TREATMENT FOR A PATIENT WITH A COMMON CONDITION- PEER RESPONSE
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PEERRESPONSETREATMENTFORAPATIENTWITHACOMMONCONDITION.docxAssignment
Respond to two of your colleagues in one of the following ways:
· If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
· If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days.
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications:
· Metformin 500mg BID
· Januvia 100mg daily
· Losartan 100mg daily
· HCTZ 25mg daily
· Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Peer 1
Treatment for a Patient with a Common Condition
A 75-year-old widow is featured in this case analysis because she sought professional help for her sleeplessness and intensifying depressive episodes. Patient's previous medical record includes diagnosis of diabetes, hypertension, and major depressive disorder. Her existing regimen consists of the following: 100mg of Sertraline daily, 500mg of Metformin twice daily, 100mg of Januvia daily, 100mg of Losartan daily, and 25mg of HCTZ daily. She has a weight of 88 kg (193.6 lbs) and a height of 64 inches (5'3"). Her Temperature is 98.6 degrees Fahrenheit and Blood Pressure is 132/86mmHg. The client is awake, alert, and oriented to person, place, and time. She does not have suicidal thoughts.
Questions and Rationale
The PMHNP must inquire as to the origins of the patient's sleeplessness and deteriorating mood to provide effective treatment. My initial inquiry would be to ask about how she handles her diabetes. The doctor needs to probe the frequency of the patient ’s drug intake and glucose levels monitoring. Poor sleep, heightened depression, and elevated glucose levels have all been linked in a variety of research (Peleg et al., 2019). The duration of Sertraline use is the next inquiry that must be addressed. Therapeutic response or remission from depression typically takes 3–4 weeks with most antidepressants, such as Sertraline (Borhannejad et al., 2020). Let us say the client has already been taking Sertraline for a while now with no noticeable improvement. Possible causes include treatment-resistant depression, which necessitates additional medicine to alleviate it. The third inquiry will be whether the individual would rather rest at home or take part in regular exercise. The third query is prompted by the fact that people with depression typically have less energy, which in turn reduces their level of participation in physical activities (Akturk et al., 2018).
Patient Relations
The development of a solid treatment plan that improves the patient's prognosis requires gathering relevant health data from the patient. Prior to notifying the client's loved ones about the client's medical histories, the practitioner is bound to get the client's written consent. The NP will contact the patient's loved one (a friend or private aid). The Nurse practitioner will make inquiries about the patient's ability to take their medications as directed, as well as their resting and eating patterns, mental health, and any suicidal thoughts or attempts. The NP will also contact the client's primary care physician to learn more about the patient's health, such as the treatment of diabetes and high blood pressure, the current medication regimen, and the date of the patient's last encounter. The Nurse practitioner will ask about the mother's connection with her kid, as well as her financial situation and social network, if the patient has children. The provider will use this data to corroborate the patient's feedback. Providers can get important data from collateral sources that they might not get from an individual's self-report (Owoyemi et al., 2021).
Physical Examination and Diagnostic Tests
The Geriatric Depression Scale-15 (GDS-15), a reliable screening tool for depression among seniors, will be given to the patient because of her advanced age and reports of depressive episodes. The GDS-15, as described by Park and Kwak (202), is a 15-questions survey yes/no with the following rating rubric:
· If your score is higher than 5, hints depression and needs further evaluation.
· If your score is at least 10, you are probably depressed.
· Fewer than 5 scores indicate that depression is unlikely.
The patient has an obesity-related body mass index of 34.3. Obese people have a tenfold increased risk of developing obstructive sleep apnea (OSA), and research shows that 60-90% of adults with OSA are overweight (Leppanen et al., 2018). To preclude sleep apnea, the provider will recommend a sleep study with overnight polysomnography at a sleep clinic or a home sleep exam. The Provider will check for peripheral neuropathy and evaluate the condition of the patient's feet.
Differential Diagnosis
The patient has the following possible diagnoses:
· Insomnia secondary to medications
· Social isolation
· Treatment-resistant depression
Among these three possibilities, treatment-resistant depression is the one that best fits the patient's symptoms. It is possible that the doctor initially prescribed a reduced amount of Sertraline and then upped the dosage to 100mg. For the treatment of depression, the recommended beginning dosage of the SSRI Sertraline (Zoloft) is 50 milligrams once day (Bui et al., 2016). The individual is more inclined to develop treatment-resistant depression as she has tried a therapeutically effective dose of Zoloft with no benefit.
Pharmacologic Agents
After determining and ruling out her pharmaceutical allergies, the options being examined for the individual are Trazodone 100 mg at nighttime as monotherapy or Remeron 15 mg at night. Monotherapy with Trazodone often begins with 100–150 mg taken twice daily or all at once before night (Fava & Papakostas, 2016). Insomnia caused by antidepressants can be treated with a modest dose of Trazodone (25-50mg) if the individual stays on Sertraline (100mg) (Fava & Papakostas, 2016). More tolerated than 2nd SSRIs, which are strongly linked to sleeplessness and anxiousness, trazodone operates by blocking both the serotonin transporter (SERT) and serotonin type 2 receptors (5-HT2A) (Fava & Papakostas, 2016). Remeron's enhanced sedation and excess weight restrict its use as a first-line treatment for depression (Fava & Papakostas, 2016).
Contraindications
When determining the appropriate starting dose of Trazodone, the practitioner should take the patient's age into account. In addition to increasing sleepiness, which is a contributing factor for falls in the older demographic, long-term use of Trazodone at doses of 150 to 200 mg is linked to extrapyramidal symptoms (Sotto Mayor et al., 2015). The authors went on to note that because of the additive sedation and hypotensive effects of Trazodone when combined with antihypertensives and CNS depressants, patients taking both drugs together need to be continuously watched.
Check Points
The provider will start the patient on 25mg of Trazodone and then reevaluate the therapeutic impact and any adverse reactions after 4 weeks. If the individual responds positively to Trazodone, the clinician may increase the dose to 50 mg at night to achieve a 50% improvement in symptoms.
References
Aktürk, U., Aktürk, S., & Erci, B. (2018). The effects of depression, personal characteristics, and
some habits on physical activity in the elderly. Perspectives in Psychiatric Care, 55(1),
112–118. https://doi.org/10.1111/ppc.12322
Borhannejad, F., Shariati, B., Naderi, S., Shalbafan, M., Mortezaei, A., Sahebolzamani, E., Saeb,
A., Hosein Mortazavi, S., Kamalzadeh, L., Aqamolaei, A., Ali Noorbala, A.,
Namazi‐Shabestari, A., & Akhondzadeh, S. (2020). Comparison of vortioxetine and
sertraline for treatment of major depressive disorder in elderly patients: A double‐blind
randomized trial. Journal of Clinical Pharmacy and Therapeutics, 45(4), 804–811.
https://doi.org/10.1111/jcpt.13177
Bui, E., Pollack, M. H., Kinrys, G., Delong, H., Vasconcelos e S, D., & Simon, N. M. (2016). The pharmacotherapy of anxiety
disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital
Psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.
Da Costa Dias, F., Teixeira, A., Guimar es, H., Santos, A., Resende, E., Machado, J., Barbosa,
M., & Caramelli, P. (2019). The influence of age, sex, and education on the
phenomenology of depressive symptoms in a population-based sample aged 75+ years
with major depression: The Diet study. Aging & Mental Health, 25(3), 462–467.
https://doi.org/10.1080/13607863.2019.1698517
Fava, M., & Papakostas, G. (2016). The pharmacotherapy of anxiety disorders. In T. A. Stern, M. Favo, T. E. Wilens, & J.
F.Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and neurotherapeutics (pp. 61–71). Elsevier.
Leppanen, T., Kulkas, A., Mervaala, E., & T yr s, J. (2018). Increase in body mass index
decreases duration of apneas and hypopneas in obstructive sleep apnea. Respiratory
Care, 64(1), 77–84. https://doi.org/10.4187/respcare.06297
Owoyemi, P., Salcone, S., King, C., Kim, H., Ressler, K., & Vahia, I. (2021). Measuring and
quantifying collateral information in psychiatry: Development and preliminary validation
of the mclean collateral information and clinical actionability scale. JMIR Mental Health,
8(4), e25050. https://doi.org/10.2196/25050
Park, S.-H., & Kwak, M.-J. (2020). Performance of the geriatric depression scale-15 with older
adults aged over 65 years: An updated review 2000-2019. Clinical Gerontologist, 44(2),
83–96. https://doi.org/10.1080/07317115.2020.1839992
Peleg, O., Cohen, A., & Haimov, I. (2019). Depressive symptoms mediate the relationship
between sleep disturbances and type 2 diabetes mellitus. Journal of Diabetes, 12(4), 305–
314. https://doi.org/10.1111/1753-0407.12996
Sotto Mayor, J., Pacheco, A., Esperan a, S., & Oliveira e Silva, A. (2015). Trazodone in the
elderly: Risk of extrapyramidal acute events. BMJ Case Reports, bcr2015210726.
https://doi.org/10.1136/bcr-2015-210726
Peer 2
Introduction
A large fraction of the general population suffers from insomnia, a widespread sleep problem that frequently co-occurs with mental health issues. To create successful treatment plans for patients, Psychiatric Mental Health Nurse Practitioners (PMHNPs) must be thoroughly aware of the reciprocal link between insomnia and mental illness. An elderly widow who lost her spouse complains of sleeplessness and deteriorating depression in this case study. This paper will explore the assessment, diagnosis, and treatment approaches that, as a PMHNP, I can use to manage the patient's health needs.
Questions to ask the Patient and their Rationale
As a PMHNP, it is essential to approach each patient encounter with a thorough assessment to develop an accurate diagnosis and treatment plan. There are several questions that I would ask the patient during the initial assessment:
1. How has your daily routine changed since your husband passed away?
2. Do you engage in any physical activity during the day?
3. Have you ever been treated for insomnia or sleep-related problems before
These questions would shed light on the patient's routines and way of life, which may be a factor in her sleeplessness. The PMHNP can assess whether any environmental elements may contribute to or aggravate her sleep disorders by comprehending the alterations in her routine following her husband's passing. Inquiring about her physical activities can help evaluate whether she gets enough exercise, which can enhance her sleep quality. Inquiring into previous insomnia therapies can help the PMHNP decide on the best course of action for this patient by revealing whether or not such medications were influential in the past.
Questions to ask People around the patient and their Importance
Talking to other people in the patient's life, such as relatives and close friends, may aid in better understanding the issue. These people can lighten the patient's mental condition and any behavioural or emotional changes that might have occurred after the patient's husband's death. I may ask specific questions, such as the following:
1. How has the patient's mood and behaviour changed since her husband passed away?
2. Have you noticed any changes in the patient's sleep habits?
3. Has the patient expressed any suicidal ideations or intentions?
These questions will help me assess the patient's social support system and provide a complete picture of her emotional state. It will also help me identify potential safety concerns like suicidal ideations.
Physical Exams and Diagnostic Tests
I would recommend a physical examination to rule out any underlying medical disorders that may be causing her insomnia symptoms, such as obstructive sleep apnea or restless legs syndrome. To determine the existence and severity of depressive symptoms, I would also recommend a depression test, such as the Patient Health Questionnaire (PHQ-9).
Differential Diagnosis And The Most Likely
I would weigh complicated grieving, major depressive disorder, and adjustment disorder with low mood as potential differential diagnoses for this patient. The most likely diagnoses are harrowing sorrow and major depressive disorder, given the patient's depressive disorders and the recent loss of her spouse.
Two Pharmacologic Agents and The Recommendable Agent
Escitalopram or venlafaxine are suitable pharmacologic agents for antidepressant treatment, and I would advise starting pharmacologic therapy with one of these medications. Escitalopram, a selective serotonin reuptake inhibitor (SSRI) with a half-life of between 27 and 32 hours, is primarily metabolised in the liver by the enzymes CYP2C19 and CYP3A4 (Talbot, 2020). A serotonin-norepinephrine reuptake inhibitor (SNRI) with a half-life of around 5 hours, venlafaxine is primarily metabolised in the liver by the enzymes CYP2D6 and CYP3A4.
Given the patient's age and comorbidities, notably hypertension, I would choose escitalopram over venlafaxine. SNRIs, like venlafaxine, can raise blood pressure and heart rate, worsening the patient's hypertension. Moreover, escitalopram has fewer adverse side effects and a reduced chance of drug-drug interactions than venlafaxine.
Contraindications in Dosing
Escitalopram should be used cautiously as it might lengthen QT intervals, which may raise the risk of sudden cardiac death. Thus, it's crucial to monitor the patient's ECG and serum electrolytes, especially their potassium and magnesium levels, during their treatment. Regular follow-up sessions should also be planned to evaluate the patient's reaction to therapy, monitor for any side effects, and check for suicidal ideation. The patient should also have follow-up sessions at weeks 2, 4, 6, 10 and 12 to gauge how well the medication works and look for potential side effects.
Conclusion
In conclusion, a PMHNP must perform an in-depth evaluation of senior patients with insomnia and a history of depression. This evaluation should include inquiries regarding daily activities, physical activity, and previous insomnia treatments. Speaking with the patient's relatives and close friends might help learn more about their emotional condition and any changes in their behaviour or mood. To rule out underlying medical disorders and determine the existence and severity of depressive symptoms, a physical examination and depression screening should be performed. Differential diagnoses like complicated grief, major depressive disorder, and adjustment disorder with depressed mood should be considered. Appropriate pharmaceutical therapy should be started cautiously, considering contraindications like escitalopram's ability to prolong QT interval.
Reference
Talbot, P. S. (2020, June). Anticonvulsants 12 Chapter for Mental Disorders: Valproate, Lamotrigine, Carbamazepine and Oxcarbazepine. In Seminars in Clinical Psychopharmacology.–Cambridge University Press (p. 362). https://books.google.co.ke/books?hl=en&lr=&id=OxfeDwAAQBAJ&oi=fnd&pg=PA362&dq=Escitalopram+is+a+selective+serotonin+reuptake+inhibitor+(SSRI)+that+has+a+half-life+of+approximately+27-32+hours+and+is+metabolized+primarily+in+the+liver+by+CYP2C19+and+CYP3A4+enzymes.+&ots=F-8L3tPZyJ&sig=WNTr4q7QbkZaRa_9rUNAeN8f0ng&redir_esc=y#v=onepage&q&f=false
