Case: An elderly widow who just lost her spouse.
Chief Complaint: A 75-year-old widow was present to the office today complaining of insomnia, and worsening depression.
PMH: DM, HTN, and MDD.
Personal/Family history: 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. Current weight: 88 kg, height: 64 inches, Temp: 98.6 degrees F, BP: 132/86
Personal history: She is awake, alert, and oriented x3. Patients normally see PCP once or twice a year. Patient denies any suicidal ideations.
Medications:
- Metformin 500mg BID
- Januvia 100mg daily
- Losartan 100mg daily
- HCTZ 25mg daily
- Sertraline 100mg daily
Insomnia is defined as a complaint of difficulty falling or staying asleep which is linked with major distress or impairment in daytime function and occurs despite an adequate opportunity for sleep. Insomnia is a common condition with an about prevalence of 10% in the general population. In most cases, insomnia concurrent with psychiatric or physical conditions, and a symptom of those conditions. Several research studies have demonstrated that there is a strong relationship between mental illness and insomnia. It is a risk factor for major depression, anxiety disorders, substance use disorders, suicidality, hypertension, and diabetes. Because insomnia is related to impairments in quality of life and an increased risk for accidents, falls and injury, it is very crucial that treatment be directed precisely to addressing insomnia (Kaur et, al.,2023).
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- What is your current sleep history?
A good current sleep history is necessary to confirm the diagnosis and establish the best treatment option for a patient with insomnia. This includes sleep/wake schedule, bedtime routine, nocturnal behavior, and daytime dysfunction (AASM, 2014).
2.What is your day/time dysfunction like?
Daytime dysfunction is part of the recognized criteria for insomnia and must be assessed. This involves worsened quality of life, concerns about memory, fatigue, mood, and success at work or school.
3.What is your bedtime routine?
It is critical to have the right environment to ensure appropriate sleep. An individual with true insomnia will not be effectively treated by only providing a dark, quiet environment. The provider to confirm the diagnosis must ensure that poor sleep is not due to environmental issues. Detailed bedtime routine could also emphasize areas for intervention during the treatment plan. For example, cell phone usage is linked with shorter sleep duration (APA, 2013)
People in the patient’s life who can provide feedback to further assess the patient’s situation. Include specific questions you might ask these people and why.
Individuals living with patients such as her children as well as her friends, and co-workers can provide feedback information about the patient.
I will ask people that the patient is living with whether the patient takes nap during the day.
Does the patient nap during the day? If a patient takes a nap during the day, this may be decreasing sleep drive in the night and may also pose a good intervention. If the patient reports a strong tendency to fall asleep during the daytime, this raises concern for another sleep disorder.
What is the patient’s sleep/wake schedule like? A detailed account of the time patient goes to bed, time for sleeping, how often she wakes up at night, time to return to sleep, time for waking up in the morning, and time getting out of bed are required. A large variation may signal a daily rhythm disorder and serve as a target for intervention.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
The information collected during a sleep study is evaluated initially by a polysomnography technologist. The technologist uses the data to chart the patient’s sleep stages and cycles. Thus, the information is reviewed by the sleep center provider. Polysomnograms (PSGs) play a crucial role in systematically evaluating insomnia, and identifying treatable sleep disorders which can reduce morbidity and mortality (Gerstenslager & Slowik, 2022).
Laboratory Workup
The laboratory test can provide supportive data to evaluate the underlying medical conditions that can be correlated with insomnia. The initial laboratory workup should include thyroid function tests, glycosylated hemoglobin, complete blood count, serum iron studies, liver function tests, and renal function tests.
Questionnaires
Self-evaluating questionnaires and assessment scales are helpful to document sleep disturbances and the quality of sleep. The most widely used ones are Epworth Sleepiness Scale (from 0 to 24 with a score of more than 15 indicating severe daytime sleepiness) and Pittsburgh Sleep Quality Index (poor sleep score of greater than 5).
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
Differential diagnosis for the patient with insomnia
- Central sleep apnea
- Cheyne-Stokes breathing pattern.
- Depression
- Medication-related insomnia
- Obstructive sleep apnea (OSA)
- Periodic limb movement disorder
- Sleeplessness and circadian rhythm disorder
The most likely diagnosis for this patient with insomnia is depression. In reference to the case study, a patient who is an elderly widow, 75 years old just lost her spouse presents in the office today complaining of insomnia, and worsening depression. Her past medical history includes DM, HTN, and MDD. It is obvious that the patient exhibiting some symptoms of depression is insomnia. Several research studies have shown that insomnia is a clinical symptom of major depressive disorder (Riemann et, al., 2019).
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.
SSRIs
Citalopram
The starting dose is 20 mg daily, and the usual maintenance dose is 20 to 40 mg daily.
Escitalopram
The starting dose is 5-10 mg daily, and the usual maintenance dose is 10 to 20 mg daily.
Serotonin/Norepinephrine Reuptake inhibitors (SNRIs)
Venlafaxine
Antidepressants should be used cautiously in patients with known hypersensitivities or taking other psychotropic medications. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs), for example, should not be taken with other SSRIs, monoamine oxidase inhibitors,
tricyclic antidepressants, and other psychotropics; this is due to the risk of serotonin syndrome, which can lead to severe neuromuscular and autonomic symptoms.
Providers may find it very useful in monitoring patient’s antidepressant levels. This therapeutic drug monitoring strategy is based on serum or plasma concentrations of antidepressants, which researchers believe is a more reliable index than dosage. Therapeutic drug monitoring of antidepressants is beneficial with agents that have a reliable therapeutic range established (Gutiérrez-Rojas et, al., 2013).
Citalopram is an effective antidepressant when administered in single daily doses of 40 to 60mg orally to patients with major depressive disorder. Several studies have shown that over 4 to 6 weeks citalopram produces noticeable improvement in 30 to 70% of patients, and moderate improvement in another 10 to 50%, using the Hamilton Depression, Montgomery-Asberg Depression Rating. Therapeutic effects can be apparent within 1 week, but the full effects take 4 to 6 weeks to develop. The therapeutic effects of citalopram appear more rapidly than Venlafaxine.
Citalopram is an antidepressant belonging to a new class of drugs which enhance serotoninergic neurotransmission through potent and selective inhibition of serotonin reuptake. its short-term therapeutic efficacy is substantially greater than that of Venlafaxine. Its elimination half-life of 33 hours permits once daily oral administration (Wong et, al., 2020).
Symptomatic improvement is seen with short term therapy and has been maintained when therapy has been extended for up to 1 year. The relapse rate is lower than with Citalopram compared to Venlafaxine. Citalopram is well tolerated. It is not cardiotoxic, not associated with seizures in humans, and is nonsedating. Unlike tricyclic antidepressants, citalopram has minimal anticholinergic effects. Mild nausea, with or without vomiting.
Citalopram offers similar therapeutic efficacy and a more favorable tolerability profile than tricyclic antidepressants (Wong et al., 2020).
Pharmacokinetic properties
Absorption: Pharmacokinetics of escitalopram is linear and dose-proportional in a dose range of 10 to 30 mg/day. Absorption is not affected by the presence of food. The time to attain peak plasma concentration is approximately 5 hours. Steady-state plasma concentrations are achieved within 1-2 weeks.
Distribution: Escitalopram has a high volume of distribution (12 L/kg). Escitalopram has low plasma protein binding (56%) and is not likely to cause interactions with highly protein-bound drugs.
Metabolism: Escitalopram is metabolized in the liver by CYP3A4 and CYP2C19.
Excretion: The terminal half-life of escitalopram varies from 27 to 33 hours. Escitalopram and its metabolites are exerted in the urine.
Escitalopram is administered via the oral route. It is available as a 1 mg/mL oral solution and 5 mg, 10 mg, or 20 mg tablets. It is taken once daily, either with or without food. The typical starting dose for escitalopram is 10 mg. After one week, the dose can be increased to achieve proper symptom control. A 4-week dose reduction is recommended when switching escitalopram from another SSRI (Krystal et, al., 2019).
Patient with Hepatic Impairment: 10 mg per day dose is recommended for patients with hepatic impairment as oral clearance was reduced by 37%, and half-life was doubled in patients with hepatic dysfunction.
Patient with Renal Impairment: No dose adjustment is needed for patients with mild or moderate renal impairment. However, it is recommended to use escitalopram with caution in patients with severe renal impairment (creatinine clearance < 20 mL/min).
Pregnancy Considerations: It is considered pregnancy category C medicine. It is recommended to monitor patients closely and adjust the dose based on individual patient needs, as escitalopram and can cross the placenta and be distributed into the amniotic fluid.
Breastfeeding Considerations: It is recommended to calculate and use a relatively smaller dose of escitalopram; its metabolite is excreted in breast milk. A safety scoring system finds the use of escitalopram possibly compatible with breastfeeding. If the mother requires treatment with escitalopram, it is not a reason to discontinue breast feeding (Grogan & Preuss, 2022).
It is advisable and beneficial to monitor patient’s blood work such as liver function test (LFT), CBC, thyroid stimulating hormone test (TSH). These tests will show the plasma concentration of the drug in the body as well as toxicity.
Trazodone is an antidepressant with a mechanism of action that remains very useful in the treatment of depression. The appropriate antidepressant doses are usually 150-300 mg/day and are often higher than the doses that are used when trazodone is prescribed to augment the antidepressant effect of another medication, for instance when trazodone is prescribed to address insomnia in a patient treated with an SSRI. Trazodone is usually well tolerated and has a low risk of anticholinergic side effects, weight gain and sexual side effects (Cuomo et, al., 2019).
References
American Academy of Sleep Medicine. (2014). International classification of sleep disorders, 3rd ed. Darien: American Academy of Sleep Medicine, 2014
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders, 5th ed. Arlington: American Psychiatric Association, 2013.
Cuomo, A., Ballerini, A., Bruni, A.C., Decina, P., Di Sciascio, G., Fiorentini,A., Scaglione, F., Vampini, C., Fagiolini, A. ( 2019). Clinical Guidance for the use of Trazodone in Major Depressive Disorder and Concomitant Conditions: pharmacology and clinical practice. Riv Psichiatr. 2019 Jul-Aug;54(4):137-149. doi: 10.1708/3202.31796. PMID: 31379379.
Gerstenslager B., Slowik, J.M. (2022). Sleep Study. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan- Available from: https://www.ncbi.nlm.nih.gov/books/NBK563147/
Grogan, S., Preuss, C.V. (2022). Pharmacokinetics. [Updated 2022 Jun 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557744/
Gutiérrez-Rojas, L., Porras-Segovia, A., Dunne, H., Andrade-González, N., Cervilla, J.A. (2020). Prevalence and Correlates of Major Depressive Disorder: a systematic review. Braz J Psychiatry. 2020 Nov-Dec;42(6):657-672. [PMC free article
Links to an external site.] [PubMed
Kaur, H., Spurling, B.C., Bollu, P.C. (2023). Chronic Insomnia. [Updated 2023 Feb 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526136
Krystal, A.D., Prather, A.A., Ashbrook, L.H. (2019). The Assessment and Management of Insomnia: an update. World Psychiatry. 2019 Oct;18(3):337-352. doi: 10.1002/wps.20674. PMID: 31496087; PMCID: PMC6732697.
Riemann, D., Krone, L.B., Wulff, K., Nissen, C. (2019). Sleep, insomnia, and depression. Neuropsychopharmacology. 2020 Jan;45(1):74-89. doi: 10.1038/s41386-019-0411-y. Epub 2019 May 9. PMID: 31071719; PMCID: PMC6879516.
Sheffler ZM, Patel P, Abdijadid S. (2023). Antidepressants. [Updated 2023 Mar 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538182/
Wong, N.M., Findon, J.L., Wichers, R.H., Giampietro, V., Stoencheva, V., Murphy, C.M., Blainey, S., Ecker, C., Murphy, D.G., McAlonan, G.M., Daly, E. (2020). Neuropsychopharmacology. 2020 Dec;45(13):2248-2256. doi: 10.1038/s41386-020-0693-0. Epub 2020 May 10. PMID: 32388538 Free PMC article. Clinical Trial.
Treatment for a Patient With a Common Condition
The case study that is offered shows a 75-year-old widow who complains primarily of sleeplessness. The patient states that the loss of her spouse around 10 months ago has caused her depressive symptoms and sleeping patterns to deteriorate. Before her husband’s death, she denied having a history of depression. The patient admits having had HTN, DM, and MDD in the past. She currently takes Metformin 500 mg BID, Januvia 100 mg daily, Losartan 100 mg daily, HCTZ 25 mg daily, and Sertraline 100 mg daily to treat these conditions. Following a mental health assessment, the patient showed the right sense of person, place, and time. She, though, denies having suicidal thoughts. She mentions that she typically sees her primary care doctor once or twice a year. Her BMI revealed high blood pressure and an obesity-indicating BMI of 34.37. The purpose of this discussion is to evaluate the patient mentioned above and to determine the best course of therapy.
Questions for the Patient
- What brought you here today? The patient can provide as much information as feasible on her health state concerning the symptoms that are now being experienced by answering this open-ended question (Patel et al., 2018).
- Do you use tobacco, alcohol, caffeine, or any other drugs? Examining all potential reasons, such as drug usage, is crucial because sleeplessness is the patient’s primary complaint (Patel et al., 2018). Alcohol, cigarettes, and caffeine are examples of recreational substances that have been linked to an increased risk of sleeplessness.
- What time do you often go to sleep, and how long does it typically take you to go off to sleep? To examine the patient’s sleeping habits and gauge how severe their insomnia is, this inquiry is necessary. The patient’s answer to this question will also influence the course of therapy that is chosen (Patel et al., 2018).
People to Question for Further Assessment of the Patients Situation
For a more thorough assessment of the patient’s state, data from close family members, such as her children, who can characterize the nature of her illness at home, must be gathered. “Does the patient doze off during the day when completing ordinary tasks?” is an example of an inquiry that should be directed to the patient’s children. “Does the patient snore loudly or cease breathing while sleeping?” The first question will assist assess how much the patient’s problem is harming her quality of life, while the second question will help determine connected symptoms caused by the patient’s insomnia (Patel et al., 2018). The patient’s caregiver should also provide information on the patient’s sleeping state and surrounding environment to assess whether they are related to her lack of sleep. “Is the patient’s sleeping environment suitable to sleep in terms of the breath, light temperature, and interruptions?” is an example of a question made to the caregiver.
Physical Exams, and Diagnostic Tests
To develop a clear diagnosis, the examination and evaluation of insomnia rely heavily on the information supplied by the patient. When the origin of the insomnia is unknown, a physical examination is undertaken to determine whether the patient’s symptoms are related to an underlying medical issue (Madari et al., 2021). The physician may need to request a blood test to evaluate whether the patient’s sleeplessness is caused by thyroid issues or another ailment. Diagnostic tests, such as the Hamilton Anxiety Rating Scale (HAM-A) and Hamilton Rating Scale for Depression (HAM-D), are critical in establishing the severity of a patient’s symptoms, particularly when insomnia is linked with anxiety or depression. The findings of this test will aid in choosing the patient’s ideal course of therapy. The severity of the patient’s insomnia and related symptoms will also be assessed using actigraphy, polysomnography, daytime multiple sleep latency testing (MSLT), sleep diaries, and other methods (Abad, & Guilleminault, 2018). Last but not least, genetic testing, such as FFI tests, will assist in the diagnosis by revealing whether the client has a family history of insomnia.
Differential Diagnosis
The three primary differential diagnoses based on the presented patient’s subjective and objective data are generalized anxiety disorder, major depressive disorder (MDD), and post-traumatic stress disorder. MDD is the most likely of the three diagnoses. The patient stated that he had a history of MDD. According to research, sleep regulation issues are linked to depressive episodes that reoccur throughout remission (Madari et al., 2021). Furthermore, the patient notes that she lost her spouse 10 months ago, putting her at significant risk of depression and sleep difficulties. According to the DSM-V, individuals with MDD must have at least five of the following symptoms: sad mood, exhaustion, worthlessness, indecisiveness, sleeplessness, anhedonia, and recurring thoughts of death (Patel et al., 2018). These symptoms must be distressing. The patient acknowledges that her depressive symptoms and sleep difficulties began following her husband’s death, making MDD the most likely diagnosis.
Antidepressant Therapy
Temazepam and Trazodone are the most commonly prescribed antidepressants for the treatment of Insomnia in adults. Temazepam is an FDA-approved benzodiazepine hypnotic for the treatment of adult insomnia. Although 15 mg of the medication should be taken at bedtime, some people may only need 7.5 mg. The medications work by increasing the GABA’s extensive inhibitory action (Bei et al., 2018). The CYP3A4 pathway in the liver is used to break it down. Given its favorable safety profile among senior patients, as well as its shorter half-life and few interactions, this medication is the most suitable option for the patient. Also, the medication is connected to reduced adverse effects and behavioral tolerance. Lastly, unlike trazodone and other antidepressants, the medication is not linked to weight gain.
Trazodone is a serotonin receptor antagonist and reuptake inhibitor (SARI) that is taken orally in split doses of 150 mg and can be titrated at 50 mg intervals for 3 to 4 days. The maximum suggested dose for adults is 600mg per day for inpatients and 400mg per day for outpatients (Flaxer et al., 2021). Trazodone works by blocking serotonin reuptake and antagonizing serotonin actions at the receptor site to provide an antidepressant effect (Madari et al., 2021). The medication is largely metabolized in the liver by CYP3A4 to active metabolites, which are then processed by 2D6, triggering P-glycoprotein. Nevertheless, the medicine has been linked to weight gain, which may exacerbate the patient’s obesity. It also has increased side effects of dizziness and somnolence during the day, making it unsuitable for the patient.
Contraindications and Dose Alterations
Given the client’s advanced age, a first dosage of 7.5mg orally at bedtime is indicated. This dose, however, can be increased at 7.5 mg intervals every 4 weeks to a maximum of 30 mg if the patients demonstrate excellent tolerance and adherence to the medicine. Because the medicine has no adverse effects such as weakness or dizziness, dose modification must be done with extreme caution while monitoring the patient’s vitals. Nevertheless, the medicine is not recommended for pregnant women or individuals who may get pregnant as a consequence of fetal injury and higher chances of congenital deformity (Abad, & Guilleminault, 2018). Yet, the client in the case study offered is 75 years old and not of reproductive age. According to studies, temazepam can make disorders including asthma, COPD, and sleep apnea worse because it impairs lung function. As a result, people with certain diseases should use this medication with care. The client should stop taking the drug and seek medical attention if they experience allergic symptoms including swelling in their face, lips, or tongue.
Follow-Up
Individuals taking temazepam are required to return to the clinic at weeks 4, 8, and 12 for additional evaluation of the therapy’s success. At an initial dose of 7.5mg, the patient is generally expected to have managed symptoms after one week. Nevertheless, if the dose is ineffective, it might be reduced to 15 mg while the patient is constantly monitored (Bei et al., 2018). The same thing repeats in weeks eight and twelve, with a maximum dosage of 30mg. In the event of a bad response or difficulties, the patient’s treatment regimen will be evaluated, and the medicine will be replaced with another antidepressant.
References
Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: recommendations for pharmacological management. Drugs & Aging, 35(9), 791-817. https://doi.org/10.1007/s40266-018-0569-8
Bei, B., Asarnow, L. D., Krystal, A., Edinger, J. D., Buysse, D. J., & Manber, R. (2018). Treating insomnia in depression: Insomnia-related factors predict long-term depression trajectories. Journal of Consulting and clinical psychology, 86(3), 282. https://doi.org/10.1037/ccp0000282
Flaxer, J. M., Heyer, A., & Francois, D. (2021). Evidenced-Based Review and Evaluation of Clinical Significance: Nonpharmacological and Pharmacological Treatment of Insomnia in the Elderly. The American Journal of Geriatric Psychiatry, 29(6), 585–603. https://doi.org/10.1016/j.jagp.2020.10.011
Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological management of insomnia. Neurotherapeutics, 1-9. https://doi.org/10.1007/s13311-021-01010-z
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024. DOI: 10.1002/wps.20674.
Thank you for your post. I appreciate how you have begun your discussion by providing a succinct introduction to insomnia, highlighting its various manifestations and its impact on the patient. The questions you have asked the patient are suitable for better understanding their mental health issue. I want to emphasize that the patient’s history is the most crucial component of the examination for insomnia. The report should thoroughly assess the individual’s sleep history, medical background, psychiatric background, social background, and review of medications. It is worth mentioning that conducting a physical examination, including a head and neck examination, can be beneficial as it may reveal indications of underlying medical conditions that contribute to insomnia. Prior to initiating therapy, it is customary for patients to maintain a sleep log for 2-4 weeks, as suggested by Riemann et al. (2019).
I concur with your decision that trazodone and Temazepam were appropriate medications for this patient’s insomnia, considering their association with depression. The FDA approves Trazodone for the treatment of depression, although it is not typically the initial medication of choice. The medication is usually administered orally, often requiring multiple daily doses. Trazodone is occasionally prescribed off-label for insomnia (Zheng et al., 2022). In contrast, Temazepam is classified as a benzodiazepine medication. This substance has a tranquillizing impact on the central nervous system. The drugs are typically prescribed for brief treatment periods, usually lasting 1 to 2 weeks or less (Lou & Oks, 2021). If the patient’s insomnia persists, advising them to consult their doctor for further evaluation and potential alternative treatment options is crucial.
References
Lou, B., & Oks, M. (2021). Insomnia. Clinics in Geriatric Medicine, 37(3), 401–415. https://doi.org/10.1016/j.cger.2021.04.003
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2019). Sleep, insomnia, and depression. Neuropsychopharmacology, 45(1), 74–89. https://doi.org/10.1038/s41386-019-0411-y
Zheng, Y., Tian, L., Wu, J., & Lyu, Y. (2022). Trazodone changed the polysomnographic sleep architecture in insomnia disorder: a systematic review and meta-analysis. Scientific Reports, 12(1). https://doi.org/10.1038/s41598-022-18776-7