week 7 peer responses /NURS 6630: Psychopharmalogical Approaches to Treat Psychopathology

Week 7 peer responses

Dathne Frazier-Sturdivant

RE: Weekly Topic Respond/ Post here- Do not Start Own Thread

COLLAPSE

Week 7

Initial Post

The first question I would ask this patient is whether she has sought grief counseling? The second would be do you consume excess caffeine? And the third would be are you compliant with taking your Zoloft? I would seek feedback from her family and friends to find out if her habits or behavior has changed in anyway?

The differential diagnosis that I would suggest would be grief. Bereavement often effects individuals both physically and mentally. Severe, persistent and disabling grief known as complicated grief (CG) as well as prolonged grief disorder (PGD) have been added to the International Classification of Diseases 11th Edition (Lancel et al., 2020). Hallmark presentation of PGD are persistent and severe yearning for the deceased and/or preoccupation with the deceased, combined with symptoms of intense emotional pain. Bereavement and grief are associated with sleep disturbances. Conversely, the lack of sleep often exacerbates or prolongs the grief process.

I would have a CMP drawn to assess overall hemodynamic status. I would perhaps order a sleep study to measure the true amount of sleep that the patient is getting and assess any physical causes that may be disturbing her sleep. I would be cautious about using sleep aids due to the patient's age and risk for falls.

The two medications that I would add would be:

Trazadone 50mg po HS, may repeat in 1hr if remains awake. Trazadone is a commonly used atypical antidepressant with strong sedative actions. Known to decrease sleep latency and prolong sleep duration; it does not cause tolerance or physical dependence (Rosenthal & Burchum,2021). I would monitor for postural hypotension and caution the patient that she may experience some daytime grogginess.

To avoid the use of another psychotropic, I would choose to begin the patient on a complementary therapy using a medicine which combines melatonin, vitamin B6 and extracts from medicinal plants California poppy extract, passionflower extract, and lemon balm extract. Novanuit Triple Action is associatied with high compliance, a benign side effect profile, and low potential for dependence and addiction (Lemoine, 2019). This product has been proven in a pilot study to significantly increase elements of sleep such as total sleep duration, decrease sleep onset latentcy and daytime impairment related to disturbed sleep pattern. During the drug trial, subjects used a daily electronic sleep diary to measure sleep quality, total sleep duration and functional daytime disability. After 2 weeks of consistent use of Novanuit, sleep was rated to increase 2 points higher on a 0-10 scale. After 4 weeks, compliance was measured at 97.5%, with reports of significant improvement of sleep and mood.

I would follow-up with the patient at 2 weeks to assess improvement of sleep quality and duration. I would continue to encourage grief counseling. I would also encourage light exercise and participating in enjoyable activities. I would also assess patient's depressive symptoms and consider increasing her Zoloft to 150mg if depression has not improved with better sleep.

I would schedule an appointment 4 weeks to check patient's progress.

References

Lancel, M., Stroebe, M., & Eisma, M. C. (2020). Sleep disturbances in bereavement: A systematic review. Sleep Medicine Reviews, 53. https://doi-org.ezp.waldenulibrary.org/10.1016/j.smrv.2020.101331

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants (2nd ed.) St. Louis, MO: Elsevier.

Lemoine, P., Bablon, J.C., & Da Silva, C. (2019). A combination of melatonin, vitamin B6 and medicinal plants in the treatment of mild-to moderate insomnia: A prospective pilot study. Complementary Therapies in Medicine, 45, 104-108

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Second response

Rosette Joseph

RE: Week 7- Initial discussion post

COLLAPSE

Treatment for a Patient with a Common Condition

Insomnia disorder in older adults is multifactorial and is associated with difficulty falling asleep or staying asleep and can also be implicated in many medical and psychiatric disorders. Insomnia is a disruption in the amount and quality of sleep that impairs functioning (Morgan & Townsend, 2021). As people age, sleep patterns and the amount of sleep can also change. A baby can sleep between 10 to 14 hours per day, whereas an older person is recommended to rest for at least 7-8 hours daily (Brewster et al., 2018). Insomnia is frequently associated with aging, related to decreased restorative stage 3 of nonrapid eye movement sleep and advance phase shift leading to early morning riser (Cherukuri et al. 2018). In the case scenario of this 75-year-old patient that already has several comorbidities of HTN, DM, & major depressive disorder (MDD), who had experienced the death of her spouse of 41 years ten months ago is a significant life event that is a risk factor of her mood and her current state of insomnia. While evaluating the current patient list of medication, she is on Sertraline 100 mg daily for her MDD. One of the side effects of that drug is difficulty falling asleep or staying asleep (U.S. Food & Drug Administration n.d).

There are many pharmacological, non-pharmacological that can be used to provide appropriate intervention for insomnia and tools used to assess insomnia, but the clinician should be cautious when evaluating an older adult due to the possibility of polypharmacy. Three questions I might ask this patient. Using an insomnia questionnaire includes:

How often do you have trouble sleeping, and when did insomnia begin?

How long does it take to fall asleep?

How often do you awaken during the night, and how long does it take to fall back to sleep? And I would even go further to ask the patient what had she tried to help improve her insomnia?

Using open-ended questions can help differentiate the type of insomnia, either acute, which is often caused by an emotional or physical discomfort such as a life stressor (DerSarkissian, 2019), in this patient situation, the passing of husband of 41 years, chronic insomnia, or pharmacological can all be a factor. Therefore, as a clinician asking her about her sleep history should be evaluated to help guide treatment. Identifying other people in the patient life that can give feedback is vital; using a patient and family-centered approach is best. If they live in the same house, the patient children can be helpful, but if they do not live in the same place, it might be hard to ask some questions regarding sleeping habits, such as if they snore or have restless leg syndrome.

Unlike other sleep disorders, insomnia disorder relies on self-report (Levenson et al., 2015). The sleep disorder test is often used to diagnose insomnia and a physical exam where the clinician assesses the patient's sleep history to determine the cause of the problem (DerSarkissian, 2019). Other diagnostic tests that may be appropriate in this patient's case would be to have her keep a sleep diary, and it can help the clinician tracking the sleep patterns; another test is an Epworth Sleeping Scale that can be used to assess her daytime sleepiness as stated by DerSarkissian, 2019. Although this patient physical exam is within the defined limit and she denies any suicidal ideation, I think a physical and mental health exam is warranted to re-evaluate her mental status. I would recommend that the patient continues with her current Sertraline 100 mg daily, but take it early in the morning and use other technique mechanisms that can help her fall asleep and return in 4 weeks.

Differential Diagnosis

A differential diagnosis is grief related to the life stressors of her husband passing, is one the diagnosis that can be applied appropriately. Two pharmacological agents I would recommend are Ambien 5 mg for women by mouth at bedtime and in older individuals like this 75-year-old patient. Restoril 7.5 mg orally once a day at bedtime is the initial therapy recommended until the individual response is determined (Sinha, 2021).

In conclusion, proper evaluation and assessment of patient insomnia can help the clinician effectively develop mechanisms and strategies for managing insomnia. As a future nurse practitioner, the main goal is to help the patient manage and cope with life stressors to help improve her insomnia.

References

Brewster, G.S., Riegel, B., & Gehrman, P.R. (2018) Insomnia in the Older Adult. Sleep medicine clinics, 13, (1) https://doi.org/10.1016/j.jsmc.2017.09.002

Cherukuri, C.M., Kaplish, N., Malepah, D.C., Khawaja, I.S, Bhatia, S.K., & Bhatia, S.C., (2018) Insomnia in Older Adult. https://doi.org.10.3928/00485713/201805514-01

DerSarkissian, C., (2019). Diagnosing Insomnia https://www.webmd.com/sleep-disorders/diagnosing-insomnia

Levenson, J.C., Key, D.B., & Buysse, D.J (2015). The Pathophysiology of insomnia. Chest 147 -A (4). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC 4388122/

Morgan, K.I., & Townsend, M.C. (2021). Bipolar and Related Disorders: Pocket Guide to Psychiatric Nursing. Eleventh ed. Chap 7 p169

U.S. Food & Drug Administration (n.d). drugs@ FDA: FDA-Approved drugs. https://www.accessdata.fda.gov/Script/cder/def/index.cfm.

Sinha, S., (2021). Restoril. https://www.drugs.com/restoril.htm