Responses

1

Student 1 Leyla parsa

Subjective: A patient presents to your primary care office today with a chief complaint of insomnia. The 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. The patient normally sees PCP once or twice a year. The patient denies any suicidal ideations. The patient arrived at the office today by private vehicle. The 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 

Questions to Ask the Patient

            The questions I would ask the patient would aim to identify the nature of the underlying insomnia. Specifically, the questions would be:

1. Does insomnia present in the form of difficulty falling asleep, early morning awakening, or frequent nocturnal awakenings?

2. If the problem you are experiencing occurs at sleep onset, do you feel sleepy when you get into bed?

3. Do you have a regular schedule for your sleeping and waking up? How has your schedule changed since your husband’s death?

Rationale

            Asking the patient about how insomnia presents itself is critical in understanding the dynamics of the underlying problem. Suppose the patient experiences a frequent nocturnal awakening. In that case, the risk of developing cardiovascular complications, and metabolic weight gain, is high, and such information will shape decision-making on the interventions to administer. Asking the patient if they feel sleepy when they go to sleep is imperative in determining the underlying insomnia triggers. Lastly, seeking clarity about the schedule is essential because it would provide information about the patient’s daily activities and help infer how they may affect sleep patterns.

People to Interview

            To obtain more accurate information concerning the patient’s condition, it would be necessary to interview the client’s caregiver. The person who stays with the patient has crucial observations concerning the client’s lifestyle. The questions and rationale include:

1. What activities is the patient involved in daily? The question will provide information necessary for assessing the client’s lifestyle, to help predict the possible insomnia triggers.

2. Does the patient take long naps during the daytime? The rationale for this question would be to determine if long daily naps cause insomnia.

3. Does the patient use cocaine, alcohol, or any other recreational drugs? The question will seek to determine if insomnia is induced by substance use.

Physical Exam

            The physical examinations necessary for the patient include checking if the client has a deviated nasal septum, a narrow throat, or enlarged tonsils. Results about the deviated nasal septum would be used to infer if the patient’s insomnia is triggered by snoring—a narrow throat leads to sleep apnea, which may lead to insomnia. Findings about enlarged tonsils are crucial in determining if the patient has insomnia or sleep apnea caused by snoring.

Differential Diagnosis

1. Primary insomnia - concerns about an individual orchestrating the condition are life issues (Zhu et al., 2021). The patient admits suffering from depression since her husband’s death ten months ago, aggravating the insomnia. This is the most probable condition the patient is experiencing.

2. Nocturia – diuretics, diabetes, or incontinence can orchestrate nocturia. The patient has underlying diabetes. However, since the patient links the onset of the insomnia condition to the depression after her husband’s demise, nocturia is the least likely condition.

Pharmacological Interventions

            Suvorexant is recommendable for the treatment of the patient’s insomnia (Tampi et al., 2019). The medication should be administered 10 mg daily, 30 minutes before sleeping. The choice of drugs is based on the fact that it does not interact with metformin, Januvia, Losartan, HCTZ and Sertraline, which are the current medications the patient is taking. Furthermore, the patient does not have conditions contributing to Suvorexant contraindication. Doxepin (Silenor) is also recommendable for treating the patient’s condition. The dosage for the medication is 25 mg/day, and the rationale for its recommendation is that it is safe for an elderly patient, and the client does not have any contraindications for the drug (Thomas, Hilleman & Malesker, 2022). The contraindications for selecting the drug are the underlying depressive disorder and diabetes. Furthermore, the medications were reconciled to ensure that there would be no interactions. The ethical concerns incorporated in the decision include the principles of non-maleficence and beneficence.

References

Tampi, R. R., Manikkara, G., Balachandran, S., Taparia, P., Hrisko, S., Srinivasan, S., & Tampi, D. J. (2019). Suvorexant for insomnia in older adults: a perspective review. Drugs in Context, 7.

Thomas, S. V., Hilleman, D. E., & Malesker, M. A. (2022). Insomnia Treatment Update With a Focus on Orexin Receptor Antagonists. US Pharm, 47(5), 43-48.

Zhu, Y., Zhao, X., Yin, H., & Zhang, M. (2021). Functional connectivity density abnormalities and anxiety in primary insomnia patients. Brain Imaging and Behavior, 15, 114-121.

Student 2

Doreen bezalem fombin

Treatment for a Patient with a Common Condition

Insomnia is a common sleep disorder that often affects seniors. Although insomnia is not considered a component of the aging process, the prevalence of insomnia increases with age. Additionally, having psychiatric disorders or other medical conditions may lead to insomnia. In the case study provided, a 75-year-old female patient presented herself to the clinic with a complaint of insomnia and depression but indicated that she had no history of depression before the death of her husband.

Some of the questions that I should ask the patient include:

· How was your relationship with your late husband?

The patient seemed to have been very close to her late husband. Being lonely has resulted in depression after her husband's death.

· How long do you sleep each night?

Knowing the amount of sleep can assist in developing a sleeping timetable.

· Whom do you consult when you need social support or feel depressed?

The patient may not have someone close to share the challenges she is experiencing.

Close People in the Patient's Life that can provide relevant sleep information.

Assessing an elderly patient with insomnia requires the nurse practitioner to interview legal guardians who also interact with the patient. Children and caregivers taking care of the elderly aid in providing a comprehensive medical history and should be involved in developing a treatment plan. The children can answer the question about the patient's sleep patterns and what she does before sleeping. The patient may have friends within a support group for the widows; hence, such friends can assist in explaining how the patient's behaviors have changed.

Physical Exams & Diagnostics to tests.

The patient had already undergone a physical examination, revealing she was obese. Other physical examinations should include general appearance, eyesight, chest and lung sounds, heart rates, muscle strength, and level of coordination. Some diagnostic and lab tests for the patient include a polysomnography test for checking sleep apnea, CBC for checking thyroid problems, and actigraphy for assessing periods of resting and activity. The results of the tests would be utilized to determine the cause of her insomnia and identify any other condition not related to her current state that may require urgent medical attention.

The differential diagnosis for the patient is as follows:

· Major Depressive Disorder (MDD): This is a mood disorder where individuals experience either a depressed mood or lose interest by exhibiting a depressed mood, diminished interest in almost all activities, insomnia, retardation, loss of energy, feeling worthless, and losing concentration (American Psychiatric Association, 2022).

· Insomnia Disorder: This is a predominant complaint of being dissatisfied with sleep quantity, which is linked to difficulty initiating and maintaining sleep, as well as the inability to return to sleep (American Psychiatric Association, 2022).

· Generalized Anxiety Disorder (GAD): This form of anxiety is marked by excessive stress, recurring worry, insomnia, fatigue, and distress for at least six months (DeMartini et al., 2019).

Primary Diagnosis: MDD is the primary because the patient complained of insomnia and depressed mood after losing her husband.

Two Pharmacologic Agents

The most appropriate medications for MDD are Celexa (citalopram) and doxepin. According to Potter (2019), Celexa, an SSRI, works by improving the neurotransmitter serotonin and blocking the serotonin reuptake pump. Start 10mg orally daily and increase by 10mg/day in at least one week as tolerated; Max dose is 20 mg orally daily. Doxetin, a tricyclic antidepressant (TCA), works by increasing certain chemicals within the brain to fall asleep and decreasing negative moods. The correct dose for doxepin is 75 mg once daily for a start, but it can be titrated to 150 mg daily as needed. However, Celexa is the most suitable medication for the elderly, as it reduces the chances of recurrence of symptoms. Rostami et al. (2022) indicated that long-term treatment of MDD using Celexa is well tolerated, and the drug does not interfere with norepinephrine levels within the brain.

Contraindications

Celexa is contraindicated with monoamine oxidase inhibitors (MAOIs, where using celexa with an MAOI could lead to serotonin hyperactivity (Shoar et al., 2021). Celexa is also contraindicated in individuals with hypersensitivity to the drug. The contraindications that are likely to be experienced by the patient are due to her age and comorbidity. Elderly patients are often poor metabolizers, thus increasing the risk of drug-drug interactions. Besides, patients with diabetes should adhere to the prescribed precautions due to the exchange of diabetes medications and antidepressants.

Check Points

 A follow-up plan should be made every four weeks, where the dose is increased to 40 mg max per day at eight weeks. Consider a reduced dose to 20 mg after 12 weeks when the patient exhibits signs of recovery. Besides, the dosage should be maintained if there is much improvement and tolerability. Celexa is not recommended for use at greater than 40mg/day because such doses cause a significant effect on QT interval (Research, 2019).   

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (Fifth edition, text revision).  https://doi.org/10.1176/appi.books.9780890425787 Links to an external site.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of Internal Medicine, 170(7), ITC49-ITC64.  https://doi.org/10.7326/AITC201904020 Links to an external site.

Potter, D. R. (2019). Major depression disorder in adults: a review of antidepressants. Int. J. Caring Sci, 12, 1936.  https://www.internationaljournalofcaringsciences.org/docs/69_potter_review_12_3.pdf Links to an external site.

Research, C. for D. E. and. (2019). FDA Drug Safety Communication: Revised recommendations for Celexa (citalopram hydrobromide) related to a potential risk of abnormal heart rhythms with high doses.  FDA.  https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-revised-recommendations-celexa-citalopram-hydrobromide-related Links to an external site.

Rostami, H., Safaei, G., Norouzi, S., Abdi, L., & Malekpour, N. (2022). Comparison between the efficacies of modafinil and citalopram in the treatment of major depression. Maedica, 17(3), 607–614.  https://doi.org/10.26574/maedica.2022.17.3.607 Links to an external site.

Shoar, N. S., Fariba, K. A., & Padhy, R. K. (2021). Citalopram. In StatPearls [Internet]. StatPearls Publishing.  https://www.ncbi.nlm.nih.gov/books/NBK482222

***Additionally explain mechanism of action of mirtazapine and trazodone