NURS 6630 Treatment for a Patient With a Common Condition

NURS 6630 Treatment for a Patient With a Common Condition

A Sample Answer For the Assignment: NURS 6630 Treatment for a Patient With a Common Condition

Three Questions to Ask the Patient and the Rationale

How much caffeine/alcohol do you consume?

Insomnia complaints are sometimes due to dietary choices. Caffeine taken late in the day can interfere with sleep. This causes a person to consume more the following day, creating a vicious cycle of being addicted to caffeine.

Do you snore?

The patient is obese, with a BMI of 34.37. Hargens et al. (2013) state that persons with obesity may report insomnia. Besides, snoring is often associated with obstructive sleep apnea (OSA). OSA is also strongly associated with obesity.

Do you have leg cramps at bedtime?

The questions help screen for restless legs syndrome (RLS). RLS can lead to delayed onset of sleep, reduced sleep time, and difficulty maintaining sleep. RLS is also associated with obesity, as those with a high BMI tend to have RLS compared to those with a low BMI (Hargens et al., 2013).

People in the Patient’s life to Speak to, Questions to Ask and the Rationale

If the patient has children and other relatives, such as siblings, they can help determine insomnia’s familial or biological cause. I can ask the family members if they have a similar problem. This will help to identify if any first-degree relative has a sleep problem (Beaulieu-Bonneau et al., 2007). Another question is about which type of sleep problem the family members experience, such as sleep apnea, restless leg syndrome, or daytime sleepiness.

Any Useful Physical Exams and Diagnostic Tests and How to Use the Results

First, the patient is taking antidepressants which can cause insomnia. The patient is also taking diabetics medications such as metformin which can lead to sleep disturbance. Losartan may also lead to sleep difficulties. Currently, the patient’s insomnia is highly likely due to medications. It is first important to treat insomnia due to medication effects.

Besides, I can assess insomnia further using sleep diaries and questionnaires that the patient can present during the follow-up visits. One tool is the insomnia rating scale which will aid in recording the symptoms and treatment response. Wrist actigraphy will also help monitor and store movement data to assist in monitoring treatment response and other circadian issues that may lead to insomnia (Patel et al., 2018).

Differential Diagnosis and the most Likely One

• Insomnia due to drugs
• Insomnia due to a medical condition

The most likely differential diagnosis is insomnia due to drugs. The patient is taking medications to manage moods, hypertension, and diabetes. Khandelwal et al. (2017) assert that sleep disturbances are common in people with diabetes. People with diabetes report higher rates of poor sleep quality, excessive daytime sleepiness, and insomnia.

Sleep disturbances may be due to rapid changes in blood glucose levels during the night due to medications. Insomnia may also be due to hypertension drugs. The patient is taking HCTZ  to manage hypertension, and the restlessness associated with the drug may lead to sleep disturbances. Sertraline, an antidepressant, may also be contributing to insomnia.

Pharmacologic Agents, Dosing and the Most Preferred

• Doxepin 3mg once a day
• Eszopiclone 1mg once a day at bedtime

At low doses, doxepin blocks the wake-promoting impacts of histamine. Adults aged 65 and older report high sleep onset with 3mg/day doxepin when taken 30 minutes before bedtime (Patel, 2018). It has a peak time of 3.5 hours (Almasi & Meza, 2019). It is highly distributed to other body tissue compartments. It is excreted through urine. It also has a high plasma protein binding rate.

Eszopiclone is rapidly absorbed and binds with plasma proteins at a rate of 52% to 59% taking about one hour. It is metabolized in the liver following oral administration. Elimination occurs after 6 hours, and about 10% or less of the dose is excreted in the urine (Brielmaier, 2006). When taken with a high-fat meal, it may lead to a one-hour delay in achieving peak concentration.

The most preferred drug is Eszopiclone 1mg/day at bedtime as there are evidence-based studies on its use among the eldrly above 65 years old. It has a peak time of one hour compared to 3.5 hours of doxepin. Fundamentally, although doxepin is highly effective, it should be avoided for patients above 65 years old (Almasi & Meza, 2019).

Contraindications of the Drug

Eszopiclone has no known contraindications. However, because the patient has depression, the drug should be cautiously administered. It is important to start with the smallest dose (Brielmaier, 2006). Long-term use of the drug may lead to physical and psychological dependence.

Check Points and Therapeutic Changes

After four weeks of 1mg eszopiclone daily, I expect improvements in total sleep time, quality, and depth of sleep, including the number of awakenings without side effects (Kirkwood & Breden, 2010). I will increase the dosage to 2mg/day. In the eighth week, I expect significant improvements in total sleep time, quality and sleep depth, daytime alertness, and a higher sense of physical well-being.

The patient will continue with 2 mg/day dosage for four more weeks. After 12 weeks of 2mg treatment, I expect a significant improvement in sleep, social life, and daily responsibilities. I will also encourage the patient to practice sleep hygiene and engage in physical activity due to her weight and to improve her sleep.

References

Almasi, A., & Meza, C. E. (2019). Doxepin. NIH National Library of Medicine, National center for biotechnology information. Statpearls. January 2022.

Beaulieu-Bonneau, S., LeBlanc, M., Mérette, C., Dauvilliers, Y., & Morin, C. M. (2007). Family history of insomnia in a population-based sample. Sleep, 30(12), 1739-1745.

Brielmaier, B. D. (2006, January). Eszopiclone (Lunesta): a new nonbenzodiazepine hypnotic agent. In Baylor University Medical Center Proceedings (Vol. 19, No. 1, pp. 54-59). Taylor & Francis.

Hargens, T. A., Kaleth, A. S., Edwards, E. S., & Butner, K. L. (2013). Association between sleep disorders, obesity, and exercise: a review. Nature and Science of Sleep, 27-35.

Khandelwal, D., Dutta, D., Chittawar, S., & Kalra, S. (2017). Sleep disorders in type 2 diabetes. Indian Journal of Endocrinology and Metabolism, 21(5), 758.

Kirkwood, C., & Breden, E. (2010). Management of insomnia in elderly patients using eszopiclone. Nature and Science of Sleep, 151-158.

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024.

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.

Reference:

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-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29
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 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

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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.
Read a selection of your colleagues’ responses.

By Day 6 of Week 7

Respond to at least two of your colleagues on two different days in one of the following ways:
• If your colleagues’ 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.Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days and

It’s evident that the comprehensive set of questions addresses the patient’s insomnia and underlying mental health concerns empathetically. By probing into the patient’s sleep patterns before and after her husband’s passing, evaluating the impact on mood and overall functioning, and exploring other emerging symptoms, the healthcare provider can grasp the multifaceted nature of her condition. Seeking feedback from family and healthcare providers further enriches the diagnostic process.

The proposed differential diagnoses, considering major depressive disorder (MDD), adjustment disorder with depressed mood, and mixed anxiety-depressive disorder, demonstrate a thoughtful approach. MDD appears most likely, aligning with the temporal relationship between symptoms and the husband’s death. The pharmacologic recommendations of sertraline and escitalopram, both SSRIs, exhibit a nuanced understanding of medication choices (Rissardo & Caprara, 2020). The emphasis on patient characteristics and preferences for selecting between the two drugs reflects a patient-centered approach.

The inclusion of contraindications and dosing alterations underscores the importance of safety. The cautious consideration of interactions and potential QTc interval prolongation reflects a commitment to patient well-being. The proposed checkpoints and therapeutic changes at weeks 4, 8, and 12 showcase a proactive and dynamic treatment plan (Szuhany & Simon, 2022). This approach, involving dosage adjustments, medication switches, and potential addition of non-benzodiazepine hypnotics, indicates a commitment to ongoing assessment and optimization.

Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!

For this discussion, a patient presents to your primary care office today with chief complaints of insomnia. Patient is a 75 y/o 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 ideation. Patient arrived at the office today by private vehicle.

Questions for Patient

1. Have you been taking your daily medications as directed? The patient is noted to be on Zoloft along with other medications for HTN and DM. Sertraline is medication is and antidepressant used as a first-line treatment of major depressive disorder. (Singh & Saadabadi, 2022) Before we try to distinguish if the medication is working, we must first have a direct conversation with the patient to ensure that the patient is adhering to the medication as directed.
2. Prior to your spouse’s death, have you ever suffered from anxiety or depression? The provider must first establish if the patient is still in the stages of grief, or if the patient is experiencing true MDD. While assessing the elderly patient for depression, it is important to remember that elderly patients often under-report their depressive symptoms and they may not acknowledge being sad, down, or depressed. (Avasthi & Grover, 2018) if the patient has been adhering to the medication, and the medication is found not to be effective, this could indicate that the patient is still experiencing grief.
3. Can you tell me about your bedtime routine? It is important that if the patient does not already have a bedtime routine that one gets established to help the patient achieve the best outcomes. Sleep disorders are among the most common disorders of aging; however, they are often overlooked by both clinicians and researchers as mere symptoms of other “primary” disorders. (Dzierzewski & Dautovich, 2018)

Questions for the family/friends of the patient

1. Although the case description does not state whether the patient has family, I would want to inquire to the patient’s family or caregivers about her daily routine. Does the patient perform her daily routines? How is the patient eating? Has the patient been more withdrawn recently? Have they noticed any changes in the patient’s behavior? Symptoms of depression may be different or less obvious in older adults, such as memory difficulties, personality changes, physical aches or pains, fatigue or loss of appetite and often wanting to stay home instead of socializing. Suicidal thinking or feelings could also be present. (Depression (Major Depressive Disorder) – Symptoms and Causes – Mayo Clinic, n.d.)
2. Does the patient attend church? Does the patient have a social routine? Has she been attending these functions? The provider needs to understand the type of life both before the patient lost her husband, and after she lost her husband to gauge what the psychosocial needs may be for this patient. Psychosocial support should be allocated to individuals at higher DL stages because of their greater mental health needs. (Na & Streim, 2017)  Lack of a social network can have an impact on the patient’s physical health.

Diagnostic Testing

I would begin with a Head-to-toe assessment of the patient while in my office. Upon completion of that, I would administer the Geriatric Depression Scale 15 (GDS-15) at this time. The 15-item GDS is a short form of the GDS and is used to screen, diagnose, and evaluate depression in elderly individuals. (Shin et al., 2019) This would help to determine where the patient is in terms of her depression. I would also consider drawing some lab work such as a CBC w/diff, and a BMP to rule out any infection.

Because the patient is a diabetic, I would also want to draw a Hemoglobin A1C to ensure that the patient’s blood glucose is within normal limits, and this will also help to see if the patient is adhering to her medications. An MRI may be warranted based on the patient’s head to toe assessment, and the answers received from family and caregivers of the patient. This would only be necessary if there were to be notable changes in the patient’s moods, mannerisms, or memory.

Differential Diagnosis

1. Major Depressive Disorder MDD is medical condition that includes abnormalities of affect and mood, neurovegetative functions, (such as appetite and sleep disturbances), cognition, (such as inappropriate guilt and feelings of worthlessness), and psychomotor activity (such as agitation or retardation). (Fava & Kendler, 2000)
2. Insomnia Sleep onset or initial insomnia is manifested by difficulty falling asleep that occurs at the start of the sleep period. (Brewster et al., 2018) If the patient is having trouble sleeping, I would encourage and teach the patient the importance of a bedtime routine or ritual to prepare the patient for bed and to encourage a healthy sleep routine.

Treatment Recommendation

 After carefully reviewing all the information provided at this visit, at this time my treatment recommendation would consist of beginning the patient on a bedtime routine and consider changing the medication to Trazadone.

Trazadone is an established medication that is efficacious for the treatment of a broad array of depressive symptoms, including symptoms that are less likely r respond to other antidepressants (e.g. SSRI) such as insomnia. (Cuomo et al., 20190701) by changing the medication, it would allow the patient to be treated for both the depression and the insomnia and would offer the patient a better patient outcome than that which was previously achieved by the Sertraline.

Ethical Considerations

Ethically, we would want to ensure that this patient has no previous history of suicidal ideation, and we would want to rule out the potential of any dementia to ensure that the patent would be able to achieve the desired effects of the new SSRI. We would also want to consider that in the elderly patient, hyponatremia can be a side effect in the patient being treated with an SSRI.

Hyponatremia is an electrolyte disorder that can be caused by multiple factors, among which the syndrome of inappropriate antidiuretic home secretion is one of the most frequent causes. This effect was more significant in elderly patients. (Mazzoglio y Nabar et al., 2022)

Check Points

I would want the patient to return to the office in 4 weeks so we can re-evaluate how she is doing upon starting the Trazadone. I would want to draw a Na level at that visit as well to check for hyponatremia. If the symptoms have improved and the patient’s sodium level remained stable, then I would make no changes. If the medication was found to not be effective, at this check point, I would consider this being treatment resistant depression and would consider both CBT and alternative treatment.

References

Avasthi, A., & Grover, S. (2018). Clinical practice guidelines for management of depression in elderly. Indian Journal of Psychiatry, 60(7), 341. https://doi.org/10.4103/0019-5545.224474

Brewster, G. S., Riegel, B., & Gehrman, P. R. (2018). Insomnia in the older adult. Sleep Medicine Clinics, 13(1), 13–19. https://doi.org/10.1016/j.jsmc.2017.09.002

Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Sciascio, G. D., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (20190701). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: Pharmacology and clinical practice. Rivista di Psichiatria. https://doi.org/10.1708/3202.31796

Depression (major depressive disorder) – symptoms and causes – mayo clinic. (n.d.). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/depression/symptoms-causes/syc-20356007

Dzierzewski, J. M., & Dautovich, N. D. (2018). Who cares about sleep in older adults? Clinical Gerontologist, 41(2), 109–112. https://doi.org/10.1080/07317115.2017.1421870

Fava, M., & Kendler, K. S. (2000). Major depressive disorder. Neuron, 28(2), 335–341. https://doi.org/10.1016/s0896-6273(00)00112-4

Mazzoglio y Nabar, M. J., Muniz, M. M., Montivero, C. A., Schraier, G., & Leidi Terren, E. E. (2022). Hyponatremia secondary treatment with ssri antidepressants in adults and elderly. CNS Spectrums, 27(2), 243–244. https://doi.org/10.1017/s1092852922000505

Na, L., & Streim, J. E. (2017). Psychosocial well-being associated with activity of daily living stages among community-dwelling older adults. Gerontology and Geriatric Medicine, 3, 233372141770001. https://doi.org/10.1177/2333721417700011

Shin, C., Park, M., Lee, S.-H., Ko, Y.-H., Kim, Y.-K., Han, K.-M., Jeong, H.-G., & Han, C. (2019). Usefulness of the 15-item geriatric depression scale (gds-15) for classifying minor and major depressive disorders among community-dwelling elders. Journal of Affective Disorders, 259, 370–375. https://doi.org/10.1016/j.jad.2019.08.053

Singh, H., & Saadabadi, A. (2022). Sertraline. StatPearls.

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