NURS 6630 Discussion Treatment for a Patient With a Common Condition

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

NURS 6630 Discussion Treatment for a Patient With a Common Condition

Insomnia, the second most prevalent mental condition, is also a significant risk factor for depression (Blanken et al., 2019). Insomnia is characterized by persistent problems with sleep quality and quantity, nightly awakenings and difficulty returning to sleep, and unscheduled early morning awakenings (Levenson et al., 2015). Insomnia is estimated to have a prevalence of between 5% and 15% and is related with an inability to sleep despite having the opportunity to do so (Levenson et al., 2015).

Three Reasonable Questions for this Patient

How many hours do you sleep at night?

This is critical to understand because proper sleep is necessary to sustain our mental, physical, and emotional health and well-being. Seven to eight hours of sleep each day is advised for persons 65 years of age and older. Sleep deprivation can have a detrimental effect on both mental and physical health (Hirshkowitz et al., 2015).

NURS 6630 Discussion Treatment for a Patient With a Common Condition

What is the pattern of sleeping issues in terms of frequency?

Sleep disturbances can occur as a result of hyperarousal caused by stress and other emotional stressors. This can have an effect on the start and quality of sleep and assist distinguish chronic from acute insomnia (Levenson et al., 2015).

Is there anyone in your family who has difficulty sleeping?

Justification: Genes are thought to be a risk factor for insomnia. It is critical to ascertain whether there is a hereditary tendency to insomnia (Blanken et al., 2019). Stressful circumstances can exacerbate the risk of chronic insomnia in persons who are already vulnerable (Blanken et al., 2019).

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Individuals for Further assessment

Individuals who are closely associated with the patient will be important. This includes her children if any, other relatives and close

friends.

Children: Have you noticed any problem sleeping at nights? Are there periods of wakefulness throughout the night? How early is she up in the mornings?

This will help to determine the duration and pattern of sleep throughout the night.

Relatives: Has there been regular communication since her husband’s death? Has her diet been ok? Are there any concerns about her wellbeing? NURS 6630 Discussion Treatment for a Patient With a Common Condition

This will help to determine if there is increased depression and hopelessness as a result of the death of her husband.

Friends: Has there been communication? Has there been any changes in her behavior? Does she appear more tired? This will also help to determine the level of depression and the functional impairment from sleep deprivation.

Appropriate Physical Tests and Diagnostic Exams

A thorough physical and mental assessment is important to screen for increased depressing and the effects of insomnia. The Mini-Mental State Exam (MMSE) to assess for cognitive impairment. The Geriatric Depression Scale (GSD) or Cornell Scale for Depression in Dementia (CSDD) This will also help to determine the level of cognitive impairment (Patel et al., 2018). NURS 6630 Discussion Treatment for a Patient With a Common Condition

Baseline blood tests that include chemistry, complete blood count, Liver enzymes is also important to evaluate any imbalance.

Assessment for other medical problems such as thyroid disease, chronic pain respiratory problems. Sleep diary or modalities such as Polysomnography and Actigraphy for sleep study and sleep pattern evaluation (Patel et al., 2018).

Differential Diagnosis

a) Increased depression due to loneliness b) Restless legs c) Sleep pattern disturbance. The selected diagnosis is Increased Depression due to Loneliness. This is so because of the loss of her husband of 41 years. This could relate to drastic lifestyle changes that is affecting her and therefore resulting in her insomnia.

Two Appropriate Pharmacological agents: A selective serotonin reuptake inhibitor (SSRI) and Buspirone, a Tricyclic Antidepressant (TCA) are possible choices for the treatment of depression. The patient is already taking Sertraline 100mg daily which is a SSRI and one of its side effects is insomnia. ROSENBAUM) It is uncertain about the length of time since she has been taking Sertraline. Changing medication without tapering the dose is not recommended therefore the dose could be reduced and the patient then closely monitored for change in symptoms (Stern et al., 2016).

Contraindications: Buspirone: patient with kidney or liver disease because of slow excretion. Sertraline: patient taking monoamine oxidase inhibitors, thioridazines and serotonergic preparation (Rosenbaum).

The patient will be evaluated on a 4-week basis and evaluated for change in symptoms and for medication adjustment as required.

NURS 6630 Discussion Treatment for a Patient With a Common Condition References

Blanken, T. F., Benjamins, J. S., Borsboom, D., Vermunt, J. K., Paquola, C., Ramautar, J., Dekker, K., Stoffers, D., Wassing, R., Wei, Y., & Van Someren, E. W. (2019). Insomnia disorder subtypes derived from life history and traits of affect and personality. The Lancet Psychiatry, 6(2), 151–163. https://doi.org/10.1016/s2215-0366(18)30464-4

Hirshkowitz, M., Whiton, K., Albert, S. M., Alessi, C., Bruni, O., DonCarlos, L., Hazen, N., Herman, J., Adams Hillard, P. J., Katz, E. S., Kheirandish-Gozal, L., Neubauer, D. N., O’Donnell, A. E., Ohayon, M., Peever, J., Rawding, R., Sachdeva, R. C., Setters, B., Vitiello, M. V., & Ware, J. (2015). National sleep foundation’s updated sleep duration recommendations: Final report. Sleep Health, 1(4), 233–243. https://doi.org/10.1016/j.sleh.2015.10.004

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

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

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Psychopharmacology and neurotherapeutics (1st ed.). Elsevier Inc. NURS 6630 Discussion Treatment for a Patient With a Common Condition

RE: Discussion – Week 7, response 1

COLLAPSE

I agree with you that depression and insomnia are somehow correlated. Chronic insomnia is the prodrome for a major depressive disorder as well as depression is a risk factor for Insomnia. It has been well documented that depression can lead to insomnia (Depression and insomnia: Questions of cause and effect. (2018, Oct 12). However, evidence from previous research and clinical experience indicates that the reverse can also be the case: long-standing insomnia can often lead to depression (Major Depression and Insomnia in Chronic pain n.d). Chronic and more severe depression responds better to a combination of antidepressant and, insomnia therapy.

PMHNP should also suggest a sleep study (including sleep history, polysomnography) to confirm if the patient has narcolepsy. PMHNP can also do screening tests for anxiety, for example, Hamilton Anxiety Rating Scale (HAM-A). The scale measures the severity of anxiety symptoms, and it consists of 14 items. Each is defined by a series of symptoms and measures both psychic anxiety (mental agitation and psychological distress) and somatic anxiety (physical complaints related to anxiety). Each item is scored on a scale of 0 (not present) to 4 (severe), with a total score range of 0–56, where less than 17 indicates mild severity, 18 to 24 mild to moderate severity, and 25 to 30 moderates to severe (UF College of Medicine, 2018).

Another question I think should be asked of the client is whether her job was a day or night job. This is because most people who have worked night shift job for an extended period do get their circadian rhythm messed up and thus suffers from circadian rhythm disorder which makes these people suffer from having a restful sleep at night and also from impairments in their cognitive performance. As indicated in your post that the client might be having difficulty sleeping due to her medications such as the HTZ, there could be other medications that the client is currently taking that alter the neurotransmitters in her brain and causes wake abnormalities that are accompanied by neurodegenerative or neurotransmitter changes. (Videnovic, & Abbott, (2016)

NURS 6630 Discussion Treatment for a Patient With a Common Condition References

Major Depression and Insomnia in Chronic Pain: The Clinical Journal of Pain. (n.d.). Retrieved October 12, 2018, from https://journals.lww.com/clinicalpain/Abstrct/2002/03000/Major_Depression_and_Insomnia_in_Chronic_Pain.2.aspx

UF College of Medicine. (2018). Hamilton Anxiety Rating Scale (HAM-A). Retrieved from https://dcf.psychiatry.ufl.edu/files/2011/05/HAMILTON-ANXIETY.pdf

Videnovic, A., & Abbott, S. (2016). Chronic sleep disturbance and neural injury: links to neurodegenerative disease. Nature and Science of Sleep, 55.

Discussion Insomnia

COLLAPSE

Discussion Week 7 Main Post

The discussion topic is on the following case study which will address questions asked to gain a better understanding of therapy approaches to effectively manage the client’s health care needs. The case study in question is about a 75-year-old female widow who recently lost her spouse of 41 years of marriage. Her chief complaint is insomnia with worsening of depression. Her PMH is DM, HTN and MDD. Her current medications are Metformin 500mg BID, Januvia 100mg daily, Losartan 100mg daily, HCTZ 25mg daily and Sertraline 100 mg daily. Her BMI is 33.3 in which obesity can be added to her list of diagnoses. V.S. stable. As the psychiatric mental health nurse practitioner, I will address her complaint of insomnia.

Questions Concerning Insomnia with Rationale

I would interview the client with specific questions concerning her insomnia to gain a better understanding of her insomnia. The psychiatric interview, Carlat (2017) addresses the following questions: Have you been sleeping normally? This helps open up the conversation to ask more questions. Have you been sleeping normally? What has your sleep pattern been lately? What time do you lie down to fall asleep? What time do you actually fall asleep? These questions help diagnose difficulty falling asleep. The next question helps to diagnose frequent awakenings: Do you sleep through the night, or do you wake up often during the night? Then to diagnose early morning awakening and diurnal variation in mood; ask the following questions: What time do you usually wake up in the morning? Do you generally feel rested when you wake up? Do you feel depressed when you wake up? How does your mood change as the day goes on? The more detailed interview gives the practitioner the ability to provide interventions accordingly (medication or alternative) and to measure the outcomes.

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 the client if there is anyone she trusts and confides in that can be present if she wished for support. What social support does she have? Is there a friend, family or neighbor that is a support person in her life? I would ask permission to speak to that support person. I would ask the support person if the client’s depression affected her activities of daily living? Does the client’s mood change over the course of the day as in “Sundowners” syndrome? The purpose of these questions would be for the client’s safety at home.

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

The client has comorbidities that evaluated by her PCP at least twice a year. I would order the following diagnostic tests unless recently completed within 3 months. I would order lab work to include CBC, CMP & EKG to evaluate the diabetes. I would order a sleep apnea test to rule out the possibility of sleep apnea causing her insomnia.

Differential Diagnosis for the Patient

The differential diagnosis I chose was “Adjustment disorder with depressed mood” because her grief is not over 12 months to diagnose complicated grieving. I would next try to determine is the insomnia episodic, persistent, or recurrent.

Two Pharmacologic Agents 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.

Interestingly, Markota et al., (2016) advises against using benzodiazepines or non-benzodiazepine hypnotics per the American Geriatrics Society. Markota suggests doxepin (Silenor) for geriatric insomnia. IBM (2020) suggests for the age of 65 years or older, the initial dose of 3 mg once daily 30 minutes before bedtime: a max of 6 mg daily. Doxepin is metabolized by CYP2C19 and CYP2D6, the active metabolite is N-desmethyldoxepin. The side effects are anticholinergic and sedative and may cause orthostatic hypotension. The patient needs to be instructed to move slowly. Markota et al., (2016) also suggests, Ramelteon is an FDA, a (melatonin receptor agonist) is an approved hypnotic for insomnia that is not mentioned in the AGS criteria. It is effective in treating initial insomnia in both the short and long term, is not sedating, has no abuse potential, and has a more benign adverse effect profile. I would prefer the Ramelteon over the doxepin for this patient because the anticholinergic side effects.

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?

In a study by Shadyab et al., (2015) suggested there were ethnic differences in nighttime sleep and daytime napping durations with type 2 diabetes. Ethnic- specific associations of sleep and napping durations with diabetes were reported. Type 2 diabetes prevalence was the highest in Filipina women. Sleep duration was in the Filipina women and napping over 30 minutes daily was associated with type 2 diabetes in white women only. I did not find ethnic dose adjustments as I did with adjusting the dose for the elderly client adjustment.

The American Geriatrics Society (AGS) Beers Criteria® (AGS Beers Criteria®) for Potentially Inappropriate Medication (PIM) Use in Older Adults are widely used by clinicians, educators, researchers, healthcare administrators, and regulators.

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.

Brasure et al., (2016) advises against benzodiazepines and nonbenzodiazepine hypnotics in older patients. Therefore, I would monitor and follow the patient at the 4 week- follow up and adjust according or switch medication to doxepin and monitor for side effects every 4 weeks until the 3- month threshold then at six months.

NURS 6630 Discussion Treatment for a Patient With a Common Condition References

Carlat, D. (2017). The Psychiatric Interview. 4^th edition. Wolters Kluwer

Brasure, M., Fuchs, E., MacDonald, R., Nelson, V. A., Koffel, E., Olson, C. M., Khawaja, I. S., Diem, S., Carlyle, M., Wilt, T. J., Ouellette, J., Butler, M., & Kane, R. L. (2016). Psychological and Behavioral Interventions for Managing Insomnia Disorder: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians. Annals of Internal Medicine, 165(2), 113–125. https://doi-org.ezp.waldenulibrary.org/10.7326/M15-1782

Markota, M., Rummans, T. A., Bostwick, J. M., & Lapid, M. I. (2016). Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies. Mayo Clinic Proceedings, 91(11), 1632–1639. https://doi-org.ezp.waldenulibrary.org/10.1016/j.mayocp.2016.07.024

Fick, Donna M., Todd P. Semla, Michael Steinman, Judith Beizer, Nicole Brandt, Robert Dombrowski, Catherine E. DuBeau, et al. “American Geriatrics Society 2019 Updated AGS Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults.” Journal of the American Geriatrics Society 67, no. 4 (April 2019): 674–94. doi:10.1111/jgs.15767.

Shadyab, A. H., Kritz-Silverstein, D., Laughlin, G. A., Wooten, W. J., Barrett-Connor, E., & Araneta, M. R. G. (2015). Ethnic-specific associations of sleep duration and daytime napping with prevalent type 2 diabetes in postmenopausal women. Sleep Medicine, 16(2), 243–249. https://doi-org.ezp.waldenulibrary.org/10.1016/j.sleep.2014.11.010

RE: Discussion Insomnia

COLLAPSE

Hello Jo, I did really enjoy reading your post; you did make some essential points. Aging is associated with changes in sleep. When aging, people spend more time in bed but less time asleep. Sleep becomes less efficient and more disrupted. This goes along with decreases in slow-wave sleep and increased early-morning awakenings. The prevalence of sleep problems increases from the age of 65 years. Approximately 50% of older adults suffer from difficulties in sleeping, of which up to 30% suffer from insomnia, and 20% suffer from sleep apnea. Sleep problems in older adults can cause fatigue, daytime sleepiness, and napping. Sleep problems also affect general functioning, activities of daily living (ADL) Moreover, they are associated with lower quality of life and cognitive and mental health issues (Effects of physical activity programs on sleep outcomes in older adults: A systematic review, 2020).

I would also like to add that the patient should be questioned if she uses alcohol. Research has shown that adults in mid to later life consume alcohol for several reasons, categorized as either positive or negative reinforcement. While stressful life events, such as bereavement or retirement, may trigger late-onset drinking in some, this is not the case for all. Alcohol use has been associated with self-medication for physical and mental health problems and insomnia and has also been linked to boredom, loneliness, isolation, and homelessness. However, the direction of causality in the relationship between alcohol use and many of these factors is often in doubt. Older people also report consuming alcohol for positive reasons such as enjoyment and socialization (Haighton, Amy O’Donnell, Wilson, McCabe & Ling, 2018

NURS 6630 Discussion Treatment for a Patient With a Common Condition References

Effects of physical activity programs on sleep outcomes in older adults: A systematic review. (2020). International Journal of Behavioral Nutrition and Physical Activity, 17, 1. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1186/s12966-020-0913-3

Haighton, C., J. K., Amy O’Donnell, Wilson, G., McCabe, K., & Ling, J. (2018). ‘I take my tablets with the whiskey’: A qualitative study of alcohol and medication use in mid to later life. PLoS One, 13(10) doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1371/journal.pone.0205956

Thank you for your post. Very informative information on medications I was not as familiar with. You mentioned Doxepin, Doxepin is said by Yeung et al. (2015), as being a sedating tricyclic drug, at 3 mg and 6 mg doses was recently approved by the U.S. food and drug administration (FDA) for the treatment of insomnia. Although TCAs’ overall efficacy in treating depression is parallel to SSRIs, Stern et al. (2016), states they have a considerable amount of side effects. It is recommended to use lower dosing in older adults: doses of 1, 3, and 6 mg were suggested (Sys et al., 2020). Studies show symptoms of insomnia improved during weeks 2 (3 and 6 mg), week 4 (3 mg), and week 12 (1 mg and 3 mg); the insomnia severity index improved with Doxepin 3 mg and 6 mg at all time points compared to placebo. Doxepin does show promising results, but Sys et al. (2020), recommends further trials are needed to evaluate long-term efficacy, safety, and its impact on daily functioning.

I’d encourage discussing side effects with the patient. Doxepin is said to cause drowsiness, dizziness, dry mouth, blurred vision, and constipation. Because dizziness and lightheadedness may occur, I agree that telling patients they should get up slowly when rising from a sitting or lying position is important. Yeung et al. (2015), states patients may experience rebound insomnia during the discontinuation period – and this was noted on low doses as well. As you stated Ramelteon, which is a FDA-approved pharmacologic agent, is recommended for people over 55 year who have difficulty sleeping. Studies performed by Yeung et al. (2015), state that Ramelteon plus doxepin was significantly more effective than Ramelteon alone.

Stern, T. A., Fava, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and Neurotherapeutics E-book. Elsevier Health Sciences.

Sys, J., Van Cleynenbreugel, S., Deschodt, M., Van der Linden, L., & Tournoy, J. (2020). Efficacy and safety of non-benzodiazepine and non-Z-drug hypnotic medication for insomnia in older people: a systematic literature review. European Journal of Clinical Pharmacology, 76(3), 363–381. https://doi-org.ezp.waldenulibrary.org/10.1007/s00228-019-02812-z

Yeung, W.-F., Chung, K.-F., Yung, K.-P., & Ng, T. H.-Y. (2015). Doxepin for insomnia: a systematic review of randomized placebo-controlled trials. Sleep Medicine Reviews, 19, 75–83. https://doi-org.ezp.waldenulibrary.org/10.1016/j.smrv.2014.06.001

Thanks again for your post and introduction to new medication,

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.

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

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

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).

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).

NURS 6630 Discussion Treatment for a Patient With a Common Condition 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

Additional questions that I will ask the patient if they were in my office

The additional questions that I would ask the patient to gather more information concerning her problem would include the following:

The first would be, “How have your sleep patterns been affected by your husband’s passing on?”. By asking this question, I would be gathering information to understand more about how her sleeping habits have changed and assess the relationship of the problem to her spouse’s death. It aids in determining her sleep length, quality, and timing, as well as any specific sleep disorders she may be having.

The second question would be, “Have you experienced any other changes in mood, appetite, or energy levels?” By asking this question, I would be able to examine the patient’s general emotional well-being and spot any signs of depression or other mental health issues. It is useful in understanding the scope and significance of her symptoms beyond insomnia.

The third question would be,” How are you coping with the loss of your spouse?” By asking this question, I would be able to assess the patient’s coping methods and emotional resilience in the aftermath of a major life catastrophe. Understanding her methods of coping with the loss would aid in identifying potential areas of support or intervention to help her deal with her grief and maintain her emotional health.

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 first people would be people within her family and especially those who are very close to her. I’d question the patient’s behavior, mood, and sleeping habits since her husband’s death. I’d ask whether they’ve noticed any changes in her daily functioning, or if they’re concerned about her mental health. This can provide other perspectives on her mental well-being as well as any changes seen by those close to her that the patient is unable to disclose.

I would also question her friends especially those who are very close to her or her family friends concerning any recent changes in her health. I’d ask whether they’ve observed any changes in her sleep patterns, mood, social participation, appetite, activity levels, or expressions of despair or hopelessness after her spouse’s death. Insights from her close circle can help provide a more complete picture of her emotional well-being and any depression symptoms.

The other person to question concerning any recent changes on her health would be her primary care physician. I’d ask them about the patient’s medical history, current medications, and any previous mental health issues. This collaboration would help guarantee a thorough grasp of the patient’s health status, including any potential interactions or contraindications connected to her medical conditions and drugs.

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

In this scenario, I would perform a physical assessment to check the patient’s overall health and possibly find any underlying physical causes of her insomnia. The evaluation would include taking vital signs, performing a neurological exam, and examining her overall physical well-being. This would help rule out any medical illnesses or causes that might be causing her sleep problems. If the physical examination reveals any abnormalities, such as neurological deficiencies or evidence of an underlying medical illness, I would do additional tests or refer the patient to a specialist if I couldn’t manage it (Santarnecchi et al., 2018).

I would perform diagnostic testing such as a complete blood count, thyroid function tests, or a sleep study for further investigations. These tests can help uncover any underlying medical diseases that may be contributing to her symptoms, such as anemia or thyroid disorders. If anomalies are discovered, I will start the necessary interventions or therapies.

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 is major depressive disorder with insomnia. Major depressive disorder is a form of mental illness characterized by persistent grief, a lack of interest or happiness, poor appetite or loss of weight, difficulties sleeping, fatigue, trouble paying attention, feelings of lack of worth or guilt, and, in severe cases, suicidal ideation. In this case, the patient’s symptoms of increased depression and disrupted sleep patterns after the death of her spouse corresponds to the diagnostic criteria for major depressive disorder. The absence of a history of depression in the patient before her husband’s death shows that the depressive symptoms are a direct effect of the stressful life event (Gutiérrez-Rojas et al., 2020).

Pharmacological agents that would be appropriate for the patient’s antidepressant therapy

Pharmacological agents that could be used as antidepressants for this patient include sertraline and mirtazapine. Sertraline is a serotonin reuptake inhibitor (SSRI) that is often used to treat depression. Sertraline’s beginning dose for adults is normally 50 mg once daily, which can be gradually elevated to a therapeutic dosage of 50-200 mg every day, based on how well the patient responds (Kishi et al., 2022). Mirtazapine is an atypical antidepressant that regulates the brain’s serotonin and noradrenaline levels. Mirtazapine’s recommended starting dose is 15 mg once daily at bedtime, which can be escalated to a maximum dosage of 45 mg per day based on the patient’s reaction and tolerance (Xiao et al., 2020).

Sertraline is frequently recommended as the initial therapy for depression due to its efficacy, safety profile, and long history of use. Because the patient is already taking 100 mg of sertraline every day and her response to the medicine is just minimal, keeping the present medication and possibly changing the amount if necessary could be a sensible option. Sertraline works by selectively decreasing serotonin reuptake in the brain, consequently boosting its availability and improving mood regulation. If the patient continues to have considerable sleep disruptions, mirtazapine may be investigated as an alternative. It has sedative qualities that can aid in the improvement of sleep patterns. However, given that the patient is already on sertraline and showing signs of improvement, improving the current treatment regimen before considering a switch or the addition of another medication might be a logical strategy (Kishi et al., 2022).

Contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making

When it comes to antidepressant drug therapy, it is critical to assess any contraindications that require changes in dosing from an ethical standpoint in order to promote patient safety. In this case, concurrent usage of sertraline with monoamine oxidase inhibitors (MAOIs) such as Phenelzine is a serious contraindication. Combining the two can result in serotonin syndrome, a potentially fatal illness. This illness is distinguished by an upsurge of symptoms such as agitation, increased blood pressure, tremors, and even seizures. To avoid such hazardous consequences, it is critical to establish that the patient is not currently taking any MAOIs before beginning or maintaining sertraline medication. In order to detect any bad effects, the patient’s response to the medicine must be monitored on a frequent basis (Suchting et al., 2021).

Follow up

I would consider following up on the progress of the patient after 4 weeks after the treatment date and then after 8 weeks. At 4 weeks, I would evaluate the patient’s reaction to the present treatment, such as changes in sleep patterns, mood, and overall well-being. If there is insufficient improvement, I would consider raising the Sertraline dosage to a higher but similar to the existing one. If there are bothersome side effects, I would consider switching from sertraline to mirtazapine.

At 8 weeks, I would reassess the patient’s development, including the influence of medications continued or change or adjusted at week 4 on her sleep and depressive symptoms. I would suggest prolonging the dosage while waiting for the symptoms to decrease and referring the patient to therapy groups based on the therapeutic response. I would then reevaluate the patient in two weeks and advise them to progressively reduce the amount until she is no longer using drugs and only participating in support groups.