Discussion: Chief complaint of insomnia.

For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.

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

By Day 3 of Week 7
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. Discussion: Chief complaint of insomnia.

• 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. Discussion: Chief complaint of insomnia.

• 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.

Respond to the these discussions. All questions need to be addressed.

Discussion 1 En

Three questions to ask the patient and a rationale for asking these questions.

How may I be of assistance today? This question creates a rapport between you and the patients, and it makes her know that the doctor is ready to listen and help her.

What are you doing to cope with grief after losing your husband? This question will help the care provider assess the approaches the patient is using to cope with grief and be able to identify the ones working and not working for the patient.

Are you living with someone at home, and are you following your regimen correctly? By asking this question, the care provider will understand the type of support system available at home and know which support to prescribe for the patient and if the support at home is helping the patient follow her regimen correctly.

People in the patient’s life to speak to or get feedback from to further assess the patient

People in the patient’s life to speak to include her children, her aide, and close friend per her authorization. The feedback I will get from these people will help me know the severity of the patient’s problem. Some of the questions I will ask them are;

1. Has the patient been experiencing worse symptoms of depression since her husband’s dead? This question will help me understand people close to her can know when she is depressed.

2. Does the patient complain about her treatment regimen? This question will allow me to know the side effects of the treatment if any.

3. Has the sleeping patterns changes recently? This question will help me understand the severity of insomnia.

Physical and diagnostic tests

The physical exams appropriate for this patient include heart rhythm, eye assessment, and oxyhemoglobin saturation. The diagnostic tests for this patient include polysomnography and actigraphy tests. These tests will be used to measure the patient’s sleep patterns. The actigraphy measures sleep efficiency, sleep latency, and total sleep time, and polysomnography will diagnose sleep disorders (Niel et al., 2020)

Differential diagnoses for the patient

The patient’s differential diagnoses include generalized anxiety disorder, major depressive disorder, and restless leg syndrome. Major depressive disorder (MDD) is likely to explain why the patient is experiencing insomnia. MDD’s clinical presentation include insomnia, difficulty concentrating, appetite loss, and hopelessness. The patient’s husband’s loss contributed to depression, which affected her sleeping pattern. According to Bennabi et al. (2019), patients with MDD are at risk of experiencing sleeping disorders. Since the patient is responding to grief, her chances of developing MDD are high.

Pharmacologic agents and their dosing

Selegiline Transdermal patch. Apply 6mg daily dose, which is applied every day. If symptoms do not improve, the dose can be increased by 3mg daily for two weeks until it reaches a maximum of 12gm daily. The drug inhibits Monoamine Oxidase-B isoenzyme (Bied et al., 2015).

Eszopiclone. The required dose is 3mg, which is administered orally before the patient goes to bed. It is the first-line drug for insomnia, and it interacts with gamma-aminobutyric acid (GABA) receptors at the allosterically binding sites at the benzodiazepine receptors. The drug works by slowing brain activities to allow sleep. The drug induces sedation and hypnosis hence causing sleep (Dixon et al., 2015). Since the patient is complaining of insomnia, eszopiclone will be appropriate in improving this symptom.

Drug therapy contraindications

Contraindications of using selegiline transdermal include increased risks of serotonin syndrome. The drug contraindicates in the patients taking selective serotonin reuptake inhibitors, mirtazapine, and other vasoconstrictors and analgesics.

Check points

After administering these drugs, the patient will be assessed after a four-week interval to determine if the symptoms have improved. If the symptoms have not improved after four weeks, selegiline transdermal will be increased by 3mg for four weeks until 12gm, which is the maximum dose per day. If the symptoms improve within the first four weeks, the regimen will be maintained until the patient completes the dose. After completing the dose, the patient will sleep well and the symptoms of depression will be well managed.

References

Bennabi, D., Charpeaud, T., Yrondi, A., Genty, J. B., Destouches, S., Lancrenon, S., … & Haffen, E. (2019). Clinical guidelines for the management of treatment-resistant depression: French recommendations from experts, the French Association for Biological Psychiatry and Neuropsychopharmacology and the fondation FondaMental. BMC psychiatry, 19(1), 1-12. https://doi.org/10.1186/s12888-019-2237-x

Bied, A. M., Kim, J., & Schwartz, T. L. (2015). A critical appraisal of the selegiline transdermal system for major depressive disorder. Expert review of clinical pharmacology, 8(6), 673-681. https://doi.org/10.1586/17512433.2016.1093416

Dixon, C. L., Harrison, N. L., Lynch, J. W., & Keramidas, A. (2015). Zolpidem and eszopiclone prime α1β2γ2 GABAA receptors for longer duration of activity. British journal of pharmacology, 172(14), 3522-3536. https://doi.org/10.1111/bph.13142

Niel, K., LaRosa, K. N., Klages, K. L., Merchant, T. E., Wise, M. S., Witcraft, S. M., Hancock, D., Caples, M., Mandrell, B. N., & Crabtree, V. M. (2020). Actigraphy versus polysomnography to measure sleep in youth treated for craniopharyngioma. Behavioral sleep medicine, 18(5), 589-597. https://doi.org/10.1080/15402002.2019.1635133Discussion: Chief complaint of insomnia.