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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:
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Metformin 500mg BID
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Januvia 100mg daily
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Losartan 100mg daily
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HCTZ 25mg daily
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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:
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List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
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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.
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Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
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List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
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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.
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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?
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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.
Read a selection of your colleagues’ responses.
Respond to at least two of your colleagues on two different days in one of the following ways:
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If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
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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.
Joseph ay answer
Three questions to ask the patient
· What brought you here today? It is always good to begin interviews with patients with open-ended questions because it always gives a patient chance to be so available to the healthcare provider.
· Do you drink caffeine? Because this can prevent the patient’s chance of getting good sleep if the patient drinks caffeine, especially near bedtime.
· Did you have any history of gastro-esophageal Reflux Disease (GERD)? This usually leads to Insomnia in most older patients.
All these questions are essential for nurse practitioners to determine the conditions while evaluating patients with open-ended questions.
Peoples in patient live
The significant people in the patient’s life that would be asked the questions are children and caregivers. The question is: Is there a recent change in the patient’s appetite, mood, energy/interest? Providing all this information to the nurse practitioner would help to treat/diagnose the patient correctly, which is all relevant to patient care.
Physical Exam
In this scenario, the patient reported a lack of sleep (Insomnia). Both physical exam and blood work can be done on this patient to determine if there is any thyroid problem. Hyperthyroidism can result in nervousness from the inactivity of the hormone, and the symptom is insomnia (Van Straten A. et al. 2018). The Hamilton Anxiety Rating Scale is essential to measure the patient’s anxiety level. The HAM-A results can be used to treat insomnia, provided it is related to anxiety. Another scan can be used in the Hamilton Depression Rating Scale, which focuses on assessing a patient’s feelings of guilt, suicidal thought, and insomnia.
Diagnosis
This patient has been diagnosed with depression, and the differential diagnosis will be generalized anxiety disorder next to her husband’s death.
Pharmacologic Agents
Temazepam belongs to the benzodiazepine class that FDA has approved for insomnia, and the patient can be benefited from treating insomnia (Miller, C. B. et al. 2017). Temazepam is also used to treat anxiety and acute mania as an off label. Temazepam restricts GABA’s activity and is metabolized in the liver in the absence of CYP450. Trazodone is another suitable medication used to treat insomnia, which the FDA also approves to treat depression. Still, it is an off label to treat anxiety caused by insomnia. HT2C inhibits the Serotonin 5-HT2A and reuptake of Serotonin. Trazodone can cause daytime sleepiness and dizziness, but it is used through CYP3A4.
Contraindications
I prefer to treat the patient with temazepam because it has no active antibodies, a short half-life, and no drug interactions. The patient is already on medications to treat diabetes, HTN, and depression, so temazepam must be given with caution when administered with other drugs to prevent drug-drug interactions.
Check Point
It is always a good decision to start with a lower dose when prescribing medication, especially with elderly patients (Abad, V. C., & Guilleminault, C. (2018). 7.5mg is the lower dose of Temazepam that we should start this patient on. For example, start the patient on 7.5 mg tab PO at Bedtime for the next four weeks. The patient should be able to sleep effectively and see reduced anxiety after the medication starts. Otherwise, Temazepam should be increased to 15mg tab PO at Bedtime. The patient should be checked at eight weeks, and the maximum dose to be prescribed is 30 mg PO at bedtime, and caution should be taken when increasing the amount.
References
Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: recommendations for pharmacological management.
Drugs & aging,
35(9), 791-817.
Miller, C. B., Valenti, L., Harrison, C. M., Bartlett, D. J., Glozier, N., Cross, N. E., … & Marshall, N. S. (2017). Time trends in the family physician management of insomnia: the Australian experience (2000-2015).
Journal of Clinical Sleep Medicine,
13(6), 785-790.
Sateia, M. J., & Buysse, D. (Eds.). (2016).
Insomnia: Diagnosis and treatment. CRC Press.
Van Straten, A., van der Zweerde, T., Kleiboer, A., Cuijpers, P., Morin, C. M., & Lancee, J. (2018). Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis.
Sleep medicine reviews,
38, 3-16
Hubert answer
insomnia Week 7 Discussion
As a PMHNP, insomnia is among the most common medical conditions in a clinical setting. According to Abbott (2016), insomnia is among the common symptoms experienced by individuals with mental illnesses such as schizophrenia, ADHD, depression and anxiety. In addition, numerous studies have also identified a correlation between insomnia and mental illnesses. For example, Abbott (2016) denotes that approximately 50% of individuals with insomnia have mental illness issues, while 90% of adults with depression also report sleep-related issues. Due to these connections, it is essential for PMHNPs to effectively understand how psychopathology treatment effects may occur on patient sleep patterns and mental health. Therefore, practitioners should be able to utilize evidence-based treatment plans to ensure optimal health and patient well-being. This discussion drafts a therapy approach that may effectively diagnose, treat and assess a 75-year-old patient with insomnia issues.
Questions to Ask the Patient
The patient presents to the clinic with insomnia as her chief complaint. Since her husband of 41 years died 10 months ago, the patient reports increased depression feelings and worse sleeping habits. Based on her medical history, the client had no history of depression before her husband’s death. She visits a PCP once to twice annually and denies suicidal ideations. In addition, she consents to take Metformin 500 mg BID, Januvia 100 mg daily, losartan 100 mg daily, HCTZ 25 mg daily and sertraline 100 mg daily to ease her discomforts. Physical examinations indicate that she weighs 88 kg with a height of 64 inches and her temperature is at 98.6 degrees F. furthermore, the client’s blood pressure is 132/86. After understanding the patient’s information, the further assessment would be essential to determine the main cause of insomnia and how to treat the condition. Therefore, the following three questions would be key to extracting further information for effective assessment, diagnosis and treatment for the 75-year-old.
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Question 1: How do you feel after losing your husband after 41 years of marriage?
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Question 2: What activities do you like before going to bed or late in the night?
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Question 3: Apart from insomnia feeling or depression, do you have any other medical conditions I should be aware of before we start a treatment procedure?
Asking the patient how they feel after the loss of their husband in question one is aimed at understanding whether the patient is stressed about the issue. According to Abbort (2016), insomnia is directly linked to mental illness and stress-related problems. In addition, concerns about family, work and finances may keep an individual’s mind active through the night, making it difficult to sleep. Question two focuses on asking the patient about key activities they like participating in before bed. According to Cleveland Clinic (2020), poor sleep habits such as irregular bedtime, an uncomfortable sleeping environment and too much watching on televisions or mobile phones can cause irregular sleep habits. In addition, eating too much before bed can make someone uncomfortable sleeping. Furthermore, the question also seeks to determine whether the patient takes stimulants at night or before sleep time which may limit sleep time. For example, coffee, cola and tea are caffeine drinks and stimulants that may hinder one from falling asleep when taken.
Furthermore, question three seeks to determine whether the patient suffers from other medical conditions that may primarily affect her sleeping time. According to Cleveland Clinic (2020), chronic insomnia is associated with certain medical conditions or the use of certain prescription drugs. Therefore, treating these medical conditions may assist in getting better sleep. Some medical conditions linked to insomnia include cancer, overactive thyroid, Parkinson’s disease, asthma, diabetes, GERD and Alzheimer’s disease. Other medical conditions, such as sleep apnea, may cause breathing interruptions hence interrupted sleep. Therefore, treating these medical conditions allows the patient to have a peaceful night’s sleep.
People in Patient’s Life to Talk to and Get Feedback
Sometimes insomnia patients may fail to offer adequate information regarding their condition. Also, the patient is elderly and may conceal or not remember certain instances in her life or activities surrounding her. Therefore, speaking to people around her who understand her better and may offer adequate information about her condition is effective. The first person to speak to may be her caregiver. A caregiver may have important information which may be used for assessment and patient treatment. Asking the caregiver whether the patient’s sleeping environment is conducive or whether she likes taking stimulants such as caffeine and coffee before sleeping may help understand the patient’s habits. Another person to talk to for further information would be the patient’s children. If the patient has children, they effectively understand their mother and any medical conditions she might suffer. As the medical practitioner , one can ask the patient’s children whether their mother has suffered any other medical conditions. Feedback from this question would help create a better treatment plan.
Appropriate Tests to Undertake
There is no specific diagnostic test for insomnia. However, healthcare professionals often prefer performing physical examinations and asking patients questions to understand more about sleep issues or symptoms. According to the Cleveland Clinic (2020), the most effective way to diagnose insomnia is by reviewing sleep history with the doctor. Additionally, doctors will review patients’ medical history and current medication to determine whether they have altered their sleeping habits. Furthermore, the doctor may need to perform certain tests such as a sleep diary, blood test and sleep study. A blood test will help to eliminate some medical conditions which may negatively impact a patient’s sleep time. Examples of such medical issues may include low iron levels and thyroid issues. A sleep diary, however, includes recording sleep patterns for a certain period. This information helps the doctor identify certain behaviour or patterns which may hinder the patient’s sleep. Lastly, a sleep study may not be necessary for an insomnia patient. If a doctor finds a patient with sleep disorders such as sleep apnea, he may refer the patient to a specialist or allow them to do the studies at home.
Differential Diagnosis
Based on the patient’s symptoms, various differential diagnoses would be suitable. These diagnoses include post-traumatic stress disorder (PTSD), sleep apnea and Hyperthyroidism. Among the listed differential diagnoses, PTSD is most likely due to losing a loved one. The patient reports her sleeping problems started after she lost her husband whom they were married for 41 years. According to Bryant (2019), PTSD is a mental health condition that occurs after a terrifying event and symptoms may last for months or years, affecting day-to-day activities. Bryant (2019) denotes that PTSD symptoms may cause troubled sleep, as experienced by the patient in the case study. The patient also reports depression which is another symptom associated with PTSD.
Pharmacological Agents
Insomnia may be treated using pharmacologic agents which help individuals get enough sleep. An example of such a drug is Eszopiclone (Lunesta). According to Medlineplus.gov (2021), Eszopiclone is a drug in the hypnotic class that physicians use for insomnia treatment. This drug works by slowing brain activity, allowing individuals to have a peaceful sleep. The recommended dosage is 1 mg of Eszopiclone daily for adults before sleeping. Depending on the doctor’s instructions, this dosage may be increased to 2 mg or 3 mg. Side effects of the drug may include daytime drowsiness, pain, headache, lack of coordination, nausea and vomiting. In addition, a patient may also take Zaleplon (Sonata) medication before going to bed or when they have sleep problems. Zaleplon dosage maybe 5 or 10 mg daily at bedtime for adults. This drug belongs to a class of medication known as central nervous system CNS depressants and works by slowing down the nervous system, allowing patients to sleep effectively. Side effects of Zaleplon may include drowsiness, dizziness, lack of coordination, vision problems and headache. Of the two medications, Zaleplon is the best for a prescription to the patient because it does not present severe side effects of sleepwalking or driving experienced rarely by Eszopiclone users.
Contradictions and Usage Alterations
The starting dosage for Sonata is 5 mg which may be increased to 10 mg depending on the patient. However, the drug should only be used after a doctor’s prescription during pregnancy. Doctors do not recommend sonata prescription during pregnancy as it passes into the breast milk, which may cause harmful effects on the infant after breastfeeding (Christoffel et al., 2022). Therefore, patients should adhere to the doctor’s prescription for the drug for optimal functionality.
Check Points
Most drugs for individuals with sleep problems take less time to start working. Sonata, for example, takes 20 to 30 minutes to start functioning for an individual. The patient in this case study will continue using the medication for the first 4 weeks, after which she shall return to the clinic for assessment. The expectations are that the sonata drug will function well for the patient, although not helping entirely with her sleep problem. After the four weeks, there will be no need to adjust the dosage but recommend alternative treatment methods for the disease. Since the patient is old and may fail to participate in physical activities, it is easier for her to undergo the cognitive behavioral therapy program. According to Christoffel et al. (2020), CBT helps individuals control their thoughts and actions, which keeps them awake. For example, the 75-year-old woman can undertake relaxation techniques, stimulus control therapy and sleep restrictions which will help her sleep better at night. Engaging in such activities will ensure the client finds the right balance to sleep at night, thus effectively addressing her problem.
In conclusion, insomnia is among the major disorders experienced by individuals, especially the elderly, globally. The patient, in this case, analysis, denotes that her situation worsened after the death of her husband, to whom they were married for 41 years. Thus, to ensure effective assessment, diagnosis and treatment, it is effective to evaluate her medical history by prompting more information and feedback from her and the people caring for her. After obtaining the relevant information, the PMHNP may perform certain diagnoses to eliminate certain conditions. When the PMHNP is sure of insomnia, a prescription of drugs is essential to help her sleep effectively. Despite offering prescription drugs which are effective in helping patients fall asleep, other alternatives, such as cognitive behavioural therapy, were also suggested to the patient to ensure they do not become drug dependent. Lastly, further follow-ups via telecommunication may be essential to assess the patient’s condition and the effectiveness of therapy and drugs.
References
Abbott, J. (2016).
What’s the link between insomnia and mental illness? Health.
https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29 Links to an external site.
.
Bryant, R. A. (2019). Post‐traumatic stress disorder: a state‐of‐the‐art review of evidence and challenges.
World Psychiatry,
18(3), 259-269.
Christoffel, L., Bends, R., Toub, D., Schiermeier, S., Pschadka, G., Engelhardt, M., … & Römer, T. (2022). Pregnancy outcomes after transcervical radiofrequency ablation of uterine fibroids with the sonata system.
Journal of Gynecologic Surgery,
38(3), 207-213.
https://doi.org/10.1016/j.jmig.2021.09.236 Links to an external site.
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Cleveland Clinic, (2020). Insomnia.
My.clevelandclinic.org. Retrieved from
https://my.clevelandclinic.org/health/diseases/12119-insomnia Links to an external site.
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Medlineplus.gov. (2021). Eszopiclone.
Medlineplus.gov. Retrieved from
https://medlineplus.gov/druginfo/meds/a605009.html Links to an external site.
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