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.
Further Assessment
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).
Differential Diagnosis
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.
Appropriate Treatment
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.
Contraindications
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.
Check Points
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.
References
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)
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?
Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O’Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O’Callaghan et al., 2018).
- How many hours of sleep are you getting each night?
Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, leading to more anxiety and insomnia (Levenson et al., 2015).
- Have you had any feelings of depression, hopelessness, or feeling down in the past month?
Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and determine if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020). The patient’s husband died ten months ago in the given scenario. If the patient responds positively to this question, it is critical to also assess for suicide risk.
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.
It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s daily life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask.
Have you noticed a change in her interest in doing things?
Have you she seemed down or hopeless?
How has she been eating?
Do you know if she is taking her medications or noticed any side effects from her medications?
Have you noticed any anxiety or changes in memory?
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults with depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015). The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as many organic illnesses can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible.
List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant 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.
The patient is currently taking Sertraline 100mg daily. If the patient takes the medication as prescribed, the patient should see improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia. At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can improve sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017).
Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the anti-depressant to Bupropion. Studies have shown that in patients with diabetes, burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish et al., 2018).
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?
Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug’s effects may increase due to slow kidney or liver removal. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020).
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.
It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone.
References
Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf
Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03
Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797
Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033
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
O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404
Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493
Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/
Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/
Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c
Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4
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Week 7 Discussion
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Edwina Etienne
07/12/2022
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
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.
Your discussion was very informative. Your questions were great, but sometimes, getting information from a close friend, family member, or the patient is more accessible when asked in an open-ended question. Try to see if the question can be answered by yes or no and if it can change it so that you have to tell a story or go into more detail to answer it.
The introduction of Escitalopram and Duloxetine into the treatment plan must be monitored. According to Starkman (2019), taking Escitalopram, Duloxetine, and Sertraline together can elevate serotonin levels in the blood and could cause a dangerous abnormal heart rhythm. If the individual has a history of heart arrhythmia and is over 65, Landy and Estevez (2020) state they should have a follow-up basic metabolic panel and ECG due to the potential prolonged QT interval. Monitoring for changes in thoughts when beginning, during, and after treatment is imperative. According to Dhaliwal et al. (2022), when an individual is taking duloxetine, especially in a geriatric individual, labs should be collected and monitored, such as serum creatine and blood urea nitrogen, to look at kidney function, sodium levels, transaminase, and blood glucose and HgbA1c in individuals such as our patient that has a history of diabetes mellitus.
References:
Dhaliwal, J. S., Spurling, B. C., & Molla, M. (2022). Duloxetine. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK549806/#:~:text=Duloxetine%20is%20a%20medication%20used
Links to an external site.
Starkman, Evan (2019). Drug Interaction Checker – Check for Interactions Between Prescription Medications. WebMD. https://www.webmd.com/interaction-checker/default.htm
Links to an external site.
Landy, K., & Estevez, R. (2020). Escitalopram. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557734/
