Treatment for a Patient With a Common Condition
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 sympto
Treatment for a Patient With a Common Condition
ms, 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.