(Answered)NURS 6630/ Nurs6630n Discussion: Treatment for a Patient With a Common Condition(Case: An elderly widow who just lost her spouse.)

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 the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?  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. Treatment for a patient with a common condition 3 question to ask the patient 1. Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time? This study source was downloaded by from CourseH on 02-28-2023 02:28:26 GMT -06:00 Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O'Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O'Callaghan et al., 2018). 2. How many hours of sleep are you getting each night? Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, which can give rise to more anxiety leading to insomnia (Levenson et al., 2015). 3. Have you had any feelings of depression, hopelessness, or feeling down in the past month? Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020) The patient’s husband, in the given scenario, died 10 months ago. If the patient responds positively to this question, it is critical to also assess for suicide risk. Further Assessment It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s day to day life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask. Have you noticed a change in her interest in doing things? This study source was downloaded by from CourseH on 02-28-2023 02:28:26 GMT -06:00 Have you she seemed down or hopeless? How has she been eating? Do you know if she is taking her medications or noticed any side effects from her medications? Have you noticed any anxiety, changes in memory? (Park & Zarate, 2019) Appropriate Physical Tests and Diagnostic Exams Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults who have depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015). The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as there can be many organic illnesses that can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, Iron studies. Differential Diagnosis A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease (Small, 2009), believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is This study source was downloaded by from CourseH on 02-28-2023 02:28:26 GMT -06:00 taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible. Appropriate Antidepressant Therapy The patient is currently taking Sertraline 100mg daily. If the patient is taking the medication as prescribed, the patient should be seeing improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia. At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can show improvements in sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017). Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the and anti-depressant to Bupropion. Studies have shown that in patients with diabetes, Burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish et al., 2018). Contraindications Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug's effects may be increased due to slow removal from the kidney or liver. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020). This study source was downloaded by from CourseH on 02-28-2023 02:28:26 GMT -06:00 “check points” It would be necessary to follow up with the patient in four weeks to see if the addition of Trazadone is improving the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient's medication to buspirone. References Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. Retrieved January 13, 2021, from Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. Retrieved January 13, 2021, from Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. Retrieved January 13, 2021, from Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. Retrieved January 13, 2021, from Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. This study source was downloaded by from CourseH on 02-28-2023 02:28:26 GMT -06:00 O'Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. Retrieved January 13, 2021, from Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568. Retrieved January 13, 2021, from Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. Retrieved December 11, 2020, from Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls [Internet]. Retrieved January 7, 2021, from Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. Retrieved January 13, 2021, from Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). Retrieved January 13, 2021, from This study source was downloaded by from CourseH on 02-28-2023 02:28:26 GMT -06:00 Powered by TCPDF ()