Treatment For A Patient With Insomnia Case Discussion

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: Treatment For A Patient With Insomnia Case Discussion

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• 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 the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

Pharmacology

Questions to ask

According to the case study provided, it is apparent that the patient is suffering from a major depressive disorder. This is evidenced by an alteration in his sleeping pattern and also feelings of depression since the demise of his spouse (Lovestone, S., & Howard,2020). Some of the essential questions to ask the patient would include,

1. When did you start encountering sleeping problems? This question would help me distinguish the severity of the illness and the system involvement level.
2. How can you describe the way you are feeling today? This is an open-ended question, and it would help me analyze and better understand the situation deeply.

• How would you describe your typical day and bedtime routine? The patient has reported to the facility with complaints of interrupted sleep patterns; environmental factors are known to hinder one’s circadian rhythm Treatment For A Patient With Insomnia Case Discussion.

People to interview

I want to talk to her children, close family members, and neighbours. They would be a good source of information that might help me determine the most effective patient care. It would also be crucial to understand her time with her close friends. I would be interested in knowing about the source of social support, the environment she lives in and whether she works or not.

Physical exam and diagnostic tests

Performing various diagnostic tests would be essential for this patient since only a little information had been provided earlier during the history taking. One of the diagnostic tests would be the urine culture test; the majority of the geriatrics do not have visible symptoms; hence there is a great need for the healthcare workers to conduct various diagnostic tests. Study by Tortora and Derrickson (2018) states that the majority of the systems of the old persons have atrophied; thus, getting accurate assessment findings is very difficult. Secondly, a Depression scale, for example, the Becks depression scale, would help me quantify the depression levels of the patient. Last task is the sleep regime; this would help determine the patient’s sleep habits which would provide information on any other possible triggers of the condition.

Differential diagnosis

The most probable diagnosis for the patient is Major depressive disorder. In my opinion, the patient’s history has most of the depressive symptoms. According to Tolentino and Schmidt (2018)Treatment For A Patient With Insomnia Case Discussion, the DSM-V for major depressive disorder should include depressed mood, insomnia, fatigue, weight loss and decreased concentration. From the patient’s history, some of the symptoms that she presents with are similar to that of the DSM V. The most likely differential diagnosis is Adjustment Disorder with Depressed Mood. I believe that the patient is still trying to adjust after his spouse’s loss, which has made him have difficulties sleeping.

Pharmacological agents

Zoloft, a trade name for sertraline, is an antidepressant that is classified under the selective serotonin inhibitors (SSRIs). In adults, a dose of 50mg per oral is believed to be efficient for use. It is regarded as the first drug of choice among elderly patients due to the low potential for drug interactions (Eap et al.,2021). Zoloft would be the most efficient drug over fluoxetine and paroxetine since the patient is already on antihypertensive medications; thus, minor medication interference will be beneficial (Romero et al.,2019). It is contraindicated for patients taking Monoamine oxidase inhibitors and those with severe renal impairment. Some of the side effects include anxiety, dizziness, neuroleptic malignant syndrome and paresthesia. The second drug is Melatonin, a hormone that is produced by the pineal gland. Melatonin is believed to play a critical role in regulating sleep patterns. Some of its side effects include increased prolactin levels and nausea.

Checkpoints

I will request the patient to come back for a checkup after four weeks to assess the drug regime’s effectiveness, her adherence, and any side effects.

Lessons Learnt from the case study

From this case study, I have learnt that depression can be worsened by losing someone dear to us, and symptoms may present after a while. Secondly, each drug has a side effect, and the nurse should be watchful when administering them to any patient, regardless of the status Treatment For A Patient With Insomnia Case Discussion.

References

Eap, C. B., Gründer, G., Baumann, P., Ansermot, N., Conca, A., Corruble, E., … & Hiemke, C. (2021). Tools for optimizing pharmacotherapy in psychiatry (therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests): focus on antidepressants. The World Journal of Biological Psychiatry, 22(8), 561-628.

https://doi.org/10.1080/15622975.2021.1878427

Lovestone, S., & Howard, R. (2020). Depression in elderly people. CRC Press.

Romero-Martínez, Á., Murciano-Martí, S., & Moya-Albiol, L. (2019). Is sertraline a good pharmacological strategy to control anger? Results of a systematic review. Behavioral Sciences, 9(5), 57.

https://doi.org/10.3390/bs9050057

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in psychiatry, 9, 450.

Tortora, G. J., & Derrickson, B. H. (2018). Principles of anatomy and physiology. John Wiley & Sons.

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:  Treatment For A Patient With Insomnia Case Discussion

• 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

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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. Treatment For A Patient With Insomnia Case Discussion