Case Study-An Elderly Widow Who Just Lost Her Spouse
List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
Can you briefly narrate to me what your day is like? This question is open-ended and could give me more information on the patient’s daily activities, which can be used to manage her insomnia.
What is your daily diet? This question is open-ended, which will offer more information on her nutritional intake, which can be the cause of insomnia.
According to you, what does a well-rested sleep mean? This is another open-ended question that will offer more information on what she expects to help design an effective treatment goal for her insomnia.
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.
Her children, people she lives with within the same household, close neighbors and friends. I will ask them the following questions:
Based on your relationship with her, can you say that she is a good neighbor/friend or mother?
Can you describe any changes that you have noticed with the patient after her husband’s death?
Can you tell me how she handles her activities like cooking meals, personal hygiene, and visiting friends and family?
Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
Diagnostic tests would be appropriate for the patient, including a depression screening test using a questionnaire to assess her depression levels (Saracino et al., 2018). Laboratory tests, including complete blood count, blood chemistry, and thyroid assessment, to evaluate the factors contributing to her depressive symptoms (Maurer et al., 2018). Renal and hepatic function tests to evaluate how well the patient can metabolize and excrete the prescribed drugs (Lala et al., 2021)
List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
The presumptive differential diagnosis for this patient is depression. The patient lost her husband. The patient has insomnia. Sleep issues such as insomnia are common mental health symptoms such as schizophrenia, attention deficit hyperactivity disorder, depression, and anxiety (Abbott, 2016). 90% of patients with depression have sleep problems (Abbott, 2016).
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.
Tricyclic antidepressants such as Tofranil- The mechanism of action of TCAs is by blocking the reuptake of norepinephrine and serotonin, thus increasing the serotonin and norepinephrine levels in the human brain (Undurraga & Baldessarini, 2017).
Selective serotonin reuptake inhibitors (SSRIs) such as Prozac- The mechanism of action of SSRIs is inhibition of the serotonin transporter at the presynaptic terminal, preventing the reuptake of serotonin (Undurraga & Baldessarini, 2017). This inhibition increases the serotonin that remains in the synaptic cleft, thus increasing the levels of serotonin. This will increase its activity and effects.
I would choose an SSRI over TCA since SSRIs have milder and fewer side effects compared to TCAs. The patient is also of advanced age; hence, the TCA side effects may cause severe side effects such as dysrhythmias or orthostatic hypotension, leading to falls, fractures, and dizziness (Undurraga & Baldessarini, 2017).
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?
Based on study results, African Americans and Asians resort to other treatment options other than drugs to manage their depression (Williams, 2018). Patients from these ethnicities thus need lower doses of antidepressants to achieve the therapeutic effects. For Caucasians, SSRIs are used on standard dosage and frequency. The patient is seventy years old with hypertension; hence, adjusting the dosage to minimize the adverse effects and polypharmacy since she is already on other medications.
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.
The progress of the patient will be evaluated after every four weeks. The possible outcomes expected include that the patient will adhere to the prescribed medications, establish a beneficial sleep-wake cycle, and adapt to dietary changes that would help in sleep quality and drug efficacy. If the patient shows signs of improvement during the clinical visits, the drug dosage will be tapered off slowly until the patient can sleep without medications. If there are no signs of improvement, the dosage will be increased and augmented with psychotherapy.
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-mentalillness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
Korhan, O., & Ahmed Memon, A. (2019). Introductory chapter: Work-related musculoskeletal disorders. Work-related Musculoskeletal Disorders. https://doi.org/10.5772/intechopen.85479
Lala, V., Goyal, A., Bansal, A., & Minter, D. A. (2021, May 9). Liver function tests. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK482489/
Maurer, D. M., Davis, B. N., & Raymond, T. J. (2018, October 15). Depression: Screening and diagnosis. AAFP American Academy of Family Physicians. https://www.aafp.org/afp/2018/1015/p508.html
Saracino, R.M., Cham, H., Rosenfeld, B., & Nelson, C.J. (2018). Confirmatory factor analysis of the Center for Epidemiologic Studies Depression Scale in oncology with examination of invariance between younger and older patients. European Journal of Psychological Assessment. Advanced online publication. http://dx.doi.org/10.1027/1015-5759/a000510
Undurraga, J., & Baldessarini, R. J. (2017). Direct comparison of tricyclic and serotonin-reuptake inhibitor antidepressants in randomized head-to-head trials in acute major depression: Systematic review and meta-analysis. Journal of Psychopharmacology, 31(9), 1184-1189. https://doi.org/10.1177/0269881117711709
Williams, D. R. (2018). Stress and the mental health of populations of color: Advancing our understanding of race-related stressors. Journal of Health and Social Behavior, 59(4), 466-485. https://doi.org/10.1177/0022146518814251
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Question 
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 Study-An Elderly Widow Who Just Lost Her Spouse
Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with a chief complaint of insomnia. The patient is 75 years old 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 had no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. The patient normally sees 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
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.
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.
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 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?
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.