Case Study in Insomnia Essay

The patient is a 75-year-old patient who lost her husband 10 months ago and presents with complaints of insomnia. The questions I might ask the patient are:

Case Study in Insomnia Essay

  • Can you tell me how I may be of assistance today? This is an open-ended question that can serve to create rapport and encourage the patient to give me a lot of information about herself with the knowledge that the doctor is ready to listen and help her.
  • Do you live with someone at home? By asking this question, I will understand the type of support system the patient has at home and know which support to prescribe for the patient.
  • Are you following your regimen correctly? This will help me know if the patient is compliant to her medication and whether the support at home is helping the patient follow her regimen correctly.
  • How would you describe a well-rested sleep? This open-ended question would give me information regarding the patient’s expectations of enough sleep and this would be useful in designing an effective goal for her personal treatment plan.

The people in the patient’s life that I would need to speak to are her children, her close friends and neighbors. I could also speak to her aide if she has one.  these people will help me know the severity of the patient’s problem. Some of the questions I will ask them are;

  • Based on your personal experience with her, can you describe her as a mother or friend or neighbor? This question will help me understand how the patient usually is so as to easily identify any anomalies from the subsequent history taken.
  • Has the patient been behaving more differently recently or experiencing worse symptoms of depression since her husband’s death? This question will help me understand the changes that the people close to her have noticed and whether they have noticed if she is depressed or not.
  • Does the patient complain about her medication or treatment regimen? This question will allow me to assess whether the patient is compliant or know the side effects the patient experiences, if any.
  • Has the sleeping patterns changes recently? This question will help me understand the severity of insomnia.

The physical exams appropriate for this patient include heart rhythm, respiratory rate, pulse rate, and oxyhemoglobin saturation. This is done because anxiety disorders can affect the findings of these parameters.

Tests such as Complete Blood count and Blood chemistry. Thyroid function tests assess possible contributing factors to her depression. Thyroid dysfunction can play a role in the pathogenesis of depression. Kidney function tests which test the ability of the kidney to eliminate waste from the body. These tests will include the urea, electrolytes and creatinine, and the GFR tests. Liver function tests which assess the liver enzymes. LFTs and KFTs test how well the body can metabolize and eliminate medications to be prescribed.

The diagnostic tests for this patient include polysomnography and actigraphy tests that are used to measure the patient’s sleep patterns. The actigraphy alone measures sleep efficiency, sleep latency, and total sleep time. The polysomnography will diagnose sleep disorders (Niel et al., 2020). Depression screening tests can also be done using different questionnaires to assess the level of her depression.

The patient’s differential diagnoses include:

  • Generalized Anxiety Disorder (GAD),
  • Major Depressive Disorder (MDD),
  • Restless Leg Syndrome.

Major depressive disorder (MDD) is the most likely disease that could explain why the patient is experiencing insomnia. MDD usually presents clinically as insomnia, difficulty concentrating, loss of appetite, and hopelessness. The patient lost her husband of 41 years and it is possible that this contributed to her depression, which has also affected her sleeping pattern. Bennabi et al. (2019) states that patients with MDD are at risk of experiencing sleeping disorders.  Since the patient is responding to grief, her chances of developing MDD are high.

The pharmacologic agents that would be appropriate for the patient’s therapy are:

  • Selective serotonin uptake inhibitor (SSRIs). An example is Prozac. The required dose is 10 mg given PO qDay. The mechanism of action of SSRIs is by inhibiting the serotonin transporter (SERT) at the presynaptic axon terminal to prevent serotonin re-uptake. Inhibition of SERT results in an increased amount of serotonin in the synaptic cleft which then increase the serotonin levels, activity and effect in the brain.
  • Tricyclic antidepressants (TCAs) are used to treat MDD. An example is Amitriptyline. The required dosage is 10-25 mg given PO qHS. The mechanism of action of TCAs is blocking the reuptake of both serotonin and norepinephrine neurotransmitters consequently increasing the levels of norepinephrine and serotonin levels in the brain.

In terms of treating MDD, both TCAs and SSRIs show equivocal efficacy. However, SSRIs are the preferred drug for treatment of MDD because of fewer and milder side effects associated with this type of antidepressant drug. TCAs cause more adverse effects because of their anticholinergic effect. Also, when considering the patient’s age, SSRIs are the preferred drug (Bauer et al., 2017). TCAs on an elderly client might result in adverse cardiovascular effects such as dysrhythmias or orthostatic hypotension that may lead to dizziness, falls, and fractures.

Various research has shown that other races such as Asians and African Americans resort to using other alternative medication to treat their depression and these medications require lesser drug dosages to achieve the desired effect. SSRI use for the white race is always on standard prescription values with regards to its dosage and schedule. Administering these drugs to elderly patients however warrant that a modification is done. This is done through dose adjustment to minimize the side effects and polypharmacy considerations for drug-drug interactions (Salehi, 2019). The drug contraindicates in the patients taking selective serotonin reuptake inhibitors are mirtazapine, and other vasoconstrictors and analgesics.

After administering these drugs, the patient will be assessed after a four-week interval to determine if the symptoms have improved. If the symptoms have not improved after four weeks, Prozac will be increased by 10-20 mg for four weeks until a maximum of 80 mg, which is the maximum recommended dose per day. If the symptoms improve within the first four weeks, the regimen will be maintained until the patient completes the dose.

After completing the dose, the patient will sleep well and the symptoms of depression will be well managed. Once the desired outcome has been achieved the patient Prozac daily should be discontinued and started on Prozac weekly after one week. The patient should be closely monitored for any changes in behavior and suicidal tendencies within the first 4- 8 weeks. Prozac may also interfere with glycemic control as it may cause hypoglycemia especially in diabetic patients (DiVall & Woolley, 2019)

I have learnt that depression is a major illness that affects many patients and details in the history of a patient should be carefully examined to make the appropriate diagnosis and commence the proper treatment modalities.

References

  • Bennabi, D., Charpeaud, T., Yrondi, A., Genty, J. B., Destouches, S., Lancrenon, S., & Haffen, E. (2019). Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental. BMC Psychiatry, 19(), 262. https://doi.org/10.1186/s12888-019-2237-x
  • Bauer, M., Severus, E., Möller, H. J., Young, A. H., & WFSBP Task Force on Unipolar Depressive Disorders. (2017). Pharmacological treatment of unipolar depressive disorders: summary of WFSBP guidelines. International Journal Of Psychiatry In Clinical Practice21(3), 166-176. https://doi.org/10.1080/13651501.2017.1306082
  • DiVall, M. V., & Woolley, A. B. (2019). CHAPTER Pharmacologic Agents. Acute Care Handbook for Physical Therapists E-Book, 431.
  • Niel, K., LaRosa, K. N., Klages, K. L., Merchant, T. E., Wise, M. S., Witcraft, S. M., Hancock, D., Caples, M., Mandrell, B. N., & Crabtree, V. M. (2020). Actigraphy versus polysomnography to measure sleep in youth treated for craniopharyngioma. Behavioral sleep medicine18(5), 589-597. https://doi.org/10.1080/15402002.2019.1635133
  • Salehi, M., Hadizadeh, H., Chang, A., & Grados, M. A. (2019). Recommendations for prescribing SSRIs. Contemporary Pediatrics36(11), 24-27.

Case Study in Insomnia Essay Instructions

Questions

  1. Are you taking any supplements for sleep?
    1. By assessing if the patient is taking anything for sleep, the provider can better determine what the next step should be and if there are any contraindications.
  2. How is your appetite?
    1. The patient is currently taking metformin and has a history of diabetes. Her symptoms may be related to poor management of her health condition.
  3. What do you do to manage your depression?
    1. This helps the provider better understand how the patient is managing her depression through use of other coping skills. If the patient is taking supplements, the provider can determine if there are any contraindications. If the patient is not currently utilizing coping skills, these can be taught to be used in addition to medication management.

Relationships

When assessing the patient, it can be helping to receive feedback from family members and other close friends who may have additional information that the patient may not think of. Questions to ask these individuals may be:

  1. Have you noticed any significant changes in behavior from the patient?
    1. This will help to identify any other symptoms the patient may be having without realizing it.
  2. Do you still see the patient as often as before her husband passed?
    1. This will help to identify if the patient is becoming withdrawn.
  3. Have you noticed if the patient has been more forgetful or having more difficulty completing every day tasks?
    1. This will help to identify if the patient is developing cognitive impairments or requires additional assistance.

Diagnostics

Two diagnostic tools I would present are the Geriatric Depression Scale and the Nutritional Health Checklist (Sullivan, 2019). The Geriatric Depression Scale assesses the patient’s mood over the course of the past week (Ball, et. al., 2019). This helps the provider to determine how severe the patient’s depression is. The Nutritional Health Checklist, as described by Sullivan (2019), assesses the patient’s nutritional intake. This is pertinent information as the patient is a diabetic and with depression, a loss of appetite can occur. With the data, the provider can determine if additional supplements or nutritional coaching is necessary.

Differential diagnosis

  1. Depressive disorder due to another medical condition
  2. Adjustment disorder with depressed mood
  3. Bereavement
  4. Sadness

According to the DSM-TR-5 (2022), Bereavement is described as the loss of a loved one because of death. Symptoms include sadness, difficulty sleeping, and poor concentration. The difference between major depressive disorder and bereavement is that bereavement causes feelings of grief such as emptiness and loss whereas depression causes symptoms such as a persistent depressed mood and inability to experience pleasure. What this patient is describing appears to be bereavement as she just recently lost her husband.

Pharmacological agents & Contraindications

  1. Paroxetine 10 mg PO daily at HS
  2. Trazodone 50 mg PO daily at HS

Both paroxetine and trazodone are antidepressants and are used for sleep management. The patient is currently taking Sertraline which is also an SSRI (Stahl, 2022). I feel that while adding a medication for sleep could be beneficial, first switching the patient to a different SSRI to eliminate the amount of medications she is on would be a better alternative. Paroxetine, a SSRI, has a common side effect of sedation which meaning this medication can assist with both the patient’s depression and insomnia (Stahl, 2022). If the patient continues to have issues with sleeping, according to Stahl (2022), Trazadone is an augmenting agent that can be used. This medication also has mild anticholinergic actions and side effects are known to subside within time.

A primary contraindication, according to the FDA (2014) is the concurrent use of MAOIs with paroxetine due to the risk of serotonin syndrome. If the patient is to be switched to an MAOI due to treatment-resistance, the patient should wait 14 days from the last dose of paroxetine to start the new medication. In addition, patient with angle-closure glaucoma should use this medication with caution due to the risk of an attack as a result of taking paroxetine.

Check points

Following the initial visit, I would suggest the patient comes back within 2-4 weeks to assess the effectiveness of the new medication. SSRIs, according to Stahl (2022), take approximately 2-4 weeks to fully work. This would give the medication enough time to reach its full potential.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (DSM-5-TR), (5th ed. revised). American Psychiatric Association

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

FDA. (2014). Paxil. https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/020031s074lbl.pdfLinks to an external site.

Sullivan, D. D. (2019). Guide to clinical documentation, (3rd ed.). F. A. Davis

Stahl, S. M. (2022). Stahl’s essential psychopharmacology prescriber’s guide, (7th ed.). Cambridge