Treatment for a Patient with a Common Condition
The case presented is of a 75-year-old female with insomnia and a history of depression, DM, and HTN. The first question I might ask the patient is whether she has been using any substance of abuse since her husband died. These substances of abuse disrupt the sleep pattern and are contributory to insomnia. I might also ask the patient whether she adheres to her antidepressant medication. If not taken appropriately, sertraline may not produce the desired antidepressant effects. I might also ask what the sleeping environment looks like and whether there are any distractions. Distractions affect sleep and sleeping patterns, thus resulting in insomnia.
Further, information can be obtained from relatives and other people living with the patient. These individuals can inform on the patient’s sleeping patterns or behaviors. I might ask them when the patient goes to sleep and for how long. There are no objective tests for insomnia and or depression. A complete blood count and toxicity test via urinalysis may inform whether the patient has been on drugs or substances of abuse.
The patient’s differential diagnoses include substance abuse disorder and infectious diseases. Substance abuse disorder is the most likely differential, and it often presents with depressive symptoms and causes insomnia (Bains et al., 2022). It is also a likely resort for grieving persons. Trazodone 50mg every eight hours and amitriptyline 25 mg every 24 hours are the pharmacological options for this patient. These medications are effective against depression and are effective in the management of insomnia. However, trazodone is preferred over amitriptyline. This is because it has a more favorable toxicology profile and has additive effects with losartan in lowering blood sugar.
Trazodone is contraindicated in persons with suicidal ideation; it may worsen these presentations. Suicidal ideation and tendency are common presentations of depression (Madrigal de León et al., 2019). With trazodone use, the patient may be at a higher risk of suicide. Follow-up is warranted with trazodone use in patients with depression. In the short term, monitoring for suicidal ideation or tendencies is justified. This may be done up to two months post-initiating therapy. Monitoring for serotonin syndrome is also explained if coadministered with sertraline or administered within 14 days of stopping sertraline (Martsenkovskyi & Napryeyenko, 2019). This is because sertraline has a long duration of action and a more extended wash-off period.
Bains, N., Abdijadid, S., & Miller, J. (2022). Major Depressive Disorder (Nursing). Ncbi.nlm.nih.gov. Retrieved 23 September 2022, from https://www.ncbi.nlm.nih.gov/books/NBK570554/.
Madrigal de León, E., Astudillo-García, C., & Durand-Arias, S. (2019). Depression, Substance Abuse, and Suicide Risk: A Rising Problem. Addictive Disorders & Their Treatment, 18(2), 99-104. https://doi.org/10.1097/adt.0000000000000155
Martsenkovskyi, D., & Napryeyenko, O. (2019). Adjunctive therapy with trazodone for insomnia in adolescents with post-traumatic stress disorder and depression. European Neuropsychopharmacology, 29, S543-S544. https://doi.org/10.1016/j.euroneuro.2019.09.682
We’ll write everything from scratch
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 a chief complaint of insomnia. The patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away ten 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 before her husband’s death. She is awake, alert, and oriented x3. The patient typically 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
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 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, explain 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 and decision-making?