The three questions I would ask the patient:
1. How long have you been using Sertraline, and have your symptoms of depression or sleeplessness improved or worsened as a result? This question aims to analyze the possibility of modifying the Sertraline dose. This will assist in determining if she is benefiting from the drug or not tolerating it well. If her symptoms worsen and she has been on the medicine for more than four weeks, you should try a new medication.
2. I would question her adherence to her prescribed medications, namely Sertraline. I will also ask if she uses over-the-counter sleep aids. Her response will direct me to the following therapy technique and further reveal underlying issues.
3. Do you have a support group or someone with whom you can share your feelings? She may feel alone and lonely since she is old and has been married for an extended period. Her social support system must be identified, and she must be made aware of the value of having friends and family by her side during this difficult time.
To gather further information, I would want to talk with my patient’s adult children. I’d determine whether they are close to her and actively participating in her care or if their connection is distant. Whether they were involved, I would ask if they had seen any behavioral changes or overheard their mother make any unsettling remarks. I would also want to know whether she has ever had sleep problems in the past and, if so, what treatments, if any, what she used. It would be necessary to educate the family on depression and what she could be going through. They must be able to provide her with social support and be there for her during these trying moments.
The Geriatric Depression Scale (GDS) may be used on healthy to mild/moderately cognitively impaired older persons to evaluate depression in the elderly (Greenberg, n.d.). A mental state evaluation may also evaluate her cognitive performance—thyroid function tests to check for issues and provide a baseline. I’d also check her levels of cortisol and adrenocorticotropic hormone. To rule out sleep apnea or other breathing issues, I would also monitor oximetry throughout hours of sleep, if possible (Lubit, 2019). She can provide her own answers, as shown by the results of the cognitive exam. The GDS can determine how depressed she is and if her condition is improving or worsening. Finally, if the results of her blood test show that her levels are indeed out of range, she may need to take drugs to bring them back into range before determining if this is what is to blame for her sadness.
For this patient, a different diagnosis may be dementia or major depressive disorder with insomnia. She may have both sleeplessness and depression at the same time, but her primary diagnosis is insomnia accompanied by major depression, in my opinion. It should not have taken her more than ten months to recover from the loss of her spouse. After all that time, she ought to be able to better manage her circumstances. Examining insomnia symptoms is complex since they might be a comorbid illness or a primary problem. The healthcare professional should assess the symptoms’ kind, frequency, course, and duration (Patel et al., 2018). Sleep issues may contribute to or cause depressive illnesses, and vice versa. Patients with depression often have insomnia (El-Gilany et al., 2021).
According to the patient’s past, she is now taking 100 mg of Sertraline every day for depression. Since she has taken Sertraline for some time without any adverse reactions or side effects being reported, I would advise keeping her on it while gradually increasing the dosage if her symptoms do not improve. If necessary, I would also advise changing the medication if the patient was experiencing side effects. However, initially, I would prescribe her trazodone 50mg PO at night to help her sleep, in addition to the higher dose of Sertraline. Trazodone is often recommended in dosages ranging from 25 to 100 mg for insomnia. It is helpful in the elderly and may lessen insomnia without using benzodiazepines, which can have significant adverse effects on the elderly. Patient using trazadone sleeps 42.5 minutes longer each night than placebo users, with an 8.5 percentage point improvement in nocturnal sleep. It had no discernible effects on daytime drowsiness, naps, cognition, or functioning (Flaxer et al., 2021). The antidepressant mechanism of Trazodone would give an additional layer of therapy for her depression. I also suggest she take Trazodone with a little snack to reduce GI disruption.
This specific case study does not disclose the patient’s ethnicity; thus, the primary emphasis would be on the safest and most suitable therapy and doses for this elderly patient, taking into account the slower medication metabolism and excretion rate.
I would make an appointment to see the patient in 4 weeks to review her labs with her and check on her progress if any. I would also find a way to watch her sleep and breathe while she is asleep. A sleep study may be helpful. I would tell her about ways to relax and “unwind her mind” before bed. I would check in with her again in 4 weeks to see how she was doing.
El-Gilany, A. H., Elkhawaga, G. O., & Sarraf, B. B. (2018). Depression and its associated factors among elderly: A community-based study in Egypt. Archives of gerontology and geriatrics, 77, 103-107.
Flaxer, J. M., Heyer, A., & Francois, D. (2021). Evidenced-based review and evaluation of clinical significance: nonpharmacological and pharmacological treatment of insomnia in the elderly. The American Journal of Geriatric Psychiatry, 29(6), 585-603.
Greenberg, S. (n.d.). The Geriatric Depression Scale (GDS): Hartford Institute for Geriatric Nursing. Retrieved January 9, 2023, from https://hign.org/consultgeri/try-thisseries/geriatric-depression-scale-gds
Lubit, M. (2019). Sleep-Wake Disorders Workup. Medscape.
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024.
Student response 2
1.”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. How many hours did you typically sleep before your husband’s passing?
Rationale: The inquiry will help determine if her insomnia issues existed before, identifying if they are caused by the current medications or depression.
1. How long have you been under the Sertraline medication, and have the symptoms improved or worsened?
Rationale: The question will help determine the medication’s effectiveness and whether there is a need for a new drug prescription or changes in dosage.
1. Do you have a recognizable support system?
Rationale: The patient is an elderly individual struggling with the recent death of her husband, making it integral to have people she can talk with concerning her feelings. Identifying her support system and educating them on their value in the patient’s life is essential.
“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.”
The first person would be any family member in close contact with the client. Essentially, the family member would be asked to describe the patient’s behaviors and whether they have reached out regularly to the patient. The inquiries will help gain further information on the client’s situation and gauge her support system. Moreover, it would be beneficial to identify and interview her caretaker to obtain insight into her daily routine and the possibility of any alarming symptoms, like memory loss. In doing so, an accurate diagnosis and treatment plan can be established for the patient.
“Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.”
It is essential to have the patient undergo a mental status checkup as part of her physical examination. The step will help analyze aspects, such as her cognitive functioning and behavior; the results will be utilized in determining whether an underlying psychological disorder contributes to her depression and insomnia. Additionally, the Geriatric Depression Scale (GDS) is a necessary diagnostic test for the client; it assists in measuring depression levels among the elderly or those with cognitive impairment (Stone et al., 2019). The test’s results will help gauge the patient’s depression levels, identifying if it is getting better or worse, paving the way for the decision to continue or change her current drug prescription.
“List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.”
In the given scenario, the primary differential diagnoses include dementia, post-traumatic stress disorder (PTSD), or generalized anxiety disorder. However, the likely diagnosis is dementia. According to Cohen et al. (2019), insomnia and depression are among the leading clinical manifestations among elderly individuals diagnosed with dementia. The client’s grieving period is taking longer than normal, resulting in increased depression and contributing to possible dementia onset. Ultimately, heightened depression and dementia alter sleeping patterns, causing 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.”
The first drug would be 5mg of Donepezil daily before bedtime. Its alternative is Zolpidem, which will adhere to a similar dosage and consumption time. Nonetheless, given that the patient is taking Sertraline, Donepezil would be the preferred pharmacologic agent. Donepezil is an acetylcholinesterase inhibitor often prescribed for patients with dementia and Alzheimer’s (Guo et al., 2020). Inherently, its interaction with Sertraline will contribute to better management of the client’s dementia symptoms, primarily insomnia and depression, unlike with Zolpidem, which leads to more adverse side effects.
“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?”
Ethical prescribing requires any formulated drug therapy plan to benefit the patient, causing no harm. Given the patient’s advanced age, the drug Donepezil should be prescribed at the lowest dosage for the first weeks. The step minimizes any vulnerability to adverse side effects if the client does not respond well to the medication. Consequently, after at least four weeks, once the patient positively responds to the drug, its dosage can be increased to 10mg.
“Include any “checkpoints” (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 primary follow-ups at weeks 4, 8, 12, and beyond would be founded on examining the patient’s response to the prescribed drug. At week 4, if the client shows improvement in sleep and depression, the drug dosage will be increased. It is essential to note that the increment is solely based on gains lower than 50%. Lastly, once symptoms decline by 50% in the following weeks, the new dosage will be maintained until full recovery is achieved.
Cohen, G., Russo, M. J., Campos, J. A., & Allegri, R. F. (2019). COVID-19 Epidemic in Argentina: Worsening of Behavioral Symptoms in Elderly Subjects With Dementia Living in the Community.
Frontiers in Psychiatry,
https://doi.org/10.3389/fpsyt.2020.00866Links to an external site.
Guo, J., Wang, Z., Liu, R., Huang, Y., Zhang, N., & Zhang, R. (2020). Memantine, Donepezil, or Combination Therapy-What is the best therapy for Alzheimer’s Disease? A Network Meta-Analysis.
Brain and behavior,
10(11), e01831. https://doi.org/10.1002/brb3.1831
Stone, A. A., Walentynowicz, M., Schneider, S., Junghaenel, D. U., & Wen, C. K. (2019). MTurk Participants Have Substantially Lower Evaluative Subjective Well-Being Than Other Survey Participants.
Computers in human behavior,
https://doi.org/10.1016/j.chb.2018.12.042Links to an external site.