response to discussion

A 75-year-old female patient presents to the primary care office with a chief complaint of insomnia. She reports that her husband of 41 years passed away ten months ago, and her depression and sleep habits have gotten worse since then. She denies any suicidal ideations. The patient has no previous history of depression prior to her husband's death. PMH includes DM, HTN, and MDD. She is awake, alert, and oriented x3. The patient normally sees the PCP once or twice a year. She arrived at the office today by private vehicle. The patient's current medications include:

Metformin 500mg BID (DM)

Januvia 100mg daily (DM)

Losartan 100mg daily (HTN)

HCTZ 25mg daily (HTN)

Sertraline 100mg daily (MDD)

Vital Signs:

Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP: 132/86 

Approximately 40% of insomnia patients have a comorbid psychiatric disorder, with depression being the most prevalent. Insomnia is a symptom for the diagnosis of depression and anxiety (Roth, 2007).

                                         Three Questions to Ask Patient

The first question would be to assess the patient's sleep patterns and routine. For example, how many hours do you sleep each night? What time do you go to bed? What time do you wake up? How long does it take you to fall asleep? Do you awake throughout the night and have difficulty falling asleep? Do you frequently wake up to urinate? Do you wake up earlier than you would like? Are you fatigued throughout the day? Do you take naps? Do you drink caffeinated beverages? If so, how many, and what time during the day do you consume them? Do you consume alcohol or nicotine? Are there distractions such as the television or light? How many nights per week does insomnia occur? Do you snore or have been told you do? Are you having any pain? Since insomnia can be related to stress, gender, age, and genetics, it is crucial to establish the patient's sleep pattern to ascertain the appropriate diagnosis and implement an optimal treatment plan (NHLBI.NIH., 2021).

The second question would be to determine when the Zoloft was ordered. I would ask the patient how long she has been taking the drug and if the dose has been recently adjusted. I would also ask when she was diagnosed with MDD and when she last saw her PCP. I would ask the patient if she had depressive symptoms before her husband's death. I would also ask if she were having increased symptoms of depression such as difficulty concentrating or making decisions, decreased interest in prior activities, feeling hopeless, and an increase or decrease in appetite. Recent evidence has implicated corticotropin-releasing factor dysregulation as the common pathological processes that depression and insomnia share, thus, making patients susceptible to both (Roth, 2007).

Lastly, I would ask the patient if she has attempted any forms of treatment for insomnia, such as over-the-counter medications, limiting caffeine intake, diet changes, exercise, cognitive behavior therapy (CBT), or stimulus control. CBT attempts to reverse the behaviors that lead to sleep-related anxiety exacerbating insomnia (Levenson et al., 2015). I would also inquire if she utilized any coping strategies to deal with her grief, such as grief support groups, CBT, and psychotherapy.

                          Questions for Family/Friends for Further Assessment

Speaking with family members can substantiate the information relayed by the patient; therefore, after obtaining verbal consent from the patient, I would ask if they had noticed any changes in her behavior recently. For example, have they noticed a change in her sleep pattern, energy level, cognitive function, mood, or suicidal behavior since her husband died? Did she have problems with insomnia prior to her husband's passing? Is she independent with ADLs, or does she require assistance from a caretaker? Does she seem tired during the day and unable to complete tasks or concentrate? Does she take her medications as scheduled, and are there any adverse effects noted? Does she participate in activities with family and friends or any exercise? Who is included in her support system? Her children, siblings, friends, or church members? Does she tend to overeat or binge on unhealthy foods? (This is a concern since the patient is obese with a BMI of 33.3.) Finally, I would ask if any family members have been diagnosed with bipolar disorder. Since the most significant risk factor for BPD is a family history, determining this would be crucial to the patient's diagnosis (Perlis & Ostacher, 2016).

                                    Physical Exams and Diagnostic Tests

            A focused physical examination should be performed to rule out any medical conditions contributing to the patient's insomnia, such as restless leg syndrome or COPD. Laboratory testing, including a CBC, BMP, LFTs, B-12, TSH, Vitamin D, and Iron testing, can be done to rule out hyperthyroidism or anemia causing depressive symptoms. A mental status exam can evaluate the patient's affect, mood, and alertness. A sleep log can assess the level of severity, and the Epworth Sleepiness Scale (ESS) measures the level of daytime sleepiness. The benchmark for measuring sleep is polysomnography. Electromyography (EMG), electrocardiography (ECG), electroencephalogram (EEG), and pulse oximetry can identify disorders such as narcolepsy or sleep apnea (Saddichha, 2010).

                                            Differential Diagnosis 

A differential diagnosis for this patient is depression. Traumatic events such as the death of a spouse, as experienced by this patient, can trigger depression. Environmental and genetic risk factors are also involved. Sleep disturbance is a major symptom of depression (Chand & Arif, 2021). Another differential diagnosis is BPDII, described as depressed mood and changes in sleep (Perlis & Ostacher, 2016). A third differential diagnosis could be drug-related therapy associated with Zoloft. SSRIs can cause chronic insomnia (Mai & Buysse, 2008).

                                            Two pharmacologic agents

            Zolpidem is a short-acting hypnotic preferred in the elderly due to its favorable side-effect profile compared to benzodiazepines. Zolpidem, a benzodiazepine receptor agonist, facilitates sleep by augmenting GABA inhibition (Levenson et al., 2015). Zolpidem has a quick onset and short duration of action, resulting in reduced cognitive changes, sedation, and falls instead of benzodiazepines. With its short half-life and rapid absorption, Zolpidem is especially useful for patients that have difficulty falling asleep. Rebound insomnia, withdrawal symptoms, and tolerance are also less than benzodiazepines. Elderly patients are recommended a dose of 5 mg (Chand & Arif, 2021).

Another option would be to prescribe Trazodone, an FDA-approved antidepressant, at lower doses of 50-300 mg at bedtime to augment the SSRI already in place. By targeting the histaminergic arousal system, sedation is accomplished.  Also, it is essential to note that the drug should be tapered and discontinued when the depression has improved (Perlis & Ostacher, 2016). I would choose Zolpidem over Trazodone due to its decreased sedation and cognitive changes that can reduce falls in the elderly (Levenson et al., 2015).                                                   

                                                       Contraindications

            There are no drug interactions noted between Zolpidem and Zoloft. Although Trazodone is recommended as an adjunct therapy for insomniac patients being treated with an SSRI for depression, it should be monitored prudently for serotonin syndrome. Also, Trazodone should be used carefully in patients with impaired liver and renal function (Shin & Saadabadi, 2021).

                                                          Checkpoints                   

The patient would be required to have a follow-up appointment in four weeks to assess the effectiveness of the medication. The goal would be to see an improvement in the patient's sleep pattern and decreased depressive symptoms. A comprehensive history obtained during the interview with the insomniac patient is an essential evaluation element (Levenson et al., 2015).                                                   

 

                                                            References

Chand SP, Arif H. Depression. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.https://www.ncbi.nlm.nih.gov/books/NBK430847

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

Mai, E., & Buysse, D. J. (2008). Insomnia: Prevalence, Impact, Pathogenesis, Differential Diagnosis, and Evaluation. Sleep medicine clinics, 3(2), 167–174. https://doi.org/10.1016/j.jsmc.2008.02.001

NHLBI.NIH. (2021). Insomnia. https://www.nhlbi.nih.gov/health-topics/insomnia

Perlis, R. H., & Ostacher, M. J. (2016). Bipolar disorder. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 48–60). Elsevier.

Roth T. (2007). Insomnia: definition, prevalence, etiology, and consequences. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine 3(5 Suppl), S7–S10.

Saddichha S. (2010). Diagnosis and treatment of chronic insomnia. Annals of Indian Academy of Neurology, 13(2), 94–102. https://doi.org/10.4103/0972-2327.64628

Shin JJ, Saadabadi A. Trazodone. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK470560/