For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
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
By Day 3 of Week 7
Post a response to each of the following:
• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
• Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
Respond to the these discussions. All questions need to be addressed.
Discussion 2 Me
Treatment of a Patient with Insomnia
The case presented this week, is that of a 75-year-old widow who just lost her spouse 10-months ago. Th patient presents with chief complaints of insomnia. Past medical history of DM, HTN, and MDD is reported. Since the passing of her husband, 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, and Sertraline 100mg daily. Current weight: 88 kg. Current height: 64 inches. Temp: 98.6 degrees F. BP: 132/86 (Walden University).
Question number one, what brings you in today? By asking an open-ended question, the patient is more willing to share information with the provider (Stern, 2016). Another question that would be of beneficial knowledge during the interview is, do you consume caffeine? If so, how much caffeine do you consume in a day? Caffeine consumption close to bedtime contributes greatly to insomnia (Farazdaq et al., 2018). Lastly, the third question that should be asked is, do you suffer from Gastro Esophageal Reflux Disease (GERD). According to Farazdaq, Andrades, and Nanji, (2018) GERD is a contributing factor to insomnia in elderly patients. By asking the above questions, the provider can rule out environmental factors while assessing the patients concerns with open-ended questions.
People in the patient’s life that could provide further information is children or caretakers. Questions that would be appropriate to ask the patient’s children or caretaker would be if there is a recent decrease in her appetite, energy, mood, or interests. By asking about these areas of the patient’s life will provide external information that the patient might be withholding or may be unaware of.
Insomnia relies heavily on self-report for a diagnosis (Levenson et al., 2015). Also, a physical exam could be performed with the order of blood testing to rule out thyroid problems. According to Dr. Abhinav Singh (2021), hyperthyroidism results in nervousness from overactivity of this hormone, and insomnia is often a symptom. Administering the Hamilton Anxiety Rating Scale (HAM-A) would assess the severity of the patient’s anxiety. The HAM-A results would aid with further treatment of the patient’s insomnia, if related to anxiety (Psychiatry & Behavioral Health Learning Network, 2021). Another appropriate scale to administer to this patient is the Hamilton Depression Rating Scale (HDRS). HDRS is an assessment that focuses on feelings of guilt, mood, suicidal ideation, activities, weight, various stages of insomnia, and many more important areas (Hamilton, 1960).
The patient presents with a previous diagnosis of depression. The differential diagnosis for this patient is Generalized Anxiety Disorder (GAD), secondary to husband’s death. There are many possible changes within the living dynamics, such as financial burdens, fear of her own death, and suddenly sleeping alone. Changes within this patient’s routine may be a cause of reported insomnia.
Temazepam is FDA approved for insomnia, and used off-label for anxiety disorders, acute mania, psychosis, and catatonia (Puzantian & Carlat, 2020). Temazepam is generally effective in the treatment of insomnia, by enhancing widespread inhibitory activity of GABA (Levenson et al., 2015). Temazepam is metabolized through the liver without CYP450 (Puzantian & Carlat, 2020). Another good sleep aid choice is Trazodone. Trazodone is widely used for insomnia (Levenson et al., 2015). Trazodone is FDA approved for the treatment of major depression and used off-label for insomnia and anxiety (Puzantian & Carlat, 2020). Trazodone inhibits serotonin reuptake, alpha-1 adrenergic receptor antagonist, and serotonin 5-HT2A and 5-HT2C receptor antagonist (Puzantian & Carlat, 2020). And Trazodone is metabolized primarily through CYP3A4 to active metabolite mCPP, that is metabolized by 2D6, inducing P-glycoprotein (Puzantian & Carlat, 2020). Trazodone, however, carries the side effect of daytime somnolence and dizziness (Puzantian & Carlat, 2020).
The favorable medication for this patient, is Temazepam. Temazepam is a safer medication to use in elderly patients because of the lack of active metabolites, its short half-life and absence of drug interactions (Puzantian & Carlat, 2020). The patient is currently taking Metformin, Januvia, Losartan, HCTZ, and Sertraline. Based on the current medications, the patient is being treated for diabetes mellitus, hypertension, and depression. Adding Temazepam to the patient’s medication regimen would not result in toxicity of other medications. Sleep is heritable and regulated by numerous genes. A genome wide association study found numerous single-nucleotide polymorphisms (SNPs) significantly associated with insomnia symptoms. The most significant SNPs occurred within genes involved in neuroplasticity, stress reactivity neuronal excitability, and mental health (Rajib, 2020).
The starting dose of Temazepam is lower in the elderly population (Puzantian & Carlat, 2020). The proper dose to begin with this patient, is Temazepam 7.5mg tab PO QHS. At the 4-week checkup, the expected outcome would be an increased ability to sleep, and reduced anxiety. If these results have not been achieved, Temazepam 15mg tab PO Q HS would be ordered. Temazepam does have the risk of weakness and dizziness, so great care and caution would need to be taken when increasing the dose. There needs to be an evaluation of the effects at week 8, or sooner if needed. The maximum dose of Temazepam is 30mg PO Q HS, and even lower in the elderly (Puzantian & Carlat, 2020).
References
Farazdaq, H., Andrades, M., & Nanji, K. (2018, December 31). Insomnia and its correlates among elderly patients presenting to family medicine clinics at an academic center. Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382090/.
Hamilton, M. (1960). Hamilton Rating Scale for Depression. PsycTESTS Dataset, 23, 56–62. https://doi.org/10.1037/t04100-000
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The Pathophysiology of Insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
Puzantian, T., & Carlat, D. J. (2020). Medication fact book for psychiatric practice. Carlat Publishing, LLC.
Rajib, D. (2020). Do genes matter in sleep? -A comprehensive update. Journal of Neuroscience and Neurological Disorders, 4(1), 014–023. https://doi.org/10.29328/journal.jnnd.1001029
Singh, A. (2021, March 8). Could Your Thyroid be Causing Sleep Problems? Sleep Foundation. https://www.sleepfoundation.org/physical-health/thyroid-issues-and-sleep.
Stern, T. A. (2016). Massachusetts General Hospital: psychopharmacology and neurotherapeutics (1st ed.). Elsevier.
Walden University. (n.d.). Treatment for a Patient with a Common Condition. https://class.content.laureate.net/14884e77402afe219224c67c4f0463b3.html.
