NR 508 Week 6 Discussions 1 (Part One) Recent

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Post 1.

Case: An Elderly widow who just lost her spouse, having difficulty with sleep.

Depression is a mood disorder in which the symptoms negatively affect how an individual feels, thinks, acts, and conducts daily life activities. This condition, often, affects the age population of sixty-five or older due to deterioration of health or loss of loved ones (Greenberg, 2019). NR 508 Week 6 Discussions 1 (Part One) Recent

Assessment Question/Recommendation:

The patient past medical history confirms a diagnosis of depressive disorder due to the sertraline 100mg daily, reevaluation of the patient’s current depression level would be completed by using the GDS scale. This would further reveal if her depression has become worse. It would also be pertinent to repeat a mental status exam since it will play a role in the diagnosis and further treatment of MDD (Bains, 2020). NR 508 Week 6 Discussions 1 (Part One) Recent

Questions:

1. Are any of your medications new or newly prescribed?

Rationale: Losartan is associated with decreased REM sleep and may contribute to daytime sedation or sleepiness- REM sleep drops as we age, and insomnia can occur (American Psychiatric Association, 2013). She is currently on sertraline, which is a SSRI- these medications cause insomnia, and can cause agitation, mild tremor, and impulsivity. It would be pertinent to also evaluate when the thiazide diuretic was started and if it is new, these have been linked to depression, as well. Discovering if any of these medications are new, or if dosages have been changed recently. NR 508 Week 6 Discussions 1 (Part One) Recent

1. Any changes to diet or environment?

Rationale: Caffeine consumption should be visited. Coffee and teas are widely consumed and can contribute to disrupted sleep cycles, and anxiety. A thorough assessment of the patient sleep environment, time she goes to bed, consumption of dinner and liquids and medications taking in the evening should be considered. The patient has had a recent change in her overall environment since her husband’s death, this could be a contributing factor. NR 508 Week 6 Discussions 1 (Part One) Recent

1. Are you taking all medications as prescribed?

Rationale: Depression is a complex disorder to treat, it takes weeks to evaluate for therapeutic effects of the medication deemed to help. Dosage adjustments may need to be made to achieve a desired outcome. Managing depression can be challenging, due to cost of medications, perception of medication, side effects, adjustments take time, all of these factors play a part in compliance. Patients feel better after a time on medications and may just stop taking the medication and feel they do not need them any longer, doing more harm than good.

Identifying family structure and asking further questions is always a viable choice.

Feedback from the PCP, children, siblings, caregivers would be beneficial.

Questions that can be approached would be:

• Have there been any changes in patients’ mood, cognition, memory?
• Any signs of being anxious, panicky, or abrupt changes in demeanor?
• What is her living environment like? Cluttered, neat, hoarding, and does she live alone?

Differential Diagnosis:

MDD

This was gathered based on the patient history, current medication of sertraline, and recent loss of spouse. Grief often hastens depression, and this can lead to physical and emotional stress leading to sleep disturbance (Fernandez-Mendoza, & Vgontzas, 2013). Reevaluate the patient mental status and get updated GDS. Develop a plan of treatment for her depression, factoring in the insomnia. She could benefit from non-pharmacological options also. NR 508 Week 6 Discussions 1 (Part One) Recent

Bipolar Disorder

Most clinicians believe that bipolar should present with mania or hypomania symptoms as signature characteristics, and most patients undergoing a depressive state will present in the outpatient setting for help with their depression. Because of this misconception, a missed diagnosis is quite common, not treating the patient accordingly- such as treating the patient as they are suffering from unipolar depression (Hirschfeld, n.d.). NR 508 Week 6 Discussions 1 (Part One) Recent

Pharmacological Options:

I would increase the sertraline from 100mg to 150mg. Effective treatment states 50-200mg day is effective treatment of major depressive disorder in elderly patients. (Stahl, 2021).

Considering the comorbidities of this patient, it is also relevant that vascular morbidity, diabetes mellitus, and arthritis does not affect the antidepressant effects of sertraline (Levenson, Kay, & Buysse, 2015). This makes the choice of not incorporating a change in medication or addition favorable for this patient. There are no reports that the patient was not tolerating the 100mg dosage, therefore it is favorable to increase dosage to 150mg and follow up again in 4 weeks to evaluate the effects of this dosage and the patient can report any adverse effects if experienced. NR 508 Week 6 Discussions 1 (Part One) Recent

Second choice would be to change from SSRI to SNRI and I would prescribe venlafaxine. This is a newer antidepressant, and it deems safe in older population. Venlafaxine has a pharmacological profile that makes it an excellent choice for geriatric patients due to the limited potential for interaction among other medications (Staab & Evans, 2000).

Dosage with this medication should remain conservative by starting at 25mg and follow up in 4 weeks for report and evaluation. An important teaching pearl with this medication is that it can cause hypertension is a small percentage of older patients, at doses of around 150mg/day (Staab & Evans, 2000). It would be pertinent to educate patient on how to take blood pressures daily and keep log to return in 4 weeks for further evaluation if this is a choice in treatment planning.

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Response 2. For student post 2.

Week 7 BreidtC initial response

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions

The following questions are just a few of the many questions I would like to ask my patient to develop a comprehensive history and build rapport.

1. How many hours of sleep are you achieving per night and quality of sleep? Samara et al., 2020 identify that approximately 50% of the elderly population struggle with insomnia. Asking this question will help determine which point of sleep is difficult for the patient for example, difficulty initiating sleep, waking early in the night, having nightmares etc. Knowing this information would help guide prescriptive course of treatment and gain a better understanding of the patients’ perception of sleep. NR 508 Week 6 Discussions 1 (Part One) Recent
2. Please describe your experience of depressive symptoms and identify any periods of mood elevation or risk-taking behavior, as well as previous psychiatric history. An SSRI is likely to benefit this patient, however, better understanding the experienced symptoms will help guide course of treatment. Additionally, there may be underlying anxiety and grief contributing to depressive symptoms which may indicate a need for psychotherapy. Inquiring about mood elevation and risk-taking behavior can help rule out a bipolar diagnosis. NR 508 Week 6 Discussions 1 (Part One) Recent
3. Are you taking your medications as prescribed? Asking the patient about medication compliance will guide weather to increase sertraline or re-initiate sertraline. It is important to frame this as an open-ended question to facilitate conversation. Increasing a dose that the patient has not been taking can cause more side effects and be harmful to the patient.

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.

People in the patients’ life that I would want to talk with include any children, close friends as well as her PCP. Having releases of information and being able to talk with children and friends will help paint a more complete clinical picture of what the patient is experiencing. Insomnia can impact “Quality of life (QOL), daytime function, and mental, physical, and emotional health to deteriorate” ( Abad & Guilleminault, 2018, p. 792). Family and friends can provide information related to how the presenting patient lost her husband.

These people will be able to speak to the patients’ mood (elevation, spending habits, risk taking behaviors), daily activities, isolation or withdrawal from activities, food consumption and sleep habits if they live together. Speaking with the PCP would allow for an assessment of response to treatment since initiation of Sertraline, overall compliance with medication and follow-up as well as clinical observations of patients’ presentation at appointments and response to prescribed and recommended interventions. The PCP could also shed light onto the patients’ past history. NR 508 Week 6 Discussions 1 (Part One) Recent

Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.

In this situation, it would be appropriate to obtain the patients weight and vital signs. For trending purposes, blood pressure reading could indicate the patients’ compliance with medication, and weight could indicate any potential eating barriers to treatment such as over or under eating.

It would also be imperative to perform a mental status examination as this will help determine which class of medication may be safely administered. From a lab perspective, it would be important to obtain in the office a glucose reading as well as a CBC, CMP, TSH HGBA1C, and GFR. NR 508 Week 6 Discussions 1 (Part One) Recent

List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

A differential diagnosis for this patient would include Generalized anxiety disorder, major depressive disorder and bipolar disorder. Given the information provided, I am choosing a diagnosis generalized anxiety disorder for the patient. When meeting the patient, it will be important to explore any fear or worries the patient endorses such as loneliness, fear of being alone, fear of death, financial stress, all of which would support an anxiety diagnosis especially after the loss of a long term significant other.

Bipolar disorder is a consideration due to the patient being prescribed an antidepressant with minimal reported effect over the last 10 months as well as the patients report of insomnia and ongoing depressed mood state. NR 508 Week 6 Discussions 1 (Part One) Recent

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.

This patient has diabetes currently managed with two oral hypoglycemic agents. She is also on two antihypertensive medications. In order to ensure the patient is able to metabolize the prescribed medication, it will be important to prescribe a medication that is not harsh on the kidneys and is metabolized safely, while also targeting symptoms. Additionally, the patients age will need to be taken into consideration, which will impact dosing. NR 508 Week 6 Discussions 1 (Part One) Recent

One option for this patient is a low dose of Doxepin. Consideration must be given to the patient taking an SSRI which could increase the serum doxepin level. Sertraline can also cause CNS depression as well as serotonin syndrow when used in conjunction with Doxepin. Doxepin in a low dose may target depressive symptoms as well as treat insomnia, though should be used with extreme caution and close monitoring.

A second pharmacologic intervention for the insomnia, and a likely better option in this patient is Zolpediem ER low dose, secondary to a major depressive disorder diagnosis and suspected renal impairment secondary to diabetes diagnosis. Onset of the Zolpidem is approximately 45- 120 minutes after administration. NR 508 Week 6 Discussions 1 (Part One) Recent

The low dose sublingual formulation has a duration of action of approximately 4 hours, which will help the patient achieve adequate sleep but not remain sedated after completion of duration of action, and will target potential mid-sleep cycle waking (Monti, Spence, Buttoo,& Pandi-Perumal, 2017, p. 81). Zolpidem selectively affects GABA receptors in the brain and promotes sleep (Monti, Spence, Buttoo,& Pandi-Perumal, 2017, p. 81). Zolpidem concentration is highest in glandular tissue, and the patients weight supports the ability to utilize this medication. When taken together, sertraline and Zolpidem, there is an increased risk for CNS depression.

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?

Abad & Guilleminault, 2018, p. 792, identify that dosing of medication should start at the lowest available dose and medication should be used in conjunction with psychotherapy interventions for long term resolution of insomnia. As patients age, metabolism slows and kidney clearance decreases which could cause toxicity if medications and side effects are not closely monitored. NR 508 Week 6 Discussions 1 (Part One) Recent

Doxepin has the potential to be sedating, can impact glucose level and has strong anticholinergic properties. In this situation, the patient will require close monitoring and significant education will need to occur if Doxepin is utilized. Zolpidem is a safe medication to use if the appropriate dosage is achieved. NR 508 Week 6 Discussions 1 (Part One) Recent  Prior to initiation of treatment it would be best to ensure this patient does not live alone or to have a family member stay overnight initially to assess risk, as the risk for falls, abnormal thinking and driving a vehicle can all be impacted.

When compared to a benzodiazepine, Zolpidem does not produce a withdrawal effect, indication that a taper would likely not be necessary at the termination of this interventions use. At future appointments, the first appointment taking place at week 4, it would be imperative to ensure the patient is not sedated, and to provide education that Zolpidem is best used short-term in conjunction with psychotherapy. With both medication options, the dosage of sertraline will have to be monitored and considered as to how it will interact with either medication choice. NR 508 Week 6 Discussions 1 (Part One) Recent

References:

Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: Recommendations for pharmacological management. Drugs & Aging, 35(9), 791-817. doi:http://dx.doi.org/10.1007/s40266-018-0569-8

Comerford, K. C., & Durkin, M. T. (2021). Doxepin, Zolpidem. In Nursing 2021 drug handbook. essay, Wolters Kluwer.

Samara, M. T., Huhn, M., Chiocchia, V., Schneider, T. J., Wiegand, M., Salanti, G., & Leucht, S. (2020). Efficacy, acceptability, and tolerability of all available treatments for insomnia in the elderly: A systematic review and network meta?analysis. Acta Psychiatrica Scandinavica, 142(1), 6–17. https://doi.org/10.1111/acps.13201

Monti, J. M., Spence, D. W., Buttoo, K., & Pandi-Perumal, S. R. (2017). Zolpidem’s use for insomnia. Asian Journal of Psychiatry, 25, 79–90. https://doi.org/10.1016/j.ajp.2016.10.006