For patient who is an elderly widow, the three questions l would ask her is if her health history of DM, HTN, MDD affects her sleep. I would also ask her if she is still grieving and it affects her getting rest. Also, l would ask patient if she sleeps in an area with bright light, might need a cooler room to allow for sleep.
In identifying people to speak to for feedback in her life, I would speak to family members or children if she has any present. I could speak to them by telehealth or by phone.
For patient, I would recommend some cognitive behavioral therapy, test her TSH level to ensure it is not hormonal he clinical diagnosis of insomnia is based on the complaint of trouble falling asleep, trouble staying asleep, or early morning awakening, and resultant daytime dysfunction This daytime dysfunction can manifest in a wide range of ways, including fatigue, malaise; impairment in attention, concentration or memory; impaired social, family, occupational or academic performance; mood disturbance, irritability, sleepiness, hyperactivity, impulsivity, aggression, reduced motivation, proneness for errors, and concerns about or dissatisfaction with sleep (Krystal et al., 2019).
I would recommend Trazodone 50 mg and Prozac 10mg for patient since she states she has depression and poor sleep habit. Since she denies any suicidal ideations, she will be okay with taking a depressant as well. Her weight is 88 kg, it plays a factor in the reason for selecting the reduced dosage.
I would recommend for patient to follow up in about 4 weeks to check for any therapeutic changes. I would also encourage her to get some deep breathing and relaxation exercises to further help with sleep. Insomnia can be treated without medications, using sleep hygiene combined with cognitive and behavioral therapies (CBT). This approach avoids potential drug side effects and toxicities and has shown long-term persistence in treating chronic insomnia that can be superior to results obtained using drug therapies. Sleep hygiene refers to environmental factors, dietary approaches, drugs, and a lack of required sleep facilitating approaches that can induce insomnia (Pagel, 2018).
References
Krystal AD, Prather AA, Ashbrook LH. The assessment and management of insomnia: an update. World Psychiatry. 2019 Oct;18(3):337-352.
Pagel, J.F., Pandi-Perumal, S.R. & Monti, J.M. Treating insomnia with medications. Sleep Science Practice 2 , 5 (2018).
Sample Answer 2 for 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
BP: 132/86
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 w
NURS 6630 Discussion Treatment for a Patient With a Common Condition ith 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
Insomnia
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.
References
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 Click here to ORDER an A++ paper from our MASTERS and DOCTORATE WRITERS: NURS 6630 Discussion: Treatment for a Patient With a Common Condition
Sample Answer 3 for NURS 6630 Discussion: Treatment for a Patient With a Common Condition 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.)
References
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
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Sample Answer 4 for NURS 6630 Discussion: Treatment for a Patient With a Common Condition
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)
Sample Answer 5 for NURS 6630 Discussion: Treatment for a Patient With a Common Condition 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
Sample Answer 6 for NURS 6630 Discussion: Treatment for a Patient With a Common Condition
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/
Sample Answer 7 for NURS 6630 Discussion: Treatment for a Patient With a Common Condition I am using the Geriatric Depression Scale (GDS). This would help determine the severity of the patient’s symptoms by revealing how much worse their GDS score is. Although the patient’s current medication regimen, Zoloft 100 mg daily, and medical history both point to a diagnosis of major depressive disorder. The instrument takes about seven minutes to complete, which is suitable for reassessing Depression (Bains, 2020).
Questions for the Patient:
How has your daily routine changed since your husband’s passing, and are there specific activities that have become more challenging or less enjoyable?
This question helps assess the impact of grief on her daily functioning and provides insights into potential depressive symptoms.
Can you describe any changes in your appetite, weight, or energy levels since your husband’s death?
This question aims to explore additional symptoms related to depression and assess the overall impact on her physical health.
Have you had any recent thoughts or feelings that life is not worth living or that you would be better off dead?
While the patient denies suicidal ideations initially, regularly checking for mood changes is crucial, as depressive symptoms can evolve.
People to Speak to:
How has the patient been coping since her husband’s passing? Have you noticed any changes in her mood, behavior, or daily activities?”
External perspectives can provide valuable information about the patient’s emotional state and daily functioning.
Patient’s offspring or close family member:
Has the patient reported side effects or concerns related to the patient’s current medications?”
Ensuring medication adherence and addressing any potential drug-related issues is crucial, considering the patient’s multiple medications.
Physical Exams and Diagnostic Tests:
Assessment of psychomotor activity, facial expressions, and overall appearance for signs of depression.
Rationale: Physical signs may contribute to the clinical diagnosis of depression and guide treatment planning.
Thyroid function tests and metabolic panel.
Rationale: To rule out medical conditions (hypothyroidism, metabolic disturbances) that may contribute to or mimic depressive symptoms.
Differential Diagnosis:
Major Depressive Disorder: The patient’s symptoms, history, and duration point to the likelihood that she is suffering from MDD. The bereavement exclusion criterion supports the diagnosis because the symptoms have persisted beyond the expected mourning period.
Antidepressant Therapy:
Selective Serotonin Reuptake Inhibitor (SSRI): Escitalopram 10mg daily.
Rationale: Escitalopram has a favorable side effect profile and is well-tolerated in older adults. Its potency as an SSRI makes it a suitable choice.
Serotonin-Norepinephrine Reuptake Inhibitor (SNRI): Duloxetine 30mg daily.
Rationale: Duloxetine, with its dual neurotransmitter modulation, can be considered if there is a lack of response or tolerance to SSRIs (Karrouri et al., 2021; Dhaliwal, 2023)
Contraindications or Alterations:
Escitalopram: Caution with concurrent use of certain antihypertensive medications due to potential interactions; regular blood pressure monitoring is essential.
Duloxetine: Monitor for potential interactions with the patient’s current medications, especially those affecting blood pressure and blood glucose levels. (Karrouri et al., 2021; Dhaliwal, 2023)
Follow-up and Therapeutic Changes:
Week 4: Assess for early response and side effects. Consider adjusting the dose if needed.
Week 8: Reevaluate the patient’s progress. If there’s an inadequate improvement, consider dose adjustments or transitioning to a different antidepressant class.
Week 12: Continue monitoring for efficacy and tolerability. If necessary, explore psychotherapy options. Consider consultation with a mental health specialist for further recommendations.
References Bains, N. (2020) Major Depressive Disorder. https://www.ncbi.nlm.nih.gov/books/NBK559078
Dhaliwal, J. S. (2023). Duloxetine . StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK549806
Karrouri R, Hammani Z, Benjelloun R, & Otheman Y. (2021). Major depressive disorder: Validated treatments and future challenges. World J Clin Cases. Nov 6;9(31):9350-9367. Doi: 10.12998/wjcc.v9.i31.9350. PMID: 34877271; PMCID: PMC8610877.
