Discussion Treatment For A Patient With A Common Condition ✓ Solved

Discussion Treatment For A Patient With A Common Condition

Discussion: Treatment for a Patient With a Common Condition Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD. 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. Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns.

Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.

Case: 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.

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?

Paper For Above Instructions

Insomnia, defined as difficulties in falling asleep or staying asleep, is a prevalent condition that affects many individuals, particularly among the elderly. In the presented case, the patient, a 75-year-old widow who recently lost her husband, suffers from insomnia compounded by major depressive disorder (MDD) and other health issues such as diabetes and hypertension. Given the complex interplay between mental health and sleep, it is crucial to adopt a comprehensive approach towards treatment.

To gain a deeper understanding of her condition, I would start with three essential questions:

1. “Can you describe your sleep patterns since your husband passed away?”
2. “How has your mood been during the day, and do you find yourself more anxious or sad?”
3. “What coping strategies or activities do you engage in to deal with your current feelings or insomnia?”

The rationale behind these questions is to gauge not only her sleep habits but also any emotional distress she may be experiencing. Understanding her daily mood will help assess the severity of her depression, and knowledge of her coping strategies will reveal her resourcefulness and resilience. Additionally, examining her nighttime habits can provide insight into possible changes that could improve her sleep.

From a holistic perspective, it is beneficial to engage individuals close to the patient, such as her children or close friends, who may offer valuable insights into her mental and emotional state. Relevant questions to ask may include: “Have you noticed any changes in her mood or behavior since her husband's death?” and “What are some activities she enjoys or used to enjoy?” These inquiries can help construct a fuller picture of her support system and any potential changes in her behavior that may not be evident in a clinical setting.

As for physical exams and diagnostic tests, a thorough geriatric assessment would be appropriate, encompassing both physical and mental health evaluations. Appropriate blood tests to assess thyroid function, complete metabolic panel, and possible screening for sleep apnea (polysomnography) may further elucidate the causes of her insomnia. The results of these tests would help tailor her treatment plan accurately and rule out any medical comorbidities contributing to her condition.

A differential diagnosis should include generalized anxiety disorder (GAD), adjustment disorder with depressed mood, and primary insomnia. However, the most likely diagnosis appears to be adjustment disorder with depressed mood, given the recent emotional trauma related to her husband's passing and the onset of depressive symptoms and insomnia following this life change. Adjustment disorders are characterized by emotional or behavioral symptoms in response to identifiable stressors, aligning with the timeline of her husband's death.

When considering pharmacologic agents for therapy, two viable options are Escitalopram and Venlafaxine. Escitalopram, an SSRI, typically starts at a dose of 10 mg daily, which can be titrated based on clinical response. Venlafaxine, an SNRI, could be initiated at a dose of 75 mg daily. A choice between these agents could rest on their pharmacokinetic properties and the patient’s specific symptoms. Escitalopram is often preferred in patients with anxiety and depression due to its favorable side effect profile, but for this older adult patient, one must also consider the risk of potential side effects such as increased blood pressure associated with Venlafaxine.

In choosing Escitalopram, one must consider dosage alterations based on the patient’s ethnicity and genetic variations in drug metabolism. For example, it is noted that individuals of Asian descent may have different metabolic processing of SSRIs which may necessitate a lower starting dose to avoid side effects such as an increased risk for serotonin syndrome. Understanding these pharmacogenomic differences is vital to tailoring the safest and most effective medication therapy for this patient population.

In summary, treating insomnia in the context of MDD requires a multifaceted approach that incorporates thorough assessments, likely multidimensional diagnoses, and personalized pharmacotherapy. Implementing these elements exemplifies a patient-centered approach to care, paving the way for improved outcomes for elderly patients experiencing the interplay of mental health and sleep disturbances.

References

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