Read below reply due tomorrow 7/16/21 at 2pm

Week 7 Discussion

 

Discussion:  Treatment for a Patient with a Common Condition

Question 1:  What are your average hours of sleep based on your sleep routine and or the number of times you wake up during the day and cannot go back to sleep?  When the patient describes their average hours of sleep based on their routine and or number of times they wake up and cannot go back to sleep indicates the severity of the patient’s insomnia and determine if sleeping during the day as most elderly people do is contributing to her sleep disturbances. The questions should also be asked due to the patient’s current medication regimen.  She is taking hydrochlorothiazide (HCTZ) which may contribute to increase urination.  

Question 2:  What does your usual nutritional intake/diet involve?  Caffeine consumption, alcohol, and or smoking habits are contributed to sleep disturbances.  Attaining the dietary information from the patient will provide data on the types of foods/drinks that may contribute to the patient’s insomnia. Treur et al. (2018) suggest that patients who consume caffeine at greater levels tend to have poorer sleep and insomnia.

Question 3:   When were you diagnosed with depression and how long have you been taking Sertraline 100 mg by mouth? Notating this data will reveal if the medication dose is appropriate for the patient and or if the dose may be too strong which may contribute to the patient’s insomnia.

Questions for the Family/Friends in the Patient’s Life

            It is important to identify the people in the patient’s life in order to get feedback from them to further assess the patient’s situation.  The patient is 75 years old, so it is important to determine if the patient has family members such as a caregiver, siblings, children, and or grandchildren.  Once this is determined, it would be beneficial to speak with these immediate family members to identify any changes in mood, behavior, habits, and or their overall appearance. These specific questions are necessary to ask to identify any causes related to the patient’s insomnia and or deteriorating depression.  It is also important to ask if the patient takes her medication appropriately.  The patient is prescribed several medications which may put the patient at risk for polypharmacy and potential drug-drug interaction/overdose.

Appropriate Physical Exams and Diagnostic Tests

            Physical exams and diagnostic test are pertinent during the initial assessment of patients. Current complaints, past medical, social, and family history are critical pieces of data necessary to create an efficient plan of care.  The client will have a full head to toe assessment completed with an emphasis on the amount of hydrochlorothiazide taken and the frequency prescribed.  HCTZ is a loop diuretic that causes increase urination causing the client to be awaken multiple times during the night.  This may be the reason for the client’s insomnia if she is taking the medication at night.  An overnight sleep study known as the polysomnogram test will be ordered to measure the clients brain wave activity, saturated oxygen level (Spo2), heart rate, respirations, and muscle movement during and after sleep which can be completed at home or at a sleep study center.  Utilizing the polysomnogram test will help determine if the patient is suffering from any sleep related disorders (Sleep Foundation, 2020).

Most Likely Differential Diagnosis

            The most likely differential diagnosis is Major Depressive Disorder (MDD).  Depression is a mood disorder that creates many different symptoms like loss of interest, insomnia, sadness, anxiety, and poor appetite.  The client’s medical history, currently symptoms, and loss of her husband indicate that she is most likely experiencing insomnia due to uncontrolled depression. The frequency of insomnia-related sleep disorders amongst major depression is roughly 90.9% (Seow et al., 2016). 

            Anxiety is also a possible differential diagnosis for the clients’ complaints of insomnia.  Anxiety is a one of the characteristics identified as a natural reaction to stress.  This natural reaction can cause insomnia due to worry, agitation, irritation, and fearfulness.  Anxiety is linked to the probability of poor sleep efficiency, and revival at night which causes insomnia (Patel et al., 2018).  Many studies have revealed that anxiety disorders have a higher rate of insomnia (Patel et al., 2018). 

            Delayed Sleep Phase Syndrome (DSPS) is also another possible differential diagnosis identified for the client.  DSPS is described as a person who is unable to sleep at a socially acceptable time.  The person may be awake for many hours after going to bed even when they are extremely fatigued. Socially acceptable times indicated for this client would be provided by the client’s close family/friends.

Appropriate Pharmacological Agents

            Appropriate pharmacological agents for the client would be Sertraline and Trazadone.  The sertraline could be increased to 150 mg by mouth daily since the patient has not complained of any side effects. This increase would be more likely because of the patient’s history with the medication.  The client had no issues prior to her husband’s death.  Trazadone 50 mg per day to treat the patient’s insomnia is also an alternative.  Trazadone is effective in treating depression due to causing an anti-depressant effect as it acts as a serotonin antagonist-reuptake inhibitor in addition to blocking serotonin transporters.  Depression, insomnia, and dementia are also the most frequent causes that Trazadone is used in treatment (Saint-Gerons et al., 2018).  Contraindications with the sertraline may become an issue with the increase from 100 mg to 150 mg. The risk for sertraline toxicity in the elderly patient may pose an issue as elderly patients take longer to metabolize medication.  This would prompt the provider to education the patient and their loved ones to monitor for any adverse reactions.  If any adverse reactions are observed, they would be prompted to call 911 and or the providers office immediately. Trazadone is considered safe to treat depression and insomnia but although safe, they too have risk.  Trazodone has been associated with induced mania and hypomania in patients older than 60 years which may be associated with decreased elimination and higher plasma concentrations (Alfurayh, 2020).

Check Points and Therapeutic Changes

            The client will be asked to return to the clinic in four weeks as a follow up discussing how the treatment regimen has been tolerated.  The client and family will be asked if any significant side effects and or adverse reactions were observed. If necessary, the medication regimen will be adjusted or tapered during this visit to identify another medication that may be more suitable for her complaints.  The patient will also be followed up on weekly via telephone to evaluate any marked improvements with the client’s depression and or sleep pattern related to her insomnia.  If things are improving, the client would be asked to follow up an additional four weeks to evaluate her progress.

Conclusion

Depression is a serious issue with public impact amongst older adults and is projected to be the second leading cause of disease burden in this population (Cheruvu & Chiyaki, 2019).  This case study provided insight on MDD and how it affects the elderly when traumatic events occur even while receiving treatment.  If MDD is left untreated, it can lead to issues such as insomnia and anxiety. Kristiansen et al. (2019) reported findings from a meta-analysis showed that the pooled prevalence estimate of depression in a widowhood is as high as 40% when using screening scales.  The death of this patient’s spouse was a traumatic life changing event associated with bouts of depression and other mental health disorders that lead to her insomnia.  Having to come to terms with her husband’s death and new sleeping arrangements without him increased her stress levels and helped to create the sleep disturbances.  Thoroughly assessing the patient, involving the family, caretake, and friends, in addition to ordering the appropriate treatment plan can all help effectively manage the clients MDD and insomnia diagnosis.  Effectively managing these issues will help to improve the patient’s overall health outcomes.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Alfurayh, I., Hind, A., Carvalhal, & Adriana, C. (2020). Mania with psychosis induced by low-

dose trazodone. Proquest. 50(6), 264-267. https://doi.org/10.3928/00485713-20191104-01

Cheruvu, V.K., & Chiyaka, E.T. (2018). Prevalence of depressive symptoms among older adults

            who reported medical cost as a barrier to seeking health care: findings from a national

            representative sample. BMC Geriatrics, 19(192).

             https://doi.org/10.1186/s12877-019-1203-2

Kristiansen, C.B., Kjaer, J.N., Hjorth, P., Andersen, K., Prina, A.M. (2019). The association

            of time since spousal loss and depression in widowhood: a systematic review and meta-

            analysis.  Social Psychiatry and Psychiatric Epidemiology, 54, 781-792.

            https://doi.org/10.1007/s00127-019-01680-3

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

            Journal of Clinical Sleep Medicine, 14(6), 1017-1024.

            doi: 10.5664/jcsm.7172

Saint-Gerons, D.M., Alverez, C.H., Poza, P.G, Corominas, D.M., & Honrubia, C.D. (2018).

Trazadone utilization among the elderly in Spain. A population-based study.

Journal of Psychiatry and Mental Health, 11(4), 208-215.

https://doi.org/10.1016/j.rpsmen.2016.11.008

 

Seow, L.S.E., Subramaniam M., Abdin E., Vaingankar, J.A., & Chong, S.A. (2016).

            Sleep disturbance among people with major depressive disorders (MDD) in Singapore

Journal of Mental Health, 25(6), 492-499.

doi: 10.3109/09638237.2015.1124390

Treur J.L., Gibson, M., Taylor A.E., Rogers, P.J., & Munafo, M.R. (2018). Investigating genetic

correlations and causal effects between caffeine consumption and sleep behaviours. Journal of Sleep Research, 27(5).  

https://doi-org.ezp.waldenulibrary.org/10.1111/jsr.12695

Sleep Foundation (2020). Diagnosing Insomia.

https://www.sleepfoundation.org/insomnia/diagnosis#:~:text=Sleep%20study%3A%20The%20doctor%20may,%2C%20limbs%2C%20and%20one%20finger