Victoria Abolarin Week 7- Initial post
Questions to ask
- How would you describe the way you are feeling today- Open-ended questions allow for further conversation which leads to in-depth knowledge of the situation. This patient will be able to explain her condition more with a question like this
- How would you describe your typical day and bedtime routine- This patient is in the clinic with complaints of insomnia, since Environmental factors can affect sleep pattern, It is important to rule out any of that before focusing on physiological causes. Daily activities can expose information that can affect the patients sleep pattern
- When did you start having problems sleeping- This question will help understand whether this is an acute or chronic problem? The length of time will also help understand the level of other system involvement.
People to interview
I would like to speak with the neighbors, children, other close family members and caregivers, friends, or anyone that works inside the home. It will also be beneficial to know how this patient spends most of her time. Some people volunteer or have religious involvement.
Physical exam and diagnostic test
sleep study- A sleep study will assess the patients sleep pattern; this patient already has comorbidities that can further worsen her health. Hollsen et al., (2020) explain that patients with a sleep disorder also have an increased risk of depression and cardiovascular disease.
urine culture to test urinary tract infection- Elderly patients do not have the typical symptoms seen in patients, so healthcare providers need to look for other signs. Dexter and Mortimore (2021) state that older people are more vulnerable due to low immunity and should be assessed for possible infection
Comprehensive metabolic panel- To assess for any underlying conditions. Due to the medications, this patient is already taking, I will like to know her kidney and liver function.
Sleep diary- Since this is her first complaint, I will suggest the patient keep a sleep diary which will be further discussed at the next visit.
Pharmacological agent
Paxil- This is a selective serotonin reuptake inhibitor (SSRI). Ostuzzi et al.,(2020) state that SSRI is the first drug of choice in the elderly due to increasing tolerability in side effects and less interference with cardiovascular health. This will be a good drug of choice because this patient is already on medications for hypertensive so the least amount of medication interference will be beneficial
Quetiapine 50mg daily by mouth HS- This medication can play two roles. First as an antidepressant then as a sedative from its side effect.
Differential Diagnosis
Anxiety disorder
Depressive disorder-I think this is the possible diagnosis for this patient, based on her history. loneliness is a major risk factor for depression among the elderly (Pan & Liu, 2021). The patient may be having worsening symptoms which is manifecting as insomnia.
Insomnia
Check points
I will request a follow up in 4 weeks to assess medication adherence, monitor effectiveness and side effects.
References
Dexter, J., & Mortimore, G. (2021). The management of urinary tract infections in older patients within an urgent care out-of-hours setting. British Journal of Nursing, 30(6), 334342. https://doi-org.ezp.waldenulibrary.org/10.12968/bjon.2021.30.6.334
Hollsten, I., Foldbo, B. M., Kousgaard Andersen, M. K., & Nexe, J. (2020). Insomnia in the elderly: reported reasons and their associations with medication in general practice in Denmark. Scandinavian Journal of Primary Health Care, 38(2), 210218.
Pan, H., & Liu, Q. (2021). Difference of depression between widowed and non-widowed older people in China: A network analysis approach. Journal of Affective Disorders, 280, 6876.
Ostuzzi, G., Gastaldon, C., Barbato, A., DAvanzo, B., Tettamanti, M., Monti, I., Aguglia, A., Aguglia, E., Alessi, M. C., Amore, M., Bartoli, F., Biondi, M., Bortolaso, P., Callegari, C., Carr, G., Caruso, R., Cavallotti, S., Crocamo, C., DAgostino, A., & De Fazio, P. (2020). Tolerability and efficacy of vortioxetine versus SSRIs in elderly with major depression. Study protocol of the VESPA study: a pragmatic, multicentre, open-label, parallel-group, superiority, randomized trial. Trials, 21(1), 114. https://doi-org.ezp.waldenulibrary.org/10.1186/s13063-020-04460-6
Ifeanuli Ona week 7/ ifeanuli
Week 7: Discussion
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 husbands 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
Everybody grieves differently and the symptoms are very similar to depression, such as withdrawal from social settings and intense feelings of sadness. But there are very significant differences between depression and grief. The patient of taking sertraline, so there is a mood problem. Individual with depression feel depressed virtually all the time but people grieving have symptoms that fluctuates.
Grief can be defined as a natural response to any loss, including physical, cognitive, emotional, behavioral and spiritual responses. According to American psychiatric association, Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Depression causes feelings of sadness and/or a loss of interest in activities you once enjoyed. It can lead to a variety of emotional and physical problems and can decrease your ability to function at work and at home. Grief can be a trigger for depression, but not everyone who grieves will experience depression.
Three are questions for patient and rationale.
Question 1: when was the first time you notice that the sleep pattern is getting worse?
Rationale: identify when the change in pattern of sleep started.
Question 2: In the past two weeks, how often have you felt down, depressed, or hopeless?
Rationale: To identity some warning sign of depression.
Question 3: Have you had any thoughts of suicide
Rationale: Ensure that patient is safe on her own. To rate the severity of depression
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.
Children or family members Question 1: Do patient prefer to stay at home rather than going out and doing new things? What is the patient regular sleep pattern?
Rationale: This question asks for a yes or no answer and recognizes that isolation and withdrawal are common signs of depression especially in the elderly. cognitive therapy, is the recommended first-line treatment of insomnia and is more effective than medications for the long-term management of insomnia. Medications, such as benzodiazepines and antidepressants, should be avoided for the treatment of insomnia in older adults (Brewster, Riegel, & Gehrman, 2018).
physical exams, and diagnostic tests would be appropriate for the patient
Lab test: CBC, CMP, cortisol level and hormone levels
Screening tool: Depression screening in older adults can be accomplished with multiple instruments, including the PHQ-2, PHQ-9, and various Geriatric Depression Scales
Differential diagnosis for the patient.
Insomnia
According to the National Institutes of Health. Insomnia is a common sleep disorder when the patient has trouble falling asleep, staying asleep, or getting good quality sleep. This happens even though you have the time and the right environment to sleep well. Insomnia interferes with your daily activities and may make you feel unrested or sleepy during the day. Short-term insomnia may be caused by stress or changes in your schedule or environment. Chronic (long-term) insomnia occurs three or more nights a week, lasts more than three months, and cannot be fully explained by another health problem or a medicine.
List two pharmacologic agents.
- Zoloft 50mg daily
Sertraline is an effective and well tolerated antidepressant for the treatment of major depressive disorder in patients aged 60 years. Since elderly patients are particularly prone to the anticholinergic effects of TCAs as a class, SSRIs such as sertraline are likely to be a better choice for the treatment of major depressive disorder in this age group. In addition, sertraline may have advantages over the SSRIs paroxetine, fluoxetine and fluvoxamine in elderly patients because of the drugs comparatively low potential for drug interactions, which is of importance in patient groups such as the elderly who are likely to receive more than one drug regimen (Muijsers, Plosker & Noble, 2002).
- Melatonin 3mg at bedtime
According to National Institutes of Health, melatonin is a hormone produced by the pineal gland that has multiple effects including somnolence, and is believed to play a role in regulation of the sleep-wake cycle. Melatonin is available over the counter and is reported to have beneficial effects on wellbeing and sleep. Melatonin has not been implicated in causing serum enzyme elevations or clinically apparent liver injury.
References
Brewster, G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the Older Adult. Sleep medicine clinics, 13(1), 1319. https://doi.org/10.1016/j.jsmc.2017.09.002
Muijsers RBR, Plosker GL, & Noble S. (2002). Sertraline: a review of its use in the management of major depressive disorder in elderly patients. Drugs & Aging, 19(5), 377392.
National Institutes of Health. Melatonin.
The American Psychiatric Association (APA). (2021) Depression. https://www.psychiatry.org/patients-families/depression/what-is-depression.
The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. Insomnia. (2019) https://www.nhlbi.nih.gov/health-topics/insomnia
PLS USE 3 REFERENCES ON EACH DISCUSSIONS.
