Respond to at least two of your colleagues in one of the following ways:
If your colleagues posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Read a selection of your colleagues responses and respond to at least two of your colleagues. Use a minimum of 2 CURRENT scholarly resources. Write in APA Format. Please see attached the original case study/questions and my original post.
1) Post by ROS OKOR
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with the chief complaint of insomnia. The 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 before her husbands death. She is awake, alert, and oriented x3. Patients normally see PCP once or twice a year. The patient denies any suicidal ideations. The patient arrived at the office today by private vehicle. The 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.
How often do you have trouble sleeping and how long has the problem lasted?
According to Basit, Damhoff, and Huecker, (2023), proper sleep is vital to maintain health and optimize overall functioning during periods of wakefulness. Sleeplessness has been linked with several health problems, such as diabetes, obesity, and heart disease. It is also linked to decreased work performance, traffic accidents, mood and relationship problems, and countless other issues. Already the patient has stressors such as current medical issues, depression, and recently lost her husband of 41 years. so, knowing how long she has had insomnia will help to plan her care.
What are your sleep habits? And when do you go to sleep, wake up, and take naps each day?
Brown (2021) states that optimal sleep enhances cognitive function, emotional well-being, and overall physical well-being. Consistently experiencing insufficient high-quality sleep significantly increases the likelihood of developing many diseases and disorders. These encompass a variety of health conditions, including cardiovascular illness, cerebrovascular accident, excessive body weight, and cognitive decline.
Do you use alcohol, tobacco, caffeine, or any other substances?
These substances are stimulants that promote wakefulness. The effects of caffeine can persist for a duration of 6-8 hours before totally dissipating (Brown, 2021). According to the National Institute of Health (2014) combining alcohol with some drugs can result in symptoms such as nausea, vomiting, headaches, sleepiness, fainting, or impaired coordination. Additionally, it can expose one to the potential hazards of internal hemorrhaging, cardiac complications, and respiratory impairments. Furthermore, alcohol has the potential to diminish the efficacy of medication, rendering it ineffective, or it may render the medication detrimental or poisonous to the body.
Elderly individuals are more susceptible to detrimental interactions between alcohol and medication. The process of aging diminishes the body’s capacity to metabolize alcohol, resulting in a prolonged presence of alcohol in an individual’s system. Elderly individuals are also more prone to consuming prescriptions that have a potential interaction with alcohol (NIH, 2014).
Identify people in the patients life you would need to speak to or get feedback from to further assess the patients situation. Include specific questions you might ask these people and why.
From the case study, nothing was said about other relatives such as children except for the deceased husband. So the person to ask further questions is her PCP. With the increasing complexity of medicine, it is important to incorporate the guidance and specialized knowledge of a healthcare team, rather than relying solely on one individual. Nursing practitioners and doctors collaborate closely in both office and hospital settings to deliver comprehensive care and they assist one another in providing excellent care (Starling Physicians, 2021). If there were family members, I would reach out to them equally and ask questions about the patients adherence to medications and if she is poly-medicating outside of prescribed medications.
Knowing this, I will ask the patients primary care physician how long he/she has been seeing the patient, how long she has been on Sertraline, if she is adhering to her treatment plan, taking her medications, keeping appointments, and following up with her labs. I will also ask if the patient is reporting any side effects from her medications.
Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
According to Bedosky, (2023), to diagnose insomnia, the healthcare professional will gather the patients medical history and request specific information regarding the patients sleep patterns. The patient should consider maintaining a sleep journal for a duration of one to two weeks and thereafter sharing the collected data with your healthcare provider. The patient should record her daily sleep schedule, including bedtime, wake-up time, and nap times. Furthermore, observe the level of drowsiness experienced throughout the day after consuming caffeine or alcohol, as well as during physical activity.
In addition, a physical examination should be conducted to see whether any other medical conditions are impacting the patients sleep.
Diagnostic tests may include:
A sleep study is conducted to assess the presence of additional sleep disorders, including circadian rhythm disorders (commonly referred to as sleep-wake cycle disorders), sleep apnea (characterized by intermittent cessation of breathing during sleep), and narcolepsy (a condition characterized by excessive daytime sleepiness).
Actigraphy is a method that monitors and records periods of rest and activity, providing a measure of sleep quality.
Hematological analysis: A hematological analysis is conducted to detect thyroid disorders or other medical ailments that may impact sleep. CBC is done to know her AIC level.
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
Basit, et al (2023) listed differentials for the patient as follows:
Post-traumatic stress disorder (PTSD) may arise following an intensely stressful, terrifying, or disturbing incident, or because of enduring a sustained traumatic encounter. Types of events that can lead to PTSD include serious health problems and the death of someone close to you. Risk factors include a history of depression or anxiety or do not receive support from family and friends. The case in point lost her husband of 41 years, now a widow, with no mention of loved ones or friends in the picture. She also has medical health problems, depression, and sleeping disturbances. The symptoms of PTSD include persistently re-experiencing the traumatic event, intrusive thoughts, nightmares, flashbacks, dissociation (detachment from oneself or reality), and intense negative emotional (sadness, guilt) and physiological reactions on being exposed to the traumatic reminder. There are also problems with sleep and concentration, irritability, increased reactivity, increased startle response, hypervigilance, and avoidance of traumatic triggers also occur (Mann, and Marwaha (2023).
List two pharmacologic agents and their dosing that would be appropriate for the patients 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.
I think Sertraline and Trazodone would be appropriate for the following reasons: Crocco, Jaramillo, Cruz-Ortiz, & and Camfield, (2017) wrote that antidepressants are the first-line treatment for anxiety disorders. The selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are more commonly used in the elderly, due to their tolerability and safety profile in this population.
Crocco, et al (2017) stated that Sertraline (Zoloft) FDA indication for anxiety is used for panic disorder, social anxiety disorder, obsessive-compulsive disorder (OCD), and Post-traumatic stress disorder (PTSD). Starting dose is 12.525 mg/day, Titration is increased by 12.525 mg every 23 days as tolerated to a target dose of 25200 mg/day. Side effects include Headache, somnolence, insomnia, diaphoresis, diarrhea, and sexual dysfunction. The patient has been on Sertraline 100 mg, so the addition of Trazodone may help improve her sleep.
Stahl, (2021) stated that Trazodone is approved by the FDA for depression, insomnia, and anxiety. Insomnia’s initial dose is 25-50 mg at bedtime, increased as tolerated usually to 50-100 mg/ day. Trazodone is also used as an augmentation of another depressant in the treatment of depression, dose as recommended for insomnia. For the mechanism of action, Shin, and Saadabadi, (2022) wrote that Trazodone reduces levels of neurotransmitters associated with arousal effects, such as serotonin, noradrenaline, dopamine, acetylcholine, and histamine. Low-dose trazodone use exerts a sedative effect for sleep through antagonism of the 5-HT-2A receptor, H1 receptor, and alpha-1-adrenergic receptors.
Trazodone is chosen because it primarily targets symptoms of depression, anxiety, and sleep disturbance (StahI, 2021). According to Shin and Saadabadi (2022), if the initial usage of selective serotonin reuptake inhibitors (SSRIs) does not demonstrate effectiveness, Trazodone has been employed as an alternative treatment for post-traumatic stress disorder (PTSD). Studies involving patients with PTSD have shown that a dosage of 50 mg to 200 mg of trazodone effectively reduces the frequency of nightmares and improves sleep patterns.
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?
Shin and Saadabadi (2022) noted that Trazodone therapy requires careful consideration for patients treated with any class of monoamine oxidase inhibitors (MAOIs), including linezolid or intravenous methylene blue.
Mayo Clinic.com, (2024) warned that Trazodone may cause a serious condition called serotonin syndrome if taken together with some medicines. Do not use trazodone with buspirone, fentanyl, lithium, tryptophan, St. John’s wort, or some pain or migraine medicines (e.g., sumatriptan, tramadol, etc.).
Therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
The patient may be reassessed after 4 weeks, 8 weeks, and 12 weeks intervals to know the effectiveness of the therapy instituted. If the medications are not working well, the patient may be encouraged to undergo psychotherapy. According to Mann, and Marwaha, (2023), trauma-focused psychotherapy is the primary and successful treatment for both adults and children. It encompasses several approaches such as trauma-focused cognitive-behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), cognitive processing therapy, and imaginal exposure. Research has demonstrated that symptoms of post-traumatic stress disorder (PTSD) experienced during the daytime exhibit improvement following just one session of cognitive-behavioral therapy (CBT). The therapy has demonstrated efficacy in reducing the duration of recovery.
2) Post by Trac Falliven
Treatment for a Patient with a Common Condition
According to the International Classification of Sleep Disorders (ICSD-3), insomnia can be defined as difficulty falling asleep or difficulty maintaining sleep (Patel et al. 2018). Insomnia in the elderly population is extremely common, affecting up to 50% of older individuals (Patel et al., 2018). In a study performed on patients aged 65 and older, it showed that 93% of these patients had one or more accompanying conditions such as depression (common), medication use, cancer, or chronic pain, to name a few (Patel et al., 2018). Moreover, according to Mookerjee et al. (2023), insomnia and depression are interrelated as insomnia-related symptoms were present in 80-90% of patients with major depressive disorder. Insomnia is linked to various adverse health conditions and can negatively impact overall quality of life. When evaluating for insomnia in elderly patients, it is crucial to perform a thorough history and physical.
Case Study
A recently widowed 75-year-old woman presents to you with complaints of insomnia. She states that her husband of 41 years passed away ten months ago. Since then, her symptoms of depression have worsened along with changes in her sleep pattern. She has a past medical history of diabetes mellitus, hypertension, and major depressive disorder (MDD). However, before her husbands death, she had no previous episodes of depression. She is awake, alert, and oriented. She denies any thoughts of self-harm or suicide. The patient sees her primary care physician once or twice yearly. She arrived today via private transportation. The patient is taking the following medication: Metformin 500mg twice daily, Januvia 100mg daily, Losartan 100mg daily, HCTZ 25mg daily, and Sertraline 100mg daily. Current weight is 88kg (194lbs), Height: 64 inches (53), BMI: 34.4, Temperature: 98.6 F, BP: 132/86
Important Questions to Address
As a psychiatric mental health nurse practitioner (PMHNP), it is crucial to perform a thorough history and physical when diagnosing and treating your patients. In this case, the following questions should provide more information regarding the patients recent complaints of insomnia.
How long have you been taking Sertraline? And what time of day do you take it? The rationale behind this question is that the onset of therapeutic action is usually delayed two to four weeks or more (Stahl, 2021b). If she started taking Sertraline recently (e.g., within the past week or so) she should wait longer to see if it is effective. In addition, side effects of sertraline include insomnia. She should be taking it in the morning to help reduce that effect.
What other symptoms of depression are you experiencing? The rationale behind this question is that to diagnose the patient with a major depressive episode, the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) states that either depressed mood or loss of interest must be present along with four other symptoms such as sleep disturbances, fatigue, weight changes, agitation, to name a few (Stahl, 2021a).
Is there a family history of mental health disorders? It would be important to ask this question as mental health disorders are often hereditary. For example, according to Streit et al. (2023), studies have shown that depression has a significant genetic component, with a rate of around 40%.
Further, to help further assess the patients situation, people that would be contacted in this individual’s life would include her children, siblings, and close friends. Some pertinent questions would include: When was the patient diagnosed with MDD? Is there a family history of MDD or any other mental health disorders? Have you noticed any other symptoms of MDD, such as depressed mood, loss of interest, weight changes, and fatigue, to name a few? Does the patient have a support system close by?
Physical Exams / Diagnostic Tests
To rule out medical conditions that could produce symptoms similar to depression, it would be necessary to perform a thorough physical exam and conduct initial lab testing. First, a complete blood count (CBC) could rule out blood-related conditions such as anemia, chronic infections, dehydration, or inflammatory conditions (Maurer et al., 2018). Patients with anemia could present with depression, anorexia, fatigue, and weight loss. Second, the Thyroid Function Test (Thyroid-stimulating hormone, T3, T4) could rule out hypo- and hyperthyroidism, which could cause cognitive issues, mood and sleep disturbances, weight changes, and fatigue, to name a few (Maurer et al., 2018). Third, a Basic Metabolic Panel (BMP) should be tested as low levels of sodium can lead to weakness and confusion. Finally, considering the patient is currently on several medications, it would be crucial to also check her liver function.
Moreover, considering the death of a spouse is a risk factor for late-life depression, Maurer et al. (2018) suggested the use of a screening tool such as The Geriatric Depression Scale or the PHQ-2. Both of these screening tools are used for older patients without dementia.
Differential Diagnoses
Differential diagnoses such as generalized anxiety disorder (GAD), bipolar disorder, or depression should all be considered. However, the patient recently lost her spouse of 41 years and has a history of major depressive disorder, so this is likely the correct diagnosis. Finally, according to Maurer et al. (2018), the death of a spouse is a risk factor for depression later in life.
Pharmacologic Treatment for Depression
Two pharmacologic agents that would be appropriate for a 75-year-old patient with a history of major depressive disorder with complaints of insomnia would be mirtazapine (Remeron) and citalopram (Celexa). First, mirtazapine belongs to the noradrenergic and specific serotonergic (NaSSAs) antidepressant class of drugs. The starting dose for mirtazapine would be 15 MG daily in the evening (Stahl, 2021b). Mirtazapine is known to cause sedation, weight gain, and hypotension. That being said, considering the patient is obese and diabetic, it would be crucial to monitor her weight during treatment. And, considering the patient takes cardiac medications, she should also be aware that mirtazapine could also cause dizziness and hypotension (Stahl, 2021b). According to Stahl (2021b), there are no notable pharmacokinetic drug interactions. Further, mirtazapine blocks specific receptors including H1 histamine, a2-adrenergic, 5HT2a, 5HT2c, and 5HT3 (Stahl, 2021a). Blocking H1 histamine will produce sedation, which can be beneficial to this patient due to her complaints of sedation. Therefore, I would proscribe this medication first to see if it is beneficial for the patient. The patient should follow up with the practitioner within the first 1-2 weeks of treatment, then, if the patient is responding well, every 4-6 weeks, and once stable, every 3-6 months.
Furthermore, the second drug, citalopram belongs to the selective serotonin reuptake inhibitor (SSRI) class of drugs. According to Stahl (2021a), this drug is typically tolerated well by the elderly population. The starting dose for citalopram is 20 MG daily. Doses exceeding 20 MG daily should not be given to patients over 60 years old (Stahl, 2021b). From a mechanism of action perspective, citalopram may be a better option than sertraline because it is less likely to interact with other medications, especially those metabolized by the cytochrome P450 system, compared to sertraline. In addition, patients might experience sedation due to the drugs mild antihistamine properties. Further, it is worth noting that citalopram can induce hypomanic or manic episodes in individuals with bipolar disorder (Stahl, 2021b). The patient should follow up with the practitioner within the first 1-2 weeks of treatment, then, if the patient is responding well, every 4-6 weeks, and once stable, every 3-6 months.
