Please review the complete instructions and the grading rubric
**THIS
DISCUSSION IS DIVIDE IN TWO PARTS
–
1.
MAIN DISCUSSION POST BY
WEDNESDAY
1/12/2022
BEFORE 8
:
00 PM EST
2.
TWO REPLIES BY FRIDAY
01/14/2022
BEFORE 8:00 PM EST
Disc
u
ssio
n: Treatment for a
Pa
tient
with
a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a
common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD
(Abbott, 2016). Various studies have demonstrated the bidirecti
onal relationship between insomnia and
mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90%
of adults with depression experi
ence
sleep problems (Abbott, 2016). Due to the interconnected
psychopathology, i
t is important that you, as the PNP, understand the importance of the effects some
psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns.
Therefore, it is important that you understand and reflect on the evid
ence
–
based research in developing
treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate
psychopharmacologic treatments for optimal health and well
–
being.
Case
study
: 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 a
go.
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.
Pa
tient denies any suicidal ideations.
Patient arrived at the office today by private
vehicle.
Patient currently takes the following medications:
·
Metformin 500mg BID
·
Januvia 100mg d
aily
·
Losartan 100mg daily
·
HCTZ 25mg d
aily
·
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Discussio
n Instructions
:
For this Discussion
u
se the above
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 hea
lth needs.
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 sit
uation. 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.
· Use at least 5 references.
· Review the Grading Rubric
**THIS DISCUSSION IS DIVIDE IN TWO PARTS
–
1.
MAIN DISCUSSION POST BY
WEDNESDAY
1/12/2022
BEFORE 8:00 PM EST
2.
TWO REPLIES BY FRIDAY
01/14/2022
BEFORE 8:00 PM EST
Discussion: Treatment for a Patient
with
a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a
common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD
(Abbott, 2016). Various studies have demonstrated the bidirecti
onal relationship between insomnia and
mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90%
of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected
psychopathology, i
t is important that you, as the PNP, understand the importance of the effects some
psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns.
Therefore, it is important that you understand and reflect on the evid
ence
–
based research in developing
treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate
psychopharmacologic treatments for optimal health and well
–
being.
Case
study
: 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 a
go.
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.
Pa
tient denies any suicidal ideations.
Patient arrived at the office today by private
vehicle.
Patient currently takes the following medications:
·
Metformin 500mg BID
·
Januvia 100mg daily
·
Losartan 100mg daily
·
HCTZ 25mg d
aily
·
Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Discussio
n Instructions
:
For this Discussion
u
se the above
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 hea
lth needs.
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 sit
uation. 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.
**THIS DISCUSSION IS DIVIDE IN TWO PARTS –
1. MAIN DISCUSSION POST BY WEDNESDAY 1/12/2022 BEFORE 8:00 PM EST
2. TWO REPLIES BY FRIDAY 01/14/2022 BEFORE 8:00 PM EST
Discussion: Treatment for a Patient with a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a
common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD
(Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and
mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90%
of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected
psychopathology, it is important that you, as the PNP, understand the importance of the effects some
psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns.
Therefore, it is important that you understand and reflect on the evidence-based research in developing
treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate
psychopharmacologic treatments for optimal health and well-being.
Case study: 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:
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
Discussion Instructions: For this Discussion use the above 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.
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.
1/10/22, 10:52 PM Rubric Detail – Blackboard Learn
https://class.waldenu.edu/webapps/bbgs-deep-links-BBLEARN/app/course/rubric?course_id=_16910090_1&rubric_id=_2774589_1 1/7
Rubric Detail
Select Grid View or List View to change the rubric’s layout.
Excellent
Point range:
90–100
Good
Point range:
80–89
Fair
Point range:
70–79
Poor
Point range: 0–
69
Main Posting:
Response to
the Discussion
question is
re�ective with
critical
analysis and
synthesis
representative
of knowledge
gained from
the course
readings for
the module
and current
credible
sources.
40 (40%) – 44
(44%)
Thoroughly
responds to the
Discussion
question(s).
Is re�ective
with critical
analysis and
synthesis
representative
of knowledge
gained from
the course
readings for the
module and
current credible
sources.
No less than
75% of post has
exceptional
depth and
breadth.
Supported by
at least three
current credible
sources.
35 (35%) – 39
(39%)
Responds to
most of the
Discussion
question(s).
Is somewhat
re�ective with
critical analysis
and synthesis
representative
of knowledge
gained from
the course
readings for the
module.
50% of the post
has exceptional
depth and
breadth.
Supported by
at least three
credible
references.
31 (31%) – 34
(34%)
Responds to
some of the
Discussion
question(s).
One to two
criteria are not
addressed or
are super�cially
addressed.
Is somewhat
lacking
re�ection and
critical analysis
and synthesis.
Somewhat
represents
knowledge
gained from the
course readings
for the module.
Post is cited
with fewer than
two credible
references.
0 (0%) – 30 (30%)
Does not
respond to the
Discussion
question(s).
Lacks depth or
super�cially
addresses
criteria.
Lacks re�ection
and critical
analysis and
synthesis.
Does not
represent
knowledge
gained from the
course readings
for the module.
Contains only
one or no
credible
references.
Name: NURS_6630_Week7_Discussion_Rubric
EXIT
Grid View List View
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Excellent
Point range:
90–100
Good
Point range:
80–89
Fair
Point range:
70–79
Poor
Point range: 0–
69
Main Posting:
Writing
6 (6%) – 6 (6%)
Written clearly
and concisely.
Contains no
grammatical or
spelling errors.
Adheres to
current APA
manual writing
rules and style.
5 (5%) – 5 (5%)
Written
concisely.
May contain
one to two
grammatical or
spelling errors.
Adheres to
current APA
manual writing
rules and style.
4 (4%) – 4 (4%)
Written
somewhat
concisely.
May contain
more than two
spelling or
grammatical
errors.
Contains some
APA formatting
errors.
0 (0%) – 3 (3%)
Not written
clearly or
concisely.
Contains more
than two
spelling or
grammatical
errors.
Does not
adhere to
current APA
manual writing
rules and style.
Main Posting:
Timely and
full
participation
9 (9%) – 10 (10%)
Meets
requirements
for timely, full,
and active
participation.
Posts main
Discussion by
due date.
8 (8%) – 8 (8%)
Posts main
Discussion by
due date.
Meets
requirements
for full
participation.
7 (7%) – 7 (7%)
Posts main
Discussion by
due date.
0 (0%) – 6 (6%)
Does not meet
requirements
for full
participation.
Does not post
main
Discussion by
due date.
1/10/22, 10:52 PM Rubric Detail – Blackboard Learn
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Excellent
Point range:
90–100
Good
Point range:
80–89
Fair
Point range:
70–79
Poor
Point range: 0–
69
First
Response:
Post to
colleague’s
main post
that is
re�ective and
justi�ed with
credible
sources.
9 (9%) – 9 (9%)
Response
exhibits critical
thinking and
application to
practice
settings.
Responds to
questions
posed by
faculty.
The use of
scholarly
sources to
support ideas
demonstrates
synthesis and
understanding
of learning
objectives.
8 (8%) – 8 (8%)
Response has
some depth
and may
exhibit critical
thinking or
application to
practice setting.
7 (7%) – 7 (7%)
Response is on
topic, may have
some depth.
0 (0%) – 6 (6%)
Response may
not be on topic,
lacks depth.
1/10/22, 10:52 PM Rubric Detail – Blackboard Learn
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Excellent
Point range:
90–100
Good
Point range:
80–89
Fair
Point range:
70–79
Poor
Point range: 0–
69
First
Response:
Writing
6 (6%) – 6 (6%)
Communication
is professional
and respectful
to colleagues.
Response to
faculty
questions are
fully answered,
if posed.
Provides clear,
concise
opinions and
ideas that are
supported by
two or more
credible
sources.
Response is
e�ectively
written in
Standard,
Edited English.
5 (5%) – 5 (5%)
Communication
is mostly
professional
and respectful
to colleagues.
Response to
faculty
questions are
mostly
answered, if
posed.
Provides
opinions and
ideas that are
supported by
few credible
sources.
Response is
written in
Standard,
Edited English.
4 (4%) – 4 (4%)
Response
posed in the
Discussion may
lack e�ective
professional
communication.
Response to
faculty
questions are
somewhat
answered, if
posed.
Few or no
credible
sources are
cited.
0 (0%) – 3 (3%)
Responses
posted in the
Discussion lack
e�ective
communication.
Response to
faculty
questions are
missing.
No credible
sources are
cited.
First
Response:
Timely and
full
participation
5 (5%) – 5 (5%)
Meets
requirements
for timely, full,
and active
participation.
Posts by due
date.
4 (4%) – 4 (4%)
Meets
requirements
for full
participation.
Posts by due
date.
3 (3%) – 3 (3%)
Posts by due
date.
0 (0%) – 2 (2%)
Does not meet
requirements
for full
participation.
Does not post
by due date.
1/10/22, 10:52 PM Rubric Detail – Blackboard Learn
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Excellent
Point range:
90–100
Good
Point range:
80–89
Fair
Point range:
70–79
Poor
Point range: 0–
69
Second
Response:
Post to
colleague’s
main post
that is
re�ective and
justi�ed with
credible
sources.
9 (9%) – 9 (9%)
Response
exhibits critical
thinking and
application to
practice
settings.
Responds to
questions
posed by
faculty.
The use of
scholarly
sources to
support ideas
demonstrates
synthesis and
understanding
of learning
objectives.
8 (8%) – 8 (8%)
Response has
some depth
and may
exhibit critical
thinking or
application to
practice setting.
7 (7%) – 7 (7%)
Response is on
topic, may have
some depth.
0 (0%) – 6 (6%)
Response may
not be on topic,
lacks depth.
1/10/22, 10:52 PM Rubric Detail – Blackboard Learn
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Excellent
Point range:
90–100
Good
Point range:
80–89
Fair
Point range:
70–79
Poor
Point range: 0–
69
Second
Response:
Writing
6 (6%) – 6 (6%)
Communication
is professional
and respectful
to colleagues.
Response to
faculty
questions are
fully answered,
if posed.
Provides clear,
concise
opinions and
ideas that are
supported by
two or more
credible
sources.
Response is
e�ectively
written in
Standard,
Edited English.
5 (5%) – 5 (5%)
Communication
is mostly
professional
and respectful
to colleagues.
Response to
faculty
questions are
mostly
answered, if
posed.
Provides
opinions and
ideas that are
supported by
few credible
sources.
Response is
written in
Standard,
Edited English.
4 (4%) – 4 (4%)
Response
posed in the
Discussion may
lack e�ective
professional
communication.
Response to
faculty
questions are
somewhat
answered, if
posed.
Few or no
credible
sources are
cited.
0 (0%) – 3 (3%)
Responses
posted in the
Discussion lack
e�ective
communication.
Response to
faculty
questions are
missing.
No credible
sources are
cited.
Second
Response:
Timely and
full
participation
5 (5%) – 5 (5%)
Meets
requirements
for timely, full,
and active
participation.
Posts by due
date.
4 (4%) – 4 (4%)
Meets
requirements
for full
participation.
Posts by due
date.
3 (3%) – 3 (3%)
Posts by due
date.
0 (0%) – 2 (2%)
Does not meet
requirements
for full
participation.
Does not post
by due date.
Total Points: 100
Name: NURS_6630_Week7_Discussion_Rubric
EXIT
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I
n
s
tructions
:
Respond
to
yo
ur colle
a
g
ue
in one
of
the
following
ways:
·
If
your
colleague
’ posts influenced your underst
and
ing of
these
c
once
pts,
be
sure to sh
are
how
and why. Include additional insights you gained.
·
If you thin
k
your colleagues might
have
m
is
understood these concepts, offer your altern
at
ive
perspective
and be
sure to provide an explanation f
or
them. Include re
so
urces to support your
perspective
*
*minimum of
three
(3)
scholarly references are required
for
each
reply
cited
with
in the body of the reply & at the end
**
Reply
#
2
Cindy
Clermont
Top of
F
orm
C
as
e:
A
n
elderly
widow
who
just
lost
her
spouse
.
Subjective:
A
patient
present
s
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
died
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
x
3.
Patient
norm
all
y
sees
PCP
once or
twice
a
year.
Patient
denies
any
sui
cidal
ideations.
Patient
arrived
at the office today
by
private
vehicle.
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
inche
s
Temp:
98.6
degrees
F
BP:
132/86
The three
questions
that
I
would
ask
my
patient and the
rationales
behind
my questions are:
1.
I would extend my condolences and ask her;
when
wa
s the last time she has had a good
night’s sleep and what nonpharmacological regimen are you doing to assist?
2.
Do you have family? Do you have a family history of depression?
3.
I would ask about her PMH,
specifically
, confirming what diagnoses do you have, wh
en were
you diagnosed, when was the last time you took your medications and when were seen for a
follow up?
I would ask these questions specifically to
better
care for the
patient.
It
is
imperative
to
understand
the
psyche
of the patient
more
so
regarding
the death of her spouse of 41
years.
The patient
does
have a history of DM,
MDD,
and
HTN.
With
the death of her
spouse,
her
stress
and
anxiety
level
due
to
grieving
can
increase
as well as her
glucose
levels,
insomnia,
blood
pressure
etc.
It is
crucial
for the
safety
of the patient and the safety of all
people
involved
that these questions
concerns
be
addressed.
Major
depressive
disorder
(MDD)
is when
symptoms
are present
during
a
two
–
week
period and representing a clinically substantial change from previous functioning such as, depressed or irritable mood for most of the day, diminished interest in previously pleasurable activities, significant unintentional weight loss or weight gain, insomnia or hypersomnia, sluggishness, lethargy, feelings of worthlessness or excessive guilt, etc. (Oyama & Piotrowski, 2021).
· 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.
I would need to address why the patient arrived at the clinic by private vehicle. I would like to know if she has family or friends. I would question her living arrangements, lifestyle, and socioeconomics. I’d inquire about her support network—does she have friends/family to talk to? I would ask about her sleeping habits. What does she do for the day? Does she seem tired? Does she nap during the day? What is her bedtime routine?
· Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
I would do comprehensive health assessment and focus on the chief complaint. I would check the glucose level at this time, and still have labs drawn to rule out other possible issues. To determine if her glucose is under control, I would schedule an HGBA1C test. I would look into the patient’s use of HCTZ, as it’s possible that it’s causing her to urinate more frequently, which could be contributing to her insomnia and uncontrolled diabetes. Medication adjustments as well as when can be adjusted to safely control the symptoms of the patient.
· List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
The differential diagnosis that I would choose would be MDD and insomnia disorder. The patient has experienced a loss and is trying to cope but her body’s way of coping is causing an imbalance in the brain, and causing her anxiety, and can be exacerbating the depression, hence, the insomnia, the sleeping habits changing. Insomnia disorder is described by an extreme amount of distress or impairment in operation, and daytime symptoms including fatigue, daytime tiredness, cognitive impairment, and mood disturbances (Levenson et al., 2015).
· 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.
I would continue with the current regimen, sertraline 100mg daily, because the decrease in serotonin, the medication will work, and in adjunct with a benzodiazepine (BZD) to treat the anxiety that she is having which should help keep the patient calm, assist with stabling her mood and body so her vitals are lower. Lormetazepam was mostly prescribed in women with psychiatric issues and insomnia (Cosci et al., 2016). The combination of the two working on the
perspective
areas of the brain decreasing the physical signs and symptoms is the goal.
· 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?
What would be problematic would be if this becomes a long-term regimen, that the patient, depending upon her socio-demographics may possibly become addicted to the BZD (Cosci et al., 2016).
· 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.
After six weeks of treatment with a selective serotonin reuptake inhibitor (SSRI), she should show significant clinical improvements which would be evident by the significant improvements (Dutt et al., 2020). Continue the regimen for the depression and assess if the symptoms for GAD has decreased. If so, slowly take the patient off the BZD while educating her as what to do nonpharmacological to assist with her symptoms when they arise.
References
Cosci, F., Mansueto, G., Faccini, M., Casari, R., & Lugoboni, F. (2016). Socio-demographic and
clinical characteristics of benzodiazepine long-term users: Results from a tertiary care
center. Comprehensive Psychiatry, 69, 211–215.
https://doi.org/10.1016/j.comppsych.2016.06.008
Dutt, R., Shankar, N., Srivastava, S., Yadav, A., & Ahmed, R. S. (2020). Cardiac autonomic
tone, plasma BDNF levels and paroxetine response in newly diagnosed patients of
generalised anxiety disorder. International Journal of Psychiatry in Clinical
Practice, 24(2), 135–142.
https://doi.org/10.1080/13651501.2020.1723642
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia.
Chest, 147(4), 1179–1192.
https://doi.org/10.1378/chest.14-1617
Oyama, O. & Piotrowski, N. A. (2021). Depression. Magill’s Medical Guide (Online Edition).
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and why. Include additional insights you gained.
·
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#
2
Cindy
Clermont
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
died
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
sui
cidal
ideations.
Patient
arrived
at
the
office
today
by
private
vehicle.
Patient
currently
takes
the
following
medications:
·
Metformin
500mg
BID
·
Januvia
100mg
daily
·
Losartan
100mg
daily
·
HCTZ
25mg
daily
·
Sertraline
100mg
daily
Current
weight:
88
k
g
Current
height:
64
inche
s
Temp:
98.6
degrees
F
BP:
132/86
The
three
questions
that
I
would
ask
my
patient
and
the
rationales
behind
my
questions
are
:
1.
I would extend my condolences and ask her; when wa
s the last time she has had a good
night’s sleep and what nonpharmacological regimen are you doing to assist?
2.
Do you have family? Do you have a family history of depression?
3.
I would ask about her PMH, specifically, confirming what diagnoses do you have, wh
en were
you diagnosed, when was the last time you took your medications and when were seen for a
follow up?
I
would
ask
these
questions
specifically
to
better
care
for
the
patient.
It
is
imperative
to
understand
the
psyche
of
the
patient
more
so
regarding
the
death
of
her
spouse
of
41
years.
The
patient
does
have
a
history
of
DM,
MDD,
and
HTN.
With
the
death
of
her
spouse,
her
stress
and
anxiety
level
due
to
grieving
can
increase
as
well
as
her
glucose
levels,
insomnia,
blood
pressure
etc.
It
is
crucial
for
the
safety
of
the
patient
and
the
safety
of
all
people
involved
that
these
questions
concerns
be
addressed.
Major
depressive
disorder
(MDD)
is
when
symptoms
are
present
during
a
two
–
week
Instructions:
Respond to your colleague in one of the following ways:
If your colleague’ posts influenced your understanding of these concepts, be sure to share how
and why. Include additional insights you gained.
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
**minimum of three (3) scholarly references are required for each reply cited
within the body of the reply & at the end**
Reply # 2
Cindy Clermont
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 died 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:
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
The three questions that I would ask my patient and the rationales behind my questions are:
1. I would extend my condolences and ask her; when was the last time she has had a good
night’s sleep and what nonpharmacological regimen are you doing to assist?
2. Do you have family? Do you have a family history of depression?
3. I would ask about her PMH, specifically, confirming what diagnoses do you have, when were
you diagnosed, when was the last time you took your medications and when were seen for a
follow up?
I would ask these questions specifically to better care for the patient. It is imperative to understand
the psyche of the patient more so regarding the death of her spouse of 41 years. The patient does
have a history of DM, MDD, and HTN. With the death of her spouse, her stress and anxiety level due
to grieving can increase as well as her glucose levels, insomnia, blood pressure etc. It is crucial for
the safety of the patient and the safety of all people involved that these questions concerns be
addressed. Major depressive disorder (MDD) is when symptoms are present during a two-week
I
ns
t
r
ucti
o
n
s:
Resp
on
d
to
yo
ur colle
a
gue
in
one
of
t
he
following
way
s:
·
If
your colleague
’ posts influenced your underst
an
d
ing of these concepts,
be
sure to sh
are
how
and
why
.
In
clude add
it
ional insights you gained.
·
If you think your colleagues might
have
m
is
understood these concepts, offer your
alter
n
at
ive
perspective
and be
sure to provide an explanation
f
or
them. Include resources to s
up
port your
perspective
**
minimum of three
(3)
scholarly references are required
for
each
reply
cited
with
in the body of the reply & at the end
**
Reply
#
1
Leslie
Williams
Week
7:
E
ld
erly
woman
with
c/o
insomnia
Questions
for
Patient
After
introducing
myself
to the
patient
,
I
wou
ld
as
k
the
open
–
ended
question
of
what
brings
her
in
today?
In
ask
ing
this
,
I
hope
to
l
et
her
set
the
tone
of the
visit
,
have
some
control,
and
hopefully
find
out
how
she
has
been
feeling,
precisely
what has
brought
her
in,
and what her
expectations
are of
today’s
visit
(Ball
et
al.,
2015).
This
way,
I
know
exa
ctly
why she is
her
e,
her
concerns,
what she is
hoping
to
accomplish,
and
we
can
then
move
forward.
I can
also
enhance
or
elaborate
on her
response
,
and she
may
answer
m
any
questions
in this response
that
I
would
have
asked
later.
My
second
question would be
asking
her to
describe
her
sleep
patterns,
habits,
the
onset
of
when
she
started
having
trouble
sleeping,
if
she has
more
of an
issue
falling
asleep,
staying
asleep,
waking
up
earlier
than
she would
like.
With
this,
I would
want
her to describe any o
ther
symptoms
she has
noticed,
such
as
daytime
sleepiness,
dry
mouth
,
or
sore
throat
in the
mornings,
etc.
I would ask this question to
determine
the
root
cause
of her sleep
issues
and
because
depending
on some of the symptoms
could
alter
pharmacological
t
reatment.
For
instance,
If the patient
were
to
say
she has
difficulty
falling asleep,
frequently
wakes
in the
night
,
wakes up way earlier than she would
like,
I would
attribute
this more to her
MDD
.
Around
80%
of
patients
that have been
diagnosed
with MDD have
complaints
of insomnia
(Stahl,
2013).
If she were to describe
gasping
at night or a dry mouth or sore throat when she wakes
up,
or have a
history
of
snoring,
it could be that she
suffers
from
sleep
apnea.
She
is
obese
and has
HTN
and
DM,
which
puts
her at
increased
risk
for insomnia and sleep apnea. If insomnia
occurred
when her
sertraline
was
increased to
100
mg,
it is
most
likely
a
side
effect
from her
medication
.
Different
pharmacological
agents
work
better
for sleep
onset,
some for sleep
maintenanc
e, and some for
both
(Abad
et al.,
2018).
Another
question I would ask would
involve
medication
adherence.
It
would be an open-ended question to
see
if she
takes
her
antidepressant
as
prescribed.
My
rationale
for asking this is
even
though
I
don’t
know exactly how
long
she has been on
sertraline,
she has been on it long
enough
to be on a
maintenance
dose,
which means it had to be working for her at a certain level for them to keep her on it and increase her dose. She complains of her depression and her insomnia “getting worse.” This indicates that she may not be taking her medication as prescribed. Insomnia is a side effect of sertraline and a side effect of discontinuation syndrome. If it is not due to a noncompliance issue, I would want to administer the HDRS and see where she falls on it compared to her last reading. She needs a different antidepressant if she is not seeing results by now. If she is also following prescription as prescribed, this would be considered treatment-resistant depression (green book).
A final question I would have to ask in addition would be, has something happened recently to trigger an increase in her symptoms of depression possibly? Has insomnia made her depression worse? Or has another stressor happened? She is grieving; his birthday could have recently come and passed or what would have been their 50th wedding anniversary. Is sleeping alone scary for her, is she worried financially? Finding this out and seeing what support she has available to help her cope during the grieving process is significant.
Identify People in the Patient’s Life
With the patient’s permission, I would want to get information from her healthcare provider on her recent visit to see how well her DM, HTN, any concerning weight gain or losses, any testing for sleep apnea has occurred, has she been checked for thyroid issues. I would want to identify any adult children or caretakers, friends, or other family members in her life that help keep an eye on her and are her support system. People and relationships in her life matter. She needs them more than ever right now. Does she have anyone? If she does, I would want to ask about appetite changes, energy level, mood, any interests that seem to boost her mood. This would help me get a better picture of how this patient is adjusting to the loss of her husband and if those close to her are seeing any improvements or declines.
Physical Exam and Diagnostic Testing
If she has any symptoms, I will want to rule out sleep apnea by referring her to her healthcare provider for testing. She goes to see her healthcare provider twice a year, which is recommended for hypertension and DM when controlled. There is nothing in the case study to signify that it isn’t. In talking with her HCP, I would want her most current lab work, including LFTs, CBC, renal function tests, A1C, and serum electrolytes. These tests will help determine any deficiencies in metabolizing the medication and help rule out medical causes. Thyroid abnormalities can be associated with depression, so I want to collect thyroid function tests. I would administer the HDRS to see her current score and compare it to her last reading to see what category of depression she is currently in (Hamilton, 1960). The HDRS also includes various stages of insomnia and depression (Hamilton, 1960). I would also want to perform a functional assessment because depression does contribute to cognitive impairment (Ball et al., 2015).
Differential Diagnosis
She could have sleep apnea due to a BMI of 32.2, a history of hypertension, and DM. There is not enough information to determine this. She may have medication nonadherence with insomnia as a side effect from discontinuation syndrome. There is not enough information to determine this. She could have treatment-resistant depression because her depression is getting worse, but I do not know if she has had an adequate trial of the medication at 100 mg and her HDRS score or if she has been adhering to the drug. She says her depression has gotten worse, but worse from what score? Based on the information given, she most likely has insomnia secondary to sertraline, MDD, and the loss of her husband. She does not have a history of insomnia which means it has started either since the loss of her husband or as a side effect of the sertraline. She could have had sleeping issues once her husband died, which initiated major depression. Or, it could be due to the increase in dosage from the sertraline. Insomnia could be exacerbating her MDD, making it worse at this time.
Pharmacologic Agents
At this point, due to not knowing how long she has been on the 100 mg of sertraline and what her HDMR score is, I am going to leave her on for now and assume she has not been on it long enough to reach efficacy or that she has not been taking as prescribed. Having insomnia can exacerbate her depression symptoms and make her irritable, and this may be why she feels like her depression is worse. There is not enough information. I would consider augmenting Trazodone 25 mg daily or mirtazapine. Augmenting with hypnotics to first-line treatments of depression makes rational sense considering insomnia is such a frequent complaint when treating depression (Stahl, 2013).
Stimulating the 5HT2A receptors through increased synaptic 5-HT is responsible for a side effect of insomnia from SSRIs (Jaffer et al., 2017)). Blocking 5-HT2 receptors using Trazadone can reduce insomnia caused by SSRIs (Jaffer et al., 2017). Trazadone helps with insomnia because it moderates cortisol suppression of the hypothalamic-pituitary-adrenal axis (Jaffer et al., 2017). There is a blockade of serotonin 5-HT2A and on histamine H1, which helps produce the hypnotic effect of trazodone, allowing patients to fall asleep and stay asleep without the side effects of larger doses that would cause daytime drowsiness and without causing addiction, mainly due to the 3-6 hour half-life (Jaffer et al., 2017). Trazadone is rapidly and almost entirely absorbed by the GI tract with a peak plasma concentration within 1-2 hours after oral administration (Jaffer et al., 2015). Having a light snack with this medication may improve absorption and help with possible side effects, including orthostatic hypotension (Jaffer et al., 2015).
Mirtazapine starting at 15mg daily, is an antidepressant that has also been used off-label for insomnia. This medication has shown improvement in helping with sleep latency, efficiency, and awakenings through the night after two weeks of treatment (Patel et al., 2018). This drug is a potent 5-HT2 antagonist and produces sedative effects quickly through histamine receptor antagonism (Patel et al., 2018). Mirtazapine has a bioavailability of 50% and reaches peak plasma levels two hours after oral administration (Patel et al., 2018). Steady-state plasma levels are achieved within five days with 50% accumulation (Patel et al., 2018).
I would choose trazodone 25 mg PO at bedtime for this patient over mirtazapine. The benefits of treating patients with MDD by taking sertraline with Trazadone outweigh the risks. Trazadone is metabolized by the liver; in RCTs performed, even in patients with liver impairment, there were no significant differences compared to patients who did not have a liver impairment (Cuomo, 2019). Studies have shown that using these two together has improved insomnia and depression (Cuomo, 2019). Trazadone carries a low risk of anticholinergic effects, weight gain, and it has strong efficacy and safety in low doses in the treatment of insomnia (Cuomo, 2019). Mirtazapine has a high potential for weight gain by increasing appetite and food cravings, and the patient is already obese, has hypertension and DM (Patel et al., 2018). I do not want this patient to gain any additional weight.
Ethical Prescribing and Decision-making
This patient is in the geriatric population and is has an increased sensitivity to medications because of pharmacokinetic changes from aging, such as reduced hepatic function. Her medical history of hypertension, obesity and DM further increases these sensitivities. Using the lowest dose that will be therapeutic for her with the least amount of side effects will be needed while using Trazadone. 25 mg PO with a snack at bedtime is recommended for her (Cuomo, 2015). The risk of serotonin increases due to both sertraline and Trazadone due to the serotonin reuptake inhibition that they both cause (Rosenthal & Burchum, 2021). Another risk is hyponatremia. Both HCTZ, tramadol, and sertraline increase the risk of hyponatremia. Increased sodium is released in response to increased serotonin, which stimulates ADH secretion (Rosenthal & Burch, 2021).
However, the risk for hyponatremia at this low dose is unlikely. A baseline of electrolytes and monitoring periodically throughout these patient visits will be necessary. Another issue could be orthostatic hypotension. Trazodone, losartan, and HCTZ all have the potential to cause this. Administering trazodone with a light snack can help slow absorption and possibly minimize this risk. These side effects are not as likely at the low dose she will be on, but because of her potential for drug sensitivity due to age and other medications that increase the risk, the risk is increased. I would also want to let this patient know that this medication is being used off-label for insomnia. The patient needs to be aware of the risks and the benefits before starting this medication.
Checkpoints
The patient will need weekly visits with the psychiatric NP for the first four weeks to monitor outcomes for insomnia and depression. Research for the efficacy of Trazodone long term is limited, so it should only be used short time (Drugs.com, n.d.). If her insomnia and depression begin to improve, it could be that the insomnia was exacerbating her depression. If her depression does not improve, but her insomnia does, at this point, we will need to look into changing her depression medication. In addition, if she is not already receiving it, I recommend her having psychotherapy to help with her grief, MDD and find positive coping skills (Patel et al., 2018). Research on trazodone’s long-term efficacy and safety for insomnia is limited (Patel et al., 2018). The existing evidence suggests that trazodone should only be a short-term solution for sleep problems, as very little research has been done on continuation treatment. This patient also needs education to assist her with sleep hygiene (Patel et al., 2018).
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to
physical examination: An interprofessional approach (9th ed.). Elsevier Mosby. Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., … & Fagiolini, A. (2019). Clinical
guidance for the use of trazodone in major depressive disorder and concomitant conditions:
pharmacology and clinical practice. Rivista di psichiatria, 54(4), 137-149.Drugs.com. n.d.
Trazodone. Retrieved from
Trazodone – Search results. Page 1 of about 8184 results (drugs.com)
HAMILTON M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960 Feb;23(1):56-
62. doi: 10.1136/jnnp.23.1.56. PMID: 14399272; PMCID: PMC495331.
Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., &
Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical
neuroscience, 14(7-8), 24–34.
Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep
medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6),
1017–1024.
https://doi.org/10.5664/jcsm.7172
Rosenthal, L. D., & Burchum, J. R. (2021). Lehne’s pharmacotherapeutics for advanced
practice nurses and physician assistants (2nd ed.). Elsevier.
Stahl, S. (2013) Stahl’s essential psychopharmacology: neuroscientific basis and practical
application. (4th ed.). Cambridge University Press.
Instructions:
Respond
to
yo
ur colleague
in one of the following ways:
·
If your colleague
’ posts influenced your understanding of these concepts, be sure to share how
and why. Include additional insights you gained.
·
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
**minimum of three
(3)
scholarly references are required for each
reply
cited
within the body of the reply & at the end
**
Reply
#
1
Leslie
Williams
Week
7:
Elderly
woman
with
c/o
insomnia
Questions
for
Patient
After
introducing
myself
to
the
patient,
I
would
ask
the
open
–
ended
question
of
what
brings
her
in
today?
In
asking
this,
I
hope
to
let
her
set
the
tone
of
the
visit,
have
some
control,
and
hopefully
find
out
how
she
has
been
feeling,
precisely
what
has
brought
her
in,
and
what
her
expectations
are
of
today’s
visit
(Ball
et
al.,
2015).
This
way,
I
know
exactly
why
she
is
here,
her
concerns,
what
she
is
hoping
to
accomplish,
and
we
can
then
move
forward.
I
can
also
enhance
or
elaborate
on
her
response,
and
she
may
answer
many
questions
in
this
response
that
I
would
have
asked
later.
My
second
question
wou
ld
be
asking
her
to
describe
her
sleep
patterns,
habits,
the
onset
of
when
she
started
having
trouble
sleeping,
if
she
has
more
of
an
issue
falling
asleep,
staying
asleep,
waking
up
earlier
than
she
would
like.
With
this,
I
would
want
her
to
describe
any
o
ther
symptoms
she
has
noticed,
such
as
daytime
sleepiness,
dry
mouth,
or
sore
throat
in
the
mornings,
etc.
I
would
ask
this
question
to
determine
the
root
cause
of
her
sleep
issues
and
because
depending
on
some
of
the
symptoms
could
alter
pharmacological
t
reatment.
For
instance,
If
the
patient
were
to
say
she
has
difficulty
falling
asleep,
frequently
wakes
in
the
night,
wakes
up
way
earlier
than
she
would
like,
I
would
attribute
this
more
to
her
MDD.
Around
80%
of
patients
that
have
been
diagnosed
with
MDD
have
complaints
of
insomnia
(Stahl,
2013).
If
she
were
to
describe
gasping
at
night
or
a
dry
mouth
or
sore
throat
when
she
wakes
up,
or
have
a
history
of
snoring,
it
could
be
that
she
suffers
from
sleep
apnea.
She
is
obese
and
has
HTN
and
DM,
which
puts
he
r
at
increased
risk
for
insomnia
and
sleep
apnea.
If
insomnia
occurred
when
her
sertraline
was
increased
to
100
mg,
it
is
most
likely
a
side
effect
from
her
medication.
Different
pharmacological
agents
work
better
for
sleep
onset,
some
for
sleep
maintenanc
e,
and
some
for
both
(Abad
et
al.,
2018).
Another
question
I
would
ask
would
involve
medication
adherence.
It
would
be
an
open
–
ended
question
to
see
if
she
takes
her
antidepressant
as
prescribed.
My
rationale
for
asking
this
is
even
though
I
don’t
know
exa
ctly
how
long
she
has
been
on
sertraline,
she
has
been
on
it
long
enough
to
be
on
a
maintenance
dose,
which
Instructions:
Respond to your colleague in one of the following ways:
If your colleague’ posts influenced your understanding of these concepts, be sure to share how
and why. Include additional insights you gained.
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
**minimum of three (3) scholarly references are required for each reply cited
within the body of the reply & at the end**
Reply # 1
Leslie Williams
Week 7: Elderly woman with c/o insomnia
Questions for Patient
After introducing myself to the patient, I would ask the open-ended question of what brings her in
today? In asking this, I hope to let her set the tone of the visit, have some control, and hopefully find out how
she has been feeling, precisely what has brought her in, and what her expectations are of today’s visit (Ball et
al., 2015). This way, I know exactly why she is here, her concerns, what she is hoping to accomplish, and we
can then move forward. I can also enhance or elaborate on her response, and she may answer many questions in
this response that I would have asked later.
My second question would be asking her to describe her sleep patterns, habits, the onset of when she
started having trouble sleeping, if she has more of an issue falling asleep, staying asleep, waking up earlier than
she would like. With this, I would want her to describe any other symptoms she has noticed, such as daytime
sleepiness, dry mouth, or sore throat in the mornings, etc. I would ask this question to determine the root cause
of her sleep issues and because depending on some of the symptoms could alter pharmacological treatment. For
instance, If the patient were to say she has difficulty falling asleep, frequently wakes in the night, wakes up way
earlier than she would like, I would attribute this more to her MDD. Around 80% of patients that have been
diagnosed with MDD have complaints of insomnia (Stahl, 2013). If she were to describe gasping at night or a
dry mouth or sore throat when she wakes up, or have a history of snoring, it could be that she suffers from sleep
apnea. She is obese and has HTN and DM, which puts her at increased risk for insomnia and sleep apnea. If
insomnia occurred when her sertraline was increased to 100 mg, it is most likely a side effect from her
medication. Different pharmacological agents work better for sleep onset, some for sleep maintenance, and
some for both (Abad et al., 2018).
Another question I would ask would involve medication adherence. It would be an open-ended question
to see if she takes her antidepressant as prescribed. My rationale for asking this is even though I don’t know
exactly how long she has been on sertraline, she has been on it long enough to be on a maintenance dose, which
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