Walden University Treatment for A Patient with A Common Condition Replies – Description
please provide a positive feedback with 2 references Treatment for a Patient with a Common Condition
(Rita) The case at hand involves a 75 YO with a chief complaint of insomnia and past medical history of diabetes mellitus, hypertension, and major depressive disorders, and she has been taking five types of medication. BMI calculations show that she is obese, a crucial health factor when considering medication options. She reports developing depressive symptoms since her husband died ten months ago. She denies having depression prior to her husband’s death but insists her sleeping habits have only gotten worse. Patient also denies suicidal thought/ideation. I believe the irregular sleeping habits could have been triggered by recent events, which could be a minor problem, a major underlying concern exacerbated by recent events. I would consider asking the patient the following questions:
How are you feeling today and what brought you in?
Asking these open-ended questions would allow the patient to describe her feelings and identify her major concerns. According to Shanahan and Cunningham (2021), understanding and addressing current wants is crucial in maintaining a good relationship with the client. Also, the information would lay an excellent foundation for asking follow-up questions.
Please describe your sleeping patterns since the problem started.
The client’s chief complaint is insomnia, and asking this question would help understand the onset and progression of the condition over time. It would help me understand how the severity has changed, allowing me to categorize it as rapid and alarming or mild or moderate sleep irregularity.
When did you start taking Sertraline? Has there been any dosage adjustment?
Client claims that her depression has only gotten worse. Hence it would be appropriate to investigate the effectiveness of the prescribed medication, considering that SSRIs usually take 4-8 weeks to show improvement.
With respect to people in the patient’s life, I would consider interviewing family members and close friends. I would inquire how the patient is coping at home and whether she has asked for any help lately. By interviewing them, I would be able to assess the level of support systems the patient has back at home to determine how it may affect the client’s mental condition. It would also aid in establishing how the situation has interfered with daily activity, including social events and gatherings.
On a different note, I would consider conducting physical exams to rule out thyroid problems that are associated with poor sleep quality. Also, it would help rule out any other medical condition or medication that may contribute to poor sleep patterns (Green et al., 2021). Another test I would consider is sleep history/habits to identify the sleep inconsistency to determine their occurrence and patterns and how they relate to the patient’s daily activity. This would be followed by an insomnia test which relies on self-reporting using a questionnaire. The insomnia test would help categorize the severity of the condition. I would also consider performing mini mental state exam (MMSE) to assess the patient’s mental state and cognitive functioning.
The differential diagnosis for the patient includes severe major depressive disorder with insomnia, prolonged grief disorder, and situational insomnia. Considering the client is already diagnosed with MDD, this could be a severe case of MDD where insomnia is one of the symptoms (American Psychiatry Association, 2022). The patient claims to have started with the health issues after the death of her husband, who could have been her comfort or depended on, considering she has a past medical history of diabetes and hypertension. Hence, this sudden change in her life may have exacerbated her MDD (Bei et al., 2018).
With respect to pharmacologic agents and their dosing, it is crucial to note that some antidepressants may interfere with sleeping habits; some worsen it while others improve. The client is already taking Sertraline, an SSRI class of medication, and its side effect include being unable to sleep and making one feel sleepy. Hence, considering a sedative medication to treat insomnia would be prioritized in this case. I would use Doxepin, an H-1 receptor that is an FDA-approved antagonist. The dosage should be 3 mg po q.d. (Chiu et al., 2021). The other option would be Trazodone, an FDA-approved medication for depression 150 mg po q.d. It works by increasing serotonin levels in the brain, helping regulate moods, sleep, appetite, memory, and attention. A possible contraindication is that Trazodone is a serotonin inhibitor, just like the Sertraline medication the client takes. Thus, administering Trazodone may trigger serotonin syndrome due to increased serotonin levels in the brain (Bollu & Kaur, 2019).
To avoid this, Doxepin would be the first priority considering it is FDA-approved for treating insomnia (Patel et al., 2018). On the same note, the first check-up point would be after four weeks, when the patient should be able to improve sleep and anxiety. If there is no noticeable improvement, the doctor should adjust the dosage by 3 mg and not exceed 6 mg per day. I would also consider adjusting the Sertraline medication by 10 mg per day as long as the dosage does not exceed the recommended maximum daily dosage of 50 mg to achieve even better outcomes.
References
American Psychiatric Association (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.s://doi.org/10.1176/appi.books.9780890425787Links to an external site.
Bollu, P.C. & Kaur, H. (2019). Sleep medicine: Insomnia and sleep. Missouri Medicine, 116(1), 68-75. https://pubmed.ncbi.nlm.nih.gov/30862990Links to an external site..
Chiu, H.Y., Lee, H.C., Liu, J.W., Hua, S.J., Chen, P.Y., Tsai, P.S., & Tu, Y.K. (2021). Comparative efficacy and safety of hypnotics for insomnia in older adults: A systematic review and network meta-analysis. Sleep, 44(5), zsaa260. https://doi.org/10.1093/sleep/zsaa260Links to an external site..
Green, M.E., Bernet, V., & Cheung, J. (2021). Thyroid Dysfunction and Sleep Disorders. Frontiers in Endocrinology (Lausanne), 12,725829. https://doi.org/10.3389/fendo.2021.725829Links to an external site..
(CASE 2 ROBIN ). The case study presented a 75-year-old woman, who lost her spouse 10 months ago, she has complaints of insomnia. She has a PMH of DM, HTN, and MDD. They were married for 41 years. Since his death, her depression has worsened, and she has had changes in her sleep pattern. She had no previous history of depression before his death. Normal Physical exam. No suicidal ideation. Her current meds include:
Metformin 500mg BID
Januvia 100mg daily
Losartan 100mg daily
HCTZ 25mg daily
Sertraline 100mg daily
Weight 88 kg
Height 64 inches
Temp 98.6 degrees F
BP 132/86
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 to describe her sleep patterns in more detail. Is she waking up in the middle of the night? Is she having trouble getting to sleep? This is important to know so the clinician can plan for the right course of treatment.
The next question I would ask is when she last had a full lab workup because certain disorders such as hypothyroidism can present with depressive-like symptoms. Hyperthyroidism can cause overactivity, which can result in insomnia. How controlled her blood sugars are, and metabolic issues can cause sleep disturbances (Suzuki, et.al, 2017).
Lastly, I would inquire about her behaviors before bed, whether she is eating large meals, and how much caffeine she has throughout the day, if any. I would ask about screen time before bed. Is she napping in the daytime because that would disturb nighttime sleep.
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.
If the patient has children, I will reach out with the patient’s permission to ask them how their mom has been over the past ten months since the death of their dad. I would ask if she has been more reclusive. Does she still do the same activities she did before?
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
A full workup would be needed to exclude any other diseases that could mimic symptoms of depression and insomnia. A thyroid panel needs to be ordered, along with an A1C, to see how controlled her diabetes is. Any physical ailments need to be ruled out before any mental health treatments began.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
The patient has a history of MDD, a differential diagnosis would be Generalized Anxiety Disorder, due to the death of her husband. The sudden loss of her husband of 41 years, change the dynamics in her home. Many people feel a loss of self, with the death of a spouse. Her sleep pattern could be interrupted due to anxiety.
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.
Trazodone is FDA-approved for depression, however, it has off labeled uses for insomnia and anxiety. Trazodone displays a good tolerability profile, with a low risk for weight gain, and anticholinergic effects (Cuomo et al., 2021). “Trazodone is Serotonin Antagonist and Reuptake Inhibitor (SARI), Trazodone behaves as a potent antagonist of 5-HT2A and 5-HT2B receptors, an antagonist of 5-HT1D, 5-HT2C, a1A, a 2C H1 receptors with moderate affinity, a partial agonist of 5-HT1A receptors, and an inhibitor of SERT” (Cuomo et al., 2021). One main concern with Trazodone, is that it can cause daytime sleepiness.
Low-dose amitriptyline is prescribed off labeled use to improve sleep maintenance in patients with insomnia disorder. Amitriptyline is a tricyclic antidepressant and acts by blocking the reuptake of both serotonin and norepinephrine neurotransmitters. “Amitriptyline is a tertiary amine with strong binding affinities for alpha-adrenergic, histamine (H1), and muscarinic (M1) receptors (Thour & Marwaha, 2023). In a study that tested 752 participants, 74 % say they had improved sleep and anxiety by taking this med (Bakker et al., 2022).
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?
I would choose the Trazodone 50 mg at bedtime. I would be sure to get baseline liver and kidney function. I would be sure to educate the patient to take the medication about 30 – 45 minutes before bed and not to drive after takin the medication. Also be sure to get at least 8 hours of sleep to offset the daytime drowsiness that could happen.
Initially, I would have her follow up in 4 weeks, if she has significant improvement, then 12 weeks after that.
Bakker, M. H., Hugtenburg, J. G., Smits, M. G., van der Horst, H. E., & Slottje, P. (2022). Off?label low Dose Amitriptyline for insomnia disorder: Patient?reported outcomes. Pharmacoepidemiology and Drug Safety, 32(4), 435–445. https://doi.org/10.1002/pds.5561
Cuomo, A., Bianchetti, A., Cagnin, A., De Berardis, D., Di Fazio, I., Antonelli Incalzi, R., Marra, C., Neviani, F., & Nicoletti, F. (2021). Trazodone: A multifunctional antidepressant. evaluation of its properties and real-world use. Journal of Gerontology and Geriatrics, 69(2), 120–129. https://doi.org/10.36150/2499-6564-n320
The post Walden University Treatment for A Patient with A Common Condition Replies first appeared on .
