NURS 6630 Discussion: Treatment for a Patient With a Common Condition
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
- List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- Has she begun grief counseling? “In a population study among the elderly, those between the ages of 75 and 84 years have a higher risk of developing complicated grief compared with a younger age group.” (PubMed Central, 2013)
- Does she dream? “Fragmented REM sleep may promote the perception of increased wakefulness and nonrestorative sleep in insomnia, which may contribute to subjective-objective sleep discrepancies insomnia.” (PubMed Central, 2015)
- How many hours of sleep is she getting and if she has trouble falling asleep, staying asleep, or waking up early? “ Greater understanding of the pathophysiology of insomnia may provide important information regarding how, and under what conditions, the disorder develops and is maintained as well as potential targets for prevention and treatment.” .” (PubMed Central, 2015)
- 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.
With her approval, I would ask to speak with:
- Anyone living with her: to gain insight on sleeping patterns, mood, appetite, ability to provide self-care and perform IADLs, medication compliance, weight gain or loss, presence of hallucinations or delusions, etc.
- Any children: they would be able to speak to who their mother “used to be” to help determine a baseline. They can also discuss how she has handled grief in the past. Also, they could be involved in grief counseling so she feels supported.
- Friends: They would be able to provide insight on her social life. Has she been going out as normal? Has she been as talkative?
- Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
- I would request the following from her provider as the results of these could indicate a physical cause of her symptoms, such as infections, endocrine disease, anemia, etc: CBC, CMP, Thyroid Function, A1C. and Urine drug screen
- I would also want the client to be evaluated by neurology to rule out the following:
- “Central nervous system diseases such as Sleep apnea, Parkinson disease, dementia, multiple sclerosis, neoplastic lesions” ((Jerry L Halverson, 2021)
*While I realize I may not be able to order all of the above tests, if I work in collaboration with her other providers, I can hopefully gather the information needed to rule out other causes.
- List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
- Major Depression
- Prolonged Grief Disorder (PGD)-I believe this is her primary diagnosis.
She meets 2 of the 4 criteria for this diagnosis. Only one is required. The two criteria are:
- “Time and impairment Persisted for an abnormally long period of time (more than 6 months at a minimum) and
- “Causes significant impairment in personal, family, social, educational, occupational or other important areas of functioning.” (PubMed Central, 2020)
- Adjustment Disorder
- Generalized Anxiety Disorder
- Substance Use Disorder
She appears to be on Zoloft 100mg already. I would consider increasing her dose to 125mg BUT, if we are to consider a second medication, the first option would be:
- Ramelteon 8mg PO QHS
- Doxepin 1mg PO QHS-I would choose this one because I can start a lower dose. I would keep in mind she is on Zoloft already.
- For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
- Concerns to using Doxepin in Combination with Trazadone is increased sedation, confusion, dizziness, dry mouth, and urinary retention. Because Doxemin can be started at a very low dose and tapered slowly, the patient can be monitored frequently and prn.
- A second concern is that Doxepin can impact blood sugars.
- 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.
- 2 weeks- if she has not had any negative side effects and reports benefits, I would keep the dose the same. The only reason I would like to see her back so soon is to evaluate for concerning side effects since she is on Zoloft also. I would also encourage her to monitor her blood sugars closely and send a note to her PCP is she agreed.
- 4 weeks-if she continues to have benefit I would increase to 2 mg PO QHS
- 8 weeks- I would keep the dose the same if she was reporting a decrease in negative symptoms.
Eisma MC, Rosner R, Comtesse H. ICD-11 Prolonged Grief Disorder Criteria: Turning Challenges Into Opportunities With Multiverse Analyses. Front Psychiatry. 2020 Aug 7;11:752. doi: 10.3389/fpsyt.2020.00752. PMID: 32848929; PMCID: PMC7427562.
Hashim SM, Eng TC, Tohit N, Wahab S. Bereavement in the elderly: the role of
primary care. Ment Health Fam Med. 2013 Sep;10(3):159-62. PMID: 24427183; PMCID: PMC3822663.
Jerry L Halverson, M. D. (2021, November 29). Depression differential diagnoses. Depression Differential Diagnoses. Retrieved July 14, 2022, from https://emedicine.medscape.com/article/286759-differential
Levenson JC, Kay DB, Buysse DJ. The pathophysiology of insomnia. Chest. 2015 Apr;147(4):1179-1192. doi: 10.1378/chest.14-1617. PMID: 25846534; PMCID: PMC4388122.
Week 7 Initial Post discussion
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List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Based on the case scenario, I will ask the following questions to collect more information.
- When do you go to bed, and how long does it take to fall asleep?
- How long do you spending in bed each night?
- What do you think is causing the insomnia problem?
Poor or insufficient sleep has been known to have profound effects on people’s health and well-being. Some people experience difficulty initiating and maintaining sleep, while others find it hard to wake up in the morning. Insomnia can also be caused by depression or psychological distress. It can be categorized as a type of sleep disorder or a medical condition (MacFarlane, 2022). When it comes to assessing the cause, it is important to ask the following questions: What do you feel is causing it? Do you believe that it is a specific situation that triggers it? This is also important to determine if the client has a sense of belief that it is the main reason for their anxiety. Having a deeper understanding of the cause of the problem is also important to help the client identify the triggers that are contributing to their condition. For instance, if the client is anxious about certain things, such as being around certain stimulants, then it is important that they identify the reason for their anxiety (Oh et al., 2019).
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.
Next of kin–It is important to contact the patient’s next of kin as they may know her well enough to provide helpful details about her condition. Even if the patient has never had children, it is still important to contact them as they may also be able to provide helpful information.
Friends/family -If the patient does not have children or friends who are frequently in touch with her, then friends may be interviewed. These individuals could be the ones who she has been sharing her thoughts about her condition.
Primary care physician- PCP may be able to provide her with more details about her health history. He or she may also be able to help her manage her condition and improve her quality of life. In addition, working with her PCP can help ensure that the patient receives the best possible care.
Questions could be asked include have you noticed recent significant mood changes in the client, or has the client shared with you any of her thoughts or worries, have you seen any of her health condition that affects her quality of life, etc.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
The tests will be ordered include labs test, physical examination, and psychiatric evaluation. A chemical laboratory test is often performed to identify the cause of a particular condition and to confirm the presence of other organic health conditions. This can be done to ensure that the patient’s symptoms are not related to other conditions. A comprehensive physical examination is often performed to check for other possible causes of the patient’s symptoms. This can be done in the form of a cephalocaudal physical examination. This type of examination can be performed to identify the presence of other conditions such as the environment or medications. A psychiatric evaluation is often performed to diagnose a patient’s condition. It can be performed to collect information about the patient’s thoughts, feelings, behavior patterns, and symptoms in association with a specific criterion in the DSM-5. Besides a general interview, the patient can also be asked to complete various condition-specific questionnaires. Some of these include the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Zung Self-rating Scale (Legg, 2018).
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
According to Psych Scene (2020), the following is the list of differential diagnosis
- Depression- is a type of mood disorder that lingers in one’s mind for a prolonged period of time. It can manifest in feelings of hopelessness, sadness, and loss of interest.
This condition is referred to as organic. It can be caused by various factors such as diabetes, hypothyroidism, and other mental health conditions. For patients, it is more likely that the condition is caused by these factors. It can also be caused by various factors that affect a person’s mood. For instance, a person can experience depression following a major event in their life, such as the death of their husband. The signs and symptoms of depression include a hopeless outlook, which can be accompanied by various other symptoms such as irritability, fatigue, and anxiety. Although the patient denies having active suicidal thoughts, she should still be evaluated for the presence of these thoughts. For instance, if the patient wishes to die in bed or in an accident, then these thoughts should be considered.
- Anxiety – Continuing worrying about things during the day often carries over into night. That can cause mental hyperarousal leading to insomnia.
- Organic- There are various types of insomnia diagnoses that are organic. For instance, it could be that the patient has a mental disorder or that their condition is caused by a substance.
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
Although it’s not widely used, Prozac is one of the few antidepressants approved by the FDA for children and teenagers. It’s also safe to use in people with diabetes, as it doesn’t increase blood sugar levels. One of the most common types of antidepressant is fluoxetine, which has a high effectivity rate. This medication belongs to a class of drugs known as selective serotonin reuptake inhibitors. These are designed to increase the levels of serotonin in the body, which helps improve mood and well-being (Sohel et al., 2022).
Another common type of antidepressant is Escitalopram, which is also known as Lexapro. It’s safe to use in children and teenagers, as it doesn’t increase blood sugar levels. It can additionally help alleviate anxiety symptoms.
For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making
There has been little difference in the response time and outcome of patients between white and minority groups in depression. Despite the various investigations that have been conducted on the subject, the exact effects of ethnicity on the treatment response remains unclear. There is still a need for further studies to understand the possible effects of different ethnic groups on the treatment response (Lesser 2010).There is currently not enough evidence supporting the link between ethnicity and the treatment outcomes of depression. In previous studies, it was shown that minority patients had worse outcomes than white patients. However, more recent studies have shown that the effects of race on the response time of African-Americans and Latinos to treatment have been refuted (Murphy et. al., 2013).
Although it is not yet clear if ethnicity affects the response time of certain medications, there are still contraindications that should be considered when taking these drugs (Pediatric Oncall, 2020). For patient who has hypersensitivity to fluoxetine or any component in its formulation or seizure should not use Prozac. It is also contraindicated to patient who is taking monoamine oxidase inhibitors (MAOI). Contraindication of Lexapro include Serotonin Syndrome, taking MAOIs, hypersensitivity to Lexapro, Activation of Mania/Hypomania, Abnormal Bleeding, Angle Closure Glaucoma etc.
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.
Fluoxetine-It should be given at a dosage of 20 mg/day in the morning. A dose adjustment may be ordered if the symptoms do not improve or if the patient’s clinical condition worsens. An increase should not exceed the maximum daily dosage of fluoxetine. Since the patient is an older adult, a lower or less frequent dosage may be considered. It should be maintained until the patient stops taking the medication, or if they can no longer tolerate the side effects. A gradual reduction should also be performed if the patient decides to stop taking the medication (Sohel et al., 2022).
Escitalopram- The appropriate dose adjustments should be made according to the patient’s needs. For instance, if she is taking extended therapy, the lowest effective dose may be maintained. In addition to age, other factors such as drug interactions and the effects of other medications should also be taken into account. Should the patient experience intolerable symptoms, a gradual reduction in the dose may be performed (NLM, n.d.)
Lesser, I. M., Myers, H. F., Lin, K.-M., Bingham Mira, C., Joseph, N. T., Olmos, N. T., … Poland, R. E. (2010). Ethnic differences in antidepressant response: a prospective multi-site clinical trial. Depression and anxiety. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113513/#:~:text=Evidence%20comparing%20depressio.
Legg, T. J. (2018). Diagnosing Depression. Healthline. https://www.healthline.com/health/depression/tests-diagnosis.
MacFarlane, J. (2022, May). Insomnia: Asking the Right Questions. The Canadian Journal of CME. Retrieved July 13, 2022, from http://www.stacommunications.com/
Murphy, E., Hou, L., Maher, B. S., Woldehawariat, G., Kassem, L., Akula, N., … McMahon, F. J. (2013, December). Race, genetic ancestry and response to antidepressant treatment for major depression. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828530/.
Oh, C.-M., Kim, H. Y., Na, H. K., Cho, K. H., & Chu, M. K. (2019). The effect of anxiety and depression on sleep quality of individuals with high risk for insomnia: A population-based study. Frontiers in Neurology, 10. https://doi.org/10.3389/fneur.2019.00849
Pediatric Oncall. (2020, September 13). Fluoxetine. Pediatric Oncall. https://www.pediatriconcall.com/drugs/fluoxetine/590.
Psych Scene. (2020). What are the Differential Diagnoses for Depression? Psych Scene Hub. https://psychscenehub.com/psychpedia/depression-co-morbidities/.
Sohel, A. J., Shutter, M. C., & Molla, M. (2022, May). Home – books – NCBI. National Center for Biotechnology Information. Retrieved July 13, 2022, from https://www.ncbi.nlm.nih.gov/books
U.S. National Library of Medicine. (n.d.). Escitalopram: Medlineplus Drug Information. MedlinePlus. Retrieved July 13, 2022, from https://medlineplus.gov/druginfo/meds/a603005.html
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- How long have you been taking Zoloft and are you currently attending psychotherapy to help with grief support and experienced depression?
Rationale: Providers need an understanding of when medication was initiated and adjusted. For the initial treatment of major depression, A combination of antidepressant medication and psychotherapy. Combination treatment is more effective than either treatment on its own. Each treatment form is effective and comparable to the other Psychotherapy may help people develop new coping skills as well as more adaptive ways of thinking about life problems (Rush, 2019).
- Do you take your Zoloft daily and have you forgotten to take or missed taking a dose? Rationale: Clarifying missed doses of this medication may contribute to patient increased depression symptoms. MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus, substance misuse and other mental disorders, reflecting both antecedent and consequence pathways. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions (UptoDate, 2022).
- Do you take any other medications or supplements? Rationale: Concern of Serotonin syndrome. Obtaining a current medication history will confirm if a patient is taking other medications elevate serotonin such as other antidepressants, certain NSAIDS, headache medications, St. John’s Wort.
When was your last visit with your PCP, Rationale: One of the most common barriers to seeking health care is out-of-pocket medical cost? In particular, among older adults with chronic conditions, the burden of out-of-pocket medical cost is a major concern (Cheruvu & Chiyaka, 2019).
What is the patient’s current mood and how does the patient rate her current mood?
Who is and where is your PCP located? As a provider you will want to retrieve medical records from current PCP and need to send release to appropriate correspondence.
MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions. Collateral information from a patient’s family/friends is a very important part of psychiatric evaluation. A complete physical examination, including neurological examination, should be performed. It is important to rule out any underlying medical/organic causes of a depressive disorder. A full medical history, along with the family medical and psychiatric history, should be assessed. Mental status examination plays an important role in the diagnosis and evaluation of MDD.
Appropriate Physical Tests and Diagnostic Examinations
The GDS (Geriatric Depression Scale) would be beneficial and used to assess patient level of depression. Screening should also be considered in cases involving bereavement effects continuing 3 to 6 months after the loss, social isolation, persistent complaints of memory difficulties, chronic disabling illness, recent major physical illness, persistent sleep difficulties, significant somatic concerns or recent onset of anxiety, refusal to eat or neglect of personal care, recurrent or prolonged hospitalization, diagnosis of dementia. This should be done as base line during office visit, even if this patient denies suicidal ideation. Assessment of the patient ‘s overall mood will determine the degree of depression and if the patient is at risk. Laboratory testing should include, complete blood count with differential, comprehensive metabolic panel, thyroid-stimulating hormone, free T4, vitamin D, urinalysis, and toxicology screening is done to rule out organic or medical causes of depression. Assessment of CMP will check the kidney functions, and electrolytes, this medication may impact these levels. Sodium levels within CMP should be checked 1 month after starting Zoloft. Common side effects of SSRIs include nausea, dry mouth, insomnia, somnolence, agitation, diarrhea, excessive sweating, and, less commonly, sexual dysfunction. Declining renal functioning associated with aging, there is also an increased risk of elderly patients. developing hyponatremia secondary to a syndrome of inappropriate antidiuretic hormone secretion (Wiese, 2011).
MDD is frequently comorbid with physical problems and illnesses including obesity, cardiovascular disease and diabetes mellitus. This may affect the efficacy of treatments for MDD as well as increasing the vulnerability of patients to adverse effects and risk of harmful drug interactions. Laboratory screenings during visits should consist of CBC, TSH, CMP, Vitamin D3. Neurological causes such as cerebrovascular accident, multiple sclerosis, subdural hematoma, epilepsy, Parkinson disease, Alzheimer disease should be considered during evaluation. Consideration of endocrine, metabolic disorders and nutritional deficits should be considered when obtaining labs that could be the primary cause for Major Depressive Disorder.
The patient is currently taking an SSRI, sertraline 100mg daily for MDD treatment. The provider should consider increasing patient sertraline to 150 mg. Selective serotonin reuptake inhibitors (SSRIs) are regarded as the treatments of choice for first line management of elderly depressed patients. The selective serotonin reuptake inhibitors (SSRIs) and the newer antidepressants bupropion, mirtazapine, moclobemide, and venlafaxine (a selective norepinephrine reuptake inhibitor or SNRI) are all relatively safe in the elderly. They have lower anticholinergic effects than older antidepressants and are thus well tolerated by patients with cardiovascular disease (Weise, 2011). This medication is safe for this patient’s depression treatment and dosage can be increased for patients up to 200mg daily. It would be appropriate for the provider to augment the sertraline with a low dose TCA, such as Trazodone, to be taken at bedtime. Patients should be educated on feelings of over sedation and discontinuation of TCA taken at HS could be lowered or discontinued.
The BEERS Criteria should be utilized prior to prescribing psychotropic medication treatment since the patient is older than 65 years of age.
Sertraline use requires caution in patients 65 years and older. It is identified in the Beers Criteria as a high-risk medication in geriatric patients, as it may induce a syndrome of inappropriate antidiuretic hormone or hyponatremia.
Patients should be scheduled for in office follow-up in 2-3 weeks to follow up on medication changes as well as their depression. The provider should repeat their GDS as well as evaluate any further mood changes or concerns.
Cheruvu, V. & Chiyaka, E. (2019). Prevalence of depressive symptoms among older adults who
reported medical cost as a barrier to seeking health care: findings from a nationally representative sample. BMJ Geriatrics. https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-019-1203-2
Rush, J. (2022). Patient education: Depression treatment options for adults (Beyond
the Basics). UpToDate.
Weise, B. (2011). Geriatric depression: The use of antidepressants in the elderly. The British
Medical Journal, 53(47). Geriatric depression: The use of antidepressants in the elderly | British Columbia Medical Journal (bcmj.org)