping patterns, and possible depressive symptoms following her husband’s death. Additionally, choosing to interview her family and the caregivers would aid in identifying behavioral and medication compliance changes as determined by her support system. I also agree with your selection of diagnostic tests and physical exams. The Geriatric Depression Scale and Sleep Study tests have been used to diagnose patients with symptoms similar to this patient in both inpatient and outpatient settings (Schenck, Mahowald, & Sack, 2019). 

 

References: 

Szelenberger, W., & Soldatos, C. (2018). Sleep disorders in psychiatric practice. World 

psychiatry: official journal of the World Psychiatric Association (WPA), 4(3), 186–190. 

Schenck, C. H., Mahowald, M. W., & Sack, R. L. (2019). Assessment and management of 

insomnia. JAMA, 289(19), 2475–2479. https://doi.org/10.1001/jama.289.19.2475 

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Amancia Normil  

RE: Week 7 Discussion  

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Reply to keyana 

Trazodone is a helpful treatment option as it is versatile and can be used to address multiple types of depression. It is also faster to respond and it will create better initial results when treating patients with comorbidities (Avasthi & Grover, 2018). 

As you mention, treating insomnia is just as important as depression in this case. Interruptions to The sleep cycle are difficult to overcome when handling multiple mental and physical health concerns. This is something that is noticeable both when handling elderly patients and those of average age (Brewster et al., 2018). Ultimately the use of different treatment options is effective only when handling the severity of symptoms and the overall scope of patient management (Cuomo et al.,2019). 

Another important component is the efficacy of depression treatment in the scope of mental health. Since this patient has fewer people that she depends on emotionally it can be challenging for her and Son alone to handle all the consequences of insomnia. Breaking the cycle of having two or more conditions as well as a limited set of outlets to engage with others are factors that will ultimately precipitate greater levels of depression or anxiety. It would be important to channel this elderly person’s interests and available time into straightforward and steadfast strategies that provide an outlet within the constraints of available time. Some of the ways to do this could be with talk therapy either with a social worker or a therapist. Feeling the patient out or feeling the family members out regarding the success of this would be important for further treatment to continue. 

References 

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian Journal of Psychiatry, 60(7), 341. https://doi.org/10.4103/0019-5545.224474 

Brewster, G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the older adult. Sleep Medicine Clinics, 13(1), 13–19. https://doi.org/10.1016/j.jsmc.2017.09.002 

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (20190701). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria. https://doi.org/10.1708/3202.31796 

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Sandra Fernandez Arias  

RE: Week 7 Discussion  

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Hello Keyana, 

Excellent post on week seven post! I enjoyed reading your post, and I agree with your differential diagnosis. Your post influenced my understanding of the concept. You helped to learn that arterial blood gas is an important test to perform for the patient. 

Insomnia poses significant challenges to public health (Krystal et al., 2019). Insomnia is a common condition that affects about 10% of the population. Insomnia remains one of the most common sleep disorders encountered in the geriatric population (Patel et al., 2018). Many times, insomnia co-occurs with psychiatric or physical conditions. Insomnia is a risk factor for major depression, anxiety disorders, substance use disorders, suicidality, hypertension, and diabetes (Krystal et al., 2019). Insomnia is associated with significant distress or impairment in functioning and daytime symptoms, including fatigue, daytime sleepiness, impairment in cognitive performance, and mood disturbances (Levenson et al., 2015). Insomnia is differentiated from sleep deprivation by difficulty sleeping despite having adequate opportunity to sleep; for example, I suffer from sleep deprivation because I work at night and do not have the time to sleep. Insomnia can also be evaluated by detailed history and thorough physical examination (Patel et al., 2018). 

References 

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: An update. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674 

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617 

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Discussion: Treatment for a Patient With a Common Condition  

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List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.  

  1. Have you ever been hospitalized or undergone any surgical procedure?  
  1. Are you allergic to any medication?  
  1. Do you smoke, drink alcohol, or take any other recreational drugs?  

Rationale: Asking the patient about her surgical and hospitalization history is crucial as it gives insight into whether the patient may be having underlying conditions which were not properly resolved and contributing to her current symptoms. Finding out about her allergies is also necessary as this helps prevent prescribing medications that might lead to allergic reactions hence undermining the patient’s health (Khaledi et al., 2019). Finding out about the patient history of substance use is also crucial to promote lifestyle modifications such as smoking cessation, or quitting alcohol which are the main risk factors for DM and HTN. 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  

Close family members such as the patient’s children: 

  1. How does the patient behave at home?  
  1. How has the patient been grieving?  

Rationale: The patient’s children or close family members with whom they reside are great historians who will provide more information regarding the patient’s behavior at home, for further understanding of her symptoms (Zaki et al., 2020). The grieving process is also crucial to promoting positive mental health. This information will also help in determining the best psychotherapeutic approach to help with the patient’s depression. 

Close friends: 

  1. Has the patient been reaching out ever since her husband passed on?  
  1. Has the patient’s behaviour in social places changed ever since her husband passed on?  

Rationale: The patient’s close friends are great historians to provide further information regarding the patient’s behavior in social settings. Asking them whether the patient has been reaching out helps determine whether she is withdrawn (Khaledi et al., 2019). Her friends will also be able to notice whether there is a change in her behavior ever since she lost her husband. This information will help determine the progress of her depression, and additional symptoms such as agitation or irritability. 

Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.  

Physical Exams: It is important to check the patient’s blood pressure to determine whether her HTN is well controlled. Blood test for lipids will also be done as healthy triglycerides and cholesterol level reduces the risks of stroke or heart attack. A blood sugar test is necessary to determine whether the patient’s DM is well managed (Zaki et al., 2020). Additional routine physical examinations for the patient include a colorectal cancer exam, vaccinations, periodontal exam, eye exam, hearing test, thyroid stimulation hormone screening, vitamin D test, bone density scan, skin check, and prostate cancer screening. 

Diagnostic tests: There are no specific diagnostic tests for the patient’s chief complaint of insomnia. However, given her advanced age and history of HTN and DM, routine tests for the patient will include complete blood count, comprehensive metabolic panel, thyroid stimulating hormone, vitamin b12 test, Hemoglobin A1C, brain natriuretic peptide (BNP) test, pap smear, ECG, and mammogram (Zaki et al., 2020). The test results will be used to find out whether the patients presenting illnesses are well managed, and whether any other underlying conditions are contributing to her current symptoms. 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.  

  1. Insomnia: According to the DSM-V insomnia has been defined as dissatisfaction with the quantity or quality of sleep associated with one or more symptoms such as difficulty starting to sleep or maintaining sleep characterized by being awakened frequently or failing to return to sleep after being awakened (Bei et al., 2018). This is the most possible diagnosis given that the patient had already been diagnosed with MDD but presented with a chief complaint of insomnia.  
  1. Major Depressive Disorder (MDD): The patient was previously diagnosed with MDD, which was precipitated by the loss of her husband. MDD is also associated with a lack of sleep which might be contributing to the patient’s insomnia (Franzen & Buysse, 2022).  
  1. Prolonged grief disorder: This disorder was recently added to the DSM-V for a patient who has lost a loved one and presents with a feeling of intense grief which persists just like the patient in the provided case study (Ahrenholz & Baernstein, 2020).  

 

 

 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.  

  1. Sertraline 150 mg PO once daily  
  1. Bupropion ER 150mg PO once daily  

Rationale: Sertraline is a selective serotonin reuptake inhibitor that is considered the first line for the management of the major depressive disorder. The drug has also been proven to suppress REM sleep in addition to delaying REM latency. Studies show that sertraline minimally reduces nocturnal wakefulness time and increases sleep efficiency which is beneficial for depressive patients with insomnia (Hassinger et al., 2020). Since the patient was already taking the drug with no reported side effects, it was necessary to increase the dose to 150mg once daily for more effectiveness in the management of the patient’s insomnia. Bupropion on the other hand is a good antidepressant that has also been associated with increasing REM sleep time among depressive patients with insomnia. However, the drug is considered a second-line therapy after SSRIs have failed to work due to increased risks of side effects. The drugs have also been reported to increase blood pressure hence not recommended for hypertensive patients like the one in the provided case study. 

 

 

 

 

For the drug therapy, you select and identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?  

Sertraline is contraindicated in patients with increased risks of bleeding, syndrome of inappropriate antidiuretic hormone, manic depression, seizures, suicidal thoughts, low sodium levels in the blood, and liver problems among others (Bei et al., 2018). These contraindications are mainly due to the potential side effects of the drug, which might compromise the health of the patients with the above conditions. Such side effects include increased suicidality, easily bruising, fainting, tremors, and serotonin syndrome among others. 

Include any “checkpoints” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.  

Close monitoring of patients on sertraline is necessary to promote positive treatment outcomes. For patients with mild symptoms, with improving health outcomes, follow-up is scheduled in 4 to 6 weeks. During follow-up visits, the physician will check for suicidal thoughts, mood, appetite, sleep habits, energy levels, ability to feel pleasure, and concentration levels (Ahrenholz & Baernstein, 2020). Dose adjustments may be necessary based on these outcomes. 

 

 

References 

Ahrenholz, N. C., & Baernstein, A. (2020). Management of Pharmacotherapy for Depression. In Chalk Talks in Internal Medicine (pp. 333-338). Springer, Cham.  https://doi.org/10.1007/978-3-030-34814-4_51 

Bei, B., Asarnow, L. D., Krystal, A., Edinger, J. D., Buysse, D. J., & Manber, R. (2018). Treating insomnia in depression: Insomnia-related factors predict long-term depression trajectories. Journal of consulting and clinical psychology, 86(3), 282. https://doi.org/10.1037/ccp0000282 

Franzen, P. L., & Buysse, D. J. (2022). Sleep disturbances and depression: risk relationships for subsequent depression and therapeutic implications. Dialogues in clinical neuroscience. https://doi.org/10.31887/DCNS.2008.10.4/plfranzen 

Hassinger, A. B., Bletnisky, N., Dudekula, R., & El-Solh, A. A. (2020). Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert opinion on pharmacotherapy, 21(9), 1035-1043. https://doi.org/10.1080/14656566.2020.1743265 

Khaledi, M., Haghighatdoost, F., Feizi, A., & Aminorroaya, A. (2019). The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies. Acta diabetologica, 56(6), 631-650. https://doi.org/10.1007/s00592-019-01295-9 

Zaki, N., Alashwal, H., & Ibrahim, S. (2020). Association of hypertension, diabetes, stroke, cancer, kidney disease, and high-cholesterol with COVID-19 disease severity and fatality: A systematic review. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 14(5), 1133-1142. https://doi.org/10.1016/j.dsx.2020.07.005 

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1 month ago  

Keyana Hobdy  

RE: Discussion: Treatment for a Patient With a Common Condition  

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Discussion Week 7 Response #1 

Cindy, I enjoyed reading your insightful approach to the care of the elderly patient who just lost her husband. I did not quite understand the three questions you had asked her prior to reading your rationale. Perhaps we should also ask what the patient’s caffeine intake is as well. I say this because if the patient and her husband were heavy coffee drinkers, then perhaps she is still drinking large amounts of caffeine which could affect her sleep. Moderate amounts of coffee (50-100 mg of caffeine or 5-10 g of coffee powder a day) are well tolerated by a majority of elderly people, who enjoy meeting and chat over a cup of coffee. Excessive amounts of coffee, however, can in many individuals cause very unpleasant, exceptionally even life-threatening side effects. (Zikovic, 2000) I also leaned towards prolonged grief disorder before choosing my diagnosis of MDD, because I read back over the patient case, and she had previously been diagnosed with MDD and had already been placed on Sertraline. I would agree with you as well about adding the Bupropion, however, Bupropion may increase REM sleep, but has not been shown to impact sleep continuity. Bupropion has a unique sleep/wake profile, which may be particularly well suited for treatment of individuals suffering from depression accompanied by significant fatigue and sleepiness. (Krystal et al., 2007) I agree also with the follow up in for weeks. As we know, the onset of therapeutic actions in depression is usually not immediate, often delayed 2-4 weeks whether given as an adjunct to another anti-depressant or as a monotherapy.(Stahl, 2021) Following up in 4 weeks will help the provider determine of the combination of medications have improved the symptoms to give this patient the best possible patient outcome. 

References 

Krystal, A., Thase, M., Tucker, V., & Goodale, E. (2007). Bupropion hcl and sleep in patients with depression. Current Psychiatry Reviews, 3(2), 123–128. https://doi.org/10.2174/157340007780599096 

Stahl, S. M. (2021). Stahl’s essential psychopharmacology (6th ed.). Cambridge University Press. 

Zikovic, R. (2000). Coffee and health in the elderly. National library of medicine. 

 

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1 month ago  

Carine Robert  

RE: Discussion: Treatment for a Patient With a Common Condition  

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 Great question and very informative post. I enjoyed reading your discussion post. I agreed with your diagnosis of situational depression and grief which is related to the loss of her husband. approach. Selecting antidepressant agents that promotes sleep, prolong latency, and decrease REM sleep is one strategy for treating insomnia in patients with depression. American Academy of Sleep Medicine recommends the addition of a low-dose, sedating antidepressant if not contraindicated. Low-dose trazodone, mirtazapine, may be given in addition to another full-dose antidepressant (Clark et al., 2011). According to Alam et al. (2013), Mirtazapine result to rapid and sustained improvement in depressive symptoms and is effective in subgroups of depressed patients, particularly anxious patients and those with, treatment-resistant depression, geriatric depression, depression, and anxiety associated with alcohol dependence, and agitated elderly patients. 

Alam, A., Voronovich, Z., & Carley, J. A. (2013). A review of therapeutic uses of mirtazapine in psychiatric and medical conditions. The primary care companion for CNS disorders, 15(5), PCC.13r01525. https://doi.org/10.4088/PCC.13r01525 

Clark, M., Smith, P., & Jamieson, B. (2011, November 01). Antidepressants for the treatment of insomnia in patients with depression.  https://www.aafp.org/afp/2011/1101/od1.html 

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Insomnia  

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    According to Stern, et al., (2016), insomnia is difficulty in falling or staying asleep for a reasonable period, 5 to 8 hours of sleep. This may vary from person to person. Sleep disorder is observed at least three times per week and for at least one month. Many mental sicknesses are as a result of insomnia, but not limited to depression, anxiety, and schizophrenia (Roth, 2007).   

Many authors have found the coloration between mental illness and insomnia. Fifty percent of adults with insomnia have a mental health problem, and up to 90% of the adults with depression experience sleep problems (Roth, 2007).  

. Many cases of insomnia have been noted in Americans. Some patients, 30 to 35% have brief symptoms of insomnia, 15 to 20% have a short-term insomnia disorder, which lasts less than three months, 10% have a chronic insomnia disorder, which occurs at least three times per week for at least three months. Riemann et al. (2015) highlighted that persistent insomnia had a 58% higher risk of premature death ( Denollet,et al., 2009).   

Three questions to ask a patient with anxiety disorder. Provide a rationale for why you might ask these questions.   

Question 1: You said that your depression has gotten worse, tell me more about it. To data more data that will assist in diagnosis.  

How long do you fall asleep? How often do you wake up at night, and how long does it take you to fall back asleep? Do you wake up tired and how tired are you during the day? These questions can be asked to get insight into the current complaint, which will aid for proper diagnosis purpose.   

Atkeson and Jelic (2008) point out that gene contributes to sleep disorder,    

An adult daughter or any adult who is involved and takes care of the patient should be a source for detailed information.  

Question 2: Do you think that patients are stressed out? Can you point out things stressing patient out?  

According to Lucassen et al., (2008). Stress has long been known to be linked with sleep problems. Most people have experienced this connection at some point in their life when difficult circumstances may have made it hard to get to sleep or fall back asleep after waking up in the night.  

Some authors have found that stress, anxiety, and depression could result from chronic insomnia. Some patients who have trouble falling asleep may experience worsening symptoms of anxiety, stress, and depression. Insomnia may have other psychological or emotional causes such as worry, anger, trauma, grief, and bipolar disorder.  

Question 3: Does a patient have a quiet environment to sleep without interruption?  

Stern, et al., (2016), highlighted that a quiet environment establishes the right conditions that may promote sleep. Make it cool, quiet, dark, comfortable, and free of interruptions. Check for and remove distractions light, heat, noise, or other things that may cause stress. Consider adding ear plugs, blackout curtains, or white noise to your bedroom.  

Physical exams, and diagnostic tests would be appropriate for the patient, family members, or care givers how the results would be used for diagnosis purposes.   

  • History taking
    Diagnosis of insomnia is based on good history taking from the patient (and/or family member or car giver) about the sleep pattern. 
  • a detailed history should be carried out to  
  • sleep pattern, pre sleep conditions  
  • If any impact   
  • Physical exam. No precise exam, but a blood test may be done to check for thyroid problems or other conditions that may be associated with poor sleep.  
  • Sleep habits review. In addition to asking you sleep-related questions, your doctor may have you complete a questionnaire to determine your sleep-wake pattern and your level of daytime sleepiness. You may also be asked to keep a sleep diary for a couple of weeks.  
  • Sleep study. This is done to monitor and record a variety of body activities while the patient is sleeping, including brain waves, breathing, heartbeat, eye movements and body movements.  
  • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.   

-Insomnia  

-Anxiety Disorder/Depression  

-Sleep Apnea  

Insomnia Treatment  

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.   

  1. Eszopiclone (Lunesta) 
  2. Zaleplon (Sonata) 
  3. Eszopiclone (Lunesta) 

INDICATION  

Eszopiclone is indicated for the treatment of insomnia in patients 18 years of age or older. Unlike other nonbenzodiazepine agents, there is no restriction on their duration of use. Besides, eszopiclone has a 6–8 h half-life, evidenced has proved that there is no reported rapid eye movement (REM) sleep rebound on discontinuation, and has been used for long term without any adverse consequences on clinical trials. Zaleplon is shorter acting (3–4 h) and can be dosed during the night of sleep.   

PHARMACOLOGY  

How eszopiclone works is not hypnotically unknown, but its effect is believed to come from its interaction with GABA receptor complexes at binding domains located close to or allosterically coupled to benzodiazepine receptors. “Eszopiclone is a nonbenzodiazepine hypnotic that is structurally unrelated to pyrazolopyrimidines, imidazopyridines, benzodiazepines, barbiturates, or other drugs with known hypnotic properties (Brielmaier, 2006)”.  

PHARMACOKINETICS  

Onset of action  

In a study conducted by Zammit et al. (2007) in adults with chronic insomnia, the average onset of sleep (measured by sleep latency) was 10.4 minutes faster in the eszopiclone 2 mg group than in the placebo group.  

Absorption and distribution  

 Najib, (2006) highlight that eszopiclone is absorbed fast following oral administration. The peak plasma concentrations are reached within 1 hour after oral consumption. It is weakly bound to plasma proteins (52%–59%).  

Metabolism  

Eszopiclone is metabolized in the liver after oral consumption by oxidation and demethylation. The primary plasma metabolites have little to no binding potency to GABA receptors. A vitro study shows that CYP3A4 and CYP2E1 enzymes are involved in the metabolism of eszopiclone (Huq, 2007).  

Elimination  

The mean elimination half-life (t1/2) of eszopiclone is approximately 6 hours. Less than 10% of an oral dose is excreted in the urine as parent drug.  

  1. Zaleplon (Sonata) 

Zaleplon, a nonbenzodiazepine sedative hypnotic from the pyrazolopyrimidine class, which is used in the treatment of insomnia.   

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1 month ago  

cherechi onyenso  

RE: week 7 Discussion  

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References  

Atkeson, A., & Jelic, S. (2008). Mechanisms of endothelial dysfunction in obstructive sleep  

 apnea. Vascular  Health and Risk Management, 4(6), 1327.  

Brielmaier B. D. (2006). Eszopiclone (Lunesta): a new nonbenzodiazepine hypnotic 

 agent. Proceedings (Baylor University. Medical Center), 19(1), 54–59. 

https://doi.org/10.1080/08998280.2006.11928127 

Buysse D. J. (2013). Insomnia. JAMA, 309(7), 706–716.  

https://doi.org/10.1001/jama.2013.193 

Caddick, Z. A., Gregory, K., Arsintescu, L., & Flynn-Evans, E. E. (2018). A review of the  

 environmental parameters necessary for an optimal sleep environment. Building and 

 environment, 132, 11-20.  

Denollet, J., Maas, K., Knottnerus, A., Keyzer, J. J., & Pop, V. J. (2009). Anxiety predicted  

 premature all-cause  

 and cardiovascular death in a 10-year follow-up of middle-aged women. Journal of clinical 

  epidemiology,  62(4), 452-456.  

Dyas, J. V., Apekey, T. A., Tilling, M., Ørner, R., Middleton, H., & Siriwardena, A. N. (2010).  

 Patients’ and  clinicians’ experiences of consultations in primary care for sleep problems and  

 insomnia: a focus group  study. British Journal of General Practice, 60(574), e180-e200./.  

Huq, F. (2007). Molecular modeling analysis of the metabolism of eszopiclone. J Pharmacol 

 Toxicol, 2, 732-736.  

Najib, J. (2006). Eszopiclone, a nonbenzodiazepine sedative-hypnotic agent for the treatment of  

 transient and chronic insomnia. Clinical therapeutics, 28(4), 491-516.  

Lucassen, P. J., Meerlo, P., Naylor, A. S., Van Dam, A. M., Dayer, A. G., Fuchs, E., … & Czeh,  

 B. (2010).  Regulation of adult neurogenesis by stress, sleep disruption, exercise, and inflammation:  Implications for   depression and antidepressant action. European Neuropsychopharmacology, 20(1), 1-17.  

Riemann, D., Nissen, C., Palagini, L., Otte, A., Perlis, M. L., & Spiegelhalder, K. (2015).  

 neurobiology,  investigation, and treatment of chronic insomnia. The Lancet Neurology,  

14(5), 547-558.  

Roth, T. (2007). Insomnia: definition, prevalence, etiology, and 

 consequences. Journal of clinical sleep medicine : JCSM : official publication of 

 the American Academy of Sleep Medicine, 3(5 Suppl), S7–S10. 

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General 

     Hospital psychopharmacology and neurotherapeutics. Elsevier.  

 

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cherechi onyenso  

RE: Insomnia  

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List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.  

  1. When was the last time you refilled your sertraline? 
  1. Are you taking your medications as instructed? 
  1. Tell me more about what goes on at home and how you manage to deal with the situation. 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  

Questions for the family members or a care giver 

  1. Who arranges patient medication? Does the patient have bottle of sertraline, is it empty or full? To assess if the patient is taking her medication. 
  1. How has the patient been coping with problems? To establish patient’s coping mechanisms 
  1. Who does the patient relate to when problems arise? To establish patient’s support system. 

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  

  • There is no specific physical exam  to diagnosed major depressive disorder; but, the diagnosis is based on the history and the mental status examination. Interviewing patient, the family members or the care taker to gather supporting data for the diagnosis. The provider may order some labs to check medication toxicity or blood level to ruled out other diagnosis that may mimic depression symptom, for example, thyroid level.  for lab tests to rule out other diagnoses.  
  •  
  • List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.  
  • Depression 
  • Anxiety 
  • Insomnia 

Depression, because according to Brenes, (2007) anxiety can be a symptom of depression. Fang et al., (2018) highlighted that depression causes Insomnia. They point out that sleep disturbance is the most prominent symptom in depressive patients and found as main secondary manifestation of depression.   

 

  • List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 
  • 1. Sertraline to 150 mg daily 

depressive symptoms as well as symptoms of agitation, anxiety, restlessness and irritability improved. Citalopram is considered not only an ant depressive drug but also an emotional stabilizer. One research shows that citalopram was well tolerated by elderly often somatically ill patients. 

  • Switch SSRI to SNRI 
  • 2. Wellbutrin XL 
  •  
  • For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. 

Sertraline may increase your risk for bleeding problems. So, avoid medications such as, aspirin, NSAID pain or arthritis medicines (e.g., diclofenac, ibuprofen, naproxen, Advil, Aleve, Celebrex, Voltaren, or warfarin (Coumadin, Jantoven.  

Sertraline may cause serotonin syndrome if taken together with some other medicines. Sertraline should not be taken with buspirone (Buspar), because it may increase the risk serotonin syndrome, which may include symptoms such as confusion, hallucination, seizure, extreme changes in blood pressure, increased heart rate, fever, excessive sweating, shivering or shaking, blurred vision 

  •  Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making? 
     
  • Patel et al. (2016) point out that bupropion can increase the blood levels of sertraline, which may increase other side effects. 

 

  • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

 

  • Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

I will consider psychotherapy if a patient’s condition is still not getting better, because many researchers have found that psychotherapy works well with therapy. Cox et al. (2014), found that patients receiving combination psychological and drug therapy were most likely to respond. They were: 27% more likely to respond than those receiving psychotherapy alone. 25% more likely to respond than those receiving drug treatment alone.   

References  

 

Brenes G. A. (2007). Anxiety, depression, and quality of life in primary care patients. Primary care companion to the Journal of clinical psychiatry, 9(6), 437–443. https://doi.org/10.4088/pcc.v09n0606 

 

Fang, H., Tu, S., Sheng, J., & Shao, A. (2019). Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. Journal of cellular and molecular medicine, 23(4), 2324–2332. https://doi.org/10.1111/jcmm.14170 

Patel, K., Allen, S., Haque, M. N., Angelescu, I., Baumeister, D., & Tracy, D. K. (2016). Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant. Therapeutic advances in psychopharmacology, 6(2), 99–144. https://doi.org/10.1177/2045125316629071 

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1 month ago  

CINDY OGOM  

RE: Insomnia  

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Hello Cherechi! This is an outstanding and insightful post about insomnia, which is the underlying condition of the patient in the case scenario. Ideally, these questions you selected are appropriate and critical in detecting the conditions that the patient may have and help in successful treatment. Asking the patient about the condition also help in improving the confidence of patient in medical care. The other important aspect is patient education. The patient should be educated about good sleep hygiene (Ng & Cunnington, 2021). Sleep hygiene are activities and tendencies that facilitate maintenance of quality sleep and entire daytime alertness. In particular, the patient should be taught to create regular sleep tendencies by ensuring a usual sleeping and waking time, having enough sleep to help her feel refreshed in the next day, and avoiding spending unnecessary time in bed. The patient should also ensure that her bedroom is relaxing, quiet, dark, and at a favorable temperature (Bollu & Kaur, 2019). Moreover, dietary changes such as avoiding caffeine, heavy meals, and alcohol before bedtime is also essential. The patient should also be advised to engage in exercise during the day to help her fall asleep easily at night. 

References 

Bollu, P. C., & Kaur, H. (2019). Sleep medicine: insomnia and sleep. Missouri medicine, 116(1), 68. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390785/ 

Ng, L., & Cunnington, D. (2021). Management of insomnia in primary care. Australian Prescriber, 44(4), 124. doi: 10.18773/austprescr.2021.027 

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Aleksander Porres Milian  

RE: Insomnia  

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Hello Cherechi, 

Your post was not only detailed but informative. Being a health issue that affects both young and elderly populations, 50% of older adults complain about difficulty initiating or maintaining sleep (Patel et al., 2018). Some of the significant characteristics of insomnia include difficulty initiating sleep, difficulty maintaining sleep, characterized by frequent awakenings as well as early-morning awakening with an inability to return to sleep (Patel et al., 2018). When making diagnostic tests for the health issue, it becomes critical for the healthcare professionals to ask pertinent questions concerning the patient’s sleeping patterns. The questions you have posed are essential when it comes to the assessment of an elderly patient. I would like to also reiterate that family members, friends, and other immediate caregivers to the patient would be a great resource during the assessment and treatment period. This is because they would be directly involved in providing critical information about the patient that the elderly patient may not be able to offer. Having a close family member during the patient’s interview would be critical. Since insomnia is frequently associated with cognitive decline,  it is partly responsible for the pathological progression of several neurodegenerative diseases and hence requires appropriate treatment. According to Wang et al. (2020), low dose trazodone (25–150 mg) is effective in blocking histamine 1 and hydroxytryptamine 2A and thus more often embraced as a sedative for treating insomnia. 

References 

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172 

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on Sleep Quality and Cognitive Function in Arteriosclerotic Cerebral Small Vessel Disease Comorbid With Chronic Insomnia. Frontiers in psychiatry, 11, 620. https://doi.org/10.3389/fpsyt.2020.00620 

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Week 7 Discussion K.Torres  

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List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. 

Some questions I believe must be asked include whether the patient is having difficulties falling or staying asleep, how many nights in a week she experiences sleep disturbances, and whether she is taking any over-the-counter medication to help herself sleep. In my opinion, it is important to determine whether the patient is having difficulties falling or staying asleep to help the provider determine which kind of medication to order. For instance, if the patient has problems falling asleep but not staying asleep, Melatonin could be a good option. According to Zisapel (2018), melatonin levels decrease with age, disrupting sleep patterns and increasing sleep disturbances. 

On the other hand, knowing the frequency the patient experiences insomnia may help the provider determine whether the patient requires a scheduled or as-needed medication. In addition, knowing whether the patient is taking over-the-counter sleeping aids prevents the provider from ordering a medication that could interact with whatever the patient may be taking. Furthermore, due to the patient’s age, knowing if she is taking an over-the-counter sleeping aid is crucial as many of these products contain diphenhydramine, which is potentially harmful to elderly patients (Abraham et al., 2018). 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. 

The provider should refrain from reaching out to anyone unless the patient provides explicit authorization to talk to a third party. If the patient gives authorization to speak to third parties, speaking with people living with the patient may expose information such as the patient sleep habits, including daytime napping, the time at which the patient goes to bed, and whether she experiences nighttime awakening. This information is crucial for the clinical assessment of insomnia (Krystal et al., 2019). Other relevant questions are those related to the patient’s daytime activities and functional level (Krystal et al., 2019). 

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. 

Based on the information provided, the patient is most likely suffering from sleep insomnia related to her depression; however, I believe it is imperative to perform a cognitive evaluation. By doing so, cognitive decline can be ruled out as causation. Although the patient presents alert and oriented to person, place, and time that does not rule out early stages of cognitive decline, which could be associated with her insomnia. According to  Wennberg et al. (2017), 60 to 70 percent of older adults with cognitive impairments suffer from sleep disturbances.  

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

  • Major Depressive Disorder  
  • Generalized Anxiety Disorder  

Mental health conditions such as anxiety and depression are common causes of sleep disturbances (Levenson et al., 2015). In this patient’s case, not only has the patient recently lost her husband, but she also reported she was already suffering from depression even before he passed away. Based on this information, one can conclude that the loss of her spouse caused her depression to worsen.  

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

In this case, to augment the effects of Sertraline and to improve the patient’s sleep, I would start the patient on Trazodone. According to Stahl (2021), medications used to augment the effect of Sertraline include Trazodone, Wellbutrin, Mirtazapine, and Atomoxetine. Trazodone is FDA-approved for the treatment of insomnia, and while it is not the first line of treatment, in this case, it will potentially solve the two complaints, increased depression and insomnia. Wellbutrin, on the other hand, is the preferred medication to augment Sertraline (Stahl, 2021), is a norepinephrine and dopamine reuptake inhibitor and insomnia is among the potential side effects of this medication (Stahl, 2021).  

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making? 

Caution must be observed when using Trazodone if the patient is elderly, suffers cardiac disease, electrolyte abnormalities, long QT syndrome, QT prolongation, ventricular arrhythmias, CHF, bradycardia, and a recent MI, among others. The medication may also cause depression in the central nervous system and should be used with caution. The medication should be started at a low dose to prevent side effects (Stahl, 2021). The patient should be educated on the possible side effects and health risks associated with the medication, so she can make an informed decision, thus exercising autonomy.  

Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

Trazodone may take two to four weeks to yield results (Stahl, 2021). The patient should be re-evaluated after six to eight weeks to determine whether the medication is effective; if no positive results are reported, the dose should be increased and re-evaluated after four weeks (Stahl, 2021). 

References 

Abraham, O., Schleiden, L., & Albert, S. M. (2017). Over-the-counter medications containing diphenhydramine and doxylamine used by older adults to improve sleep. International journal of clinical pharmacy, 39(4), 808–817. https://doi.org/10.1007/s11096-017-0467-x 

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry: official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674 

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617 

Stahl, S. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications. (5th ed.). Cambridge University Press. DOI: 10.1017/9781108975292 

Wennberg, A., Wu, M. N., Rosenberg, P. B., & Spira, A. P. (2017). Sleep Disturbance, Cognitive Decline, and Dementia: A Review. Seminars in neurology, 37(4), 395–406. https://doi.org/10.1055/s-0037-1604351 

Zisapel N. (2018). New perspectives on the role of Melatonin in human sleep, circadian rhythms and their regulation. British journal of pharmacology, 175(16), 3190–3199. https://doi.org/10.1111/bph.14116 

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1 month ago  

Krisnamor Torres  

RE: Week 7 Discussion K.Torres  

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Add to the original post.  

While Trazodone’s lower dose is 50mg, the patient can be started on half a tablet for a week and then increase to a whole table. This reduced the incidence of side effects. 

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1 month ago  

cherechi onyenso  

RE: Week 7 Discussion K.Torres  

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Hello Torres,  

I think your decision of Trazodone is wonderfull, because trazodone trazodone is still SSRI and It helps to improve patient mood, appetite, and energy level as well as decrease anxiety and insomnia related to depression. Macías et al., (2018) did a study to determine the use of trazodone in the elderly population in Spain. The result shows  a total of 11,766 patients receiving a first prescription of trazodone.. The incidence rate of trazodone use was 47.2 (95% CI: 46.33–48.04) per 10,000 person-years. An increasing trend in the use of trazodone was observed (5-fold increase in 2011 as compared to 2002). The most common therapeutic indications were: depression (21.41%), Alzheimer/dementia (20.36%), sleep disorders (16.22%), and anxiety disorder (8.91%). The median dose was 100mg/day. The use of trazodone concomitantly with interacting medicines was frequent: anti-hypertensives (53.60%), and CNS depressors (59.32%). So , they concluded that trazodone use has increased in elderly patients, and a high proportion of use in non-approved indications was observed. Trazodone is not being used at high doses, but interacting medicines were frequent, and it may pose additional risks for elderly patients. If used close monitoring is needed.   

Yi, et al. (2018)  highlight that trazodone is used to help with sleep latency and maintaince. They found that trazodone was effective in sleep maintenance by decreasing the number of early awakenings and it was corolated with improvement of sleep quality, although there were no significant improvements in sleep efficiency or other objective measures. Trazodone however, presented good tolerance in the short-term treatment of insomnia.  

I think that your choice is good.  

 

 

Brogden, R. N., Heel, R. C., Speight, T. M., & Avery, G. S. (1981). Trazodone: a review of its pharmacological properties and therapeutic use in depression and anxiety. Drugs, 21(6),  

401-429.  

Macías Saint-Gerons, D., Huerta Álvarez, C., García Poza, P., Montero Corominas, D., & de la Fuente Honrubia, C. (2018). Trazodone utilization among the elderly in Spain. A  

population based study. Revista de Psiquiatría y Salud Mental (English Edition), 11(4), 208–215. https://doi.org/10.1016/j.rpsmen.2016.11.008 

Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., … & Zhou, X. Y. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep  

medicine, 45, 25-32.  

 

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Krisnamor Torres  

RE: Week 7 Discussion K.Torres  

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Hello Cherechi,  

Thank for your reply. When I first read the case, I was sure the main complaint was insomnia, and we were to choose treatment for it. So originally, I had chosen Suvorexant as it is a first line or treatment for insomnia and has a low side effects profile on elder patients (Tampi et al., 2018).  Because the question was the medications would we give the patient for her depression, I had considered changing the dose of her Sertraline but because of the patient’s age I decided to augment it with Trazodone instead. According to Stahl (2021), Trazodone is indicated to treat insomnia and it is also a good choice to augment Sertraline. Trazodone is an antagonist to serotonin, and “has a moderate antihistamine and low anticholinergic activity” (Jaffer et al., 2017).  

Reference 

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34. 

Stahl, S. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications. (5th ed.). Cambridge University Press. DOI: 10.1017/9781108975292 

Tampi, R. R., Manikkara, G., Balachandran, S., Taparia, P., Hrisko, S., Srinivasan, S., & Tampi, D. J. (2018). Suvorexant for insomnia in older adults: a perspective review. Drugs in context, 7, 212517. https://doi.org/10.7573/dic.212517 

 

 

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1 month ago  

Lymarie Vilella  

RE: Week 7 Discussion K.Torres  

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hello Krisnamor 

 

Great presentation.  I like your question about how many nights in the week she experiences sleep disturbance and if she is taking any over-the-counter medication for this.  I think this is very important because she is probably using a natural remedy (such as tea, valerian root, etc) but is not working 100%.  Melatonin is a good option, however, is not going to work for depression.  I agree with you on your decision to add Trazodone to Sertraline.  Stahl (2017) stated, “Trazodone has therapeutic actions in Insomnia immediately if dosing is correct.  The Onset of therapeutic actions in depression usually not immediate, often delayed 2-4 weeks whether given as an adjunct to another anti-depressant or as a monotherapy”. 

Reference 

Stahl S. (2017).  Essential psychopharmacology prescribers guide. (6th eds).  Cambridge, United Kingdom.  

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Krisnamor Torres  

RE: Week 7 Discussion K.Torres  

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Hello Lymarie,  

Thanks for your reply. In my opinion, determining whether a patient is taking over-the-counter medications or supplements is crucial to avoiding drug-to-drug interaction and educating the patients regarding such medications. More often than not, I have had patients that are currently taking over the counter medciations and are ither taking more than they should have or taking medications they should avoid, for example, Diphenhydramine. According to Abraham et al. (2017), an important number of older patients are currently taking sleep aids that contain Dypehnhydramine and have no idea of the health risk associated with the medication. This medication is listed on the BEERS criteria as potentially inappropriate and has been associated with adverse effects, including increased risk for falls and drug-to-drug interactions (Osei et al., 2016). In addition, elderly patients may take more than one over-the-counter medication, each with the potential for side effects and drug-to-drug interactions. Avoiding polypharmacy is critical for all patients, but most so in the elders. Polypharmacy-related complications may land these patients in the hospital and diminish their quality of life (Osei et al., 2016).  

Reference 

Abraham, O., Schleiden, L., & Albert, S. M. (2017). Over-the-counter medications containing Diphenhydramine and doxylamine used by older adults to improve sleep. International journal of clinical pharmacy, 39(4), 808–817. https://doi.org/10.1007/s11096-017-0467-x 

Osei, E. K., Berry-Cabán, C. S., Haley, C. L., & Rhodes-Pope, H. (2016). Prevalence of Beers Criteria Medications Among Elderly Patients in a Military Hospital. Gerontology & geriatric medicine, 2, 2333721416637790. https://doi.org/10.1177/2333721416637790 

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week 7 – discussion  

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Good evening Professor and class, 

 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.  

 

The three question I might ask the patient are:  

 

1- . How many hours do you sleep per night? 

Sleep pattern is essential for many brain activities including how nerves cells (neurons) communicate with one another. Prolonged sleep deprivation or poor-quality sleep increases the risk of illnesses such as high blood pressure, cardiovascular disease, diabetes, depression, and obesity. (National Institute of Neurological Disorders and Stroke. n.d.). 

2- Do you consume alcohol or caffeine? 

Caffeine is a natural psychoactive agent that inhibits adenosine receptors. Adenosine is sleep- promoting chemical produced by the brain during the owns’ waking hours. Adenosine accumulates in the brain the longer we are awake. The more it accumulates the sleepier we get. Thus, why someone’s sleep cycle may be disturbed. (Foley, L. 2021). 

3- How long have been you on sertraline?  

Previous research has found that “selective serotonin reuptake inhibitors (SSRIs) can cause or worsen REM sleep without atonia (RSWA) and increase the likelihood of developing REM sleep behavior disorder (RBD)”. (Zhang, B., et al. 2013). 

Sertraline’s side effect is sleep deprivation/Insomnia reduces quality of life and is linked to an increased risk of physical and mental health issues such as anxiety, depression, drug and alcohol misuse, and increase hospitalization. Everitt, H., et al. (2018). 

 

 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.  

 

The people that we would need to speak for additional feedback would be the care giver, the children/relative and friends. Gathering information’s from other source will assist the healthcare provider to better understand his/her patient medical condition and to provide quality care. The question that might be ask to these people are:  

 

*Have you recently mentioned any changes in the patient’s mental status? This question is asked in regard to patient’s age and maybe a potential declined cognitive level that may only be observed by the patient’s entourage. 

 

* Does anyone in the family have any other serious illnesses such as cancer. Stroke…etc. Many diseases are hereditary and familial gathering more information will help in establishing a proper diagnosis and treatment plan. 

 

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.  

Both a physical examination and diagnostic tests are appropriate for this patient.   

Though a physical examination cannot be used to diagnose insomnia; it can however be an essential tool in identifying or ruling out underlying causes of sleep disorders, such as obstructive sleep apnea and Parkinson’s disease. (Ong, J. C., & Crawford, M. R. 2013). According to the National Heart Lung and Blood Institute, diagnostic test such as sleep study is recommended to monitor the circadian rhythm (sleep-wake cycle) along with blood tests such as estrogen and thyroid level (n.d.). Thyroid dysfunction can cause sleeplessness as well as fatigue and depression. Specially if the patient’s B12 is not in normal limit. (National Heart Lung and Blood Institute n.d.). Estrogen on the other hand is known to have an indirect role that influence the thyroid economy by increasing the thyroid biding globulin and hypothyroid women’s requirement for thyroid hormone. (Santin, A. P., & Furlanetto, T. W. 2011).  An evaluation of the patient’s mental status and depression should also be part of the diagnostic tests to establish the patient level of depression and cognition.  

 

 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.  

 

The possible differentials diagnosis for this patient are: Grief, sleep disorder, Anxiety, stress and dementia. The chosen differential diagnosis would be Dementia. 

 

The chosen differential diagnosis would be dementia.  Dementia is the loss of cognitive functions with array of symptoms that may include, memory loss, poor judgment, confusion, difficulty expressing thoughts, anxiety, depression, mood swings…etc. (NIH. 2012). Dementia is quite frequent in old age, with the risk doubling every five years beyond the age of 65,2 and reaching up to 50% among people over 90. (Corrada, et al., 2010). This patient is at risk for dementia due to her medical history of diabetes and HTN.  According to the Journal of the American Heart Association, blood arteries in the brain are vulnerable and are at increased risk of harm from high blood pressure. The mechanisms underpinning the association of diabetes and dementia are unclear, but it may be multifactorial in nature, involving factors such as cardiovascular risk factors, glucose toxicity, changes in insulin metabolism and inflammation. (Ninomiya T. 2014). 

 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.  

 

The two chosen pharmacological agent chosen are Zolpidem tartrate (Ambien) and Temazepam (Restoril).  

Zolpidem is classified as a hypnotic du– GABA- Receptor Modulators. Is a schedule IV classified as miscellaneous anxiolytics, sedative and hypnotics’ drug. (Drugs.com. n.d).  Zolpidem is used for the treatment for the short term of Insomnia. 5 mg and 10 mg strength tablets for oral administration. Zolpidem has a half-life of 2 to 3 hours, but up to an estimated 2.6 hours in healthy individuals. This implies that once you’ve taken your last dose, your body will have eliminated half of it within a few hours. (Bouchette, D., & Quick, J. 2019).  

The initial recommended in the treatment of insomnia is 5 mg. Lower doses of Ambien are less likely to result in physical harm, dependence and withdrawals when the treatment is stopped. The pharmacokinetics of zolpidem remain unaltered when administered in numerous doses. There are no significant differences in the pharmacokinetic parameters between various racial groups and gender. (Salvà, P., & Costa, J. 1995). Zolpidem can have serious side effect on the cardiovascular, respiratory digestive and sensory systems and the potential reaction are: nausea and vomiting, double vision, respiratory depression rapid or irregular heart rate…etc. (Drugs.com (n.d.). The use of zolpidem in conjunction with other CNS depressants raises the risk of CNS depression. Ambien is contraindicated in the use Alcohol, opioids, Haldol, sertraline, liver disease, renal disease…etc. (Drugs.com. n.d.). 

 

Temazepam is a benzodiazepine hypnotic agent classified as a schedule 4 drug with a low potential for abuse and recommended for a short treatment of insomnia. (7-10 days). (Drugs.com. n.d.). Temazepam is metabolized in liver and its dosage is 7.5 to 30 mg orally once a day at bedtime.  In elderly or debilitated patients, therapy should be initiated at 7.5 mg until individual responses are determined. (Drugs.com. n.d). The FDA warns that comparable benzodiazepine and opioids should not be used since they can cause extreme drowsiness, respiratory depression, coma, and death. 

 

The drug of choice in treating this patient currently is Temazepam at 7.5 mg which is indicated as the starting dose for individuals 65 and older since the risk of developing oversedation, dizziness, disorientation, ataxia, and/or falls increases significantly with higher benzodiazepine dosages in elderly and debilitated patients. (Drugs.com. n.d.). also, that temazepam time to peak 1.2 -1.6 hours and a half-life of elimination of 3.8 to18.4 hours and its excretion is from the urine at 80% to 90% Temazepam. And finally, has no significant drugs interactions in regard to the patient current prescribed medication.  

During drug therapy, the problematic would be the multitude of medications previously ordered. Thus, why it is important for the healthcare provider to selects carefully the appropriate medication and focus on evaluating and defining the patient’s needs. The use appropriate tool such as electronic drug references to reduce prescription errors, to considered the patient age, weight, heigh and symptom to adequately prescribed the right medication, to monitor the patient’s response to treatment regularly, to select the right medication and dosage and to educate patient to report any undesirable side effect so proper action can be follow for example, the discontinuation of the medication. Other therapeutic adjustments that should be implemented in the management of Sertraline-treated persons include regular monitoring of the patient’s liver and renal function, as well as other labs, including A1c triglyceride. In addition, their treatment plan must be modified as needed to avoid any metabolic changes. (Kesim, et al., 2011). 

 

Catherine. M 

 

 

 

REFERENCES: 

Bouchette, D., & Quick, J. (2019). Zolpidem. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK442008/ 

 

Corrada, et al., (2010). Dementia incidence continues to increase with age in the oldest old: the 90+ study. Annals of neurology, 67(1), 114–121.  

 

Everitt, H., et al. (2018). Antidepressants for insomnia in adults. The Cochrane database of systematic reviews, 5(5), CD010753.  

 

Drugs.com. Ambien (n.d.) – FDA prescribing information, side effects and uses. https://www.drugs.com/pro/ambien.html 

 

Foley, L. (2021). Caffeine & Sleep Problems. Sleep Foundation. https://www.sleepfoundation.org/nutrition/caffeine-and-sleep 

 

Harvard Health. (2012). Depression early sign of dementia.  

https://www.ninds.nih.gov/health-information/patient-caregiver-education/brain-basics-understanding-sleep  

 

Kesim, et al., (2011). The effects of sertraline on blood lipids, glucose, insulin and HBA1C levels: A prospective clinical trial on depressive patients. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences, 16(12), 1525– 

 

National Heart Lung and Blood Institute (n.d.). Insomnia Diagnosis. https://www.nhlbi.nih.gov/health/insomnia/diagnosis 

 

National Institute on Aging. (2021). What Is Dementia? Symptoms, Types, and Diagnosis. National Institute on Aging. https://www.nia.nih.gov/health/what-is-dementia 

 

Ninomiya T. (2014). Diabetes mellitus and dementia. Current diabetes reports, 14(5), 487.  

 

Ong, J. C., & Crawford, M. R. (2013). Insomnia and Obstructive Sleep Apnea. Sleep medicine clinics, 8(3), 389–398.  

 

Sleep Foundation (n.d.). Dementia and Sleep. https://www.sleepfoundation.org/mental-health/dementia-and-sleep 

 

Zhang, B., et al. (2013). Sertraline and rapid eye movement sleep without atonia: an 8-week, open-label study of depressed patients. Progress in neuro-psychopharmacology & biological psychiatry, 47, 85–92. 

 

Santin, A. P., & Furlanetto, T. W. (2011). Role of estrogen in thyroid function and growth regulation. Journal of thyroid research, 2011, 875125.  

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1 month ago  

Muhammad Imam  

RE: week 7 – discussion  

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I appreciate the originality of your response. I avoid using benzodiazepines because of their addictive potential. Instead, I would rely on prescribing trazodone as an antidepressant sleeping agent. There is substantial consensus for the benefit of trazodone to induce better sleep in patients. I would have the starting dose for the patient at 50 mg trazodone daily (Oggianu et al., 2020). Because SSRI are widely reported with side effects including but not limited to problems with libido, I think trazodone is a more fitting use for this patient (Jaffer et al., 2017). I would also consider the use of mirtazapine 7.5 mg daily, but I would be concerned about the side effect of weight gain for the patient (Praharaj, Gupta, & Gaur, 2018).  

References 

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34. 

Oggianu, L., Ke, A. B., Chetty, M., Picollo, R., Petrucci, V., Calisti, F., Garofolo, F., & Tongiani, S. (2020). Estimation of an Appropriate Dose of Trazodone for Pediatric Insomnia and the Potential for a Trazodone-Atomoxetine Interaction. CPT: pharmacometrics & systems pharmacology, 9(2), 77–86. https://doi.org/10.1002/psp4.12480  

Praharaj, S. K., Gupta, R., & Gaur, N. (2018). Clinical Practice Guideline on Management of Sleep Disorders in the Elderly. Indian Journal of Psychiatry, 60(Suppl 3), S383–S396. https://doi.org/10.4103/0019-5545.224477 

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1 month ago  

Lymarie Vilella  

RE: week 7 – discussion  

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Hello Catherine 

 

Great presentation.  I like your question How long have been you on Sertraline? Because this will give us information to make decisions such as if we should increase sertraline, change it, or add an augmentation agent.  I like the use of benzos when necessary; however, we should be very careful with Zolpidem because it is not recommended for the general population as a first-line treatment because of its high potential for abuse.  In addition, patients who are depressed should not take zolpidem as it worsens depression, suicidal ideations, and actions (Bouchette et al., 2022).  I suggest you use Trazodone because it has therapeutic actions on Insomnia immediately if dosing is correct.  The onset of therapeutic actions in depression is usually not immediate, often delayed 2-4 weeks whether given as an adjunct to another anti-depressant or as a monotherapy (Stahl, 2017). 

 

References 

Bouchette D, Akhondi H, Quick J.  [Updated 2022 May 8]. Zolpidem.  In: StatPearls [Internet].  Treasure Island (FL): StatPearls Publishing; 2022 Jan-.  Available from: https://www.ncbi.nlm.nih.gov/books/NBK442008/ 

Stahl S. (2017).  Essential psychopharmacology prescribers guide. (6th eds).  Cambridge, United Kingdom.  

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Week 7 Discussion Post 

Case 1, V2: Elderly Depression Case 

The patient is 70 years of age and currently struggles with emotional and mood disorders. She currently receives help from her adult son due to limitations in her ability to hear. These issues are accompanied by difficulty with mobility and underlying medical conditions. Cardiology, anemia and hypothyroidism are amongst the complaints that she has lived with for many years. 

Relevant questions to follow up the available data from the case study would include the following:  

  1.   

To what extent is your sleeping interrupted by medical or emotional disturbances? Are there factors that make it easier for you to wake up throughout the night? How would you evaluate the restfulness of your sleep? 

  

  1.   

With what frequency are you able to take the medication? How can deviating from a prescription be influenced and do you feel the need to continue medical advice when there are problems?  

  

  1.   

How would you characterize your feelings of anxiety or depression? Are these feelings that you experience on a regular basis? Do you identify these feelings in relation to events outside of your control? 

  

Since the patient’s chief complaint is related to her mental and emotional state, these questions are meant to identify core issues or problems that she may be experiencing. Since she has been under the care of other people such as your son, it would be helpful to know what his opinion is about some of the same issues. The home aid would be another person to consult about these issues.  

  1.   

What are some of the ways that the patient communicates with others and shows when she is depressed? How does the patient’s mental state affect her ability to discuss problems with people in her life such as her son or the home aid? 

  

  1.   

Is the patient exhibiting abnormal signs during sleep? Are there impediments to her breathing ability? Is sleep apnea a risk or concern? 

  

  1.   

In addition to these issues, a mental status exam is necessary in order to identify problem solving solutions. Forgetfulness, confusion or disorientation should be documented as well as signs of dementia or Alzheimer’s. 

  

Testing:  

To characterize geriatric illness, the GDs is a helpful metric of depression signs and symptoms. To confirm any documented blood work in terms of vitamin levels that may be off, and MRI would be helpful as well. These are three tools to confirm the medical necessity for chemical or biological intervention with pharmacokinetics. TSH, BMP, BNP, and TSH are the main levels that need to be assessed. By documenting these a substantial case for dysfunction in cognitive areas or dementia can be established (Stahl, 2013). 

Differential Diagnosis :  

  1.   

Major Depressive Disorder (MDD) is the most likely diagnosis  Based on the symptoms described by the patient. She has been in an altered mental state, absent from chemical intervention or any outstanding events. Even though her husband had passed away several years ago, there have been no recent events to affect her mood as drastically as the symptoms have presented. The DSM criteria for this diagnosis includes a persistent lack of interest, comma losing focus on things that used to be engaging and having difficulty interacting with others. Bressert (2019) documents this illness as well as the potential for the elderly to be influenced on an ongoing basis  when they are lonely or in a situation that causes anxiety. 

  

  1.   

 Restless leg syndrome or RLS is a potential diagnosis because of the disturbed sleeping pattern that has perpetuated for several weeks. The patient may be woken up by this problem or have suffered a result of continued sleep pattern interruptions. ROS does not necessarily constitute all of the symptoms that the patient has and therefore isn’t the most accurate in terms of encompassing all potential problems. It could be a co-morbid condition that is brought on by the patient’s lack of sleep and other factors (Fagiolini et al., 2021). 

  

  1.   

 Insomnia is a likely diagnosis and could affect multiple areas of the patient’s life. Since the elderly lady does have difficulty with anxiety and depression it is possible that these are onset due to disturb sleep. The comorbidity of other issues that she has had over the years may constitute  More problems for her mental state and emotional well being. Helping to solve the insomnia either through prescription or other methods of relaxation could help create a better baseline for the type of emotional distress or physical problems experienced by the patient. 

  

Treatment : One of the most effective therapy for 2 of these differential diagnoses would be serotonin therapy. Regulating the mood as well as entering a better state of chemical balance can provide for the most effective results with this patient. 

 This is the best potential treatment especially at an earlier and smaller dose because it creates the propensity for change. Those symptoms may begin to subside as the patient’s brain chemistry changes and the long term results could be substantial enough to support a full recovery (Osawa et al., 2019). Treatment also may improve the signs of depression or instances where anxiety attacks or other incidents take place.  

60 milligrams of Duloxetine  Is the standard dosage to begin helping with daily consumption for depression. It is important for the SSRS to be monitored carefully because of the patient’s previous diagnosis including hypothyroidism and depression. Agonist agent action is another potential way to help with treatment. This includes M T1 receptors and an example of its medication would be Rozerem. Since disturbance to sleeping patterns is one of the most continued problems that the patient faces come on this must be carefully monitored across the continual timeline (Stahl, 2013). 

Ethical Responsibilities:  Treating elderly patients is an important and sensitive task. The mental well being as well as emotional distress of multiple medication changes must be kept in mind in order to ascertain the best level of a level of care. Knowing the exact situation as well as the potential for medication medication and multiple dosages to affect a person is often subjective and without much prior information. In this case, there are several conditions to be wary of including hypothyroidism and insomnia, anxiety and depression. Since the patient is already dependent on her son the issue of autonomy is further important (Tisher & Salardini, 2019). By managing the expectations of the care providers in the hospital as well as the in-home team such as the aid and the son come up it is possible to have a more straightforward and least invasive method in handling this patient. 

 

Lessons & Remarks:  There are several factors that influence the potential success of treatment in this case. Diagnosis means that the patient should be appropriately characterized whether there are one or multiple illnesses. Meanwhile collaboration amongst multiple people in the home as well as her care providers outside the home can substantiate a much more effective result when it comes to long term symptom management. Pharmacology should be used sparingly due to the patient’s higher age and their increased risk for co-morbid symptoms. This case also presents a unique challenge for the autonomy of patient information and decision making due to the multiple parties involved in her treatment. 

There are a lot of lessons based on pharmacology in this study. Multiple conditions are shared among the elderly and can lead to complexities in both diagnosis and treatment. Collaboration and titration are essential to getting the best in both medication and symptom management. 

 

References 

Bressert, S. (2019). Depression Symptoms (Major Depressive Disorder). Psych Central.  

Retrieved from https://psychcentral.com/depression/depression-symptoms-major- 

depressive-disorder 

Fagiolini, A., Florea, I., Loft, H., & Christensen, M. C. (2021). Effectiveness of vortioxetine on emotional blunting in patients with major depressive disorder with inadequate response to SSRI/SNRI treatment. Journal of Affective Disorders, 283, 472-479. 

Osawa, R. A., Carvalho, A. P., Monteiro, O. C., Oliveira, M. C., & Florêncio, M. H. (2019). Degradation of duloxetine: Identification of transformation products by UHPLC-ESI (+)-HRMS/MS, in silico toxicity and wastewater analysis. Journal of Environmental Sciences, 82, 113-123. 

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.  

Tisher, A., & Salardini, A. (2019, April). A comprehensive update on treatment of dementia. In Seminars in neurology (Vol. 39, No. 02, pp. 167-178). Thieme Medical Publishers. 

 

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1 month ago  

Fidelia Ileka  

RE: Main Post  

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Hello Amancia, 

 

Great Post! 

I share your insight prescribing medications to older people are difficult due to comorbidity, limited evidence for efficacy, increased risk of adverse drug reactions, polypharmacy, and altered pharmacokinetics (Milton et al. 2008). Birrer & Vemuri, (2004) postulates that pharmacotherapy for acute episodes of depression usually is effective and free of complications. Underuse or misuse of antidepressants and prescribing inadequate dosages are the most common mistakes physicians make when treating elderly patients for depression (Birrer & Vemuri, 2004).  Depression is treatable in 65 to 75 percent of elderly patients.   A biopsychosocial strategy that includes both medication and counseling is necessary for effective treatment. The benefits of therapy often include higher life satisfaction, more functional ability, potential medical health status improvement, longer life expectancy, and fewer medical expenses. Though complete therapeutic results may not be seen for many months of treatment, improvement should be seen as soon as two weeks from the commencement of therapy (Birrer & Vemuri, 2004). It often takes six to twelve months to recover from a serious depressed episode. According to studies, therapy that is forceful and consistent is most effective for older individuals who are depressed. As a result, elder individuals should get treatment for longer periods of time than are normally recommended for younger patients (Birrer & Vemuri, 2004). 

 

Reference 

 Birrer, R. B., & Vemuri, S. P. (2004). Depression in Later Life: A Diagnostic and Therapeutic  

Challenge. Am Fam Physician ;69(10):2375-2382 

 

Milton, J. C., Hill-Smith, I., & Jackson, S. H. (2008). Prescribing for older people. BMJ.   

 

15;336(7644):606-9. doi: 10.1136/bmj.39503.424653.80. PMID: 18340075; PMCID:  

 

PMC2267940. 

 

 

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Wk7 Discussion-Initial Post  

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Insomnia is defined as the inability to fall asleep or stay asleep. Aging as well as acute stressors are contributing to risk factors for insomnia. It is important to assess primary and secondary causes of insomnia to provide the most appropriate interventions.   

Three questions to ask include; 

  1. Prior sleep quality, quantity prior to death of her husband? This will provide a framework to evaluate the progression of sleep disturbances.   
  1. How many hours do you sleep on average per night? There are normative sleep changes that occur across lifespan such as shifts in circadian rhythms that occur in elderly which is important to differential from insomnia (Lavoie et al., 2018).   
  1. Compliance with medication and the time of day each are taken. The root cause of sleep disturbances can be impacted by the side effects of medications, medical comorbidities, and lifestyle habits such as daytime napping.   

To assess the patient’s situation further, it would be important to include other individuals who have an ongoing relationship with the patient. This may or may not include immediate relatives. It may be the neighbor who accompanied the patient to the appointment or religious members or paid or unpaid caregivers. It would be useful to ask the patient who she spends time with or is supportive to her.   

Additional questions to ask include; 

  • Any noticeable change in mood or attitude, such as sad, withdrawn?   
  • Any avoidance of interactions or socialization?  
  • Any observance of excessive daytime sleepiness?  

Subtle changes in mood and interaction may not be noticeable or significant for the patient to be aware of or report but may be observed by independent parties. It is important to establish which factor, whether depression or insomnia is responsible for the worsening symptoms which have a bi-directional relationship (Stone & Xiao, 2018).   

 

Physical and Diagnostic Examination 

Physical examination would be necessary to rule out pathological causes such as sleep disordered breathing (SDB), obstructive sleep apnea (OSA) nocturia, polyuria resulting in interrupted sleep. Non-pathological changes should also be assessed including sleep habits and physiological changes in sleep (Lavoie et al., 2018). Laboratory testing such as CBC, CMP, hormone levels (e.g., TSH (Thyroid Stimulating Hormone), Estrogen, cortisol, adrenocorticotropic, melatonin) which can detect imbalances that may lead to depression and insomnia.   

Other diagnostic evaluations would include depression assessment using tools such as Geriatric Depression Short Form (SGDS), Pittsburgh sleep quality index (PSQI)  

 or HAM-D which can evaluate both depression and anxiety and can serve as a baseline to evaluate effectiveness of treatment.   

Differential Diagnosis  

A differential diagnosis could be complicated grief which resulted in impairment of psychological functioning. Grieving is a normal following death and typically the indicators such as yearning, anger and depression peaks in six months after the death of a loved one, however in CG the symptoms are prolonged and mimic features of major depressive disorder (Nakajima, 2018). Losing a partner after 40 years of marriage can be challenging.   

Pharmacological Agents  

Different classes of drugs used to treat insomnia include orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines. Elderly patients are very sensitive to hypnotics and most drugs will lead to an increased risk of confusion, falls and sedation.   

Since the patient is taking a first-line antidepressant Sertraline 100mg, it would be crucial to determine the length of use and efficacy. Two pharmacological agents appropriate for the adjunct management of depression and insomnia would be zolpidem and melatonin.  

The first decision would be to add a hypnotic such as Zolpidem 5mg po at bedtime and re-evaluate the patient in 7-10 days (about 1 and a half weeks) for improvement in sleep quality. Patients will be educated on correct use and precautions to take since the medication leads to impairment in alertness and motor coordination.   

Non-FDA-approved hypnotic such as Melatonin shown to improve sleep onset and duration (Abad & Guilleminault, 2018). Melatonin 3mg po at bedtime is another option which provides safe and alternative therapy without comparable side effect profile. According to Pierce et al., (2019), in older adults a dose between 1mg-6mg of Melatonin appears to be effective.   

Ethical Prescribing and Follow-Up 

Elderly or debilitated patients may be especially sensitive to the effects of zolpidem tartrate and other hypnotics. It is important not to exceed the recommended dose or take several doses during the night. The use of Zolpidem is contraindicated in patients with severe hepatic impairment and may lead to encephalopathy.   

Initial follow up for sleep improvement following initiation of Zolpidem is within 10 days. If symptoms improve then the dose can be continued as short-term adjunct while antidepressant effectiveness is achieved. After 4 weeks of insomnia treatment, the dose of Sertraline can be reevaluated and potentially increased if necessary.   

  
 

 

References  

 

Abad, V. C., & Guilleminault, C. (2018). Insomnia in Elderly Patients: Recommendations for Pharmacological Management. Drugs & Aging, 35(9), 791–817. https://doi.org/10.1007/s40266-018-0569-8 

Lavoie, C. J., Zeidler, M. R., & Martin, J. L. (2018). Sleep and aging. Sleep Science and Practice, 2(1). https://doi.org/10.1186/s41606-018-0021-3 

Nakajima, S. (2018). Complicated grief: recent developments in diagnostic criteria and treatment. Philosophical Transactions of the Royal Society B: Biological Sciences, 373(1754), 20170273. https://doi.org/10.1098/rstb.2017.0273 

Pierce, M., Linnebur, S. A., Pearson, S. M., & Fixen, D. R. (2019). Optimal Melatonin Dose in Older Adults: A Clinical Review of the Literature. The Senior Care Pharmacist, 34(7), 419–431. https://doi.org/10.4140/TCP.n.2019.419 

Stone, K. L., & Xiao, Q. (2018). Impact of Poor Sleep on Physical and Mental Health in Older Women. Sleep Medicine Clinics, 13(3), 457–465. https://doi.org/10.1016/j.jsmc.2018.04.012 

HIGHLIGHTS OF PRESCRIBING INFORMATION. (n.d.). Retrieved July 14, 2022, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/019908s038lbl.pdf 

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1 month ago  

MARYANN EBOM  

RE: Wk7 Discussion-Initial Post  

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Hello Meredith, 

This is an exceptionally detailed post about the case scenario given. The questions you have suggested are essential in providing the healthcare professional insights of the current situation of the patient and also guiding proper diagnosis of the patient’s condition. Apart from the physical and diagnostic examinations you have mentioned, the other potential diagnostic test in this patient is cognitive examination. Many elderly people with cognitive impairments often encounter interruptions in sleep. Therefore, it is imperative to perform cognitive assessment in this patient to establish possibility of cognitive decline (Wardle-Pinkston et al., 2019). Although the examination revealed that the patient is alert and oriented to place, time, and person, the cognitive impairment could be at the initial stages, which could be associated with her insomnia. The pharmacological agents you described are appropriate. However, it is important to ensure ethical conduct in prescribing the medications including informing the patients about the rationale of prescribing the medications and the potential side effects of the drugs (Khazzaka, 2019). The informed consent of the patient must be sought before prescription. 

References 

Khazzaka, M. (2019). Pharmaceutical marketing strategies’ influence on physicians’ prescribing pattern in Lebanon: ethics, gifts, and samples. BMC health services research, 19(1), 1-11. https://doi.org/10.1186/s12913-019-3887-6 

Wardle-Pinkston, S., Slavish, D. C., & Taylor, D. J. (2019). Insomnia and cognitive performance: a systematic review and meta-analysis. Sleep medicine reviews, 48, 101205. https://doi.org/10.1016/j.smrv.2019.07 

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1 month ago  

Meredith Ximines-Mullings  

RE: Wk7 Discussion-Initial Post  

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Hi Maryann,  

 

Thanks for your thoughtful feedback! I agree cognitive assessement is crucial, especially at her age to rule out cognitive decline. 

 

Keep up the great job 🙂 

Meredith 

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Andrew Wargo – Main Post  

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Questions for Patient 

If I were the nurse practitioner dealing with the case study of the 75-year old widowed woman, this is how I would approach her treatment plan. Based upon the information provided, I assume the patient is suffering from insomnia due to depression. I would ask questions in the assessment like, are you having any thoughts of suicide or ever attempted suicide in the past? The main risk factors for suicidal death are becoming a widow/widower, having other mental disorders, physical illness, and bereavement (Conjero et al., 2018). Screening for suicide is one of the most important things during a psychiatric evaluation, even if they have previously denied suicidal thoughts or ideations. 

Have you changed your diet patterns, exercise, or taken any drugs/alcohol since your partner’s passing? This question is important in determining if the patient’s sleep patterns are being affected by something other than her mental health. The patient is on a plethora of medications for medical conditions and one/some of these medications could possibly be causing insomnia. Also, there are sometimes foods/drinks that people don’t know contain caffeine that they are consuming before bed, and it is interfering with their sleep.  The patient’s sleeping patterns, daily activities, and compliance with the current medication can have a significant impact on a patient’s mental health (Lechtzin et al., 2017). 

Do you have someone that you can talk to and socialize with on a consistent basis? This question is imperative to ensure the patient is safe and has someone else they can talk to and checks up on them. According to Kleiman & Liu (2013), having social support is associated with a decreased likelihood of a lifetime suicide attempt. 

Family and Friends 

As an older woman, who has a combination of comorbid conditions it is your responsibility to ensure the patient is safe. Getting feedback from close family or friends about the patient’s status can determine if the patient is capable of living alone or need assistance. There are a few questions I would ensure to ask her friends or family. Has the patient been keeping up with her hygiene? Have you noticed any significant weight gain or loss? Have you noticed any changes in the patient since her husband passed away? Can the patient independently perform all her daily activities of living? Asking these questions gets honest feedback from a third party because sometimes patients will not tell the truth in order to protect their liberties. Older people especially do not want to admit they need help, so having trusted friends and family’s opinions can prove worthwhile. Also, you do want to make sure the lady has someone who is checking up on her and noticing her health changes. 

Diagnostic Tests 

Diagnostic tests in this case study I would include would be a sleep study, including polysomnography. This monitors brain wave activity, heart and breathing rates, oxygen levels, and muscle movements that occur prior to, during, and after sleep. Another important test to run is a sleep apnea test. This is a study to measure your vitals during your sleep, specifically checking for a drop in oxygen levels during sleep. Other diagnostic tests to run would be blood tests like TSH, CBC, and CMP. These tests can help determine if there are other underlying medical conditions that may be inhibiting her sleep. I also would have the patient fill out the HAM-D. Also called the Hamilton Depression Rating Scale, this is a multiple-item questionnaire used to provide an indication of depression, and as a guide to evaluate recovery. 

Differential Diagnoses  

A possible differential diagnosis is sleep apnea. Sleep apnea is a sleep disorder where breathing is interrupted repeatedly during sleep, causing the person to constantly awaken. Sleep apnea can also be caused a drug, the patient is on a plethora of medications. If the insomnia is not caused by depression and anxiety then I would say that sleep apnea is the most likely differential diagnosis. Another differential diagnosis is restless legs syndrome. Although, restless legs syndrome is a common cause of insomnia, most patients will report that their legs are uncomfortable and the urge to move them does not stop during nighttime. Restless legs syndrome can be the side effect of medications and an effect from conditions like high blood pressure or diabetes. 

Possible Medications 

I would recommend the patient begin on 50 mg Trazodone PO at bedtime. I would choose the medication because it is an effective antidepressant that is also used for insomnia. Trazodone acts by binding at the 5-HT2 receptor and acts as a serotonin agonist at high doses. At low doses, it acts as a serotonin antagonist. The activity is likely to result from reuptake by inhibiting the serotonin reuptake pump at the presynaptic neuronal membrane. The prolonged usage of trazodone may affect postsynaptic neuronal receptor binding sites and cause a sedative effect resulting from modest histamine blockade and adrenergic blocking action at the H1 receptor (Yi et al., 2018). The initial dosage is 150 mg daily in divided doses and increased after four days to 200 mg daily. 

Another medication therapy that could be used is Eszopiclone 3 mg PO at bedtime. Sold under the brand name Lunesta, the medication is used to treat insomnia. The medication interacts with GABA receptor complexes at the binding domains allosterically coupled close to benzodiazepine receptors (Brielmaier, 2006). I would prefer starting this patient on Trazodone 50 mg PO at bedtime, over the Lunesta because trazodone’s mechanism of action is aimed at increasing serotonin, which aids in depression and insomnia. 

Ethics and Contraindications 

With any medication comes contraindications. Contraindications of trazodone include glaucoma because the drug has the potential to increase intraocular pressure leading to the deterioration of vision. Trazodone is also contraindicated in people with liver disease because the drug is mainly metabolized in the liver. If the liver function is compromised, then the pharmacokinetics of the drug on the body could be slowed down. This leads to the slower metabolism of the drug resulting in the diminished therapeutic effects of the medication. Another contraindication is renal disease because trazodone is significantly eliminated by the kidneys, in urine. Individuals with renal disease and diminished renal function cannot eliminate trazodone normally, which allows the medication to be in the bloodstream longer, thus increasing the risk for side effects and toxicity with medication. Because the patient is elderly the drug may be eliminated slower, so it is ethical to prescribe the smallest possible dose first to see how the patient reacts. The elderly are at increased risk of side effects of medications due to 

Follow-Ups 

Follow-up appointments are very important to see how the patient is tolerating the medication along with its effectiveness in treating the patient’s symptoms. Things to screen for include side effects including hypertension/hypotension, dizziness, weight gain, and confusion. The patient is also prescribed sertraline 100 mg, which combined with trazodone can increase the chance of serotonin syndrome. Recognizing signs of serotonin syndrome like restlessness, insomnia, confusion, and increased HR and BP is important. It is a possibility that I would have to make therapeutic changes based on the patient’s response. Increasing the medication to 100 mg daily is a possibility if the medication does not seem to be strong enough for her depression or insomnia. The 50 mg is a good starting dose to test for any possible side effects the patient might exhibit. I would include all these “check points” at week 4, 8, 12, etc.). 

References 

Brielmaier, B. (2006). Eszopiclone (Lunesta): a new nonbenzodiazepine hypnotic agent. Proc (Bayl Univ Med Cent). 2006 Jan;19(1):54-9. doi: 10.1080/08998280.2006.11928127. PMID: 16424933; PMCID: PMC1325284. 

Conejero I, Olié E, Courtet P, & Calati R. (2018). Suicide in older adults: current perspectives. Clin Interv Aging. 2018 Apr 20;13:691-699. doi: 10.2147/CIA.S130670. PMID: 29719381; PMCID: PMC5916258. 

Kleiman EM, Liu RT. Social support as a protective factor in suicide: findings from two nationally representative samples. J Affect Disord. 2013 Sep 5;150(2):540-5. doi: 10.1016/j.jad.2013.01.033. Epub 2013 Mar 5. PMID: 23466401; PMCID: PMC3683363. 

Lechtzin, N., Mayer-Hamblett, N., West, N. E., Allgood, S., Wilhelm, E., Khan, U., & Aitken, M. L. (2017). Home monitoring of patients with cystic fibrosis to identify and treat acute pulmonary exacerbations eICE study results. American Journal of Respiratory and Critical Care Medicine, 196(9), 1144-1151. https://doi.org/10.1164/rccm.201610-2172OC 

Levenson, J. C., Kay, D., & Buysse, D. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179-1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/ 

Yi, X., Ni, S., Ghadami, M., & Meng, H. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 45, 25-32. https://doi.org/10.1016/j.sleep.2018.01.01 

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1 month ago  

Sloane Caruso  

RE: Andrew Wargo – Main Post  

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Andrew,
Thank you for your post. The possibility of sleep apnea for this patient didn’t cross my mind initially, but
after reading your post it is definitely something to consider. She is overweight, and by calculating her
BMI, giving us a result of 33.1, she is considered obese, which is the most common risk factor of sleep
apnea (Veasey & Rosen, 2019). Some studies have shown that there is a significant correlation in the
improvement of mood, anxiety, depression, and cognition with the use of a CPAP in patients with
obstructive sleep apnea (Gad et al, 2020). In general, we have all experienced a poor night’s sleep and
how much it affects our mood and ability to function at our prime. I couldn’t imagine having to function
with poor sleep every night and be expected to be chipper and at the top of my game all the time. 

 

Doaa M Gad, Hala A Fathy, & Samah M Shehata. (2020). Effects of continuous positive airway pressure
treatment on mood, cognition, and quality of life in patients with obstructive sleep apnea. Egyptian
Journal of Chest Disease and Tuberculosis, 69(4), 688–697. https://doi.org/10.4103/ejcdt.ejcdt_222_19 

 

Veasey, S. C., & Rosen, I. M. (2019). Ostructive Sleep Apnea in Adults. The New England Journal of
Medicine, 380(15), 1442. 

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1 month ago  

Eddy Dominguez  

RE: Andrew Wargo – Main Post  

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Hello Andrew, 

I really liked your response and especially the organized format. Each question’s clear header allows me as a reader to better grasp the subject being spoken on compared to a paragraph style, facilitating my ability to understand and respond to this post. I especially liked your “Family and Friends” section as it covers several crucial points to the field of psychiatry that can be overlooked when only looking at pharmaceutical solutions; from my experience, having solid communication with family and friends of the patient exponentially improved treatment and patient adherence to treatment, also having a pillar of support to help the patient through rough episodes of treatment. Additionally, I really liked how you mentioned Trazodone for one of the medications to give to this patient. Trazodone, a rather unique SSRI, has been found to be effective in treating individuals with secondary insomnia stemming from depression and in a study evaluating these effects, it has been “reported that trazodone normalized sleep and mood by interacting with melatonin (Jaffer, 2017). I also found your dosage of trazodone of 50 mg PO HS very helpful for the patient as well, as the dosage is low enough to test for tolerance but sufficient to see desired effects. Additionally, your second medication, Eszopiclone, was also a good choice in my opinion. In addition to its FDA approval for sleep maintenance, a study found that “eszopiclone 2 mg improved both sleep initiation and sleep maintenance subjective and objective parameters and improved daytime function with improved alertness, ability to concentrate, and physical well-being” (Abad, 2018). Finally, I appreciate the additional mention of the careful consideration of kidney damage due to the use of Trazodone, as the patient is diabetic and that must be considered before possibly putting more pressure on the patient’s kidneys. Great response! 

 

References: 

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34. 

 

Abad, V.C., Guilleminault, C. Insomnia in Elderly Patients: Recommendations for Pharmacological Management. Drugs Aging 35, 791–817 (2018). https://doi.org/10.1007/s40266-018-0569-8 

 

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1 month ago  

MARYANN EBOM  

RE: Andrew Wargo – Main Post  

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Hello Andrew! This is an outstanding post. I agree with you. Regarding the possible medications, I concur with you that Eszopiclone 3 mg PO at bedtime is one of the appropriate medications that could be used in this case. The medication is indicated for insomnia management in patients who are 18 years and above. Eszopiclone is linked to a half-life of between 6 and 8 hours and is not associated with rapid eye movement (REM) sleep relapse when discontinued (Madari et al., 2021). The medication has also been used for a long time without any adverse effect on clinical trials. The effects of the Eszopiclone are traced to its interaction with GABA receptor coupled with benzodiazepine receptors. Regarding ethical requirements and contradictions, the prescription of these medications should consider ethical practices including ensuring appropriate dosage and also the strength, frequency, and route of administration (Khazzaka, 2019). Clinicians should also check contradictions such as interactions with other therapies, allergies, and patient’s underlying conditions. 

References 

Khazzaka, M. (2019). Pharmaceutical marketing strategies’ influence on physicians’ prescribing pattern in Lebanon: ethics, gifts, and samples. BMC health services research, 19(1), 1-11. https://doi.org/10.1186/s12913-019-3887-6 

Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological management of insomnia. Neurotherapeutics, 18(1), 44-52. https://doi.org/10.1007/s13311-021-01010-z 

 

 

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1 month ago  

Keyana Hobdy  

RE: Andrew Wargo – Main Post  

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Discussion Post Response #2 

Andrew, I enjoyed your post on Insomnia for this patient. I did not consider sleep apnea, because when I read the original post, it appeared that the patient was complaining of not sleeping and her sleep “habits” being affected. You had me look at it from a different perspective. I am unsure if I would order a sleep study at the first visit, as the provider I would want to possibly prescribe something first that the patient can try to get to sleep. One of the things that I did think of was to ask the patient at what time of the day is she taking her HCTZ. Thiazides are commonly prescribed to older people for the management of hypertension. (Sommerauer et al., 2017) One simple change that we could be overlooking is when the medication is taken. If the patient is taking the medication at night, this could be causing her to have to stay up or perhaps be up and down throughout the night to use the restroom. Hydrochlorothiazide is in a class of medications called diuretics (‘water pills’). It works by causing the kidneys to get rid of unneeded water and salt from the body into urine. (Hydrochlorothiazide: Medlineplus Drug Information, n.d.) Educating the patient on changing the administration time to the a.m. would possibly keep the patient from having to get up and down in the night. I agree with you choice of adding Trazadone as well so that the patient can finally try and get some sleep, this along with a good sleep routine and medication changes and education could possibly help the patient to finally be able to get a good night’s rest. 

References 

Hydrochlorothiazide: Medlineplus drug information. (n.d.). https://medlineplus.gov/druginfo/meds/a682571.html#:~:text=Hydrochlorothiazide%20is%20in%20a%20class,the%20body%20into%20the%20urine. 

Sommerauer, C., Kaushik, N., Woodham, A., Renom-Guiteras, A., Martinez, Y. V., Reeves, D., Kunnamo, I., Al Qur‵an, T., Hübner, S., & Sönnichsen, A. (2017). Thiazides in the management of hypertension in older adults – a systematic review. BMC Geriatrics, 17(S1). https://doi.org/10.1186/s12877-017-0576-3 

 

 

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1 month ago  

Aleksander Porres Milian  

RE: Andrew Wargo – Main Post  

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Hello Andrew, 

Excellent post on the week seven discussion! I enjoyed reading your post, and I agree with your differentials. Your post helped me to understand the mechanism of action of caffeine better. I know that caffeine causes insomnia but did not know how. The use of caffeine at night may cause increased worrying at night and sleeplessness (Chaudhary et al., 2016). The use of caffeine at bedtime has proved to cause decreased total sleep time, difficulty falling asleep, increased nocturnal awakenings, and daytime sleepiness. The use of caffeine can also cause increased sleep latency, decreased stages two and four of non-rapid eye movement sleep, sleep fragmentation with brief arousals from sleep, and reduced sleep duration. Insomnia increases the risk of many mental illnesses (Hertenstein et al., 2019). 

 In addition to the checkpoint you stated above, at four weeks follow-up, you also need to find out if the patient is tolerating the medication and discuss the side effects that the patient may have encountered. Patients receiving insomnia treatment had an increased risk of falls and mortality compared with the people not receiving treatment for insomnia (Amari et al., 2022). Trazodone and benzodiazepines are associated with the most significant risk of falls, especially in the elderly. At the beginning of the treatment, the provider must have discussed the anticipated side effects of Trazodone with the patient, and at four weeks follow-up, the provider must find out from the patient if she has experienced or experiencing the side effects and follow up as needed based on the information that the provider received from the patient. 

References 

Amari, D. T., Juday, T., Frech, F. H., Wang, W., Wu, Z., Atkins, N., Jr, & Wickwire, E. M. (2022). Falls, healthcare resources, and costs in older adults with insomnia treated with zolpidem, Trazodone, or benzodiazepines. BMC Geriatrics, 22(1), 484. https://doi.org/10.1186/s12877-022-03165-6 

Chaudhary, N. S., Grandner, M. A., Jackson, N. J., & Chakravorty, S. (2016). Caffeine consumption, insomnia, and sleep duration: Results from a nationally representative sample. Nutrition (Burbank, Los Angeles County, Calif.), 32(11-12), 1193–1199.https://doi.org/10.1016/j.nut.2016.04.005 

Hertenstein, E., Feige, B., Gmeiner, T., Kienzler, C., Spiegelhalder, K., Johann, A., Jansson-Fröjmark, M., Palagini, L., Rücker, G., Riemann, D., & Baglioni, C. (2019). Insomnia as a predictor of mental disorders: A systematic review and meta-analysis. Sleep Medicine Reviews, 43, 96–105.https://doi.org/10.1016/j.smrv.2018.10.006 

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Week 7  

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Question 1 

The following are the three questions that I might ask the patient if she were in my office:  

  1. “How are you feeling today, physically and emotionally?”  

Rationale: Understanding how the patient feels will help, establish ideas regarding the possible underlying causes of her symptoms. This also assesses the patient’s current mood and affect and enables me to understand her better. 

  1. “How would you describe your sleep habit?”  

Rationale: The sleep habits, length of sleep and nature of sleep of this patient can be assessed. How sleep impacts and affects her daily activities can also be assessed, how the patient copes with lack of sleep can also be evaluated.  

  1. “What cognitive and physical symptoms have you been feeling lately?”  

Being able to assess and measure the cognitive levels of a patient helps to rule out wrong diagnoses and the presence of physical symptoms specific to certain illnesses helps narrow down the potential etiology of her insomnia. 

Open-ended questions were asked to obtain more information from the patient.  

Question 2 

I would speak to the following persons in the life of the patient for further evaluation.  

Children: Speaking with the children of the patient will help understand the background, more of an insight into the social life of the patient.  

Friends: Most people hang around friends and can be greatly influenced by their peers, so interacting with the friends of the patient will provide more information about the lifestyle of patients.  

Question 3 

Physical examination and diagnostic testing will be based on the clinical presentation of the patient. The following can be the assessments that the patient can undergo (Legg, 2018): 

  • Laboratory testing. There are multiple laboratory tests, such as hormonal levels, viral infection tests that could be done (Legg, 2018).  
  • Physical examination. A cephalocaudal physical examination (inspection, palpation, percussion, auscultation) can be done to assess for other apparent signs of other health conditions or individual factors (e.g., medications, environment, etc.) that may contribute to the symptoms being experienced by the patient.  
  • Psychiatric evaluation. Mental health assessment could be performed to assess the patient’s symptoms, thoughts, feelings, and behavior patterns in association with the specified criterion in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Aside from a general interview, the patient may be requested to fill in condition-specific questionnaires.  

Question 4 

Based on the clinical presentation of the patient, the following are the differential diagnoses (Psych Scene, 2020). 

(1) Depression. This pertains to a mood disorder that results in a persistent feeling of sadness, hopelessness, and loss of interest 

(2) Anxiety. Characterized as the feeling of persistent and excessive worry about various aspects of one’s life. 

(3) Organic. These are physical health conditions or diseases. For the patient, it is more likely to be hypothyroidism which could be plausible above the other possible organic causes known to cause similar symptoms experienced by the patient. 

It can be inferred that the one that I think is most likely would be DEPRESSION. Depression can be described as persistent hopelessness and despair. It can manifest following major events in one’s life, such as death or loss, which was experienced by the patient when she lost her husband 10 months ago. Signs and symptoms include a hopeless outlook, which may be matched with her verbalization of “depression has gotten worse”, increased fatigue and sleep problems, anxiety, and irritability. Although the patient denies any active suicidal ideations, she should be assessed for the presence of passive suicidal ideations, or self-harming thoughts that may not be evident (e.g. wishing to die in her sleep or in an accident) to ensure her safety. 

Question 5 

Two pharmacological agents that are appropriate for the patient’s antidepressant therapy basing on their pharmacokinetics and pharmacodynamics would be: 

(a) Fluoxetine (Prozac). This is one of the most common antidepressants prescribed due to its recorded high effectivity rate. This belongs to a class of antidepressants known as selective serotonin reuptake inhibitors (SSRIs), helping to increase the neurotransmitter serotonin, which improves overall mood and well-being. I’ve considered Prozac given that it’s one of the few antidepressants that the FDA has approved for children, teenagers, and elderly use. It was also documented to be safe in patients with diabetes (like the patient) and undergoing diabetes treatment regimen, as this does not increase sugar levels (Ullman, 2000).  

(b) Escitalopram (Lexapro). Given that it comes from the same drug family, Lexapro is also one of the few medications that have been approved by children, teenagers, and the elderly for use as they are also relatively safe (Schimelpfening, 2020). It was also proven to alleviate the manifestations of anxiety, which may possibly be causing the patient’s difficulty in sleeping. 

Question 6 

So far, studies have proven that there is not enough evidence on the influence of ethnicity in treatment outcomes of depression. Past studies, which revealed poorer outcomes for minority patients than Caucasians, or conversely, that African Americans and Latinos respond more quickly than Caucasians have been debunked by more recent clinical trials. There has been little to no differences in the outcome or speed of response between minority and Caucasian patients. Despite these contemporary investigations, current data are still limited in terms of whether, to what extent, and in what way ethnicity may influence treatment response in depression Thus, there is still a persistent need for prospective studies regarding possible ethnic group differences (Lesser 2010; Murphy et. al., 2013) 

Regardless of ethnicity, still, there are still contraindications for both medications to take note of. They are the following (Pediatric Oncall, 2020): 

(a) Fluoxetine (Prozac).  

  • Hypersensitivity to fluoxetine or any component in its formulation  
  • Intake and use of other medications, such as monoamine oxidase inhibitors (MAOI), linezolid, pimozide, thioridazine, or tamoxifen.  
  • Individuals with a history of seizures.  

(b) Escitalopram (Lexapro). 

  • Hypersensitivity to citalopram/escitalopram, or any component in its formulation  
  • Those taking other medications, such as MAOIs, anticoagulants, thrombolytic,  
  • Those that shall undergo electroconvulsive therapy.  
  • Individuals currently suffering from other health conditions, such as dehydration, hyponatremia, and hypovolemia, Apheresis, AV block, bradycardia, cardiomyopathy, celiac disease, heart failure, human immunodeficiency virus (HIV) infection, hyperparathyroidism, hypocalcemia, hypokalemia, hypomagnesemia, hypothermia, hypothyroidism, long QT syndrome, myocardial infarction, pheochromocytoma, QT prolongation, rheumatoid arthritis, sickle cell disease, sleep deprivation, stroke, systemic lupus erythematosus (SLE), and hepatic and renal failure.  

Question 7 

The following are the therapeutic changes that I might make based on possible outcomes that may happen given my treatment options chosen: 

(a) Fluoxetine (Prozac). Initially, it shall be given at a dosage of 20 mg/day orally in the morning. Dosage adjustment may be considered if inadequate clinical improvement or relief of symptoms has been noted. An increase of the dosage may be ordered; however, it should be within the maximum fluoxetine dosage, which should not be more than 80 mg/day (RxList, 2020). Furthermore, given that the patient is an older adult (on multiple concomitant medications and with concurrent diseases) a lower or less frequent dosage should be taken into consideration. Upon withdrawal of treatment, should ever (e.g., for reasons such as the patient cannot tolerate the side effects, or switching to another medication), a gradual dose reduction should be performed (Drugs.com, 2020) 

(b) Escitalopram (Lexapro). Dosing adjustments should be according to the individual needs of the patient. Given that she would more likely be engaged in extended therapy of this medication, the lowest effective dose should be maintained as she is continually assessed. Age considerations and drug interactions with other concomitant medications should also be noted. Should intolerable symptoms occur, and discontinuation of treatment would be imminent, gradual dose reduction should be performed. Hepatic and renal functioning should also be constantly monitored (Medscape, 2020). 

References 

Drugs.com. (2020). Fluoxetine Dosage Guide with Precautions. Drugs.com. https://www.drugs.com/dosage/fluoxetine.html#Dose_Adjustments. 

 

Legg, T. J. (2018). Diagnosing Depression. Healthline. https://www.healthline.com/health/depression/tests-diagnosis. 

 

Medscape. (2020, September 5). Lexapro (escitalopram) dosing, indications, interactions, adverse effects, and more. https://reference.medscape.com/drug/lexapro-escitalopram-342961. 

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1 month ago  

Hope OKOROIGWE  

RE: Week 7  

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Hi Yvette, 

I enjoyed reading your post. I would also agree with your diagnosis of MDD. MDD can be a lifelong struggle and difficult to manage. When dealing with major depressive disorder, it is important to maintain control over one’s symptoms and be aware of the onset stage and symptoms that appear immediately before a major depressive episode. A person suffering from major depressive disorders exhibits symptoms such as unrealistic anxiety, despair, hopelessness, chronic fatigue, irritability, constant crying, lack of attention and concentration, inability to make decisions, and a general lack of interest in life (Legg, 2018). To determine if someone has MDD, information about their past, childhood, past traumas, medical history, family history of mental illnesses, and current symptoms are all examined. 

To manage MDD, it is important to engage in 30 minutes of physical activity each day. Yoga, walking, jogging, a walk around the block, and gardening are all options (Monroe, & Harkness, 2017). If this seems too daunting, start with 10-15 minutes per day and gradually increase by 5 minutes each day. Make sure to feed your body well-balanced meals. And getting enough sleep is essential for physical health, mental acuity, and concentration. Finally, ensure to take the prescribed medication on a regular basis. 

 

References: 

Monroe, S. M., & Harkness, K. L. (2017). Recurrence in major depression: conceptual 

analysis. Psychological review, 118(4), 655–674. https://doi.org/10.1037/a0025190 

Legg, T. J. (2018). Diagnosing Depression. Healthline. 

https://www.healthline.com/health/depression/tests-diagnosis. 

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Week 7 Forum  

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A 75-year old female presented to the office with a complaint of insomnia.  Ten months ago, her husband of 41 years passed away.  She has a hx of diabetes Type 2, HTN and MDD.  She states since her husband’s passing, she has been depress and her sleep habits have gotten worse.  She denies a hx of depression prior to her husband’s passing.  She is alert and oriented x3 and sees her PCP twice a year.  She denies any H/I,S/I.  She is currently prescribed Metformin 500mg BID, Januvia 100mg QD, Losartan 100mg QD, HCTZ 25mg QD, and Sertraline 100mg QD.  Her height is 64-inches and her weight is 88kg.  VS are: T98.6 and BP132/86. 

            

The first question I will be asking patient is how is her blood sugar level. Reason I will be asking her is because patient with diabetes tend to develop depression (Satorius, 2018). Moreover, people with diabetes tend to have high blood sugar level when they are sick. Knowing her glucose levels would help determine how controlled her diabetes is. 

   Next i would ask about her medication and if she had any changes and if she compliant.  Any change in medications could cause adverse effects. Moreover, the Seroquel that has been added to her medication although used for both insomnia and major depressive disorder can have a side effect of insomnia (IBM Corporation, 2020).  

  Finally, i would ask her about her duration of depression and level.  She states her depression is getting worse.  It would be important to know if the depression is constant and if it stays at a certain level.  Knowing her baseline is important to know where she needs to be or how much worse her depression has become.  

            It would be important to speak to someone who knows her well.  Any family such as children or siblings.  If she lives with someone, that person could give information about the patient’s habits and any changes they have noticed.  If she lives in a group home, nursing home, skilled facility or other type of facility, speaking with the nurse or caregiver would be important.  It would also be a good idea to speak to her PCP. 

            A CBC and BMP along with A1C would be important for the patient due to her health history.  I would also want an EKG due to her hypertension.  A liver function test due to medication management. A serotonin test related to her medication.  And a HAM-D would need to be done. 

            A differential diagnosis could be insomnia disorder (American Psychiatric Association, 2013). She reports her sleep habits have changed and presents with insomnia as her primary complaint.  She meets criteria depending on her disturbance.  Does her issue happen at least three nights a week?  Has it been happening for three months?  She has a dissatisfaction with her sleep quantity or quality.  This diagnosis can be given along with another mental disorder, such as major depressive disorder.  While the onset of insomnia is most common in young adulthood, it can also be situational and related to life events. Insomnia in the older adult is sometimes related to increasing health problems or aging.  The patient is overweight with multiple health issues in addition to her mental health complaint that is most likely related to her loss.  Insomnia is most prevalent in females and “advancing age” is associated with an increased chance of insomnia.  

            Pharmacologically, I would look at Doxepin 1mg QHS as a treatment for the patient’s insomnia.  This is an antidepressant that is selective for histamine 1 receptors (Patel, 2018).  This medication has been shown to be successful in patients 65 years old and older. If needed, higher doses (3-6mg) have been shown to be effective in patients with significant insomnia.  There is a contraindication of MAOI use, which the patient does not have.  The patient is obese. This medication should not be used in a patient with sleep apnea (IBM Corporation, 2020).   Re-evaluation would need to be in 7-10 days to monitor symptoms persisting (IBM Corporation, 2020) 

            A second option would be Mirtazapine 15mg QHS.  Mirtazapine is a drug that is used commonly due to the sedative effects being produced through histamine receptor antagonism (Patel 2018). This medication has been shown to improve sleep in patients 18-75.  The report states this medication should be used only in a patient with depression.  The patient does have depression and is diagnosed as such.  There is a contraindication of MAOI use, which this patient does not have.  There is an increased risk of suicidal thoughts.  There is a risk for hypotension so the patient being on medication for HTN could be a caution (IBM  Corporation, 2020).  This medication has shown improvement within two weeks of therapy beginning (Patel, 2018).  A four week follow-up would be good, but if needed, a two week follow up could be a better plan.  The patient’s sodium level would need to be monitored after 3-4 weeks of initiation and her weight should be monitored. (IBM Corporation, 2020). 

                                                               References 

American Psychiatric Association. (2013). Insomnia Disorder. In Dagnostic and statistical manual of mental disorders (5th ed., pp. 362-368) Arlington, VA: Author. 

IBM Corporation. (2020). Quetiapine Fumarate. IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/CS/E1D950/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/B19FF9/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.GoToDashboard?docId=924369&contentSetId=100&title=Quetiapine+Fumarate&servicesTitle=Quetiapine+Fumarate&brandName=SEROquel# 

 

 

IBM Corporation. (2020). Mirazapine. IBM Micromedex. from:https://www.micromedexsolutions.com/micromedex2/librarian/CS/4AA09B/ND_PR/evidencexpert/ND_P/evidencexpert/DUPLICATIONSHIELDSYNC/3B7C3D/ND_PG/evidencexpert/ND_B/evidencexpert/ND_AppProduct/evidencexpert/ND_T/evidencexpert/PFActionId/evidencexpert.DoIntegratedSearch?SearchTerm=mirtazapine# 

 

 

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172 

 

Sartorius N. (2018). Depression and diabetes. Dialogues in clinical neuroscience, 20(1), 47–52. https://doi.org/10.31887/DCNS.2018.20.1/nsartorius 

 

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1 month ago  

Meredith Ximines-Mullings  

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Hi Carine,   

Highly informative post!   

The management of elderly becomes so complicated especially with the presence of comorbidities. There are so many factors to consider, as mentioned in your post, the correlation to diabetes and elevated blood sugar levels can impact sleep. Likewise, insomnia can lead to depression and depression can cause insomnia, leaves us wonder, which was first…the egg or the chicken.   

The patient is currently taking HCTZ which inhibits sodium reabsorption leading to more sodium being excreted in the kidneys (Herman & Khalid Bashir, 2019). The patient is also on Sertraline, which is associated with an increased risk of hyponatremia especially in elderly patients (Moscona-Nissan et al., 2021). Notably, Mirtazapine also presents a moderate risk of low sodium levels, and it is recommended not to be used with antidepressants to prevent adverse effects or hospitalization (Moscona-Nissan et al., 2021).   

 

 

References  

Herman, L. L., & Khalid Bashir. (2019). Hydrochlorothiazide. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK430766/ 

Moscona-Nissan, A., López-Hernández, J. C., & González-Morales, A. P. (2021). Mirtazapine Risk of Hyponatremia and Syndrome of Inappropriate Antidiuretic Hormone Secretion in Adult and Elderly Patients: A Systematic Review. Cureus. https://doi.org/10.7759/cureus.20823 

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Week 7 discussion  

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Questions I would ask 

I would want to determine the root cause and length of her depression. In her own words, did her “depression” begin prior to her husband’s death or after? Is her grief related to the loss of her husband? Does she feel lonely, vulnerable, powerless, remorseful, hopeless, or empty? 

I would also want her perspective on her current state. I would ask what she feels grateful for? I would ask what her daily routine looks like? I would ask her who she confides in, to trust and get better? 

I would also explore her sleep patterns, by probing whether she has difficulty falling asleep, or waking up, or if she has mid-sleep awakenings? There are many reasons why people can have impaired sleep. (Levenson, Kay, & Buysse, 2015) 

Collateral 

I would want collateral information from people in her lives that she typically spends the most time with. For example, if she spends time with relatives, I would ask family members to tell me her state of being compared to her “normal” prior to her husbands’ death. Whereas, if she spent time with friends, I would ask those friends for collateral.  

Physical exams and diagnostics 

I would do the Patient Health Questionnaire – 9 to screen for depression (Lai et al., 2017). I would also use the Generalized Anxiety Disorder Scale (GAD-7) to explore her level of anxiety. I would do the Insomnia Severity Index and Sleep Assessment Questionnaire to assess her current level of sleep. I would also do a Montreal Cognitive Assessment to assess for dementia.  

Differential diagnosis 

  1. Persistent complex bereavement disorder  
  1. Major depressive disorder  
  1. Adjustment disorder  

Although grief is a natural course of emotions after loss of significant people, there is a certain type of bereavement that does not resolve naturally. The DSM-5 diagnosis for this type of grief is Persistent Complex Bereavement Disorder. This is characterized as a grief for a period greater than 6 months, disabling, and impaired functionality in daily life (Lee, 2019). I believe this diagnosis is more fitting than the other diagnosis to her situation. Although there can be sufficient argument made that the other diagnosis are more suitable, I think this diagnosis describes her situation better.  

Medications and contraindications 

I would start her on citalopram (Celexa) 10 mg daily or venlafaxine (Effexor) 37.5 mg daily. Either are fine as a first-line treatment for depression. They are SSRI and SNRI, respectively. The doses are starting doses, which are half of the usual dosage for the patient. Because the mechanism of actions of the medications are so similar, and the evidence based literature has shown similar efficacy, I wouldn’t prioritize one medication over the other, and simply ask the patient what she prefers. That would give the patient a level of involvement that is important in generating buy-in for the treatment plan.  

Some side effects may include nausea, or people from certain ethnic backgrounds that are more likely to metabolize SSRI at slower rates depending on certain liver enzymes. That is why the prescriptions are starting dose, with a follow-up within 4 weeks to assess for side effects. These contraindications can leave to overdose or serotonin syndrome in the patients (Furukawa et al., 2019).  

Follow-up and check points 

I would do a follow up in four weeks to check for side effects. I would increase the dose to the usual dose at this point, if side effects are not observed. I would do another follow-up at the Week 8 of the treatment period, to determine if the medication is achieving the desired treatment objective. I would assess in Week 12 as well to see if the medication met expectations for treatment or if the medication failed for the treatment of the patient. If the medication did not meet the intended goals, then other second-line treatments would have to be considered.  

References 

Furukawa, T. A., Cipriani, A., Cowen, P. J., Leucht, S., Egger, M., & Salanti, G. (2019). Optimal dose of selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine in major depression: a systematic review and dose-response meta-analysis. The lancet. Psychiatry, 6(7), 601–609. https://doi.org/10.1016/S2215-0366(19)30217-2  

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617  

Lai, C., Luciani, M., Galli, F., Morelli, E., Moriconi, F., Penco, I., Aceto, P., & Lombardo, L. (2017). Persistent complex bereavement disorder in caregivers of terminally ill patients undergoing supportive-expressive treatment: a pilot study. Journal of mental health (Abingdon, England), 26(2), 111–118. https://doi.org/10.3109/09638237.2016.1167855 

Lee S. A. (2019). Persistent complex bereavement symptoms explain impairments above depression, posttraumatic stress, and separation anxiety: an incremental validity study. Death studies, 43(10), 634–638. https://doi.org/10.1080/07481187.2018.1509909  

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1 month ago  

Andrew Wargo  

RE: Week 7 discussion  

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Muhammad, you make great points about the case study. However, I would like to add some things to your discussion. Regarding questions during the psychiatric interview, I would explore questions surrounding suicide. Questions like do you think about being dead? Do you want to be dead? Do you ever think about killing yourself? Screening for suicide is one of the most important things during a psychiatric interview to ensure the safety of the patient.  According to Heisel et al. (2010), older adults have high rates of suicide and often do not directly or spontaneously report thoughts of suicide, which can impede suicide prevention efforts. 

Additionally, using questionnaires are a good indicator for the symptoms of psychiatric disorders. But, using diagnostic tests like a sleep study, blood tests, and sleep apnea test can indicate if the patient’s insomnia could be the result of some underlying condition. Considering, the patient has a plethora of comorbid conditions like diabetes and HTN. These tests could also give insight into a differential diagnosis like sleep apnea. 

I want to also suggest some alternative medication choices to the ones you chose. Yes, the SSRIs and SNRIs are typical first line treatments for depression; however, I feel there are better options available for insomnia. Also, since the patient is already on an SSRI (Zoloft) adding another SSRI may not be the best medical decision for sleep. A medication like trazodone is an antidepressant that is FDA approved for depression but also commonly prescribed off-label for insomnia. Also, because trazodone is not a controlled substance, it has less abuse potential and safer side effects than other alternatives for insomnia. that works by inhibiting both serotonin transporter and serotonin type 2 receptors. It is a triazolopyridine derivative. Trazodone inhibits the reuptake of serotonin and blocks the histamine and alpha-1-adrenergic receptors (Shin & Saadabadi, 2022).  

 

References 

Heisel, M., Duberstein, P., Lyness, J., & Feldman, M. (2010). Screening for suicide ideation among older primary care patients. J Am Board Fam Med. doi: 10.3122/jabfm.2010.02.080163. PMID: 20207936; PMCID: PMC3138552. 

Shin, J., & Saadabadi, A. (2022). Trazodone. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;  https://www.ncbi.nlm.nih.gov/books/NBK470560/ 

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1 month ago  

shynetra jackson  

RE: Week 7 discussion  

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Reply #1 

Hello Muhammad 

I agree with you by trying to find the root cause of her depression, that is very important in order to determine the right treatment plan for her. She could have been experiencing depression before or after her husband deaf, if it was after her husband death one can say it’s kind of expected due to the fact that the person you once lived with your life with is no longer with you, as an elderly adult that’s a traumatic loss. Depression is real and need to asses quickly. Rates of major depression among older adults substantially higher in particular subsets of the older adult population, including medical outpatients (5-10%, though estimates vary widely), medical inpatients (10-12%), and residents of long term care facilities (14 to 42%; Blazer, 2003; Djernes, 2006). 

 

I also agree with the group of people you chose ask as it relates to the patient. I like the fact that we have different ways of seeing thing from different perspective. As it relates to the medication for her depression I initially chose celexa 20mg for the treatment however, upon more research I found that celexa is not recommended for elderly because the adjustment in the dose is not possible with the available dose strength of this particular medication. Sometimes elderly patients receive medication from different places, which is known as polypharmacy, Polypharmacy may also lead to decreased medication compliance, poor quality of life, and unnecessary drug expenses (Abdulraheem IS., 2013). 

You made a good point when you stated you would give the patient a preference of which medication they would like to take which was a very good idea because it allow the patient to think and like what they say matters and will most likely take their medication as ordered.  

 

When diagnosing the elderly, the provider should conduct full ROS due to the fact that important information could be missed or an improper diagnosed could happen. Sometimes the elderly present with symptoms of one thing but end up being diagnosed with something totally different.  

 

 

References 

Abdulraheem IS. Polypharmacy: A risk factor for geriatric syndrome, morbidity &mortality. Aging Sci. 2013;1:e103 

 

Blazer DG. Depression in late life: Review and commentary. J. Gerontol. A Biol. Sci. Med. Sci. 2003;58:249–65.  

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1 month ago  

Carine Robert  

RE: Week 7 discussion  

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I enjoyed reading your post. I did not have much idea about the Persistent Complex Bereavement Disorder (PCBD) andAdjustment Disorder before reading your post. Those were very significant and well-researched differential diagnoses you came up with.  Reading your post gave me the opportunity to research more about this disorder. This patient fits the criteria of these disorders. Persistent insomnia can be very debilitating and that is the very reason why it may be significant to be able to narrow down on the differential diagnoses with a very comprehensive physical assessment to arrive at an accurate diagnosis to treat the patient with the right medication.   

A patient with a diagnosis of bereavement disorder and Adjustment Disorder with depressed mood would require psychotherapy with other prescriptions (Rosenthal & Burchum, 2018). Insomnia associated with precipitating life eventssuch as bereavements can significantly affect a person’s e psychological and cognitive-emotional state and is perceived by the patient as very stressful.  It is a very good idea to encourage the patient to be an active part of her treatment decisions since this can help, her be more compliant to treatment.  Maintaining a sleep journal with activities around sleep will be a very important thing to help the patient document the activities surrounding their sleep. 

 

References 

Rosenthal, L. D. & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier 

Discussion: Treatment for a Patient With a Common Condition  

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Summary of the Case 

            A 75-year-old female patient arrives at a primary care clinic with a chief complaint of insomnia. She has a past medical history of hypertension, diabetes, and major depressive illness, and she is currently taking the following medications to treat her conditions: Metformin 500mg BD, Januvia 100 mg OD, Losartan 100 mg OD, HCTZ 25 mg OD, and Sertraline 100 mg OD. Her husband died ten months ago, and her insomnia has worsened since then. The following is a discussion of various aspects of her diagnosis and treatment interventions. 

Questions to Ask the Patient and Rationale 

What is your predominant complaint of dissatisfaction with sleep? 

            Insomnia disorder can manifest itself in a variety of ways, including difficulty initiating sleep, difficulty maintaining sleep (as evidenced by frequent night awakenings), and, in another form, early morning awakening with an inability to return to sleep. Knowing the primary complaint improves a clinician’s ability to make the correct diagnosis. Furthermore, the primary complaint may assist a clinician in ruling out other possible differential diagnoses of insomnia disorder. 

For how long have you been having insomnia? 

            According to the DSM V diagnostic criteria for insomnia disorder, a minimum of three months of symptoms is required for the diagnosis. As a result, any insomnia lasting less than three months does not qualify as an insomnia disorder (Seow et al., 2018). If the time constraints are not met, other potential differential diagnoses are considered. 

Do you use alcohol, cigarettes, stimulants, or any other recreational substance? 

            Insomnia may be attributed to the physiological effects of a substance such as drug of abuse. Being that insomnia is an exclusionary diagnosis, the question is critical in eliciting a primary diagnosis of insomnia. Even if the patient takes any substance, it should not adequately explain the patient’s primary complaint of insomnia for an insomnia disorder diagnosis to be made. 

People in the Patient’s Life 

            People become more reliant on those around them as they get older. The three people who would be extremely involved in the patient’s life are her primary care physician, her house help or the people with whom she lives, and her chauffeur. I will ask the primary care physician when the patient’s medical conditions (diabetes, hypertension, and major depressive illness) were diagnosed. The question would help to rule out medical conditions as possible causes of the patient’s insomnia. I will ask the housekeeper or anyone else who is staying with the patient about any associated predominant symptoms such as fatigue, low energy, and mood changes. These symptoms may indicate a different psychiatric condition, which may also manifest as insomnia. I’ll ask the chauffeur if he/she always chauffeurs the patient or if the patient can drive on her own at times. Insomnia may be associated with significant impairment in daily functioning, potentially impairing the patient’s ability to drive. 

Physical Examination and Diagnostic Tests 

            A thorough general examination of the patient is required, which includes checking for pallor, jaundice, lymph nodes, edema, and cyanosis. The patient’s vital signs, which include temperature, heart rate, respiratory rate, and oxygen saturation, are critical because they provide a snapshot of the body’s physiological functioning (Elliott, 2021). The results show that the patient is obese, with a BMI of 33.30 kg/m2, and has high blood pressure of 132/86 mmHg. Furthermore, examination by system, with a focus on the cardiovascular, respiratory, and neurological systems, is beneficial in ruling out any medical causes of insomnia in the patient. Baseline entry tests such as complete blood count, urea, and electrolytes help to rule out infection, and anemia and evaluate kidney function. As the patient is diabetic, random blood sugar levels and HbA1C help in assessing glycemic control. The lipid profile will also aid in treatment modification. Polysomnography may show impaired sleep continuity in patients with insomnia, and quantitative electroencephalographic analysis may show that patients with sleep disorders have greater high-frequency electroencephalography power than good sleepers. 

Differential Diagnosis 

            Major depressive illness is a top differential diagnosis in the case presented. The patient’s insomnia symptoms could be the result of a depressive illness caused by the loss of a loved one, her husband. Another possibility for the patient’s differential diagnosis is normal sleep variation. Sleep differs greatly between individuals, according to the diagnosis. According to Patel et al. (2018), the overall prevalence of insomnia symptoms among the elderly ranges between 30 and 48%. Clinical insomnia should thus be distinguished from age-related sleep changes. 

Antidepressant Therapy, Dosing, Rationale for Choice, and Contraindications 

Selective serotonin reuptake inhibitors (SSRI) are the first-line antidepressant therapy. Sertraline or Fluoxetine, both of which belong to the same class of drugs-SSRI, would be appropriate for the patient. Sertraline’s starting dose is 50 mg PO daily, which can be increased by 25 mg at weekly intervals up to a maximum of 200 mg PO daily (Cosci & Fava, 2021). Fluoxetine, on the other hand, is given as an initial 20mg PO daily dose, and the dose may be gradually increased after several weeks by 20 mg/day, not to exceed 80 mg per day (Cosci & Fava, 2021). While both medications are effective, Sertraline has been found in empirical studies to have less severe side effects, which is why I will choose Sertraline over Fluoxetine. Sertraline is contraindicated in patients who have previously experienced hypersensitivity to the drug, in patients who use Disulfiram concurrently due to the alcohol preparation, or in patients taking Pimozide due to the risk of long QT syndrome (Cosci & Fava, 2021). Fluoxetine is not recommended for patients who have previously developed hypersensitivity to the drug, are breastfeeding, or are taking Pimozide or Thioridazine concurrently (Cosci & Fava, 2021). Aside from the contraindications, the two drugs are generally good SSRI options for major depression. 

Follow-Up 

            After the first two months of Sertraline use, the patient will be seen at the primary care clinic. This gives enough time for the effects of Sertraline to be felt. However, the patient must monitor her blood sugar levels and blood pressure daily. Sertraline dosage may be increased at weekly intervals depending on the patient’s response and the severity of the illness. 

Conclusion 

            The case illustrates how life events can precipitate an individual’s illness. The patient has been a widow for the past ten months and has a history of hypertension, diabetes, and major depressive illness. She, too, suffered from insomnia; however, her sleep disorder has worsened since her husband’s death. In most cases, appropriate pharmacotherapy, psychotherapy, and family support are sufficient in helping elderly patients with psychiatric illnesses. Following the patient’s multiple comorbidities and waning strength due to her advanced age, a multidisciplinary team is required for her management. 

 

 

References 

Cosci, F., & Fava, G. A. (2021). Prescribing pharmacotherapy for major depressive disorder: How does a clinician decide? Biomedicine Hub, 6(3), 118–121. https://doi.org/10.1159/000519656 

Elliott, M. (2021). The global elements of vital signs’ assessment: a guide for clinical practice. British Journal of Nursing (Mark Allen Publishing), 30(16), 956–962. https://doi.org/10.12968/bjon.2021.30.16.956 

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A review. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 14(06), 1017–1024. https://doi.org/10.5664/jcsm.7172 

Seow, L. S. E., Verma, S. K., Mok, Y. M., Kumar, S., Chang, S., Satghare, P., Hombali, A., Vaingankar, J., Chong, S. A., & Subramaniam, M. (2018). Evaluating DSM-5 insomnia disorder and the treatment of sleep problems in a psychiatric population. Journal of Clinical Sleep Medicine: JCSM: Official Publication of the American Academy of Sleep Medicine, 14(2), 237–244. https://doi.org/10.5664/jcsm.6942 

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1 month ago  

Leilani Davis  

RE: Discussion Week 7: Peer Response #1  

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Hello Maryann, 

            Great post.  I enjoyed reading your post.  You provided a comprehensive assessment of the patients’ condition, possible differential diagnosis, and treatment options.  I agree with many of your recommendations and have been able to obtain a deeper understanding of a comprehensive assessment after reading your post.  I would like to offer some things that I researched after reading your post below. 

                Insomnia has a significant impact on the quality of life of many adults.  Prolonged depression can affect sleep patterns, while lack of sleep can exacerbate depression.  This can lead to a cycle of problematic issues, warranting assessment, diagnosis, and treatment of the primary condition.  Criteria for diagnosis of insomnia includes difficulty falling or maintaining sleep and impairment in daily functioning (Krystal et al., 2019).  I agree that it is important to assess the specific factors that the patient is experiencing and for how long she has been experiencing them.  I also agree that speaking to those that regularly interact with the patient may be able to provide important information regarding changes or impacts on daily functioning that the patient herself may not notice.   

            Performing a thorough physical assessment will contribute important information regarding overall health.  I agree that assessment of current hemoglobin A1c is essential because uncontrolled hyperglycemia can contribute to many serious illnesses and can exacerbate symptoms of insomnia.  I would examine diet to determine whether the patient is compliant with recommendations and that she demonstrates understanding of her specific diet.  Metformin and Januvia are both associated with insomnia, so if they are not providing effective treatment for her diabetes, I would consider use of insulin.  (Wiwanitkit & Wiwanitkit, 2012).  Lack of sleep contributes to poor glycemic control and poor glycemic control contributes to insomnia, so it is necessary to treat both conditions concurrently.  Along with obtaining a sleep log or diary I would also recommend starting a glucose log.  

            Considering the age of this patient and the fact that she has a history of depression, I would assess her ability to care for herself.  It may be necessary to obtain a home care nurse for the management of diabetes, and blood pressure.  Assessing the level of understanding in diabetes management may reveal the need of a diabetes educator (Ernawati et al., 2021).  Evaluation of ability to complete ADLs would also be helpful, as the patient recently lost her husband and may not have sufficient help.  Use of HCTZ can also increase blood sugar levels, I would consider changing the medication to Chlorthalidone, which is effective at lowering blood pressure, lowering cholesterol (commonly a problem in diabetics), providing cardioprotective effects, and less likely to increase blood sugar.  If labs show a decrease in kidney function, use of an ACE inhibitor may also be warranted (Khalil & Zeltser, 2022).   

References 

Ernawati, U., Wihastuti, T. A., & Utami, Y. W. (2021). Effectiveness of diabetes self-management education (DSME) in type 2 diabetes mellitus (T2DM) patients: Systematic literature review. Journal of public health research, 10(2), 2240. https://doi.org/10.4081/jphr.2021.2240 

Khalil H, Zeltser R. Antihypertensive Medications. [Updated 2022 May 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK554579/ 

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674    

Wiwanitkit, S., & Wiwanitkit, V. (2012). Metformin and sleep disorders. Indian journal of endocrinology and metabolism, 16 Suppl 1(Suppl1), S63–S64. https://doi.org/10.4103/2230-8210.94262 

 

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1 month ago  

Marianela Chinea  

RE: Discussion: Treatment for a Patient With a Common Condition  

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Hello Maryann, 

I totally agree with your differential diagnosis where you suspected that the patient might be going through adjustment disorder which takes time post loss of a loved one as we can in this case. But then it’s important we understand what her base line is prior to the loss she has experienced. 

According to “Chen, 2022” Support from family members especially during this time of grief has a significant role to play in minimizing the depressive mood. 

Depression is a clinical diagnosis, based on the history and physical findings. No diagnostic laboratory tests are available to diagnose major depressive disorder, but focused laboratory studies like Liver function tests (LFTs), blood and urine toxicology screen Electrolytes, including calcium, phosphate, and magnesium levels may be useful to exclude potential medical illnesses that may present as major depressive disorder. Thyroid function test need to be to rule out hypothyroidism as too little thyroid hormone affects the body’s metabolism which can affect one’s sleep. 

According to Baek et al., (2016), signs of improvement can be evidenced by a Hamilton Depression Rating Scale (HAM-D) score less than or equal to seven. 

References 

Baek, H. J., Nierenberg, A. A., Fava, M. (2016). Pharmacological Approaches to Treatment-Resistant Depression. In T. A. Stern, M. Favo, T. E. 

Chen, R. (2022). Social support as a protective factor against the effect of grief reactions on depression for bereaved single older adults. In Death Studies (Vol. 46, Issue 3, pp. 756–763). https://doi.org/10.1080/07481187.2020.1774943 

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Treatment for a Patient with a Common Condition 

Three Questions for the Patient  

 Foremost, I would ask the patient to describe her sleeping pattern. The assessment helps understand the number of hours the patient sleeps in a week and any factors affecting sleep quality. Secondly, I would ask the patient to describe her mood related to her depression. Questioning about her mood helps determine the level of response to the antidepressant medication she is using (sertraline). The assessment can help in making dose adjustments for the patient appropriately. I would also ask the patient about her level of compliance with the medications she is using. Assessing the level of compliance helps determine whether her symptoms are related to a lack of medication compliance. All three assessments can help determine the appropriate treatment plan for the patient. 

Patient Relationships  

I would need to speak to people in the patient’s life, including the patient’s children, grandchildren, and extended family members. I will ask the individuals about what differences they have seen in the patient mood over the recent months. The question helps determine whether the close family members have noticed her depression. I would also question them about any concerns about the patients’ sleep they have noticed. The patient’s primary care provider is another individual I would like to speak to. I would ask for further health history related to mood, weight gain, and management of her diabetes. 

Physical Exams and Testing 

A comprehensive physical examination is essential for the patient since she presents with medical conditions. A comprehensive physical examination will aid in determining the patient’s physical health status that influences her sleeping pattern. Blood sugar and blood pressure measurements should also be done on the patient. Administering the Hamilton Anxiety Rating Scale (HAM-A) can aid in assessing a patient’s anxiety severity (Hallit et al., 2020). HAM-A results can aid in determining further treatment for the patient if it is related to anxiety. Hamilton Depression Rating Scale (HDRS) is another appropriate scale for the patient. HDRS is an assessment focusing on feelings of guilt, mood, suicidal ideation, weight, activities, various stages of insomnia, and other significant areas (Obeid et al., 2018). 

Differential Diagnosis   

The patient has a previous diagnosis of depression as a mental health disorder. The differential diagnosis for this patient is generalized anxiety disorder (GAD), secondary to her husband’s death. The patient has experienced significant changes in the living dynamics encompassing financial burdens, suddenly sleeping alone, and fear of her death. Another possible differential diagnosis is bipolar disorder. Bipolar disorder presents alternating periods of elevated and depressed mood, leading to sleep disturbance (American Psychiatric Association, 2022). 

Pharmacologic Agents 

Trazodone is the first pharmacologic agent to prescribe to the patient. Trazodone is associated with minimal side effects such as weight gain, sexual drive changes, and anticholinergic effects and helps relieve depression and insomnia symptoms (Cuomo et al., 2019). Because trazodone inhibits SERT, 5-HT2A, and 5-HT2c receptors, it does not cause the problems that SSRIs and SNRIs do concerning sexual dysfunction, sleeplessness, and anxiety. The start dosage for trazodone is 50 mg at bedtime (Cuomo et al., 2019). 

Mirtazapine is the second medication that should be considered.  Mirtazapine, a noradrenergic and selective serotonergic antidepressant, is frequently recommended to elderly patients with sleeplessness and low weight. The medication is associated with sedating and weight gain effects. The start dosage is 7.5 mg daily (Praharaj et al., 2018). Taking into consideration the patient’s weight of 88 kg and height of 64 inches, trazodone is the most appropriate medication as it doesn’t cause weight gain or other side effects. Mirtazapine can result in further weight gain, diabetes, blood pressure, and self-care (Praharaj et al., 2018). 

Contraindication  

The contraindication for the using trazodone in patient management includes patients using monoamine oxidase inhibitors (MAOIs). MAOI impairs serotonin metabolism, and concurrent use with trazodone increases serum levels of serotonin (Shin & Saadabadi, 2020). Trazodone is also contraindicated in an individual with liver and renal function issues. The problematic issue resulting from this medication is coma and death associated with sleep and depression. Healthcare providers should ensure patient safety during decision-making. 

Check Points  

The checkpoints for the patient should be after four weeks, eight weeks, and twelve weeks. After four weeks, the patient should be reassessed. If the patient reports trazodone side effects, the medication should be decreased to 25 mg (Cuomo et al., 2019). If no side effects are reported, the dosages should be maintained. At eight weeks, the patient should be reassessed for the symptoms he is presenting with. The dosages should be adjusted appropriately. After twelve weeks, the patient should be reevaluated, and the dosages readjusted. 

 

 

References 

American Psychiatric Association. (2022). Diagnostic And Statistical Manual Of Mental Disorders, Fifth Edition, Text Revision. American Psychiatric Association. 

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista Di Psichiatria, 54(4), 137–149. https://www.rivistadipsichiatria.it/archivio/3202/articoli/31796/ 

Hallit, S., Haddad, C., Hallit, R., Akel, M., Obeid, S., Haddad, G., Soufia, M., Khansa, W., Khoury, R., Kheir, N., Elias Hallit, C. A., & Salameh, P. (2020). Validation of the Hamilton Anxiety Rating Scale and State Trait Anxiety Inventory A and B in Arabic among the Lebanese population. Clinical Epidemiology and Global Health. https://doi.org/10.1016/j.cegh.2020.03.028 

Obeid, S., Abi Elias Hallit, C., Haddad, C., Hany, Z., & Hallit, S. (2018). Validation of the Hamilton Depression Rating Scale (HDRS) and sociodemographic factors associated with Lebanese depressed patients. L’Encéphale, 44(5), 397–402. https://doi.org/10.1016/j.encep.2017.10.010 

Praharaj, S. K., Gupta, R., & Gaur, N. (2018). Clinical Practice Guideline on Management of Sleep Disorders in the Elderly. Indian Journal of Psychiatry, 60(Suppl 3), S383–S396. https://doi.org/10.4103/0019-5545.224477 

Shin, J. J., & Saadabadi, A. (2020). Trazodone. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470560/ 

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1 month ago  

Yvette Kamayou  

Peer Response #1  

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Hello Rose,  

I like how organized and detailed your post it. It is very important to ask the patient about what medications they are taking, how often they are taking the medication and when they are taking the medication. Usually, healthcare providers are more interested in the first two questions as they indicate whether the patient is being adherent or not. However, having an understanding of the timing of the medications can indicate how much the side effect of a medication can affect the daily activities of the patient. Sertraline as you point out can cause insomnia and taking 100 mg of the medication around bedtime can enhance the insomnia the patient is experiencing. This can also provide an opportunity to provide patient education by letting them know that taking the medication in the morning, as opposed to taking it later in the day can cause a reduction in the risk of sleep interference. (“When is the best time to take sertraline (Zoloft)?” 2021) 

 

References 

When is the best time to take sertraline (Zoloft)? (2021, January 15). Optum Perks Blog. https://perks.optum.com/blog/when-is-the-best-time-to-take-sertraline-zoloft/ 

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1 month ago  

Andrew Wargo  

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Rose, I think you bring up good points that I did not think about. Your question regarding medication compliance is important because a lot of older patients might forget to take their medication or not adhere to the instructions correctly. The mismanagement of medication like sertraline can inhibit the effectiveness of the medication to treat depression. Also, the patient has already been prescribed five medications, which can make it confusing to differentiate when to take each one. The more medications a patient has been prescribed, the greater chance that the patient does not properly follow the medication regimen of the medications (Kim et al., 2018). 

I like that you touched on a possible anxiety diagnosis. Anxiety can also be the cause of the patient’s insomnia. Screening for anxiety using the Hamilton Anxiety Rating Scale (HAM-A) could be an important diagnostic tool to see if the patient could be suffering from anxiety, as well. Additionally, I would like to note that tests to screen for underlying medical conditions would be appropriate also. Blood tests, sleep study, and a sleep apnea test can be indicators if the patient’s insomnia is coming from more than just depression or anxiety. 

I also like your medication choice of mirtazapine. Mitrazpine or Remeron is an atypical antidepressant. However, this medication is typically prescribed to treat insomnia. Mirtazapine inhibits the central presynaptic alpha-2-adrenergic receptors, which causes an increased release of serotonin and norepinephrine (Jilani et al., 2022). Mirtazapine is also sometimes called a noradrenergic and specific serotonergic antidepressant (NaSSA).  

References 

Kim, L., Koncilja, K., & Nielsen, C.. (2018). Medication management in older adults. Cleve Clin J Med. doi: 10.3949/ccjm.85a.16109. PMID: 29425085. 

Jilani, T., Gibbons, J., & Faizy, R. (2022). Mirtazapine. [In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK519059/ 

Week 7 Discussion  

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Patient is a 75-year-old who has lost her husband of 41 years, 10 months ago present to the office with past medical history significant of DM, HTN, and MDD.  She stated that her depression has worsened, and she has not been sleeping well. Grief is a roller coaster involving a wide variety of emotions and a mix of good and bad days. Insomnia is usually a symptom of depression. Studies have found that insomnia is also a risk factor for new depression or depression that comes back, particularly in older adults.  Insomnia poses significant public health challenges. It is a common condition that causes significant impairment in function and quality of life, as well as psychiatric and physical morbidity and accidents. As a result, it is critical that clinical practice provide effective treatment. Insomnia is defined as difficulty falling or staying asleep that is associated with significant distress or impairment in daytime function and occurs despite adequate sleep opportunity. It is a common condition, with a general population point prevalence of about 10% (Krystal et al., 2019).  

Duration is also key to the diagnosis of insomnia, to meet criteria for chronic insomnia according to the third edition of the International Classification of Sleep Disorders (ICSD-3) or for persistent insomnia according to the DSM-5, symptoms must be present at least three days per week for at least three months. Short term insomnia (ICSD-3) or episodic insomnia (DSM-5) has the same criteria as chronic insomnia but lasts for fewer than three months (Krystal et al., 2019). Some of the questions to ask based on this information would be to obtain a good sleep history in order to confirm the diagnosis of insomnia; asking what time she goes to bed and what time she wakes up, if she wakes up during the night, and what her day is like after she has trouble sleeping (Krystal et al., 2019). Another question would be whether she has tried anything to help her sleep and how well it has worked.  Inquire about, if she wakes up in the middle of the night, if she falls back to sleep easily If not, what does she do. Also, caffeine intake, alcohol and nicotine use should be asked as these can affect sleep and interact with any medications given (Krystal et al., 2019).  I would ask her of her family, any children or family friend that can be of help. If the patient lives alone, it is more difficult to find a family member to ask questions because there is no one who can relate to what the patient is experiencing. The practitioner needs to know if she is incompliance with taking her medications, how often she visits the doctor, if she sets up her own medications, and how often they visit their mother. These questions give the provider a better understanding of the patient’s self-care and the family’s involvement in her care. 

A thorough physical examination with particular emphasis on the neurological is essential in detecting concurrent medical disorders in all depressed patients. Insomnia can be diagnosed using a variety of diagnostic tests. One of these is actigraphy, which is a wristband-worn device that records any movement during the patient’s sleep time (Krystal et al., 2019). It then takes that data and feeds it into an algorithm, which estimates the patient’s sleep/wake patterns (Krystal et al., 2019). It is not required to perform in order to diagnose insomnia, but it can be beneficial for patients who are not consistent in keeping a sleep diary (Krystal et al., 2019). A polysomnography is another device that is considered the “gold standard” of tests for insomnia (Krystal et al., 2019). This can be used to rule out other possible causes of sleep deprivation (Krystal et al., 2019). 

Some of the differential Diagnoses include depression, Obstructive Sleep Apnea (OSA), Periodic Limb Movement Disorder, Restless Legs Syndrome, Sleeplessness and Circadian Rhythm Disorder (Krystal et al., 2019). I believe that depression is the most likely differential diagnosis, and this is because of the patient losing her husband. I can imagine, it is hard for her to get over the loss of her husband. It is possible that the patient is avoiding her bed because of this, and this causes impaired sleep patterns. 

Insomnia is problematic for older adults. After behavioral modifications fail to show adequate response, pharmacologic options are used. The pharmacokinetics of agents used to treat insomnia may be altered. Commonly prescribed types of antidepressants include selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and norepinephrine-dopamine reuptake inhibitors (NDRIs). These medications are commonly prescribed because they improve symptoms related to a broad group of depressive and anxiety disorders and are associated with fewer side effects than older types of antidepressants (Schroeck et al., 2016). I will increase Zoloft dose from 100 mg to 150 mg: Researchers report that “sertraline (50-200 mg/day) is effective in the treatment of major depressive disorder in elderly patients (Muijsers, Plosker, and Noble, 2002). Furthermore, there are no definitive indications that the patient’s initial dose of 100 mg was contraindicated. The mechanism of action for Zoloft (an SSRI) includes the inhibition of 5-HT (serotonin receptors) reuptake, which increases serotonin activity and aids in the relief of major depression symptoms (Rosenthal and Burchum, pg. 618, 2018). “The drug is highly bound (99 percent) to plasma proteins in the blood and undergoes extensive hepatic metabolism followed by elimination in the urine and feces,” according to the study (Rosenthal and Burchum, pg. 618, 2018). Because the plasma half-life is approximately one day, the recommended starting dose of 25 mg by mouth daily is appropriate (Rosenthal and Burchum, pg. 618, 2018). I would ask the patient to return in four weeks to see if this dosage is therapeutic or causing adverse effects. Patient education on medication adherence is critical at this point to ensure medication compliance. Medication adherence is important to achieve goals of treatment and ensure that medications work correctly. Not taking medications how they are prescribed could cause patient to get sicker, decrease quality of life, and increase visits to the clinic or hospital.  

Ethical considerations in prescribing for the elderly. Many elderly people are on multiple medications to treat chronic conditions that develop with age. Most of these treatments focus on symptom management and the prevention of symptoms caused by untreated diseases. When prescribing for the elderly, extreme caution should be exercised. Allowing the elderly and their families to participate in their treatment, as well as providing social support and cost-benefit analysis, are examples of these.  A lack of clear therapeutic guidelines exists for prescribing in this group of people that is confounded by factors such as quality of life and life expectancy (Khalil, 2011). 

On each visit following the start of antidepressant medication, it is critical to monitor for further decreases in depression, increased agitation, increased anxiety, increase in suicidal ideation or homicidal thoughts (Wiese, 2011). Therapeutic changes that may be made at follow-up appointments include increasing the dose, supplementing with another medication, or changing medications entirely. It is determined by the patient’s response to the medication, any side effects, and overall satisfaction with the drug. If the patient is dissatisfied and wishes to try a different drug, this may be necessary if education does not work. 

References 

Asmare, Y., Ali, A., & Belachew, A. (2022). Magnitude and associated factors of depression  

among people with hypertension in Addis Ababa, Ethiopia: a hospital based cross-sectional study.  

BMC Psychiatry, 22(1), 327. https://doi.org/10.1186/s12888-022-03972-6 

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of  

insomnia: An update. World Psychiatry, 18(3), 337–352. https://doi.org/10.1002/wps.20674 

Khalil, H. (2011). Prescribing for the elderly: ethical considerations. Aust J Prim Health. 17(1):2- 

  1. doi: 10.1071/PY10052. PMID: 21616016.

Muijsers, R. B., Plosker, G. L., & Noble, S. (2002). Spotlight on Sertraline in the Management of  

Major Depressive Disorder in Elderly Patients*. CNS Drugs, 16(11), 789-794. doi:10.2165/00023210- 200216110-0001 

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice  

nurses and physician assistants (1st ed.) St. Louis, MO: Elsevier. 

Schroeck, J.L., Ford, J., Conway, E.L., Kurtzhalts, K.E., Gee, M.E., Vollmer, K.A.,  

Mergenhagen, K.A. (2016). Review of Safety and Efficacy of Sleep Medicines in Older Adults.  

Clin Ther. 38(11):2340-2372. doi: 10.1016/. clinthera.2016.09.010. Epub. PMID: 

Wiese. (2011). Geriatric depression: The use of antidepressants in the elderly. BCMJ, 53(47),  

341–347. https://bcmj.org/articles/geriatric-depression-use-antidepressantselderly#:  

~:text=SSRIs%20considered%20to%20have%20the, their%20cytochrome%20P 450%20interactions 

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1 month ago  

Meredith Ximines-Mullings  

Response 2  

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Hello Fidelia  

You touch on some particularly important points.  

Polypharmacy in the elderly puts them at greater risk due to biological changes impacting pharmacodynamic and pharmacokinetics, which impact safety and efficacy of medications (Pazan & Wehling, 2021).   

I agree that pharmacologic options for insomnia should only be considered after behavioral modification. According to Anderson, (2018), cognitive behavioral is the first-line insomnia-specific treatment and reduces the risk associated with the use of hypnotics in the elderly population.   

Your decision to increase the dose prior to augmenting with another medication is a safe option especially since the patient has not reached the maximum dose of Sertraline of 200mg/day.  

 

 

References  

Anderson, K. N. (2018). Insomnia and cognitive behavioural therapy—how to assess your patient and why it should be a standard part of care. Journal of Thoracic Disease, 10(S1), S94–S102. https://doi.org/10.21037/jtd.2018.01.35   

Pazan, F., & Wehling, M. (2021). Polypharmacy in older adults: a narrative review of definitions, epidemiology and consequences. European Geriatric Medicine. https://doi.org/10.1007/s41999-021-00479-3 

Discussion Week 7  

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Insomnia can be caused by a variety of factors, including a mental health disorder. Loss of a loved one, as well as drug dosage, can all contribute to insomnia. Insomnia can be a complication of another disorder, or it can be a separate condition (Levenson, Kay, & Buysse,2015). The case presented is that of a 75-year-old woman suffering from depression and insomnia. The patient’s clinical history indicates that she is sleep deprived, which must be the root cause of her depression. The patient has been grieving the death of her husband, who died ten months ago. This discussion will focus on treating this patient with insomnia, emphasizing a specific diagnosis and treatment for her condition. 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. 

Some of these questions would include: – 

  1. When do you go to bed and when do you wake up?  
  1. Do you go to bed and wake up at the same time every day, and has your routine changed?  
  1. What are the daytime effects? for instance do you experience daytime fatigue, irritability, or difficulty focusing?  

The purpose of the first two questions is to determine the patients’ sleeping habits. The last question is intended to help her understand the daytime effects of her insomnia. Patients who are truly experiencing insomnia have daytime effects (Fernandez-Mendoza, & Vgontzas,2018). These questions can assist in making an accurate diagnosis. 

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why. 

Caregivers, who spend most of their time with the patient, would be an excellent source of information about her condition. This could be the patient’s children, her caregiver, or the nurse who comes to her home. 

The following are the most important questions to ask the individuals caring for the patient:  

  1. When did the patient’s sleeping habits begin to change?  
  1. What does the patient do all day?  
  1. Have you noticed any other symptoms, such as irritability?  

These questions will help me to know if there are any progress on the treatment plan or any change that needs to be made on the treatment plan. 

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. 

Physical exams, such as heart rhythm assessment and oxyhemoglobin saturation, will be appropriate for the patient. Diagnostic tests such as polysomnography and actigraphy are also important. This will assist in determining her average sleep-in order to diagnose her sleep disorder. Laboratory tests are also required to rule out other organic conditions that may present with major depressive disorder and insomnia. A complete blood cell count, thyroid-stimulating hormone tests, and electrolytes may be included. Kidney and liver function tests can also be used to determine how the patient’s body metabolizes and eliminates medications (Levenson, Kay, & Buysse,2015). 

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

The patient’s differential diagnoses are generalized anxiety disorder and major depressive disorder. The patient’s most likely diagnosis is major depressive disorder. This is because the patient exhibits all clinical signs of MDD, such as insomnia and depression. The circumstances surrounding the patient’s husband’s death may have caused mental distress, resulting in insomnia as a secondary effect. 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other. 

Antidepressants are effective in the treatment of insomnia and depression. Doxepin 3 mg orally taken half an hour before bedtime and Amitriptyline 25 mg oral daily at bedtime are the two pharmacologic agents that would be appropriate for the patient’s antidepressant therapy (Abad, & Guilleminault, 2018).  

In this case doxepin is the best drug for the patient, and the drug is the only antidepressant approved by the FDA for the treatment of insomnia. This medication can help people who are suffering from both depression and anxiety. The drug works by blocking the histamine H1 receptor. The drug selectively and strongly blocks histamine 1 receptors, making it more difficult to stay awake and easier to fall asleep (Glass et al., 2019). It also inhibits norepinephrine and serotonin reuptake at synapses in the central nervous system. This helps in the treatment of depressive symptoms.  

For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making? 

Fewer drugs are needed to have the same effects when treating depression in patients from diverse ethnicities, such as African Americans. In addition, a subgroup of Caucasians known as poor metabolizers has lower activity of the isoenzyme that metabolizes the medication. When tricyclic antidepressants are taken at the recommended doses, they are more likely to accumulate in the blood of individuals who do not metabolize them well. Furthermore, the dosage of the therapy must be adjusted based on the patient’s age to reduce side effects and account for potential drug interactions. Diabetes patients should use this medication with caution because it can cause weight gain (Glass et al., 2019). 

Include any “check points” and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen. 

After the drugs are administered, the patient should be checked in four weeks to see if her symptoms have improved (Abad, & Guilleminault, 2018). If the symptoms do not improve after four weeks, the dose of the medication should be increased to a maximum daily dose that can be given to an elderly patient to treat insomnia. A sleep-inducing antidepressant called Trazodone should be added to the medication. The goal of treatment would be to improve the patient’s sleep quality, which could affect the amount of time they are awake. Though, If the symptoms improve within the first four weeks, the first dose should be continued.  

 

References: 

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 

147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617 

Fernandez-Mendoza, J., & Vgontzas, A. N. (2018). Insomnia and its impact on physical and 

mental health. Current psychiatry reports, 15(12), 418. https://doi.org/10.1007/s11920-013-0418-8 

Glass, J., Lanctôt, K. L., Herrmann, N., Sproule, B. A., & Busto, U. E. (2019). Sedative 

hypnotics in older people with insomnia: meta-analysis of risks and benefits. BMJ (Clinical research ed.), 331(7526), 1169.  

https://doi.org/10.1136/bmj.38623.768588.47 

Abad, V. C., & Guilleminault, C. (2018). Insomnia in Elderly Patients: Recommendations for 

Pharmacological Management. Drugs & aging, 35(9), 791–817. https://doi.org/10.1007/s40266-018-0569-8 

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1 month ago  

cherechi onyenso  

RE: Discussion Week 7  

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Hope, thanks for your insights,  

I noticed that both depression and insomnia go hand in hand, or one precedes the other. Also, looking at many scholarly studies, I have noticed that a patient can have depression and sleep disorder. Depression can manifest first or insomnia, or verse vasa. This 75-year-old, we can say, has depression and insomnia and needs treatment for both. I noticed also that many diseases do not follow only way treatment regime. Riemann et al. (2020), highlight that sleep disturbances are primary attribute of depression. They found in their study that insomnia and short sleep predict the prevalence of depression, but their interactive effect was negative. Depression and sleep problems are intricately linked. People with insomni , for example, may have higher risk of developing depression than people who get a good night’s sleep. And among people with depression, 75 percent have insomnia (Nutt, Wilson, & Paterson, 2008). Franzen and Buysse (2008), said” majority of individuals with depression experience sleep disturbances. Depression is also over-represented among populations with a variety of sleep disorders. Although sleep disturbances are typical features of depression, such symptoms sometimes appear prior to an episode of depression. The bidirectional associations between sleep disturbance (especially insomnia) and depression increase the difficulty of differentiating cause-and-effect relationships between them”  

Depression and insomnia can be independent of each other, in the case of this patient the best treatment is to give her the medication that will treat both at the same time. So, the provider can add Trazodone at a lower dose and increase 50 mg per day every 3 or 4 days to a desired dose. The maximum dosage is 400 mg per day in divided doses. Another option is to increase sertraline to 150 mg and add benzo, ramelteon or short-acting Z-drugs. Suvorexant or low-dose doxepin can improve her sleep and maintenance the duration. Zolpidem extended release can also be used to help her fall sleep and maintain the duration (Schroeck el.al, 2016).   

 

Franzen, P. L., & Buysse, D. J. (2008). Sleep disturbances and depression: risk relationships for  

 subsequent depression and therapeutic implications. Dialogues in clinical 

 neuroscience, 10(4), 473–481. https://doi.org/10.31887/DCNS.2008.10.4/plfran 

Nutt, D., Wilson, S., & Paterson, L. (2008). Sleep disorders as core symptoms of depression.  

Dialogues in clinical neuroscience, 10(3), 329–336.  

Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and depression.  

Neuropsychopharmacology : official publication of the American College of  

Neuropsychopharmacology, 45(1), 74–89. https://doi.org/10.1038/s41386-019-0411 

Schroeck, J. L., Ford, J., Conway, E. L., Kurtzhalts, K. E., Gee, M. E., Vollmer, K. A., &  

   Mergenhagen, K. A. (2016). Review of safety and efficacy of sleep medicines in olde   

 adults. Clinical therapeutics, 38(11), 2340-2372.  

 

 

Treatment for a Patient with a Common Condition  

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Treatment for a Patient with a Common Condition 

The case involves a 75 years old widow who had been struggling with insomnia for more than half her life. Additionally, the patient suffers from hypertension, depression, and diabetes-related comorbidities. When her husband died ten months ago, she was still married to him for 41 years. Since the death of her spouse, the patient claims that her depression has gotten worse and she has trouble sleeping. Before the loss of her husband, she had no history of depression. It’s clear that the patient is well-adjusted in our care. It is not known if she has ever had suicide thoughts, although she does see her PCP on a yearly basis. At the moment, she’s taking 500mg of Metformin BID, 100mg of Januvia daily, 100mg of Losartan, 25mg of HCTZ and 100mg of Sertraline. 

At our clinic, I would ask the patient the following questions: 

  1. Do you feel like you can handle your thoughts when experiencing anxiety episodes?  

Ascertaining whether or not the patient is aware of her illness is critical when asking if she feels she can control her anxiety. It aids her in accepting the possibility that she could want assistance if her experience deviates from what she had expected. Acknowledging there is a problem and then searching for answers is the first step in getting treatment (Cohen, 2016). 

  1. What do you think is the cause of your anxiety? What are the things or situations that triggers your anxiety levels?  

The patient’s view of the root cause of her illness is critical. Because of their perspective, we can better understand why they are experiencing symptoms. She has a specific form of mental illness since she believes that she is suffering from an anxiety disorder because of her husband’s death. 

  1. Do you feel like anxiety has reduced the quality of your life? Are there important aspects of life you feel like you are missing on due to anxiety?  

It’s critical to figure out if the patient believes her overall well-being has suffered as a result of the treatment. PMHNPs use this information to determine whether or not the patient is a constant worrywart or if anxiety just appears at certain points in time (Cohen, 2016). 

I’m going to interview the patient’s daughter and sister to get their perspectives on the situation. Her sister has known her for a long time, and her daughter has been with her ever since her husband died. These two may be able to shed light on the onset of the patient’s anxiousness. I would check with the patient’s sister to see whether she had ever displayed any signs of anxiety disorders or been treated for one as a child. This information is crucial as most anxiety disorders begin at a young age and proceed to adulthood (Bonnet & Arand, 2016).  I would check in with her daughter and see whether the patient had had any setbacks as a result of her husband’s death. In order to understand the patient’s concern, it’s critical to learn how she dealt with her husband’s death. 

I would do physical exams on my patient to look for any indicators of depression. Her medical history and the medications she is taking at the moment would be examined to see if any of them could be causing her insomnia. When treating mental illness, it is not recommended to take more than one drug at a time. To evaluate the patient’s anxiety, I would ask her to complete a self-rating. Symptoms can also be assessed with the Hamilton Anxiety Scale (HAM-A) (Benz et al., 2020). As a result of the scale, we could figure out how severe our client’s anxiousness is. 

A generalized anxiety disorder (GAD) would be my diagnosis for the patient (GAD). Insomnia is a sign of a number of anxiety disorders, including GAD in this example. Since the death of her husband, my patient may be suffering from GAD as a result of the many stressful events that have occurred. She must be experiencing a great deal of anxiety about what life will be like for her if she is left to live by herself. 

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for GAD (SSRIs). Taking Zoloft 25mg a day or Wellbutrin 75mg twice a day would be my recommendation in this scenario. The greatest option is Zoloft. The Food and Drug Administration (FDA) has approved this medication for the treatment of anxiety disorders in general. It is possible to increase the dosage to 50mg per day if the patient responds well to the medication. 

Some of the negative effects that the patient may encounter include a decrease in appetite, sweating, shaking, fatigue, and drowsiness. The PMHNP should be informed of these. The contraindications for Zoloft include known hypersensitivity, taking pimozide, and taking within 14 days of quitting MAOIs (Attarian, 2019). I will check in with the patient after four weeks to see if she’s had a reduction in anxiety symptoms. I have the option of increasing her dosage to 50mg per day if the improvement isn’t significant enough for me. 

 

 

References 

Attarian, H. P. (2019). Psychophysiological insomnia. Clinical Handbook of Insomnia, 67-80. https://doi.org/10.1385/1-59259-662-2:67 

Benz, F., Hertenstein, E., Johann, A., & Riemann, D. (2020). Insomnia disorder—Pathophysiology. Management of Sleep Disorders in Psychiatry, 89-102. https://doi.org/10.1093/med/9780190929671.003.0008 

Bonnet, M. H., & Arand, D. L. (2016). Pathophysiology of insomnia. Clinical Handbook of Insomnia, 41-57. https://doi.org/10.1007/978-3-319-41400-3_4 

Cohen, D. (2016). Antipsychotic-related mortality. Life-Threatening Effects of Antipsychotic Drugs, 311-332. https://doi.org/10.1016/b978-0-12-803376-0.00015-0 

 

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1 month ago  

Catherine Murad  

RE: Treatment for a Patient with a Common Condition  

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Good evening, Maribel. 

Your post was verry interesting. If I may ask why, you were prescribing a low dose of Zoloft (Sertraline), When the patient was already on 100 mg of Zoloft.? If the plan is to taper the patient, and to introduce a different medication, it is recommended that you monitor the patient closely for example, Hallucinations, vivid dreams, irritability, insomnia, blurred vision…et. (Drugs.com. n.d.) 

 Some people will only have minor symptoms and may not identify them with changes in their medication regimen. Others are so incapacitated by their symptoms that they are hesitant to stop taking their antidepressant for fear of the consequences. 

Antidepressants with longer half-lives, such as Prozac (fluoxetine),(5-to 6 days) are less likely to elicit discontinuation syndrome because the body has more time to acclimate to the change. Zoloft, on the other hand, has a shorter half-life and is more prone to cause withdrawal symptoms. (Orlando Marriage Therapy. (2011). 

Catherine. M 

Drugs.com. (2019). Zoloft. Drugs.com; Drugs.com. https://www.drugs.com/zoloft.html 

Orlando Marriage Therapy. (2011). An In Depth Look at Zoloft: An Academic Article | Psychologicalgrowth.com. http://www.psychologicalgrowth.com/site-articles/sertraline-zoloft/ 

Week 7: Main Post  

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Hello All,  

 

Introduction 

Case: An elderly widow who just lost her spouse. 

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:  

  • Metformin 500mg BID   
  • Januvia 100mg daily   
  • Losartan 100mg daily   
  • HCTZ 25mg daily   
  • Sertraline 100mg daily   

Current weight: 88 kg 

Current height: 64 inches 

BMI: 33.2 

Temp: 98.6 degrees F 

BP: 132/86  

Questions to Ask 

 

  1. How long have you been taking sertraline?  It is important to know why the patient was prescribed an SNRI.  If it was prescribed for depression, was it prescribed by the PCP or by a psychiatrist?  Length of treatment, starting dose, and history of changes in dosing are needed to assess effectiveness of medication.  Effectiveness of medication can be evaluated 4-8 weeks after initiation of treatment, therefore, timeline of initiation of treatment is important.  It is also prudent to consider the fact that use of sertraline in elderly patients can induce SIADH and/or hyponatremia.  Since this patient is 75 years old, electrolyte imbalance may contribute to sleep disturbances (Singh & Saadabadi, 2022).  
  1. Do you have any family history of mental illness, especially depression?  Both genetics and situational stressors can contribute to predisposition of depressive disorders (Shadrina et al., 2018).  Thorough health history, including primary family history can assist in accurate diagnosis.   
  1. When was the last time that you had your hemoglobin A1c checked and what was the result?  This is a crucial factor because diabetic patients are prone to insomnia while Metformin and Januvia can also cause sleep disturbances.  Either uncontrolled diabetes can contribute to insomnia; therefore, understanding length of treatment with Metformin as well as compliance with overall diabetes treatment contributes to comprehensive assessment (Wiwanitkit & Wiwanitkit, 2012).   

Obtaining History 

I would identify who her primary support system consists of, and who provides care for her.  Does she have children or grandchildren?  Does she have help at home such as home health aides or nursing care?  Does she have extended family involved in her care such as cousins, nieces or nephews, and/or siblings?  I would ask her primary support systems how the patient obtains groceries and prescriptions.  Considering the fact that the patient is diabetic, hypertensive, and obese, diet may be a contributing factor.  Is the patient able to prepare meals or is she consuming high calorie/carbohydrate/sodium fast/frozen foods? Does the patient have access to her prescription medications?  Does she understand her medical conditions, medications, and dosing schedule?  How is the patient’s cognitive ability?  Is the patient able to afford medical care and prescriptions?   I would also speak to any current medical providers to obtain a comprehensive understanding of her current conditions.  

Diagnositcs 

      I would obtain a CBC, BMP, hemoglobin A1c, and TSH.  Abnormalities in electrolyte balance, blood glucose, and thyroid function among others are associated with sleep disorders.  Sleep logs, history of sleep/wake cycles, bedtime routines, caffeine intake, and activity patterns can be used to reveal possible causes of disturbed sleep patterns.  Medication levels should also be checked to assess therapeutic indexes.  BMI, neck circumference, and airway assessment to rule out sleep apnea is an option if it is suspected (Krystal et al., 2019).  The HAM-D depression screening test can be used to assess severity of depression, and the CGD test can be used to diagnose complicated grief disorder (Nakajima, 2018).   

       

Differential Diagnosis 

  1. Complicated Grief Disorder  
  1. Ineffective coping  
  1. Uncontrolled Hyperglycemia  

I believe the most likely diagnosis would be complicated grief disorder since the patient has a PMH of MDD that has worsened since the death of her husband of over forty years ten months ago and current chief complaint of insomnia also coincides with the passing of patient’s husband.   

 

 

Pharmacologic Agents 

Trazadone: 25 mg is a normal starting and 50 mg is a normal maintenance dose.  This medication does not generally carry a side effect of insomnia (Avasthi & Grover, 2018).    Mechanism of action: Trazodone is an antidepressant that inhibits serotonin transporters, serotonin type 2 receptors, reuptake of serotonin while also blocking histamine and alpha-1-adrenergic receptors. It can induce changes in 5-HT presynaptic receptor adrenoreceptors.  Trazadone is used in both the treatment of insomnia and depression, which could potentially be used in the treatment of both conditions (Shin & Saadabadi, 2022).   

Mirtazapine: 7.5 mg is a normal starting and 15-30 mg is a normal maintenance dose.  This medication does not generally carry a side effect of insomnia (Avasthi & Grover, 2018).   Mechanism of action: Mirtazapine inhibits central presynaptic alpha-2-adrenergic receptors, activating effect on the sympathetic nervous system, acts as a potent antagonist of H1 histamine receptors, and 5-HT2A, 5-HT2C, and 5-HT3 serotonin receptors (Jilani et al, 2022).  Mirtazapine is used in both the treatment of insomnia and depression, which could potentially be used in the treatment of both conditions.   

 

Contraindications 

            Contraindications associated with Trazadone include GI distress, mild anticholinergic effects, drowsiness, orthostatic hypotension, arrhythmia, weight gain, and severe hepatotoxicity.  Medication should be started at the lowest effective dose of 25 mg, assessing effectiveness, and adjusting dose after 4 weeks if needed.  Effect of drowsiness will help with the insomnia and may need to be taken at night if drowsiness is disruptive during the day.  Due to established obesity, weight monitoring is beneficial.  Due to history of diabetes and use of metformin, liver function should be monitored.  Due to history of hypertension and use of antihypertensives, blood pressure should be followed closely.  Risk of suicide is higher in the elderly, self-harm potential should be assessed when increasing dose, usually 4 weeks after initiation of treatment.  Ethical considerations include assessing extent of drowsiness to prevent risk of falls or motor vehicle accidents.  Social history should be assessed to identify barriers that may be caused by treatment (Avasthi & Grover, 2018). 

            Contraindications associated with Mirtazapine include GI distress drowsiness, orthostatic hypotension, and weight gain.  Dose should be initiated at 7.5 mg and assessed for effectiveness after 4 weeks.  Increase medication by 7.5 mg as needed to achieve desired effect, not to exceed 45 mg.  Weight, blood pressure, and level of sedation should be assessed regularly.  Ethical considerations include assessing extent of drowsiness to prevent risk of falls or motor vehicle accidents.  Social history should be assessed to identify barriers that may be caused by treatment including isolating from friends-family or lack of interest in normally enjoyed activities.  (Avasthi & Grover, 2018).  Mirtazapine is more expensive than trazadone, finances should be considered.   

References: 

 

 

             

Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474 

Jilani TN, Gibbons JR, Faizy RM, et al. Mirtazapine. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519059/ 

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674 

Nakajima S. (2018). Complicated grief: recent developments in diagnostic criteria and treatment. Philosophical transactions of the Royal Society of London. Series B, Biological sciences, 373(1754), 20170273. https://doi.org/10.1098/rstb.2017.0273 

Shadrina, M., Bondarenko, E. A., & Slominsky, P. A. (2018). Genetics Factors in Major Depression Disease. Frontiers in psychiatry, 9, 334. https://doi.org/10.3389/fpsyt.2018.00334 

Shin JJ, Saadabadi A. Trazodone. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470560/ 

Singh HK, Saadabadi A. Sertraline. [Updated 2022 May 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK547689/ 

Wiwanitkit, S., & Wiwanitkit, V. (2012). Metformin and sleep disorders. Indian journal of endocrinology and metabolism, 16 Suppl 1(Suppl1), S63–S64. https://doi.org/10.4103/2230-8210.94262 

 

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1 month ago  

Sloane Caruso  

RE: Week 7: Main Post  

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Leilani, 

Thank you for your post. I realize I completely looked over the basics as far as lab values that could be contributing to sleep or mood dysfunction. Although like you said it is likely grief but having a baseline knowledge of the patient’s labs can give us a point of reference in the future too. “The association between metabolic disturbances and mood disorders appeared to be bidirectional 9. In longitudinal studies, several metabolic dysregulations have been associated with sustained depressive states over time.” (Jones et al., 2021). Studies also show that with poor sleep habits there is an increased A1C, showing that quality and quantity of sleep have a direct correlation to glucose metabolism (Lee et al., 2017). 

 

Brett D. M. Jones, Salman Farooqui, Stefan Kloiber, Muhammad Omair Husain, Benoit H. Mulsant, & Muhammad Ishrat Husain. (2021). Targeting Metabolic Dysfunction for the Treatment of Mood Disorders: Review of the Evidence. Life, 11(819), 819. https://doi.org/10.3390/life11080819 

Lee, S. W. H., Ng, K. Y., & Chin, W. K. (2017). The impact of sleep amount and sleep quality on glycemic control in type 2 diabetes: A systematic review and meta-analysis. Sleep Medicine Reviews, 31, 91–101. https://doi.org/10.1016/j.smrv.2016.02.001 

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1 month ago  

Muhammad Imam  

RE: Week 7: Main Post  

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I like your points about using BMI and neck circumference to evaluate insomnia. I would also use some diagnostics such as sleep study and a sleep apnea test to evaluate the insomnia. I appreciate the use of trazodone to treat to treat the insomnia and the use of mirtazapine, for the dual benefits of treating depression and insomnia (Avasthi & Grover, 2018) (Shin & Saadabadi, 2022). There is significant evidence for the use of trazodone for the treatment of insomnia, and its off-label use has also been widely practiced in clinics around the country (Jaffer et al., 2017).  

References 

Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474 

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34. 

Shin, J., & Saadabadi, A. (2022). Trazodone. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK470560/  

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1 month ago  

Rose Butler  

RE: Week 7: Main Post: Response 2  

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Hello Leilani 

Thank you for sharing your informative discussion on this week’s case study. Your three questions can help in understanding the patients presenting health issues. In addition, the patient can be questioned about her sleep hygiene. Sleep hygiene questions should include the sleeping environment, foods consumed before sleeping, and the available noise. Individuals with a patient relationship that should be questioned include grandchildren, her children, extended family members, and family friend. The individuals may have more knowledge about the patient, hence the evaluation’s need. In addition, the patient primary care provider can be questioned to obtain information about her current diagnosis. Your diagnostic tests list is appropriate for the patient for the assessment. Moreover, Pittsburgh Quality Sleep Index (PSQI) can be used to assess sleep quality (Faulkner & Sidey-Gibbons, 2019). Complicated grief disorder can be a patient diagnosis based on history. 

I agree with you; trazodone is the best medication for this patient. The medication is associated with minimal side effects and is indicated for treating insomnia and depression (Shin & Saadabadi, 2020). The contraindications of trazodone include renal and liver function issues and patients using monoamine oxidase inhibitors. Patients should have follow-up care for four weeks, eight weeks, twelve weeks, and onward. Dose adjustments should be made in response to the treatment. 

References 

Faulkner, S., & Sidey-Gibbons, C. (2019). Use of the Pittsburgh Sleep Quality Index in People With Schizophrenia Spectrum Disorders: A Mixed Methods Study. Frontiers in Psychiatry, 10. https://doi.org/10.3389/fpsyt.2019.00284 

Shin, J. J., & Saadabadi, A. (2020). Trazodone. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK470560/ 

Sloane Caruso Week 7 Discussion post 1  

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Questions to ask 

  1. How would you describe the way you are feeling today? Open-ended questions allow for further conversation which leads to in-depth knowledge of the situation. This patient will be able to explain her condition more with a question like this.  
  1. How would you describe your typical day and bedtime routine? This patient is in the clinic with complaints of insomnia, since environmental factors can affect sleep patterns, it is important to determine if there are other factors before focusing on physiologic causes.  
  1. When did you start having problems sleeping? This question will help us to understand whether this is an acute or chronic problem and if this has been a problem since before her husband’s passing.  

People to interview 

Speaking with close friends, children, and other close family members and caregivers would give us insight into the patient’s daily life, and if they have noticed any acute changes in her behavior, cognition, and mood. It will also be beneficial to know how this patient spends most of her time. Is our patient active or sedentary? Does she have any community involvement or a sense of responsibility to anyone outside of the home? Have there been any noticeable cognitive changes? Has she been giving any of her belongings away? Has she been trying to get her affairs in order (living will, life insurance, etc.)? 

Physical exam and diagnostic test 

Sleep study- A sleep study will assess the patient’s sleep pattern; this patient already has comorbidities that can further worsen her health. Elderly patients with a sleep disorder have an increased risk of hypertension, which the patient already has, and sleep disturbances can cause daytime sleepiness that studies have shown to correlate with decreased quality of life (Uchmanowicz et al., 2019). 

Urinalysis- Elderly patients do not have the typical UTI symptoms seen in younger patients, so healthcare providers need to look for other signs. “The spectrum of [elderly] patient presentations of UTI vary from classic signs and symptoms to non-specific symptoms, such as increased lethargy, delirium, blunted fever response, and anorexia” (Levander & Tingstrom, 2020). 

Sleep diary- knowing the pattern of her sleeping and or napping will help us see how much sleep she is actually getting, or what external factors may be contributing to her lack of sleep. 

Pharmacological agent 

Decrease sertraline to 50mg for 2 weeks, then decrease to 25 for two weeks as a taper off. Studies have shown that depressed patients with symptoms such as fatigue respond less well to SSRIs (Stern et al., 2016). 

Introduce Wellbutrin 150XL in the mornings. It has been shown to be as effective as SSRIs for depression, but it is more effective than SSRIs in the treatment of sleepiness and fatigue (Stern et al., 2016). 

Melatonin 3mg QHS. We naturally produce melatonin, but adding the supplement of it can help to restore function and naturally occurring levels in those with insomnia (Stern et al., 2016). 

Differential Diagnosis 

Insomnia- “insomnia is defined by the presence of subjective report of difficulty with sleep resulting in too little sleep or poor-quality sleep.” (Uchmanowicz et al., 2019). 

Complicated grief- This patient has been with her spouse for a lifetime, and he is now gone. She does not have young children in the home that her day revolves around anymore. Her husband was whom her day revolved around. Sleeping in the same bed as him, next to him for over forty years is a huge change in her life. “The symptoms of complicatedgrief may be distinct from depressive symptoms and appear to be associated with enduring functional impairments. The symptoms of complicatedgrief, therefore, appear to define a unique disorder deserving of specialized treatment.” (Prigerson et al., 1995). 

Checkpoints 

I will request a follow-up in 4 weeks to assess medication adherence, and monitor effectiveness, and side effects. 

References 

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier. 

Märta Sund Levander, & Pia Tingström. (2020). Complicated versus complexity: when an old woman and her daughter meet the health care system. BMC Women’s Health, 20(1), 1–11. https://doi.org/10.1186/s12905-020-01092-5 

Prigerson, H. G., Frank, E., Kasl, S. V., Reynolds, C. F., Anderson, B., Zubenko, G. S., Houck, P. R., George, C. J., & Kupfer, D. J. (1995). Complicated Grief and Bereavement-Related Depression as Distinct Disorders: Preliminary Empirical Validation in Elderly Bereaved Spouses. American Journal of Psychiatry, 152(1), 22–30 

Uchmanowicz I, Markiewicz K, Uchmanowicz B, Kołtuniuk A, & Rosińczuk J. (2019). The relationship between sleep disturbances and quality of life in elderly patients with hypertension. Clinical Interventions in Aging, ume 14, 155–165. 

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1 month ago  

Fidelia Ileka  

RE: Sloane Caruso Week 7 Discussion post 1  

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Hello Sloane, 

 

Great post! 

 

I share your insight; insomnia is still one of the most prevalent sleep disorders seen in geriatric clinics, with subjective complaints of trouble falling or sustaining sleep, or nonrestorative sleep, causing severe daily symptoms such as problems focusing and mood changes (Patel et al., 2018). There is a recognized high frequency of insomnia among the elderly. Medical, mental, and pharmacological difficulties, circadian rhythm alterations, sleep disorders, and psychological variables all contribute to insomnia. The elderly use sleeping aids often. The risks associated with the use of hypnotic pharmaceuticals by elderly patients are attributed to concurrent comorbid conditions, the use of several medications, changed pharmacokinetics, and greater sensitivity of the central nervous system to these agents. Insomnia may be treated with behavior modification and pharmacotherapy (Ancoli-Israel, 2000). The most crucial part of evaluating insomnia is a comprehensive history and physical examination. Compared to pharmaceutical therapy, nonpharmacological therapeutic alternatives provide beneficial and lasting advantages (Patel et al., 2018). 

Reference 

Ancoli-Israel, S. (2000). Insomnia in the elderly: a review for the primary care practitioner.  

Sleep. 2000 Suppl 1: S23-30; discussion S36-8. PMID: 10755805. 

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. J Clin Sleep Med.  

14(6):1017-1024. doi: 10.5664/jcsm.7172. PMID: 29852897; PMCID: PMC5991956. 

 

 

 

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1 month ago  

shynetra jackson  

RE: Sloane Caruso Week 7 Discussion post 1  

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Reply #2 

 

Hello Sloane,  

 

I enjoyed reading your post, it seems as though we wrote about some similar things in our post as it relates to the patient. It’s very important know whether the patient was experiencing these symptoms before or after her husband death because knowing that information can determine the route of treatment plan for the patient. For instance, short term or longer-term treatment.  Sometimes when a person is experiencing depression due to death of a love one, the depression can be short term as well as the treatment however, it can also be a long-term issue. According to research the time of onset of depression can determine important information. Those with early onset depression are more likely than those with late onset depression to have a family history of depression (e.g., Heun, Papassotiropoulos, Jessen, Maier, & Breitner, 2001). Depression in the elderly can cause them to be suicidal, so a focus assessment on their mental health status is very important to obtain as well as background information about the patient. Often times the patient may have loves that could help provide pertinent information about the patient medical history.  

 

I agree with your decision to taper the patient Zoloft medication depending upon if the symptoms started after the patient begin taking Zoloft or did these symptoms start after an increase in dosage. Sometimes medications can cause problems as such and since this is an elderly patient, they can be sensitive when it comes to taking medication and the effect it can cause on their bodies. The absorption, distribution, metabolism and excretion of drugs are affected to a varying extent by the ageing process itself and by diseases commonly associated with ageing (Kirkwood TB., 2008). Do you think a UTI could be causing the patient to have insomnia?  

 

References 

 

Heun R, Papassotiropoulos A, Jessen F, Maier W, Breitner JC. A family study of Alzheimer disease and early- and late-onset depression in elderly patients. Arch. Gen. Psychiatry. 2001;58:190–6. 

 

Kirkwood TB. A systematic look at an old problem. Nature. 2008;451(7179):644-647. 

 

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