Week 7 _ Discussion_Treatment for a Patient With a Common Condition

Instructions:

Respond to your colleague in one of the following ways:

· If your colleague’ 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

**minimum of three (3) scholarly references are required for each reply cited within the body of the reply & at the end**

Reply # 1

Leslie Williams

Week 7: Elderly woman with c/o insomnia

Questions for Patient

After introducing myself to the patient, I would ask the open-ended question of what brings her in today? In asking this, I hope to let her set the tone of the visit, have some control, and hopefully find out how she has been feeling, precisely what has brought her in, and what her expectations are of today's visit (Ball et al., 2015). This way, I know exactly why she is here, her concerns, what she is hoping to accomplish, and we can then move forward. I can also enhance or elaborate on her response, and she may answer many questions in this response that I would have asked later.

My second question would be asking her to describe her sleep patterns, habits, the onset of when she started having trouble sleeping, if she has more of an issue falling asleep, staying asleep, waking up earlier than she would like. With this, I would want her to describe any other symptoms she has noticed, such as daytime sleepiness, dry mouth, or sore throat in the mornings, etc. I would ask this question to determine the root cause of her sleep issues and because depending on some of the symptoms could alter pharmacological treatment. For instance, If the patient were to say she has difficulty falling asleep, frequently wakes in the night, wakes up way earlier than she would like, I would attribute this more to her MDD. Around 80% of patients that have been diagnosed with MDD have complaints of insomnia (Stahl, 2013). If she were to describe gasping at night or a dry mouth or sore throat when she wakes up, or have a history of snoring, it could be that she suffers from sleep apnea. She is obese and has HTN and DM, which puts her at increased risk for insomnia and sleep apnea. If insomnia occurred when her sertraline was increased to 100 mg, it is most likely a side effect from her medication. Different pharmacological agents work better for sleep onset, some for sleep maintenance, and some for both (Abad et al., 2018).

Another question I would ask would involve medication adherence. It would be an open-ended question to see if she takes her antidepressant as prescribed. My rationale for asking this is even though I don't know exactly how long she has been on sertraline, she has been on it long enough to be on a maintenance dose, which means it had to be working for her at a certain level for them to keep her on it and increase her dose. She complains of her depression and her insomnia "getting worse." This indicates that she may not be taking her medication as prescribed. Insomnia is a side effect of sertraline and a side effect of discontinuation syndrome. If it is not due to a noncompliance issue, I would want to administer the HDRS and see where she falls on it compared to her last reading. She needs a different antidepressant if she is not seeing results by now. If she is also following prescription as prescribed, this would be considered treatment-resistant depression (green book).

 A final question I would have to ask in addition would be, has something happened recently to trigger an increase in her symptoms of depression possibly? Has insomnia made her depression worse? Or has another stressor happened? She is grieving; his birthday could have recently come and passed or what would have been their 50th wedding anniversary. Is sleeping alone scary for her, is she worried financially? Finding this out and seeing what support she has available to help her cope during the grieving process is significant. 

Identify People in the Patient's Life

With the patient's permission, I would want to get information from her healthcare provider on her recent visit to see how well her DM, HTN, any concerning weight gain or losses, any testing for sleep apnea has occurred, has she been checked for thyroid issues. I would want to identify any adult children or caretakers, friends, or other family members in her life that help keep an eye on her and are her support system. People and relationships in her life matter. She needs them more than ever right now. Does she have anyone? If she does, I would want to ask about appetite changes, energy level, mood, any interests that seem to boost her mood. This would help me get a better picture of how this patient is adjusting to the loss of her husband and if those close to her are seeing any improvements or declines.

Physical Exam and Diagnostic Testing

If she has any symptoms, I will want to rule out sleep apnea by referring her to her healthcare provider for testing. She goes to see her healthcare provider twice a year, which is recommended for hypertension and DM when controlled. There is nothing in the case study to signify that it isn't. In talking with her HCP, I would want her most current lab work, including LFTs, CBC, renal function tests, A1C, and serum electrolytes. These tests will help determine any deficiencies in metabolizing the medication and help rule out medical causes. Thyroid abnormalities can be associated with depression, so I want to collect thyroid function tests. I would administer the HDRS to see her current score and compare it to her last reading to see what category of depression she is currently in (Hamilton, 1960). The HDRS also includes various stages of insomnia and depression (Hamilton, 1960). I would also want to perform a functional assessment because depression does contribute to cognitive impairment (Ball et al., 2015). 

Differential Diagnosis

She could have sleep apnea due to a BMI of 32.2, a history of hypertension, and DM. There is not enough information to determine this. She may have medication nonadherence with insomnia as a side effect from discontinuation syndrome. There is not enough information to determine this. She could have treatment-resistant depression because her depression is getting worse, but I do not know if she has had an adequate trial of the medication at 100 mg and her HDRS score or if she has been adhering to the drug. She says her depression has gotten worse, but worse from what score? Based on the information given, she most likely has insomnia secondary to sertraline, MDD, and the loss of her husband. She does not have a history of insomnia which means it has started either since the loss of her husband or as a side effect of the sertraline. She could have had sleeping issues once her husband died, which initiated major depression. Or, it could be due to the increase in dosage from the sertraline. Insomnia could be exacerbating her MDD, making it worse at this time. 

Pharmacologic Agents

At this point, due to not knowing how long she has been on the 100 mg of sertraline and what her HDMR score is, I am going to leave her on for now and assume she has not been on it long enough to reach efficacy or that she has not been taking as prescribed. Having insomnia can exacerbate her depression symptoms and make her irritable, and this may be why she feels like her depression is worse. There is not enough information. I would consider augmenting Trazodone 25 mg daily or mirtazapine. Augmenting with hypnotics to first-line treatments of depression makes rational sense considering insomnia is such a frequent complaint when treating depression (Stahl, 2013). 

Stimulating the 5HT2A receptors through increased synaptic 5-HT is responsible for a side effect of insomnia from SSRIs (Jaffer et al., 2017)). Blocking 5-HT2 receptors using Trazadone can reduce insomnia caused by SSRIs (Jaffer et al., 2017). Trazadone helps with insomnia because it moderates cortisol suppression of the hypothalamic-pituitary-adrenal axis (Jaffer et al., 2017). There is a blockade of serotonin 5-HT2A and on histamine H1, which helps produce the hypnotic effect of trazodone, allowing patients to fall asleep and stay asleep without the side effects of larger doses that would cause daytime drowsiness and without causing addiction, mainly due to the 3-6 hour half-life (Jaffer et al., 2017). Trazadone is rapidly and almost entirely absorbed by the GI tract with a peak plasma concentration within 1-2 hours after oral administration (Jaffer et al., 2015). Having a light snack with this medication may improve absorption and help with possible side effects, including orthostatic hypotension (Jaffer et al., 2015). 

Mirtazapine starting at 15mg daily, is an antidepressant that has also been used off-label for insomnia. This medication has shown improvement in helping with sleep latency, efficiency, and awakenings through the night after two weeks of treatment (Patel et al., 2018). This drug is a potent 5-HT2 antagonist and produces sedative effects quickly through histamine receptor antagonism (Patel et al., 2018). Mirtazapine has a bioavailability of 50% and reaches peak plasma levels two hours after oral administration (Patel et al., 2018). Steady-state plasma levels are achieved within five days with 50% accumulation (Patel et al., 2018).

I would choose trazodone 25 mg PO at bedtime for this patient over mirtazapine. The benefits of treating patients with MDD by taking sertraline with Trazadone outweigh the risks. Trazadone is metabolized by the liver; in RCTs performed, even in patients with liver impairment, there were no significant differences compared to patients who did not have a liver impairment (Cuomo, 2019). Studies have shown that using these two together has improved insomnia and depression (Cuomo, 2019). Trazadone carries a low risk of anticholinergic effects, weight gain, and it has strong efficacy and safety in low doses in the treatment of insomnia (Cuomo, 2019). Mirtazapine has a high potential for weight gain by increasing appetite and food cravings, and the patient is already obese, has hypertension and DM (Patel et al., 2018). I do not want this patient to gain any additional weight. 

Ethical Prescribing and Decision-making

This patient is in the geriatric population and is has an increased sensitivity to medications because of pharmacokinetic changes from aging, such as reduced hepatic function. Her medical history of hypertension, obesity and DM further increases these sensitivities. Using the lowest dose that will be therapeutic for her with the least amount of side effects will be needed while using Trazadone. 25 mg PO with a snack at bedtime is recommended for her (Cuomo, 2015). The risk of serotonin increases due to both sertraline and Trazadone due to the serotonin reuptake inhibition that they both cause (Rosenthal & Burchum, 2021). Another risk is hyponatremia. Both HCTZ, tramadol, and sertraline increase the risk of hyponatremia. Increased sodium is released in response to increased serotonin, which stimulates ADH secretion (Rosenthal & Burch, 2021).

However, the risk for hyponatremia at this low dose is unlikely. A baseline of electrolytes and monitoring periodically throughout these patient visits will be necessary. Another issue could be orthostatic hypotension. Trazodone, losartan, and HCTZ all have the potential to cause this. Administering trazodone with a light snack can help slow absorption and possibly minimize this risk. These side effects are not as likely at the low dose she will be on, but because of her potential for drug sensitivity due to age and other medications that increase the risk, the risk is increased. I would also want to let this patient know that this medication is being used off-label for insomnia. The patient needs to be aware of the risks and the benefits before starting this medication. 

Checkpoints

The patient will need weekly visits with the psychiatric NP for the first four weeks to monitor outcomes for insomnia and depression. Research for the efficacy of Trazodone long term is limited, so it should only be used short time (Drugs.com, n.d.). If her insomnia and depression begin to improve, it could be that the insomnia was exacerbating her depression. If her depression does not improve, but her insomnia does, at this point, we will need to look into changing her depression medication. In addition, if she is not already receiving it, I recommend her having psychotherapy to help with her grief, MDD and find positive coping skills (Patel et al., 2018). Research on trazodone's long-term efficacy and safety for insomnia is limited (Patel et al., 2018). The existing evidence suggests that trazodone should only be a short-term solution for sleep problems, as very little research has been done on continuation treatment. This patient also needs education to assist her with sleep hygiene (Patel et al., 2018). 

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to

physical examination: An interprofessional approach (9th ed.). Elsevier Mosby. Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., ... & Fagiolini, A. (2019). Clinical

 guidance for the use of trazodone in major depressive disorder and concomitant conditions:

pharmacology and clinical practice. Rivista di psichiatria, 54(4), 137-149.Drugs.com. n.d.

Trazodone. Retrieved from Trazodone - Search results. Page 1 of about 8184 results (drugs.com)

HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960 Feb;23(1):56-

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Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., &

Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical

neuroscience, 14(7-8), 24–34.

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

medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6),

1017–1024. https://doi.org/10.5664/jcsm.7172

Rosenthal, L. D., & Burchum, J. R. (2021). Lehne's pharmacotherapeutics for advanced

practice nurses and physician assistants (2nd ed.). Elsevier.

Stahl, S. (2013) Stahl’s essential psychopharmacology: neuroscientific basis and practical

application. (4th ed.). Cambridge University Press.