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The case study recalls a 75-year-old female who just lost her spouse about 10 months ago and is here today due to insomnia. The patient has a past medical history of diabetes, hypertension, and major depressive disorder. The patient reports her depression and insomnia have gotten worse. No reports of previous history of depression before husband’s death. Mental status exam reveals the patient to be awake, alert, and oriented x3. The patient denies any reports of suicidal ideations. The patient is an independent driver. Current medications consist of Metformin 500mg BID, Januvia 100mg daily, Losartan 100mg daily, HCTZ 25 mg daily, and Sertraline 100mg daily. Objective assessment reveals the patient’s BP: 132/86, Temp: 98.6 F, Wt. 88kg/194Ibs, Ht. 64 inches/5’4”, and BMI: 33.3 (Obesity) (NIH, 2021).

Insomnia is a common sleep disorder in which you either have trouble falling asleep or wake up throughout the night and cannot fall back to sleep. According to Morin et al. (2015), acute insomnia lasts a month, while chronic insomnia lasts more than 3 months. Moreover, insomnia affects the quality and quantity of sleep causing it much harder for individuals to reach restorative levels leading to daytime fatigue, restlessness, anxiety, and depression. Insomnia can lead to more significant mental health conditions, cardiovascular complications, and lung disease (Moran & Pouya, 2004). According to Morin et al. (2015), it is not unusual for individuals to experience insomnia after the death of a loved one.

• List three questions and rationale

1. How long does it take for you to fall asleep? Insomnia is characterized by dissatisfaction or difficulty in falling asleep and thus, understanding how many hours the patient sleeps, provides an opportunity to differentiate if she is getting enough hours of sleep and is still tired or having a hard time falling back to sleep (Patel et al., 2018). This is important because if the patient is getting enough hours to sleep but is still tired, and fatigued, this may indicate that the depression is more severe or if the patient is not getting enough hours of sleep, that in turn can also cause depressive symptoms to worsen.

2. Do you keep a sleep diary? This will provide an opportunity to understand what is going on or what is exacerbating her insomnia. For instance, is the patient having frequent afternoon naps, is their exposure to bright lights causing a decrease in melatonin released from the pineal gland, is the T.V. kept on, and information about caffeine and alcohol intake. As studies show, it is useful to maintain a 2 -week sleep diary for accurate accounts of sleeping habits to be recorded (McCall, 2004). 

3. Do you snore loudly or wake up gasping for air? Do you have any leg discomfort at bedtime? According to studies, more than 50% of patients that report insomnia, also have pulmonary disease. Reasons this occurs is due to the sleep activity of the individual, such as lying down or trying to sleep causes increased work of breathing and pooling of secretions resulting in pulmonary complications. Moreover, asking about snoring may elicit a sleep apnea diagnosis (Patel et al., 2018).

4. Are you having any pain? Can you please rate your pain on a scale of 1-10? According to studies, pain can be a precipitating factor that leads to worsening insomnia (McCall, 2004).

Further assess the patient’s situation

The case study recalls the patient driving independently. Therefore, I would communicate and gather the necessary information regarding the patient's support system. If the patient has children, family, or a guardian that support her, this would provide more information to inquire. I would ask if they have noticed the patient taking her medications? According to studies, antidepressants and antihypertensives can interfere with sleep (Morin et al., 2015). Does the patient seem more depressed lately? According to research, a critical precipitating factor to insomnia is related to patients suffering from severe depression and generalized anxiety disorder (Patel et al., 2018). I would also ask about socioeconomic status and how the patient has been living. Does the patient consume alcohol, smoke, or drink caffeine beverages? According to studies, smoking, drinking alcohol, and caffeine are factors associated with higher rates of insomnia (Morin et al., 2015). Does the patient have family or friends that check on her throughout the week? I’d also gather more information about her sleep pattern. For instance, does the patient nap during the day? Spends excessive time in bed? Anxiety level before sleeping? According to research, cognitive or behavioral changes can lead to acute insomnia.

Physical exams, and diagnostic tests

It is important to complete a full history and physical examination related to medical and mental health disorders that could potentially be exacerbating the patient's insomnia. Moreover, a comprehensive history of sleeping issues and relevant comorbidities obtained from the patient, family, or guardian, to help with evaluating and diagnosing insomnia is important. Insomnia may be the primary disorder or the result of other comorbid conditions, such as depression. For instance, according to McCall, The Beck Depression Inventory is one of the most validated, self-administered scales used to detect depression (2004). Depression has been linked as being one of the strongest correlates of insomnia. 

The patient has a history of diabetes and hypertension. Performing an HbA1c to check her glycemic levels and when she’s taking her HCTZ would be important. These two factors may be causing her to wake up in the middle of the night, affecting how much she sleeps. I would order labs to monitor her thyroid levels. According to studies, hypo/hyperthyroidism can lead to depression and worsening insomnia (Patel et al., 2018). Another test called polysomnography (PSH), the gold standard for diagnosing sleeping difficulties. This test requires the patient to be monitored by a professional that would monitor the patient's sleep, perform an EEG, EKG, and eye and extremity movements. Results would confirm if the patient has sleep apnea or restless leg syndrome that could be exacerbating her insomnia. CT scan/MRI to rule out any serious medical complications such as brain tumor. Other tests such as CBC, electrolyte levels, liver function (AST, ALT), and kidney function would be important to complete. For instance, the liver and kidneys are vital for metabolizing and eliminating drugs/medication, and therefore, if there is impairment, this can cause an accumulation of medication in the body leading to complications

Differential Diagonosis

The selected differential diagnosis for the patient is Major Depression Disorder. Others include Generalized Anxiety Disorder, Insomnia Disorder, Uncomplicated Bereavement, Substance-use disorder, Obstructive sleep apnea, and Restless legs syndrome. I believe the patient is suffering from Major Depression Disorder. The patient has a history of depression since the loss of her husband. Moreover, the patient is now suffering from insomnia or hypersomnia. According to studies, approximately half of patients with insomnia have a mental health disorder and those with a mental health disorder, such as depression, also have insomnia. Furthermore, several studies indicate that patients with depression have significantly higher rates of insomnia compared to other comorbid factors (Patel et al., 2018). 

List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy 

The patient is a 75-year-old female and because of her age, special cautions need to be considered with regards to pharmacokinetics and pharmacodynamics. Another consideration is polypharmacy that causes an increase in the potential for drug-drug interactions. Also, studies show older adults require lower doses than usual of medications, especially when beginning treatment. As such, the patient is currently being treated with an SSRI, Sertraline 100 mg daily for Depression. Accordingly, SSRIs are frequently used as first-line antidepressants because of efficacy, tolerability, and safety (Article). Since the patient just lost her loved one, the dosage of sertraline is 100 mg and it would be appropriate to continue the same dose while adding a medication to help with insomnia and depression. Studies show, providing treatment for both depression and insomnia has shown to provide an enhanced therapeutic response for both complications while allowing for decreased dosage of the antidepressants (article 24). Moreover, a side effect of Sertraline is difficulty sleeping, and thus, keeping the dose at 100 mg would be appropriate at this time. Hence, her depressive symptoms may be worsening her sleeping pattern, leading to insomnia or her insomnia may be causing her depression to be worse. Since the patient is suffering from insomnia and has a history of depression, Doxepin, a tricyclic antidepressant, is the only antidepressant that is FDA approved for the treatment of insomnia. Studies showed significant improvement in sleep onset, duration, quality, and treatment outcomes over 12 weeks with dosage range from 3mg to 6mg for men and women older than 65 years. Therefore, Doxepin 3mg Oral HS would be added to the treatment. The main goal was to not prescribe any benzodiazepines due to significant sedation resulting in CNS depression and increased fall risk.

Any contraindications 

There are no contraindications that were used or alterations in dosing that needed to be considered for decision making. Moreover, none of the medications interact with one another. But for ethical consideration, patient autonomy is the ethical principle that underlies informed consent (Moran & Pouya, 2004). Therefore, for the patient to make her informed decision regarding her treatment, as providers, we must inform the patient of all critical information regarding dosing, mechanism of action, and why selecting a medication over another is most applicable. Moreover, another consideration is non-maleficent, or to do no harm (Moran & Pouya, 2004). Hence, providing all the required educational material, and explaining the medications, dosage, and interactions with other substances such as alcohol, would be critical to avoid severe complications.  

Include any “check points”

A common side-effect of Sertraline is difficulty falling asleep or staying asleep. Therefore, with the addition of Doxepin, after 4 weeks, I would reassess the patient’s quality of sleep and depressive symptoms. Though studies show that Doxepin requires at least 12 weeks for significant improvements in treating insomnia, I would consider both her sleep pattern and depressive symptoms and adjust dosages accordingly (Matheson & Hainer, 2017). As studies have shown, treating insomnia and depression separately has resulted in using less dosage of antidepressants. 

References

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147(4), 1179-1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

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companion to the Journal of clinical psychiatry, 6(1), 9–20.

https://doi.org/10.4088/pcc.v06n0104

Matheson, E. M., & Hainer, B. L. (2017). Insomnia: pharmacologic therapy. American family

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Moran, D., & Pouya, P. (2004). Caring for the frail elderly: Ethical considerations. Advanced

Emergency Nursing Journal, 26(1), 14-18.

Morin, C. M., Drake, C. L., Harvey, A. G., Krystal, A. D., Manber, R., Riemann, D., &

Spiegelhalder, K. (2015). Insomnia disorder. Nature reviews Disease primers, 1(1), 1-18.

National Institutes of Health (NIH). (2021). Calculate your BMI - Standard BMI calculator.

Advancing Heart, Lung, Blood, and Sleep Research & Innovation | NHLBI, NIH.

https://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical

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Rojas-Fernandez, C. H., & Chen, Y. (2014). Use of ultra-low-dose (≤6 mg) doxepin for

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