Discussion: Treatment for a Patient With a Common Condition Essay

Discussion: Treatment for a Patient With a Common Condition Essay

Patient Assessment

Insomnia is a common complaint among the adult population with predisposing, precipitating, and perpetuating factors increasing the likeliness of occurrence for many individuals. The factors that are likely contributing to insomnia in this patient includes being a woman older than 45, having recently lost her spouse, and a recent diagnosis of depression (Patel et al., 2018, pg. 1018). This patient reports worsening depression since her husband passed away 10 months ago, so I would follow-up with specific questions regarding to the onset of her depressive symptoms and what, if any, grief counseling she received. To further assess the worsening of her sleep habits that negatively impact sleep quality, I would ask her the following open-ended questions:

• How often do you take naps?
• How much alcohol or caffeine do you have throughout the day, particularly in the evening?
• What type of stimulating activities does the patient partake in prior to bed, such as watching TV or using the computer/phone?
• Discussion: Treatment for a Patient With a Common Condition
• What type of activities are you involved in throughout the day?

These questions would give insight into possible nonpharmacological remedies that would promote better sleep quality. If the patient is excessively sleeping throughout the day, falling asleep in front of the TV, or having caffeine in the evening then changing these behaviors can help improve sleep quality. Relaxation techniques such as meditation and paced diaphragmatic breathing are sleep promoting activities that can be used to replace some of the patient’s poor sleep habits (Patel et al., 2018, pg. 1018-1020).

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Collaboration

It is important to maintain privacy standards when gathering information about a patient to ensure HIPAA laws are not violated. However, if the patient allows accompanying family members, or caregivers, to provide their input they could help ensure a thorough clinical history is obtained, especially for the patient’s sleep problems and depression (Patel et al., 2018, pg. 1019). As the patient’s depressive symptoms and difficulty sleeping worsened after the death of her husband, I would ask family members, or caregivers, the following questions:

1. 1. What type of mood changes have they seen in the past 10 months since the patient’s husband passed away?
   2. Has the patient expressed difficulty accepting her husband’s death?
   3. How often does the patient avoid, or excessively bring up, her deceased husband?
   4. Discussion: Treatment for a Patient With a Common Condition

I would ask these questions to assess the patient for signs that she is having difficulty grieving her husband’s death. If symptoms such as inability to accept her husband’s death, decreased social activities, intense emotional pain, and the absence of positive mood have persisted longer than 6 months then the patient may be suffering from a complicated grief disorder (Szuhany et al., 2020, pg. 2).

Diagnostic Tests and Exams

A comprehensive examination should include a detailed sleep history. Laboratory data, questionnaires, and sleep logs can be used to rule out sleep-related disorders or to reveal medical conditions that may impact the patient’s sleep. Discussion: Treatment for a Patient With a Common Condition Sleep diaries are useful to measure the amounts of sleep the patient gets, circadian rhythm disturbances, and unhealthy sleep hygiene behaviors. There are multiple self-reported questionnaires designed for different purposes such as measuring quality of sleep, as with the Pittsburgh Sleep Quality Index, or how sleepy an individual is throughout the day, such as the Epworth Sleepiness scale (Bollu & Kaur, 2019, pg. 71) Discussion: Treatment for a Patient With a Common Condition. It is also important to review the patient’s past medical history and current medications to reduce the risk of drug-drug interactions (Neubauer et al., 2018, pg. 2). Patient records from any prescribing providers should be requested and an opportunity to communicate potential medication changes should be attempted.

Differential Diagnosis

A differential diagnosis I would consider is prolonged grief disorder (PGD), or complicated grief, depending on the results of the patient’s response to questionnaires and input from her family or caregivers. PGD is characterized by difficulty adapting after the death of a loved that results in impairments. PGD symptoms last longer than 6 months (Szuhany et al., 2020, pg. 2). In this case study scenario, the patient appears to have some difficulty coping with her husband’s death for the past 10 months. Research has shown complicated grief to negatively impact sleep quality, however, psychological interventions targeting grief and appropriate pharmacological treatment has been shown to enhance sleep quality (Szuhany et al., 2020, pg. 7) Discussion: Treatment for a Patient With a Common Condition.

Antidepressant Therapy

Studies have shown that some types of antidepressant medications may disrupt sleep while others may improve sleep. Selective serotonin reuptake inhibitors (SSRIs) are linked to reports of daytime somnolence and treatment emergent insomnia. Sedative antidepressants are often used to address depressive symptoms and insomnia in patients with depressive disorders (Wichniak et al., 2017, pg. 4). Doxepin, a tricyclic antidepressant (TCA), is an H-1 receptor antagonist that is FDA-approved for insomnia, but only when used in low doses of 3-6mg. The antidepressant effects of doxepin occur at higher doses between 25-300mg. I would consider replacing the patient’s current depression medication with a low dose of doxepin, after an appropriate taper-down of her current SSRI, sertraline. If the patient tolerates doxepin well at the low dose for insomnia, I would increase the dose to 25mg to treat her depressive symptoms (Bollu & Kaur, 2019, pg. 73).

Trazodone blocks serotonin 5-HT2a receptors while acting as an agonist to serotonin 5HT2c receptors. With the addition of being a weak serotonin inhibitor reuptake, the net result is the accumulation of extracellular serotonin in the brain. This increases the risk of serotonin syndrome with the use of trazodone (Stern et al., 2016, pg. 29). Patel et al. (2018) warns against the use of trazodone in the elderly population due to adverse effects such as dizziness and cardiac arrhythmias. Doxepin, on the other hand, is FDA approved for insomnia and is shown to improve sleep onset, duration, and quality (pg. 1021).

References

Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri medicine, 116(1), 68–75.

Neubauer, D. N., Pandi-Perumal, S. R., Spence, D. W., Buttoo, K., & Monti, J. M. (2018). Pharmacotherapy of Insomnia. Journal of Central Nervous System Disease. https://doi.org/10.1177/1179573518770672

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172

Stern, T. A., Favo, M., Wilens, T. E., & Rosenbaum, J. F. (2016). Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.

Szuhany, K. L., Young, A., Mauro, C., Garcia de la Garza, A., Spandorfer, J., Lubin, R., Skritskaya, N. A., Hoeppner, S. S., Li, M., Pace-Schott, E., Zisook, S., Reynolds, C. F., Shear, M. K., & Simon, N. M. (2020). Impact of sleep on complicated grief severity and outcomes. Depression and anxiety, 37(1), 73–80. https://doi.org/10.1002/da.22929

 

Discussion: Treatment for a Patient With a Common Condition Response

Thank you for your informative post. You have provided a different approach in patient interviewing. The patient complained of symptoms of Insomnia. I originally believed that the insomnia was caused by her difficulty with the loss of her husband. I did not include assessment questions for poor sleep quality, such as caffeine intake, how many hours of sleep, or daytime functioning and activities. Sleep disturbances can be cause by excessive caffeine intake, alcohol use, substance abuse, and other medications. (Shultz & Videbeck, 2013). My thought process was that if the clinician can fix what is causing the depressive symptoms, the insomnia could resolve as well. It is theorized that insomnia is precursor to worsening depression and usually a sign that medications are not effective. (Manzar et al., 2021).

I agree that the family should be incorporated into treatment planning with the patient’s consent. Information from the family can be valuable because more than likely, the have seen the patient at their worst and best. The patient may be too acute for expression of feelings or may be in denial of certain symptoms that the family may observe.

RCTs have shown that low dose Doxepin can have sedative effects by blocking histamine receptors. (Yeung et al., 2015). However, studies show that TCAs can impair cognition and increase risk of delirium in the elderly. (Yeung et al., 2015). Although, it is prescribed at low doses, increasing the medication may develop these effects Discussion: Treatment for a Patient With a Common Condition.

 

References

Shultz, J. M., Videback, S. L. (2013). Lippincott’s manual of psychiatric nursing care plans 9^th ed. sleep disorders. https://dl.uswr.ac.ir/bitstream/Hannan/138867/1/9781609136949.pdf

Manzar, M. D., Jahrami, H. A., & Bahammam, A. S. (2021). Structural validity of the Insomnia Severity Index: A systematic review and meta-analysis. Sleep Medicine Reviews, 60. https://doi.org/10.1016/j.smrv.2021.101531

Yeung, W.-F., Chung, K.-F., Yung, K.-P., & Ng, T. H.-Y. (2015). Doxepin for insomnia: A systematic review of randomized placebo-controlled trials. Sleep Medicine Reviews, 19, 75–83. https://doi.org/10.1016/j.smrv.2014.06.001 Discussion: Treatment for a Patient With a Common Condition

 

 

Discussion: Treatment for a Patient With a Common Condition sample post 2

• 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 time do you go to sleep/how many hours do you sleep at night?
    • This is to note a lack of sleep. When elderly patients don’t get the recommended hours of sleep (5-7 hours a night), this can lead to medical and psychiatric effects (Patel et al., 2019).
  • Are you taking your medication regularly like you’re supposed to?
    • Many times patients with depression may not take their medications at the correct time or even may skip taking the medication completely. It is important to ask this just to rule out her symptoms occurring because of an irregular drug schedule.
  • Do you have family or friend support?
    • Patients without any strong support in their life whether it be in the form of family, friends, neighbors, or someone else may have increased depression. This can lead to extra worries and from there, insomnia.
• 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. 
  • Children
    • What differences have you noticed in her day-to-day schedule?
    • Do you notice a difference in her sleeping pattern or schedule?
    • How many meals does she consume a day?
  • Friends
    • Has she been in regular communication with you?
    • Have you notice a difference in her?
  • Relatives
    • Has she been in regular communication with you?
    • Do you have any concerns you would like to discuss about her privately?
  • Driver
    • Has she asked for drives often or does she stay to herself at her home?
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. 
  • Sleep study/diary
    • Allows practitioner to look at sleeping patterns
  • Mini Mental State Exam (MMSE)
    • Look at any cognitive impairment
  • Geriatric Depression Scale (GSD)
    • Look at any cognitive impairment and help assess where her depression stands currently
  • Blood work (??)
    • Change in certain levels
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 
  • Insomnia
  • Recurrent depression
• 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. 
  • Trazodone, 15mg HS. This treats depression and insomnia.
  • Mirtazapine, 15mg HS. This treats depression, insomnia, and helps in stimulating appetite. I would pick this one over Trazodone because this could help stimulate her appetite if she lacks one.

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• 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?
  • Mirtazapine, 15mg HS. Mirtazapine off-label is used to treat insomnia and appetite stimulant with the FDA approval for depression. Patients with high cholesterol and on MOAs should let their practitioner know before start this drug. The black box warning includes paradoxically causing depression and anxiety and in worst cases lead to suicidal idealationlation. Medications such as Mirtazapine and other anti-depressants also have a black box warning of increased mortality in the elderly (Crock et al., 2017).
• 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. 
  • The patient would come back every 4 weeks to determine if this treatment is right for her. A change in the medication (with the correct tapering) is dependent on any changes in symptoms.

References:

Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological Management of Anxiety Disorders in the Elderly. Current treatment options in psychiatry, 4(1), 33–46. https://doi.org/10.1007/s40501-017-0102-4

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172

Discussion: Treatment for a Patient With a Common Condition

Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being. Discussion: Treatment for a Patient With a Common Condition

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Discussion: Treatment for a Patient With a Common Condition sample post 3

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. 

1. Did you start on the sertraline?
2. Have you made any adjustment on your medications?
3. What do you do before trying to go to sleep?

It is essential to ask the patient if she started on sertraline and if she has adjusted her current medications to establish if it is necessary to increase her current medication. It is also vital to understand activities that the patient engages in before going to sleep to educate the patient on the importance of relaxing exercises. Özkan and Rathfisch (2018) mentioned that relaxing exercises before going to bed reduce the risks of heart attack and prevent depression.

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 Discussion: Treatment for a Patient With a Common Condition. 

Individuals who would help provide patient assessment information are her adult children, especially those who are close to her or involved in her care. Specific questions I might ask include:

1. Does anyone in your family have a history of insomnia?
2. Have you noticed any recent changes in your mother’s mood?
3. What are your concerns or suggestions regarding your mother’s care?

It is crucial to understand the patient’s family medical history to establish if insomnia might be associated with genetic disorders. It is essential to engage the family members to understand the patient’s family history, including the risks of developing various diseases (Jazieh et al., 2018).

Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.

            A complete blood count test would be necessary to check for disorders, such as thyroid disease and low iron levels, and provide for baseline values if her primary care provider did not capture them. A basic metabolic panel (BMP) test would help provide information regarding the patient’s body’s metabolic and chemical balance. I would also assess her heart, lungs, and neck to identify risks associated with sleep apnea, including a large neck. Another instrument for assessing the patient is the Hamilton Depression Rating Scale to identify if her current medication has helped lower her MDD.

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why. 

The differential diagnosis for the patient includes anxiety disorders, depression, and bipolar disorder. Thus, the most likely diagnosis for the patient includes depression. Her husband died ten months ago, and she might still be grieving his death, causing depression. Insomnia is a common sign of depression (Fang et al., 2019) Discussion: Treatment for a Patient With a Common Condition.

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. 

It is vital to start by prescribing selective serotonin reuptake inhibitors (SSRIs) for patients with depressive symptoms (Jakobsen et al., 2017). Thus, I would maintain the current dose of sertraline 100mg daily and add Lexapro 10mg orally daily to help address depressive symptoms. I would also add melatonin 6mg to help improve insomnia. Sertraline helps improve serotoninergic transmission and exhibits half-life elimination, which is suitable for once-daily administration (Lewis et al., 2019). On the other hand, Lexapro is associated with increased nervousness, restlessness, and insomnia, worsening the patient’s experience of having trouble sleeping.

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?

            Contraindications for melatonin include renal and hepatic dosing. Clinicians must be cautious with dialysis patients because it would be difficult to clear melatonin, increasing adverse effects (Posadzki et al., 2018). Furthermore, the metabolism of melatonin would be slow in patients with impaired liver functioning (Posadzki et al., 2018). Therefore, it is crucial to assess the patient’s liver and renal functioning before prescribing melatonin to avoid adverse effects.

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. 

            I would require the patient to report to the office after four weeks. Still, I would check the patient weekly through telehealth or phone calls. I expect an improvement in her depressive symptoms, including insomnia, after four weeks. The patient would keep a sleep log and document hours of sleep and sleep quality. I would also monitor the adverse reactions associated with the prescribed medications.

 

References

Fang, H., Tu, S., Sheng, J., & Shao, A. (2019). Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms and treatment. Journal of Cellular and Molecular Medicine, 23(4), 2324–2332. https://doi.org/10.1111/jcmm.14170

Jakobsen, J. C., Katakam, K. K., Schou, A., Hellmuth, S. G., Stallknecht, S. E., Leth-Møller, K., Iversen, M., Banke, M. B., Petersen, I. J., Klingenberg, S. L., Krogh, J., Ebert, S. E., Timm, A., Lindschou, J., & Gluud, C. (2017). Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and trial sequential analysis. BMC Psychiatry, 17(1). https://doi.org/10.1186/s12888-016-1173-2

Jazieh, A. R., Volker, S., & Taher, S. (2018). Involving the family in patient care: A culturally tailored communication model. Global Journal on Quality and Safety in Healthcare, 1(2), 33–37. https://doi.org/10.4103/jqsh.jqsh_3_18

Lewis, G., Duffy, L., Ades, A., Amos, R., Araya, R., Brabyn, S., Button, K. S., Churchill, R., Derrick, C., Dowrick, C., Gilbody, S., Fawsitt, C., Hollingworth, W., Jones, V., Kendrick, T., Kessler, D., Kounali, D., Khan, N., Lanham, P., . . . Lewis, G. (2019). The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): A pragmatic, double-blind, placebo-controlled randomised trial. The Lancet Psychiatry, 6(11), 903–914. https://doi.org/10.1016/s2215-0366(19)30366-9

Özkan, S. A., & Rathfisch, G. (2018). The effect of relaxation exercises on sleep quality in pregnant women in the third trimester: A randomized controlled trial. Complementary Therapies in Clinical Practice, 32, 79–84. https://doi.org/10.1016/j.ctcp.2018.05.008

Posadzki, P. P., Bajpai, R., Kyaw, B. M., Roberts, N. J., Brzezinski, A., Christopoulos, G. I., Divakar, U., Bajpai, S., Soljak, M., Dunleavy, G., Jarbrink, K., Nang, E. E. K., Soh, C. K., & Car, J. (2018). Melatonin and health: An umbrella review of health outcomes and biological mechanisms of action. BMC Medicine, 16(1). https://doi.org/10.1186/s12916-017-1000-8   Discussion: Treatment for a Patient With a Common Condition