NURS 6630 Discussion Treatment for Patient With Common Condition

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How to Research and Prepare for NURS 6630 Discussion Treatment for Patient With Common Condition                     

Whether one passes or fails an academic assignment such as the Walden University NURS 6630 Discussion Treatment for Patient With Common Condition depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

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The introduction for the Walden University NURS 6630 Discussion Treatment for Patient With Common Condition is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

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After the introduction, move into the main part of the NURS 6630 Discussion Treatment for Patient With Common Condition assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6630 Discussion Treatment for Patient With Common Condition                     

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6630 Discussion Treatment for Patient With Common Condition                     

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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

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

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!

 Hey Aileen! I thoroughly enjoyed reading your discussion post this week on the patient with insomnia. I personally did not choose sertraline due to the patient being on this medication and her having depressive symptoms. According to Stahl (2021), sertraline is generally tolerated in lower doses in elderly patients, so increasing the dose may not be the best method of pharmacological intervention, and may require switching agents to find one that works best for her depressive symptoms (Stahl, 2021). Additionally, escitalopram may not be an appropriate choice for this patient due to the side effect of insomnia (Stahl, 2021). For this patient, I would choose a medication such as Trazodone that has the FDA approval for the treatment of depression as well as the FDA off label indication for insomnia (Stahl, 2021). Trazodone, according to Jaffer et. Al (2017) is a medication that is used for the primary or secondary treatment of insomnia as well as depression (Jaffer et. Al, 2017). It is also described that this medication is a very good choice in regards to patients with depression who also suffer with insomnia due to it being well tolerated and having effects on both of these symptoms (Jaffer et. Al, 2017).

     Next, I appreciated the questions you would ask the patient for the initial interview of the patient. I fund these questions to encompass much of the problem at hand. One of the other questions that can be asked of the patient is their behavioral habits before they go to sleep at night with such inquiries as if they watch television at night before bed, or what they do before they lay down at night (Pacheco & Rehman, 2023). Another question that can be asked is about caffeine intake. These questions can indicate whether medic action is not the first line treatment for this patient, or if this insomnia is related to behavioral changes instead. Thank you for your post!

References

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.

Pacheco, D., & Rehman, A. (2023, December 22). Diagnosing insomnia. Sleepfoundation.org. Retrieved January 11, 2024, from

Diagnosing Insomnia

Stahl, S. M. (2021). Stahl’s essential psychopharmacology prescriber’s guide (7th ed.). Cambridge University Press.

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Submission and Grading Information

Grading Criteria

To access your rubric:

Week 7 Discussion Rubric

Post by Day 3 of Week 7 and Respond by Day 6 of Week 7

To Participate in this Discussion:

Week 7 Discussion

Week 7: Therapy for Patients With Schizophrenia

According to the Schizophrenia and Related Disorders Alliance of America, approximately 3.5 million

people in the United States are diagnosed with schizophrenia (n.d.), and it is one of the leading causes of disability. In practice, patients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals.

Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders, such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for patients.

This week, as you examine antipsychotic therapies, you explore the assessment and treatment of patients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies.

_Reference:

_{Schizophrenia and Related Disorders Alliance of America. (n.d.). About  schizophrenia. https://sardaa.org/resources/about-schizophrenia/#:~:text=Quick%20Facts%20About%20Schizophrenia.%20Schizophrenia%20can%20be%20found,is%20one%20of%20the%20leading%20causes%20of%20disability}

Learning Objectives

Students will:

• Assess client factors and history to develop personalized therapy plans for patients with insomnia
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for insomnia
• Assess patient factors and history to develop personalized plans of antipsychotic therapy for patients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring antipsychotic therapy
• Synthesize knowledge of providing care to patients presenting for antipsychotic therapy
• Analyze ethical and legal implications related to prescribing antipsychotic therapy to patients across the lifespan

Learning Resources

Required Readings (click to expand/reduce)

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002

Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

amisulpride aripiprazole asenapine brexpiprazole cariprazine chlorpromazine clozapine flupenthixol fluphenazine haloperidol iloperidone loxapine lumateperone	lurasidone olanzapine paliperidone perphenazine pimavanserin quetiapine risperidone sulpiride thioridazine thiothixene trifluoperazine ziprasidone

Required Media (click to expand/reduce)

Case study: Pakistani woman with delusional thought processes
Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources (click to expand/reduce)

Chakos, M., Patel, J. K., Rosenheck, R., Glick, I. D., Hammer, M. B., Tapp, A., Miller, A. L., & Miller, D. D. (2011). Concomitant psychotropic medication use during treatment of schizophrenia patients: Longitudinal results from the CATIE study. Clinical Schizophrenia & Related Psychoses, 5(3), 124–134. https://doi.org/10.3371/CSRP.5.3.2

Fangfang, S., Stock, E. M., Copeland, L. A., Zeber, J. E., Ahmedani, B. K., & Morissette, S. B. (2014). Polypharmacy with antipsychotic drugs in patients with schizophrenia: Trends in multiple health care systems. American Journal of Health-System Pharmacy, 71(9), 728–738. https://doi.org/10.2146/ajhp130471

Lin, L. A., Rosenheck, R., Sugar, C., & Zbrozek, A. (2015). Comparing antipsychotic treatments for schizophrenia: A health state approach. The Psychiatric Quarterly, 86(1), 107–121. https://doi.org/10.1007/s11126-014-9326-2

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.

Three possible questions to ask the patient, along with the rationale for each:

1. How has your sleeping routine changed since your husband’s death? – This inquiry helps analyze the precise sleep difficulties the patient is having, their duration, and their influence on her daily functioning (Someren, 2021). Understanding variations in sleep patterns might provide information into the degree and type of the insomnia and medications to prescribe.
2. How have you been feeling since your husband died? – The purpose of this question is to measure the patient’s emotional condition as well as the evolution of her depression following the loss. It aids in identifying the link between depressed symptoms and grief, offering a better knowledge of the patient’s mental health.
3. Have you observed any changes in your appetite or weight following your husband’s death? – This inquiry examines any changes in appetite or weight that may be related to the patient’s depression. It aids in determining the overall impact of the loss on her overall well-being and can provide extra information on her depressive symptoms.

People to involve for further assessment:

1. Family members/close friends: Speaking with the patient’s family members or close acquaintances can provide insight on the patient’s behavior, emotional state, and any noticeable changes in her everyday functioning following her husband’s death. Questions might include: How has the patient’s mood been lately? Have you observed any noticeable changes in her behavior or routines? How would you define her sleeping habits and overall well-being?
2. Previous Mental health practitioners (if applicable): Consulting with mental health specialists who have treated or assessed the patient’s depression might provide significant information about her mental health history, previous treatment responses, and relevant suggestions for ongoing therapy.

Given the facts supplied, the patient’s primary complaint of insomnia, and her medical history, the following evaluations and tests may be appropriate:

1.  Physical exam: A general physical examination would be performed to examine vital signs, overall health, and detect any physical abnormalities that may contribute to or exacerbate the patient’s symptoms.
2. Laboratory tests: To rule out underlying medical disorders that could contribute to her depressive symptoms or sleep disturbances, laboratory tests such as a complete blood count (CBC), comprehensive metabolic panel (CMP), and thyroid function tests (TSH, T4) may be performed (Benz. Alt. ,2022).

Differential diagnoses for the patient’s symptoms may include:

1. Adjustment disorder with sad mood: The patient’s depressive symptoms could be attributed to the recent loss of her husband, as well as the associated bereavement and adjustment issues.
2. Major depressive disorder (MDD): Given the duration and development of her depressed symptoms, the patient may also fit MDD criteria.
    

Based on the information presented, the most likely diagnosis is MDD, as the patient’s depression has deteriorated after her husband’s death, and she has no history of depression prior to the loss.

Two pharmacologic agents for antidepressant therapy that could be considered are:

1. Trazadone- a serotonin antagonist and reuptake inhibitor (SARI). Trazadone is an FDA approved medication that has an off-label use for sleep disturbances (Shin & Saadabadi, 2022). Trazadone has shown to be as effective as first line antidepressants such as SSRIs without the risk of insomnia as a side effect.
2. Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine: If the patient does not respond effectively to the present SSRI or develops unbearable side effects, SNRIs may be tried. Venlafaxine is an SNRI that can be used to treat depression.
    

The rationale for selecting one agent over the other can include considerations such as the patient’s previous response to sertraline, tolerability of side effects, potential drug interactions, and the prescriber’s knowledge with the medication.

Contraindications or dosage changes that must be considered for ethical prescribing or decision-making include:

1. Assessing potential drug interactions with the patient’s current drugs, notably sertraline, to avoid adverse effects or interactions that may jeopardize patient safety.
2. To minimize risks and guarantee optimal dosing, consider the patient’s age, comorbidities, and the potential side effects of the chosen medicine.

Checkpoints or follow-up data at regular intervals (e.g., Week 4, 8, 12, etc.) would be required to assess the patient’s reaction to the chosen antidepressant therapy. 

Therapeutic modifications that may be considered based on potential consequences include:

1. Adjustment of medication dosage: If the patient does not respond satisfactorily or develops major side effects, adjusting the dosage of the present medication or trying a different medicine within the same class can be considered.
2. If the patient’s symptoms persist or worsen despite medication modifications further evaluation and further treatment options, such as psychotherapy.

References

Riemann, D., Benz, F., Dressle, R. J., Espie, C. A., Johann, A. F., Blanken, T. F., … & Van Someren, E. J. (2022). Insomnia disorder: State of the science and challenges for the future. Journal of Sleep Research, 31(4), e13604.  10.1111/jsr.13604

Links to an external site.

Van Someren, E. J. (2021). Brain mechanisms of insomnia: new perspectives on causes and consequences. Physiological reviews, 101(3), 995-1046. 10.1152/physrev.00046.2019

Links to an external site.

Shin, J., & Saadabadi, A. (2022). Trazodone – StatPearls – NCBI Bookshelf. NCBI. https://www.ncbi.nlm.nih.gov/books/NBK470560/

Poor eating habits may be a factor in the symptoms of insomnia. Caffeine has been demonstrated to interfere with sleep when consumed late in the day. This causes a domino effect of increased caffeine consumption the following day, solidifying the addiction. Siblings, children, and other family members may shed light on whether the patient’s insomnia is caused by genetics or environmental factors. I might ask family members if anyone else is having this problem. This will allow you to learn if someone in your immediate family suffers from a sleep disorder (Oliveira et al., 2019).

The survey also asks if sleep disorders like snoring, insomnia, and excessive daytime sleepiness are common in the family. The patient is initially taking antidepressants, which could cause insomnia. The patient is also taking metformin, a medication used to treat diabetes that has a side effect of drowsiness. Another undesirable side effect of taking losartan is insomnia (Krystal et al., 2019). The patient is having trouble sleeping, which is almost certainly a side effect of their medication.

References

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337-352.

Oliveira, P., Coroa, M., & Madeira, N. (2019). Treatment options for insomnia in schizophrenia: a systematic review. Pharmacopsychiatry, 52(04), 165-169. DOI: 10.1055/a-0658-1645

Sample Answer for NURS 6630 Discussion Treatment for Patient With Common Condition

Three Questions I Would Ask the Patient, With a Rationale 

The questions asked include: 

1. What motivated you to come to the hospital today?  

Asking this open-headed question will prompt the patient to provide further information about his ailment and develop a trusting care relationship. 

2. Are you a regular consumer of caffeinated drinks or beverages?  

Evaluating the patient’s possible caffeine addiction and regular use before bedtime is crucial since it can contribute to insomnia. 

3. Have you ever suffered from Gastro Esophageal Reflux Disease (GERD)?  

The open-headed question is vital in establishing a connection with the current symptoms. According to Awadalla and Al-Musa (2021), GERD can contribute to insomnia among elderly patients due to poor sleep quality and discrepancies in circadian preferences. The three questions aim to rule out the possible influence of environmental factors and assess the patient’s worries to better understand her health status. 

People in the Patient’s Life for Providing Feedback to Further Assess the Patient’s Situation 

The ideal people in this patient’s life for providing responses to evaluate her situation include her caregiver and a close family member conversant with her history. Her caregiver will be acquainted with her medications and response to drugs, while an immediate family member will have a better overview of her social life before and after her husband’s death. 

Specific questions for the caregiver include: 

1. For how long has the patient been on the prescribed medications? 

2. Are the doses maintained, or are there occasional adjustments? 

3. Have the remedies effectively managed diabetes, hypertension, and major depressive disorder (MDD)? 

4. Has her state varied or worsened after her husband’s death despite taking the medications? 

Consequently, specific questions for the close family member include: 

1. What has been the nature of the patient’s social life? 

2. From your observations, how was her medical status before her husband’s death? 

3. Did her state worsen after her long-time husband passed on? 

Physical Exams and Diagnostic Tests Appropriate for the Patient 

A self-report is ideal for diagnosing insomnia. A blood test can be ordered to rule out potential thyroid problems. Green et al. (2021) note that hyperthyroidism results in excess thyroid hormone, leading to sleep dysfunction. Besides, the Hamilton Anxiety Rating Scale (HAM-A) can be administered to examine the severity of her anxiety (Slater et al., 2019). The scale will assist in managing insomnia if it is connected to anxiety. Hamilton Depression Rating Scale (HDRS) is also viable in examining the symptoms of depression (Nixon et al., 2020). It will significantly help to appraise the patient’s feelings of suicidal ideation, guilt, and her current stage of insomnia. 

  

A Differential Diagnosis for the Patient 

The patient’s medical history shows that she was previously diagnosed with depression. As such, the definitive differential diagnosis will be generalized anxiety disorder (GAD), which might have intensified after the death of her husband. According to Landreville et al. (2021), GAD causes anxiety about various situations and hinders relaxation as the affected person continually feels anxious. The conclusion is informed by changes in her social and living dynamics as she has to sleep alone and bear financial burdens. She also has to deal with thoughts about her husband’s death. Unexpected changes in her routine and social life may be attributed to insomnia. 

Pharmacologic Agents Appropriate for the Patient’s Antidepressant Therapy Based on Pharmacokinetics and Pharmacodynamics 

The U.S. Food and Drug Administration (FDA) approved Temazepam for the management of insomnia. According to Stenveld et al. (2019), it is in the category of benzodiazepines and is effective in managing insomnia by modulating gamma-aminobutyric acid (GABA) to elicit sedation, relax skeletal muscles, and hypnosis. The drug is metabolized in the liver into inactive metabolites. Related side effects include clumsiness, dizziness, and a reduction in the patient’s alertness (Stenveld et al., 2019). Consequently, Trazodone would be an ideal remedy for insomnia. It is approved by the FDA to manage major depression. It acts by blocking serotonin reuptake (Wang et al., 2020). The drug is metabolized via CYP3A4 into the active metabolite, meta-chlorophenylpiperazine (mCPP). The active metabolite is subsequently metabolized into 2D6 to induce P-glycoprotein. Wang et al. (2020) caution that Trazodone can cause daytime dizziness. Prescription of this medication to an elderly patient should consider this side effect. 

Contraindications to Use or Alterations in Dosing That May Need to be Considered Based on Ethical Prescribing or Decision-Making 

Temazepam is the ideal and safer medication for this elderly patient because the drug does not have active metabolites. Additionally, it has a brief half-life and no history of interactions with the present medicines taken by the elderly patient (Stenveld et al., 2019). Adding this drug to the current treatment regimen will not induce drug toxicity. The problem with using this drug in individuals in line with ethical decision-making is related to the awareness that sleep regulation has a genetic link. It can be overlooked in the treatment process if it is not considered during the diagnosis phase. 

“Check Points” and Therapeutic Changes Based on Possible Outcomes Given the Treatment Options Chosen 

The commencing dose is low for an elderly patient. For instance, Temazepam 7.5mg tab PO at bedtime would be an ideal starting dose. In the check-up for the four weeks, outcomes expected entail a reduction in anxiety and improvement in the sleep pattern. If the outcomes have not been actualized, ordering 15mg tab PO at bedtime would be beneficial. Nevertheless, the medication has the side effect of dizziness and body weakness (Stenveld et al., 2019). In week 8, the medical outcomes can be reviewed to gauge the progress. The dose should not surpass 30mg PO at bedtime. Caution is necessary when increasing the dose for this elderly patient to minimize the intensity of the side effects. 

References 

Awadalla, N. J., & Al-Musa, H. M. (2021). Insomnia among primary care adult population in Aseer region of Saudi Arabia: Gastroesophageal reflux disease and body mass index correlates. Biological Rhythm Research, 52(10), 1523-1533. https://doi.org/10.1080/09291016.2019.1656933 

Green, M. E., Bernet, V., & Cheung, J. (2021). Thyroid dysfunction and sleep disorders. Frontiers in Endocrinology, 12, 1-4. https://doi.org/10.3389/fendo.2021.725829 

Landreville, P., Gosselin, P., Grenier, S., & Carmichael, P. H. (2021). Self-help guided by trained lay providers for generalized anxiety disorder in older adults: Study protocol for a randomized controlled trial. BMC Geriatrics, 21(1), 324. https://doi.org/10.1186/s12877-021-02221-x 

Nixon, N., Guo, B., Garland, A., Kaylor-Hughes, C., Nixon, E., & Morriss, R. (2020). The bi-factor structure of the 17-item Hamilton Depression Rating Scale in persistent major depression; dimensional measurement of outcome. PloS One, 15(10), e0241370. https://doi.org/10.1371/journal.pone.0241370 

Slater, P. F., Bunting, B., Hasson, F., Al-Smadi, A., Gammouth, O. S., Ashour, A., & Jordan, D. (2019). An examination of factor structure of the Hamilton anxiety rating scale in a non-clinical Persian sample. International Journal of Research in Nursing, 10, 1-9. https://pure.ulster.ac.uk/ws/files/78269982/Published_version_76899993.pdf 

Stenveld, F., Bosman, S., van Munster, B. C., Beishuizen, S. J., Hempenius, L., van der Velde, N., … & de Rooij, S. E. (2019). Melatonin, Temazepam and placebo in hospitalised older patients with sleeping problems (MATCH): A study protocol of randomised controlled trial. BMJ Open, 9(5), 1-8. http://dx.doi.org/10.1136/bmjopen-2018-025514 

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on sleep quality and cognitive function in arteriosclerotic cerebral small vessel disease comorbid with chronic insomnia. Frontiers in Psychiatry, 11, 1-9. https://doi.org/10.3389/fpsyt.2020.00620 

Sample Response for NURS 6630 Discussion Treatment for Patient With Common Condition

Temitope,  

Hi there! Thank you for your post, it was very thorough and informative.  

I appreciate your concern and assessment of a possible GERD diagnosis. This is a great insight as to possible insomnia causes that very well may have been overlooked.  Larger numbers of elderly patients have different GERD symptoms versus general heartburn/reflux which increases the chances of a GERD diagnosis being overlooked. (Kurin & Fass, 2019) I can understand how and why you brought this forward for sure. It helped me understand another reason the patient could be suffering from insomnia. 

I also enjoyed reading your discussion on the use of temazepam for this case. To be honest, my concern about temazepam is with it being a benzodiazepine it can cause short-term cognitive issues which can increase falls and of course falls can lead to fractures and overall, mortality.  (Chiu et al., 2020) I am not opposed to trying a low-dose, I would just be extra cautious with the elderly and be sure to educate loved ones and caregivers on increased falls risks. They may want to institute some fall precautions around the bedroom/bathroom she will be utilizing.  

  

  

References 

Chiu, H.-Y., Lee, H.-C., Liu, J.-W., Hua, S.-J., Chen, P.-Y., Tsai, P.-S., & Tu, Y.-K. (2020). Comparative efficacy and safety of hypnotics for insomnia in older adults: A systematic review and network meta-analysis. Sleep, 44(5). Retrieved July 10, 2023, from https://doi.org/10.1093/sleep/zsaa260  

Links to an external site. 

Kurin, M., & Fass, R. (2019). Management of gastroesophageal reflux disease in the elderly patient. Drugs & Aging, 36(12), 1073–1081. Retrieved July 10, 2023, from https://doi.org/10.1007/s40266-019-00708-2  

Sample Response for NURS 6630 Discussion Treatment for Patient With Common Condition

Hi Temitope. 

I liked reading your post. Temazepam is of course an interesting medication, but should be used with caution. Even though the incidence of adverse effects of temazepam is not frequent, the medication may increase the risk of serious or life-threatening breathing problems, sedation, or coma if used along with certain medications (Medline Plus, 2003). The percentage of complaints reported by patients who were treated with temazepam resulting from the use of temazepam is 7.8% (Morin et al, 2003). Though temazepam helps many people, this medication may sometimes cause addiction, which can lead to overdose. This risk may be higher if the patient has a substance use disorder (Webmd, n. d.). Although benzodiazepines are generally effective, they carry significant risks, especially when used long-term. With long-term use, dependence and withdrawal symptoms may occur when the drug is stopped. Benzodiazepines can impair cognition, motor skills, and driving ability and increase the risk of falls in older people. A recent study also found an association between benzodiazepine use and an increased risk of Alzheimer’s disease in older adults (National Institutes of Health, 2015). 

Another challenge patients have with the use of benzodiazepines is withdrawal. Withdrawal symptoms are usually most severe in the last quarter of the phase-out stage. Patients and healthcare providers are hesitant to stop taking benzodiazepines for fear of withdrawal symptoms or relapses. Withdrawal symptoms occur in up to 50% of patients who succeed in tapering (Tannenbaum, 2015).    

Cognitive behavioral therapy is effective for treating chronic insomnia and facilitating benzodiazepine tapering in older adults. The addition of cognitive-behavioral interventions when using temazepam will however reduce both the amount of medication used and the incidence of adverse effects, with comparable sleep improvements (Morin et al, 2003).. 

  

References 

National Institute of Health, (2015). Benzodiazepine Often Used in Older People Despite Risks. https://www.nih.gov/news-events/nih-research-matters/benzodiazepine-often-used-older-people-despite-risks#:~:text=But%20while%20effective%2C%20they%20have,increase%20the%20risk%20of%20falls. 

Medline Plus (n. d.). Temazepam. https://medlineplus.gov/druginfo/meds/a684003.html 

Morin, C. M., Bastien, C. H., Brink, D., Brown, T. R. (2003). Adverse effects of temazepam in older adults with chronic insomnia. Hum Psychopharmacol. 2003 Jan;18(1):75-82. doi: 10.1002/hup.454. PMID: 12532318. 

Tannenbaum C. (2015). Inappropriate benzodiazepine use in elderly patients and its reduction. J Psychiatry Neurosci. 2015 May;40(3):E27-8. doi: 10.1503/jpn.140355. PMID: 25903036; PMCID: PMC4409441. 

Webmd (n. D.). Temazepam – Uses, Side Effects, and More. https://www.webmd.com/drugs/2/drug-8715/temazepam-oral/details 

Sample Answer for NURS 6630 Discussion Treatment for Patient With Common Condition

Three questions I might ask this patient would be: 

Have you tried any OTC sleep-aids? 

Do you have trouble falling asleep, staying asleep, or both? 

What is your daily routine like?  

I would ask the above questions to get a better assessment of what I may be treating. Say she has already tried melatonin, antihistamines, etc. to sleep OTC; it may very well be an opportunity for a prescription sleep medication. Asking what part of sleep troubles her can give me a better idea of dosing ranges and types of medications I would prescribe. Sometimes people just cannot fall asleep and a lighter medication or lower dose would be beneficial. Those who have trouble staying asleep could possibly utilize something with a longer half-life. Getting a better idea of her daily routine, I could help her make a better sleep hygiene plan to follow and incorporate nonpharmacologic methods as well such as using a lavender lotion, trying to listen to white noise, exploring therapy, etc. Also, if she is napping during the day, this may be interfering with her sleep cycles.  

I could speak with her family (children, siblings, etc.) and friends. I could ask them about her daily habits, does she consume caffeine, especially later in the day? She may not realize the negative effect it is having. Is she kept up by pets? They may need their toys removed at night or a pet door closed. Is her sleeping space dark and somewhat cool? That has been determined to be the best sleeping environment. I would also be curious when she takes her medications and when/if she checks her blood sugars, uses alcohol, etc. For example, if she is taking her diuretic later, it may be producing nocturia effects for her.  

As far as exams and diagnostic tests, I would recommend a full physical with her PCP and various labs to rule out other contributing factors as well as a baseline EKG. I would suggest a baseline CBC, CMP, thyroid panel, lipids, A1c. Her sugars could be off contributing to polyuria and keeping her up for example. More extensive testing could be something such as GeneSight to see how she is metabolizing her medication too. If she did have something abnormal with her lab results, these could be addressed in real-time and then follow-up in an appropriate timeframe.  

A differential diagnosis could potentially be PTSD. Though losing a spouse is often a common part of life, it is still heartbreaking. Her depression did not occur until the death of her husband and her insomnia presented. This was likely a hugely life-changing event for her, affecting many aspects of her day-to-day lifestyle. 

In a recent review, Zoloft, Lexapro, and Celexa are the ‘preferred’ SSRI’s for the elderly as they have lower drug-drug interactions. (Norman, 2021) With this information, two potential medications for this patient could be Lexapro 5mg daily to start or Celexa 20mg daily. Considering they are both SSRIs, I would prefer to start the Lexapro as it has less cardiac side effects than Celexa. Though she does not have a known strong cardiac history, she is elderly and more likely to have cardiac side effects. Lexapro is also used off-label for PTSD. (Potter, 2019) 

Lexapro contraindications include increased suicidality.  In fact, an increase in suicidal ideations in those taking SSRIs, particularly children and teens, have been documented. (Aloysius, 2022) She is not in these age categories of course, but this should still be considered. The dose is not recommended above 10mg/day in those over 65 years old or with renal impairment, another reason to check labs before and periodically on treatment. I believe this caution exists as the medication is metabolized via the kidneys, so if there is renal impairment, there may also be issues metabolizing the medication(s.) I don’t believe there is a problem prescribing the medication as long as the guidelines are followed appropriately. It would be ethically important too to make sure and describe side effects to the patient and loved ones as well as warning signs to beware of.  

As far as checkpoints, I would follow up in two weeks to assess any mood changes and/or assess and side effects. At this point if she is free of bothersome or dangerous side effects and is not having the desired outcome yet, we could increase the dose to 7.5mg daily. I would then like to follow up at the four-week mark to assess the entire situation again. If we increased to 10mg daily and still had medication treatment failure or too great of side effects, I would taper her slowly off the Lexapro at that time.  

  

  

References 

Aloysius, S. E. (2022). Escitalopram. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK557734/  

Links to an external site. 

Norman, T. R. (2021). Antidepressant treatment of depression in the elderly: Efficacy and safety considerations. OBM Neurobiology, 05(04), 1–1. Retrieved July 9, 2023, from https://doi.org/10.21926/obm.neurobiol.2104108  

Links to an external site. 

Potter, D. (2019, September). [PDF]. Retrieved July 9, 2023, from https://www.internationaljournalofcaringsciences.org/docs/69_potter_review_12_3.pdf  

Sample Response for NURS 6630 Discussion Treatment for Patient With Common Condition

Peer Response 1 

Hello Nicole, great post. It is important to use open ended questions when asking patients questions so they can elaborate and provide sufficient information on the topic. You mentioned non pharmacological measures of sleep and I think that is a great idea to explore prior to using pharmacological sleep agents. I recently read in an article about how low magnesium levels can also cause lnsomnia.  As per the article nearly half adults males and females are magnesium deficient in the U.S. Healthy magnesium levels protect metabolic health, stabilize mood, keep stress in check, promote better sleep, and contribute to heart and bone health. (Breus, 2018).Supplementation of magnesium appears to improve subjective measures of insomnia such as, sleep efficiency, sleep time and sleep onset latency, early morning awakening.(Abbasi et al., 2012). In regards to your medication of choice. Lexapro your drug is recommended for older adults but has increased suicidability for younger populations as you mentioned. The potential for escitalopram to cause slight QT prolongation has also been demonstrated in some studies. (Funk & Beach, 2022). Lexapro side effects also include insomnia. The check point biweekly can definitely provide us with information in regards to medication efficacy, increase Lexapro may not be the best decision based on negative side effects. A new medication of choice may have to be considered.  

  

References 

Abbasi, B., Kimiagar, M., Sadeghniiat, K., Shirazi, M. M., Hedayati, M., & Rashidkhani, B. (2012, December 17). The effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trial. Journal of research in medical sciences : the official journal of Isfahan University of Medical Sciences. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3703169/  

Breus, M. J. (2018, May 2). Magnesium – how it affects your sleep. Psychology Today. https://www.psychologytoday.com/us/blog/sleep-newzzz/201805/magnesium-how-it-affects-your-sleep  

Funk, M., & Beach, S. (2022, March 25). Escitalopram. Escitalopram – an overview | ScienceDirect Topics. https://www.sciencedirect.com/topics/medicine-and-dentistry/escitalopram