30.Wk7DisRep

Jane,

I need discussion replies for each case. There are 2. Thanks!

-Case 1: Volume 2, Case #16: The woman who liked late-night TV (Case study itself is attached)

-Student’s post (Keeli)

The case patient is a 70-year-old female with chief complaints of sadness. She exhibits depression symptoms associated with heightened loneliness. She also has hearing problems and various medical issues, including obesity, hypothyroidism, and allergies. Hence, her home aide and son assist her in activities of daily living. The woman has a restless leg syndrome (RLS) that could be influencing her sleeplessness. She also has a family history of depression and reports daily crying episodes.

            The three questions I would ask her include,

1. How would you describe your usual night sleep in terms of quality and hours of sleep? Additional probing questions regarding her sleep should explore whether she feels sleepy or has sleep attacks during the day. This line of questioning would help determine whether the patient has significant sleep issues and how they affect the quality of her daily living. Severe sleep deprivation causes depression due to neurochemical changes in the brain (Almondes, Costa, Malloy-Diniz, & Diniz, 2016). For these reasons, sleep deprivation can result in depression or worsening of the mental disorder.

2. Has any of your family members had a history of mental health issues, including depression and suicidal ideation? This question is crucial because genetic factors significantly influence the development of major depressive disorder. It is also important to ask her if she has any thoughts of committing suicide or harming herself.

3. Have you suffered from depression or any other mental disorder in the past? The patient exhibits symptoms of depression, such as sadness and crying.

The people in the woman’s life that I would need to get feedback from to examine her situation further are her son and home aide. They are the primary caregivers in the patient’s life that offer her constant care. Due to their constant interaction with the woman, they are more likely to witness her experiences with medications, disease symptoms, and her description regarding her daily life. Therefore, they will provide information regarding her description of depression, the restless leg syndrome while sleeping, and their observation of sleeping patterns and snoring.

The physical examinations and diagnostic tests that would be appropriate for the patient include actigraphy and polysomnography. The latter is a sleep study test that would help record the patient’s brain waves, oxygen concentrations, her breathing, and heart rate (Mellor, Bucks, Maul, Sanders, McGowan, & Waters, 2018). The test also monitors and records leg and eye movement when one is asleep. This test would detect the woman’s sleep pattern and help treat insomnia if diagnosed. Actigraphy involves use of a device to measure and record activity cycles, including human rest (Mellor et al., 2018). It is useful for assessing insomnia through the evaluation of an individual’s sleep-wake cycles. These tests would establish whether the patient has insomnia.

Three differential diagnoses for this patient include major depressive disorder (MDD), insomnia, and persistent depressive disorder. MDD is a mental health condition characterized by a depressed mood that extends for, at least, two weeks. Its symptoms include insomnia, sadness, loss of appetite and motivation to engage in fun activities, crying spells, and impaired quality of life. The patient’s sleeping issue could be an underlying factor for depression. Her RLS could also be the cause of insomnia. Since it is unknown when the patient’s depression first occurred, she may be clinically depressed for over a year without remission, hence the persistent depressive disorder diagnosis. However, MDD is the most likely diagnosis for this patient based on symptoms and family history of the condition.

The chosen pharmacological intervention for this patient includes prescription of selective serotonin reuptake inhibitors (SSRIs), such as Sonata and Celexa, for insomnia. Oral Celexa 10 mg daily and 5mg of Sonata every night at bedtime are the recommended dosages. Celexa is an antidepressant capable of blocking serotonin reuptake pumps, consequently desensitizing the receptors (Behere, Das, & Behere, 2018). It takes nearly two to four weeks for the onset of therapeutic action. According to Chigome, Nhira, and Meyer (2018), inhibitions of actions in an individual’s sleep centers provide sedative hypnotic effects. Sonata is an effective regimen because it is a non-benzodiazepine hypnotic that functions by providing more selective hypnotic effects. These two drugs would be effective in treating the patient’s depression and insomnia.

This case study shows the dynamics of depression among geriatrics. The greatest lesson ensuing from its analysis is that depression in this population is likely due to psychosocial changes and comorbidities such as those exhibited by this case study patient. Evidently, optimal treatment and management of such patients requires a multidisciplinary approach from a physician and therapist.

 

References

Almondes, K. M. D., Costa, M. V., Malloy-Diniz, L. F., & Diniz, B. S. (2016). The relationship between sleep complaints, depression, and executive functions on older adults. Frontiers in psychology, 7(7), 1547. doi: 10.3389/fpsyg.2016.01547

Behere, P. B., Das, A., & Behere, A. P. (2018). Clinical psychopharmacology: An update. New York, N.Y.: Springer.

Chigome, A. K., Nhira, S., & Meyer, J. C. (2018). An overview of insomnia and its management. SA Pharmaceutical Journal, 85(2), 32-38. Retrieved from https://www.researchgate.net/publication/325882954_An_overview_of_insomnia_and_its_management

Mellor, A., Bucks, R. S., Maul, J., Sanders, K. A., McGowan, H., & Waters, F. (2018). Sleep and cognition in older adults: Does depression matter? An actigraphy and polysomnography study. Archives of Psychology, 2(1), 1-29. Retrieved from https://www.cogstate.com/wp-content/uploads/2018/02/sleep-and-depression-in-older-adults.pdf

Case 3: Volume 1, Case #5: The sleepy woman with anxiety (Case study itself attached)

-Student’s post

The three questions I would ask the client in this case are

1. Are your feelings of anxiety occasional or continuous?

The rationale for this question is that occasional anxiety is a normal reaction to stress and be beneficial to humans. For example, it can alert us to danger and help us prepare and pay full attention. On the other hand, continuous and excessive fear or anxiety is a mental disorder that leads to depression, sleep disorders, social withdrawal, low job performance, and poor personal relationships (American Psychiatric Association, 2020; Anxiety and Depression Association of America, n.d.).

1. Do you have a blood relative who has anxiety or depression?

The rationale for this question is to elicit whether the client chief complain of anxiety has genetic or epigenetic predispositions. According to Schiele & Domschke (2018), strong evidence exists that there a considerable genetic influence on the pathogenesis of anxiety disorder. For example, family and twin studies show a significant contribution of genetic factors in the etiology of anxiety up to sixfold in first-degree relatives suffering from an anxiety disorder.

1. Do you have a plan to harm yourself or others?

The rationale for this question is that several clients with anxiety often have depression, which makes them vulnerable to suicidality risk. Anxiety and its comorbid such as depression, hopelessness, and stress increase the risk of suicide (Bentley, 2016; Lew, et al.2019).

People in Client Life

The people in the client life that I would like to speak with or get feedback from to further assess the client's situation include but are not limited to the husband, closed relative/families, and friends. These support systems are crucial to the client's mental health and alleviations of her anxiety and depression. For example, questions about the client's daily life activities, prescribed medication, interaction or relationship husband and others, previous suicidality ideation or attempt, and coping skills will be channeled to the client's husband. I believe the husband will be the best resource to provide more personal feedback on her wife. Again, close relatives/families such as brother, sister, parents can also be asked about the client’s past and current social and mental behaviors. The client’s close friend will be asked questions relating to social interaction with others, smoking, drug use. They will also answer questions about anxiety triggers and coping and adaptability to stressors.

Physical Examination and Diagnostic tests

The physical exam and diagnostic tests that I believe would be appropriate for this client include but are not limited to:

1. A comprehensive history and physical examination: to rule other organic problems associated with the client presenting anxiety and depression.

2. Hamilton depression rating scale (HAM-A)

3. Hamilton depression rating scale (HDRS or HAM-D)

4. Baseline cardiac function with EKG

5. Baseline kidney and liver function tests such as BUN/Creatine, ALT/AST.

6. CBC/diff to ensure normal blood level

7. Etoh and drug use tests

8. A1C to reveal blood sugar level over the last 3 months.

Differential diagnoses

1. Generalized anxiety disorder (GAD) with recurrent depressive mood

2. Major depressive disorder

3. Posttraumatic stress disorder

Although the client has a complicated history, however, the diagnosis that I think would be the most like for her will be GAD with recurrent depressive mood.  GAD is an anxiety disorder characterized by excessive anxiety and worry, lasting for days, with several events or activities where the person finds it difficult to control the worry. The anxiety or worry is associated with at least three of the following: restlessness, sleep disturbance, irritability, agitation, difficulty concentrating, muscle tension, and fatigue.

Pharmacological Agents

1. Selective serotonin reuptake (SSRI) and serotonin and norepinephrine reuptake are antidepressants, first-line therapy for GAD such as Lexapro, Cymbalta, and Effexor XR

I will be starting the client on Effexor XR 75 Mg/day orally daily and will adjust the dose up based on patient tolerability. The maximum recommended daily dose is 225 mg/day as a single dose. I will choose this medication over the later because SSRI is a first-line drug for treating GAD unless the client is not tolerating it.

1. Buspirone XL, an antianxiety medication can also be used continuously. I will start with 450 mg orally per day in the morning since the patient has reported this medication is helpful. Buspirone is indicated for depressive symptoms associated with this client's GAD.

 Follow-up

Nurse practitioners should follow-up accordingly with their clients especially when psychopharmacological agents such as antidepressants or antianxiety such as Effexor and Wellbutrin are prescribed. This is important to check for tolerability, adverse effects, Drug-drug interactions, as well as suicidality thinking and plans. For example, Effexor should not be taken with or within 2 weeks of taking monoamine oxidase inhibitors (MAOIs) such as Nardi, Parnate, Marplan, Azilect, or Emsam (National Alliance on Mental Illness. 2016). The dosage of these drugs can be adjusted or tapered based on the client's response. Other therapeutic changes I could make include augmenting this medication with mindful therapy or cognitive therapy such as physical exercise, stress management, relaxation techniques, or learning and identify a changing pattern of thinking that lead to anxiety, challenge such change pattern of thinking, and change the catastrophic thinking (Kaczkurkin & Foa, 2015).

Lesson Learn

            I have learned a lot of lessons in this case and recognized that treating a patient presenting with anxiety and depression can sometimes be challenging to treat. I also learned that the client presenting with recurrent anxiety and depression could be because of disease comorbid, genetic, or because of polypharmacy. I hope to apply this valuable information in my clinical practice in the future. 

 

 

References

American Psychiatric Association. (2020). What Are Anxiety Disorders? Retrieved from

https://www.psychiatry.org/patients-families/anxiety-disorders/what-are-anxiety-disorders

Anxiety and Depression Association of America. (n.d.).  Sleep Disorders. Retrieved from

            https://adaa.org/understanding-anxiety/related-illnesses/sleep-disorders

Bentley, K. H., Franklin, J. C., Ribeiro, J. D., Kleiman, E. M., Fox, K. R., & Nock, M. K. (2016).

Anxiety and its disorders as risk factors for suicidal thoughts and behaviors: A meta-

analytic review. Clinical Psychology Review, 43, 30–46. https://doi-org.ezp.waldenu

library.org/10.1016/j.cpr.2015.11.008

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an

update on the empirical evidence. DIALOGUES IN CLINICAL NEUROSCIENCE, 17(3),

337–346.

Lew, B., Huen, J., Yu, P., Yuan, L., Wang, D.F., Ping, F., Abu Talib, M., Lester, D., & Jia, C. X.

(2019). Associations between depression, anxiety, stress, hopelessness, subjective well-

being, coping styles and suicide in Chinese university students. PLoS ONE, 14(7), 1–10.

https://doi-org.ezp.waldenulibrary.org/10.1371/journal.pone.0217372

Schiele, M. A., & Domschke, K. (2018). Epigenetics at the crossroads between genes,

environment and resilience in anxiety disorders. Genes, Brain, and Behavior, 17(3),

e12423. https://doi-org.ezp.waldenulibrary.org/10.1111/gbb.12423