TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Walden University TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630-Step-By-Step Guide
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How to Research and Prepare for TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Whether one passes or fails an academic assignment such as the Walden University TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630 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.
How to Write the Introduction for TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
The introduction for the Walden University TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630 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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How to Write the Body for TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
After the introduction, move into the main part of the TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630 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 TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
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 TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
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: TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Treatment for a Patient with Insomnia
Three questions for the patient
Do you have trouble falling asleep, and how often do you wake up at night after managing to sleep? Inquiring about the frequency will help determine the severity of the condition and the right intervention.
Do you snore loudly and have trouble breathing when you wake up at night? This will help determine if there could be other underlying issues causing insomnia besides grief and depression.
Are there distractions like noise, light, and noise around your place? This will help determine if the environment is contributing to insomnia.
People to speak to and why
I will speak with the people close to the patient, particularly her friends and family members. The family members will help explain her sleep habits, while the friends will help establish how insomnia affects her daily activities
Physical exams and diagnostic tests
I would physically assess the nasal septum and the tonsils. According to Krystal et al. (2019), this examination will help determine if insomnia could be aggravated by obstructive sleep apnea. I will also use actigraphy to monitor the patient’s movement after falling asleep. Actigraphy will help determine the severity of the condition.
Most likely differential diagnosis and why
The differential diagnosis for insomnia includes mental illness, medical conditions, drug or substance use, obstructive sleep apnea, or inadequate sleep hygiene. The most likely differential diagnosis for this case is mental illness. The patient suffered a loss; thus, she is likely to be experiencing sleep disturbance due to bereavement and depression.
Two pharmacologic agents and their dosing
Benzodiazepines and Agomelatine are highly suitable for treating patients with insomnia resulting from depression. The patient should take 15 to 30 mg of Benzodiazepines daily and 25 to 50 mg of Agomelatine daily (Morera-Fumero et al., 2020). The two present a combination of sedative and non-sedative antidepressants; hence, they’ll suit the patient. The combination also offers both long-term and short-term solutions.
Contradictions or alteration in the dosing drug and why
Agomelatine dosage can be increased to 50mg daily if the condition does not improve. However, Norman and Olver (2019) warn that the drug should not be used for more than 24 weeks as extended use can result in dementia in patients above 75 years. The drug also has side effects like active liver disease and liver cirrhosis.
Benzodiazepines should not be used for long-term solutions as they may lead to addiction. Morera-Fumero et al. (2020) explain that the other side effects of Benzodiazepines include drowsiness, headache, and respiratory arrest.
Checkpoints and any therapeutic changes
I will monitor for improvement after three, six, twelve, and 24 weeks of treatment to determine the effectiveness of the Agomelatine drug. Norman and Olver (2019) explain that monitoring any side effects of liver disease, like dark urine, yellow skin, eyes, and fatigue, is crucial. Regarding the Benzodiazepines, I will evaluate changes after three days, one week, and four days. The treatment will not last for more than two weeks, and in each period, I will monitor headaches and breathing challenges.
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.
Morera-Fumero, A. L., Fernandez-Lopez, L., & Abreu-Gonzalez, P. (2020). Melatonin and melatonin agonists as treatments for benzodiazepines and hypnotics withdrawal in patients with primary insomnia. A systematic review. Drug and Alcohol Dependence, 212, 107994.
Norman, T. R., & Olver, J. S. (2019). Agomelatine for depression: expanding the horizons?. Expert opinion on pharmacotherapy, 20(6), 647-656.
Three questions to ask the patient and a rationale for asking these questions.
Who do you live with now?
I would like to know if she lives by herself, or if she is having company during this time when she is feeling depressed and unable to sleep. I would be concerned for her if she wakes up in the middle of the night due to Insomnia, is probably tired or confused, and falls. In addition, if someone helps her monitor her medication and make sure that she is taking it correctly.
Could you tell me your medications, and how are you taking them?
In this way, I will know if she really knows each medication, dosage, and frequency or if she is forgetting any of them. Maybe she is not taking sertraline correctly or forgetting to take it and therefore she is feeling depressed again.
Are you having negative thoughts or suicidal ideation?
It is important to know how severe her depression is and if she needs to be monitored 24 hrs in a mental health facility to prevent any event until the medication works.
People in the patient’s life to speak to or get feedback from to further assess the patient
I would like to know if she has any children, caregivers, or any support system that she usually goes to (such as a Pastor, church, friend, etc) I would like to know her living situation, socio-economic status, if she does her ADLs or if she needs help, if she is having company during the day and at night, how many hours she is sleeping, if her house is safe for her (no cables or rugs on the floor), and if she normally does any activity that she is not doing anymore.
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Physical and diagnostic tests
CBC, CMP, HGA1C, EKG, hepatic function panel, and Polysomnography. I will know her renal function (GFR), electrolytes, B12, if she has any QT interval or any heart dysrhythmia, thyroid function, etc. before I start any medication.
According to Gerstenslager & Slowik (2021), stated “Polysomnography is a sleep study to diagnose any sleep disorder and in addition may be used to help initiate or adjust treatment plan”. Psychiatrists frequently prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for torsade de pointes (Funk ET al., 2018).
Differential diagnoses for the patient
1) Major depressive disorder (MDD)
2) Sleep Apnea
3) DM
My first differential is MDD- according to Otte et al., (2016) “MDD is a debilitating disease that is characterized by depressed mood, diminished interests, impaired cognitive function, and vegetative symptoms, such as disturbed sleep and appetite. Occurs about twice as often in women than it does in men”.
Pharmacologic agents and their dosing
Trazodone- FDA approved for depression and insomnia. I will use this medication for an add augmentation with Sertraline 100 mg. I will start low and slow 25 mg first 2 -4 weeks, especially for her age. This medication is metabolized CYP450, half-life. The first phase is approximately 3-6 hours and the second phase is approximately 5-9 hours.
Blocks serotonin 2 A receptors potently, blocks serotonin reuptake pump. Onset therapeutic actions in Insomnia are immediate if dosing is correct. The onset of therapeutic actions in depression is usually not immediate, often delayed 2-4 weeks whether given as an adjunct to another anti-depressant or as a monotherapy (Stahl, 2017).
Lunesta- metabolized by CYP 450 3A4 and 2E1, terminal elimination half-life approximately 6 hours, heavy high fat meal slow absorption, which could reduce the effect on sleep latency. FDA approved for insomnia. May bind selectively, a subtype of the benzodiazepine receptor. May enhance GABA inhibitory actions that provide sedative-hypnotic effects more selectively than other actions of GABA. Inhibitory actions in sleep centers may provide sedative-hypnotic effects and generally takes less than an hour (Stahl, 2017).
Drug therapy contraindications
One of the contradictions of using Trazodone– Do not take it with MAOI, caution for patients with a history of seizures, and reports of increased and decreased prothrombin time in patients taking warfarin (Stahl, 2017).
Checkpoints
Initial dosage 25-50 for 4 weeks. If the symptoms are not improved, then I will increase the dosage as usually tolerated by 50-100 mg/day, but some patients may require up to the full antidepressant dose range. However, I prefer to go low and slow due to her age (Stahl, 2017).
References
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). Resources Document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://content.waldenu.edu/content/dam/laureate/laureate-academics/wal/ms-nurs/nurs-6630/week-07/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf
Gerstenslager B, Slowik JM. Sleep Study. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563147/
Stahl S. (2017). Essential psychopharmacology prescribers guide. (6th eds). Cambridge, United Kingdom.
TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Treatment of a Patient with Insomnia
The process of sleeping is important for the body to facilitate recovery, regaining strength, body restoration, discharge of emotions, and consolidation of memory. As such, the average adult must get at least 7 hours of sleep a night (Ellis et al., 2021). Insomnia is a condition characterized by a lack of adequate sleep. It may occur as a primary disorder or as a manifestation of other illnesses be they medical, psychiatric, or surgical. In patients with mood disorders like depression and bipolar, insomnia is a distinct character with the patient being unable to fall asleep or maintain sleep for at least 7 hours (Sweetman et al., 2021). This discussion aims to devise a treatment plan for a patient suffering from insomnia and MDD.
Case Study
The patient is a recently widowed 75-year-old woman who suffers from DM, hypertension, and MDD. She complains of insomnia. She reports that the MDD and symptoms started after her husband’s passing, 10 months ago. She is on: HCTZ 25mg daily, Losartan 100mg daily, Januvia 100mg daily, Sertraline 100mg daily, and Metformin 500mg BID. She has no suicidal ideation. She is awake, oriented, and alert, her temperature was 98.6 degrees F, her BP is 132/86, her height is 64 inches and her weight is 88kg.
Questions to Ask the Patient
The line of questioning should provide more information about her illness and include:
- Do you have difficulty falling asleep or staying asleep? This would guide the pharmacologic intervention. If the patient is having difficulty falling asleep, a drug with a shorter half-life would be preferred and vice versa (Hassinger et al., 2020).
- What does your average evening consist of? This is to determine the sleep hygiene practices, I would further ask about specific sleep hygiene practices.
- What do you do when you are unable to sleep? This is to determine the patient’s coping mechanisms, and whether they are successful and healthy.
Other Persons to Question
The patient’s close relatives and other individuals who have daily contact with her should be questioned. They would provide insight on the severity of her insomnia and any other symptoms she may be exhibiting but not have insight on.
I would ask about her memory and whether it has deteriorated rapidly. This could point toward the severity of insomnia. Questions on her adherence to her MDD medication would also be asked. The insomnia is likely linked to her MDD; therefore, non-adherence can lead to a recurrence of symptoms (Fang et al., 2019).
Physical Examination and Diagnostic Tests
On physical examination, I would look out for deformities and malformations that would cause obstructive sleep apnea. This is a common cause of insomnia (Ong et al., 2020). In the HEENT examination, I would look for a narrowed throat, hypertrophied tonsils, and a deviated septum. These can all compromise the airflow. I would conduct a thorough neurological examination to determine the presence of neuropathic pain that would contribute to insomnia.
The diagnostic tests of choice are polysomnography and actigraphy. Polysomnography observes various parameters during sleep to note abnormalities allowing for the study of sleep patterns and diagnosis of sleep disorders (Withrow et al., 2019). Actigraphy measures motor activity during sleep to determine the quality of sleep experienced (Withrow et al., 2019).
Differential Diagnosis
The differential diagnoses for this case include sleep apnea, Cheyne Stokes breathing, insomnia due to mental illness, insomnia due to medical illness, and insomnia due to medications.
The most likely diagnosis is insomnia due to mental illness. The patient is suffering from MDD. One of the major symptoms is sleep disturbances, either insomnia or hypersomnia.
Pharmacologic Management of MDD
For the patient in question, Citalopram and Amitriptyline are suitable for the management of MDD. Citalopram (20mg OD) is an SSRI with minimal side effects, the most significant being weight loss. This would prove advantageous for the patient who is already overweight. Further, the bioavailability of this drug is 86% such that a small dose goes a long way (Yang et al., 2019). Amitriptyline (75mg per day in divided doses) is a TCA with a half-life of 62% (Zhai et al., 2020). However, the drug is lipophilic and therefore spread throughout the body across all membranes and barriers. I would choose Citalopram for this patient owing to its bioavailability and weight-reduction properties.
Contraindications of Citalopram
Citalopram is contraindicated in patients who have experienced an allergic reaction to it before due to the potential fatal outcome. It is contraindicated with monoamine oxidase inhibitors due to the risk of developing serotonin syndrome. It is important to wait at least 14 days between doses of citalopram and monoamine oxidase inhibitors to prevent serotonin syndrome (Scotton et al., 2019).
Therapy Checkpoints
The therapy checkpoints must include the therapeutic effects of the drugs administered and the adverse drug reactions experienced. The therapeutic effect of citalopram begins one to four weeks after starting the drug. It is therefore prudent to have the first checkpoint at four weeks at the earliest. Ask about the improvement of symptoms at this time and alter the dose appropriately. Adverse effects of the drug such as dry mouth, nausea, xerostomia, and increased sweating should be probed for.
References
Ellis, J. G., Perlis, M. L., Espie, C. A., Grandner, M. A., Bastien, C. H., Barclay, N. L., Altena, E., & Gardani, M. (2021). The natural history of insomnia: Predisposing, precipitating, coping, and perpetuating factors over the early developmental course of insomnia. Sleep, 44(9), zsab095. https://doi.org/10.1093/sleep/zsab095
Fang, H., Tu, S., Sheng, J., & Shao, A. (2019). Depression in sleep disturbance: A review on a bidirectional relationship, mechanisms, and treatment. Journal of cellular and molecular medicine, 23(4), 2324–2332. https://doi.org/10.1111/jcmm.14170
Hassinger, A. B., Bletnisky, N., Dudekula, R., & El-Solh, A. A. (2020). Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert opinion on pharmacotherapy, 21(9), 1035–1043. https://doi.org/10.1080/14656566.2020.1743265
Ong, J. C., Crawford, M. R., Dawson, S. C., Fogg, L. F., Turner, A. D., Wyatt, J. K., Crisostomo, M. I., Chhangani, B. S., Kushida, C. A., Edinger, J. D., Abbott, S. M., Malkani, R. G., Attarian, H. P., & Zee, P. C. (2020). A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: Main outcomes from the MATRICS study. Sleep, 43(9), zsaa041. https://doi.org/10.1093/sleep/zsaa041
Scotton, W. J., Hill, L. J., Williams, A. C., & Barnes, N. M. (2019). Serotonin Syndrome: Pathophysiology, clinical features, management, and potential future directions. International journal of tryptophan research: IJTR, 12, 1178646919873925. https://doi.org/10.1177/1178646919873925
Sweetman, A., Lack, L., McEvoy, R. D., Catcheside, P. G., Antic, N. A., Chai-Coetzer, C. L., Douglas, J., O’Grady, A., Dunn, N., Robinson, J., Paul, D., & Smith, S. (2021). Effect of depression, anxiety, and stress symptoms on response to cognitive behavioral therapy for insomnia in patients with comorbid insomnia and sleep apnea: a randomized controlled trial. Journal of clinical sleep medicine: JCSM: Official publication of the American Academy of Sleep Medicine, 17(3), 545–554. https://doi.org/10.5664/jcsm.8944
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
Insomnia is one of the most common medical conditions you will encounter as a PMHNP. 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 PMHNP, 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
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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.
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 Reply button to complete your initial post. Remember, once you click on Post Reply, you cannot delete or edit your own posts and you cannot post anonymously. Please check your post carefully before clicking on Post Reply!
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
- 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.
- 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.
- 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
- 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.)
- 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
- 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)
- 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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Thank you for sharing this information in your post. I think you bring up a really great point in your very first question to the patient. Your question about caffeine consumption is so important because so many people have regular access to caffeine and consume it on a regular basis, including at night. This could be the reason the patient is having trouble sleeping and the solution would be very easily fixed by having the patient stop caffeine consumption by noon each day (Frozi, 2018). I remember being a child and having trouble sleeping at night and not knowing why. As I grew older and I learned what caffeine was and what foods contained caffeine, I realized that I had often consumed caffeine late in the evening with sodas and the cappuccino drinks that I would make for myself out of a powder mix that was in our pantry. I thought it was a fancy chocolate milk and I had no idea it was loaded with caffeine. Sometimes, people simply do not understand how caffeine effects their body.
I feel that you also make a good point with the differential diagnosis of insomnia due to drugs. It is possible that the medications this patient is taking would cause her to have difficulty sleeping. It would be a good idea to find out what time of day that the patient is taking her medication and see if she is able to take her medications in the morning or before noon or one in the afternoon to avoid issues with insomnia (Xue, 2021).
References
Frozi, J., de Carvalho, H. W., Ottoni, G. L., Cunha, R. A., & Lara, D. R. (2018). Distinct sensitivity to caffeine-induced insomnia related to age. Journal of Psychopharmacology, 32(1), 89–95.
Xue, P., Wu, J., Tang, X., Tan, X., & Benedict, C. (2021). Oral Antidiabetics and Sleep Among Type 2 Diabetes Patients: Data From the UK Biobank. Frontiers in Endocrinology, 12, 763138.
Sample Answer for TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
Three Questions I Would Ask the Patient, With a Rationale
The questions asked include:
- 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.
- 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.
- 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:
- For how long has the patient been on the prescribed medications?
- Are the doses maintained, or are there occasional adjustments?
- Have the remedies effectively managed diabetes, hypertension, and major depressive disorder (MDD)?
- Has her state varied or worsened after her husband’s death despite taking the medications?
Consequently, specific questions for the close family member include:
- What has been the nature of the patient’s social life?
- From your observations, how was her medical status before her husband’s death?
- 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 TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
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
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 TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
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 TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
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/
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
Potter, D. (2019, September). [PDF]. Retrieved July 9, 2023, from https://www.internationaljournalofcaringsciences.org/docs/69_potter_review_12_3.pdf
Sample Response for TREATMENT FOR A PATIENT WITH A COMMON CONDITION NURS 6630
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
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