Review This Discussion: Case Learning Resources

For This Discussion Review The Case Learning Resources And The Case S

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. The case involves an elderly widow who recently lost her spouse, presenting with insomnia, with a history of diabetes mellitus (DM), hypertension (HTN), and major depressive disorder (MDD).

The patient is a 75-year-old woman, awake, alert, and oriented, with no prior history of depression before her husband's death 10 months ago. She reports worsening depression and sleep disturbances since her loss. She currently takes medications for DM, HTN, and depression, has stable vital signs, and no suicidal ideation. The assessment includes questions about her coping mechanisms, support system, physical examinations, and diagnostic testing such as polysomnography and actigraphy to evaluate her sleep patterns. Differential diagnoses consider generalized anxiety disorder, depression, and restless leg syndrome, with depression being the most likely cause of her insomnia relative to her recent grief. The pharmacologic treatment includes considering agents like selegiline transdermal patches and eszopiclone, with attention to contraindications and dosing adjustments based on her age, comorbidities, and ethnicity. Follow-up assessments at 4, 8, and 12 weeks guide therapy adjustments.

Paper For Above instruction

The case of a 75-year-old woman presenting with insomnia in the context of recent bereavement and a history of chronic medical conditions illustrates the complexity of geriatric mental health assessment and management. Addressing her sleep disturbance and depression requires a comprehensive, multidisciplinary approach, integrating psychosocial and pharmacological strategies tailored to her unique clinical profile.

Assessment and Initial Questions

Initial assessment begins with targeted questions that elucidate the severity and context of her symptoms. Three vital questions include:

1. “Can you describe your sleep patterns over the past few weeks?” This question helps assess sleep hygiene, duration, awakenings, and quality, providing baseline data essential for diagnosing sleep disorders (American Academy of Sleep Medicine, 2014).
2. “Have you experienced any changes in appetite, energy, or interest in activities?” This explores the presence and severity of depressive symptoms beyond sleep disturbance (American Psychiatric Association, 2010).
3. “Are you experiencing any physical symptoms such as restlessness, pain, or abnormal movements in your legs?” This identification of physical symptoms can help rule out differential diagnoses like restless leg syndrome or other sleep-related movement disorders (Walters et al., 2017).

Rationale for these questions centers around understanding her sleep patterns, psychiatric state, and physical complaints, enabling an accurate diagnosis and treatment planning. The focus is on differential diagnosis to distinguish between primary sleep disorders, depression-related insomnia, or other comorbid sleep conditions.

Collaborating with Family and Support System

Gathering information from her family and support system offers additional insights into her functional status and daily adherence. Key questions include:

• “Have you noticed any recent changes in her mood, activity levels, or sleep habits?” This provides context from close contacts to gauge worsening symptoms or support deficits (Knutson & Van Cauter, 2017).
• “Does she have any difficulty with daily tasks or functioning?” Understanding her functional status guides holistic care planning (Fiske et al., 2020).
• “Are there any signs of increased distress or suicidal ideation that we should be aware of?” Ensuring safety and determining the need for urgent psychiatric intervention (American Psychiatric Association, 2013).

Engaging her support system not only enriches clinical understanding but also fosters adherence and emotional support during treatment.

Physical Examination and Diagnostic Testing

The physical examination should include vital signs, cardiovascular assessment, neurological evaluation, and general health status. Specific assessments involve:

• Cardiac examination to evaluate for arrhythmias that could disrupt sleep or be related to comorbidities (Kemp et al., 2017).
• Neurological assessment for signs of peripheral nerve involvement or movement disorders (Plazzi et al., 2019).
• Basic laboratory tests including fasting blood glucose, hemoglobin A1c, thyroid function tests, and complete blood count to rule out metabolic or endocrine contributors to her sleep disturbance and mood symptoms.

Diagnostic sleep studies, namely polysomnography and actigraphy, are indicated to objectively evaluate her sleep architecture and patterns. Polysomnography provides data on sleep stages, periods of awakenings, and potential sleep disorders like sleep apnea or periodic limb movements (Niel et al., 2020). Actigraphy offers a less invasive measure of sleep-wake cycles over several days, aiding in long-term assessment of sleep patterns in her natural environment.

The results from these tests inform whether structural sleep disorders or primary sleep pathology underpin her insomnia, or if her sleep disturbance is secondary to depression or grief. This guides targeted treatment interventions.

Differential Diagnosis and Most Likely Cause

The differential diagnoses for this patient include:

• Major depressive disorder (MDD): Given her recent loss, worsening depression, and sleep disturbance, MDD is the most probable diagnosis.
• Anxiety disorder: Especially generalized anxiety disorder, which can coexist with depression and exacerbate insomnia.
• Restless leg syndrome (RLS): Characterized by uncomfortable leg sensations and an urge to move the legs, common in older adults with sleep fragmentation.
• Sleep apnea: Obstructive sleep apnea is prevalent among the elderly, especially those with hypertension and obesity, and could cause fragmented sleep and daytime fatigue.
• Grief-related insomnia: The psychological impact of bereavement directly affecting sleep quality without other underlying pathology.

Most likely, her insomnia is secondary to grief-related depression, compounded by chronic medical conditions that may predispose her to sleep disturbances. The recent crisis and absence of prior depression suggest that her current symptoms are reactive, although depression is a primary consideration due to her clinical presentation (Karp et al., 2019).

Pharmacologic Therapy Options

Two medications considered include:

1. Selegiline transdermal patch: Starting at 6 mg daily, applied once daily, with titration up to 12 mg as needed. It inhibits monoamine oxidase B, increasing central dopaminergic and monoaminergic activity, useful if depression persists or is resistant to other agents (Bied et al., 2015). Since her depression seems reactive, this agent can be beneficial if depressive symptoms dominate.
2. Eszopiclone: Administered at 3 mg orally prior to sleep, working on GABA receptors to induce sedation. It is effective for short-term management of insomnia, especially when sleep latency and maintenance are problematic (Dixon et al., 2015).

The choice between these agents depends on her predominant symptoms. If her primary concern is persistent insomnia without severe depression, eszopiclone is appropriate. If her depressive symptoms are prominent and resistant to initial therapy, a trial of selegiline may be warranted. Combining the two may be considered cautiously, with close monitoring for interactions, especially serotonin syndrome risk.

Contraindications and Ethnic Considerations

Selegiline transdermal patches contraindicate concurrent use with serotonergic agents like SSRIs due to the risk of serotonin syndrome. Dose adjustments are necessary for elderly patients to reduce adverse effects, and careful consideration of her ethnicity is essential. For example, individuals of Asian descent may have altered pharmacokinetics due to differences in metabolizing enzyme activity, influencing drug plasma levels and side effect profiles (Yasuda et al., 2018). Such pharmacogenetic variations can impact drug efficacy and safety, necessitating tailored dosing and vigilant monitoring.

The contraindication exists because selegiline enhances monoamine levels, and when combined with other serotonergic agents, it can cause excessive serotonergic activity leading to hyperthermia, agitation, and neuromuscular abnormalities. Ethnic differences in enzyme activity such as CYP450 isoforms further influence drug metabolism, requiring specific dosing considerations (Li et al., 2020).

Follow-up and Monitoring

Follow-up assessments at 4, 8, and 12 weeks are crucial to evaluate therapeutic response. Key points include:

• Monitoring sleep quality via patient report and sleep diaries.
• Assessing depressive symptoms using standardized scales such as the PHQ-9.
• Evaluating for adverse drug reactions, especially signs of serotonin syndrome or excessive sedation.
• Adjusting medication dosages based on response and tolerability, with a possible tapering or augmentation strategy if required.

Suppose no improvement occurs at 4 weeks; dose escalation or switching agents may be warranted. If adverse effects develop, dose reduction or discontinuation is necessary. Long-term management also includes psychosocial interventions, grief counseling, and sleep hygiene education to optimize outcomes.

Conclusion

This comprehensive approach emphasizes individualized care, integrating assessment, collaboration, appropriate diagnostics, pharmacologic management, and vigilant follow-up. Recognizing the interplay of grief, medical comorbidities, and aging is vital in crafting effective interventions to improve sleep and mood in elderly patients.

References

• American Academy of Sleep Medicine. (2014). The AASM manual for the scoring of sleep and associated events. American Academy of Sleep Medicine.
• American Psychiatric Association. (2010). Diagnostic and statistical manual of mental disorders (5th ed.).
• American Psychiatric Association. (2013). Practice guideline for the assessment and treatment of patients with suicidal behaviors.
• Fiske, A., Wetherell, J. L., & Gatz, M. (2020). Depression in Older Adults. Annual Review of Clinical Psychology, 16, 371-393.
• Karp, A., et al. (2019). Grief, depression, and sleep disturbance in older adults. Journal of Clinical Psychiatry, 80(4), 18m12411.
• Kemp, B., et al. (2017). Cardiac causes of sleep disturbance in the elderly. Sleep Medicine Reviews, 34, 71-81.
• Knutson, K. L., & Van Cauter, E. (2017). Associations between sleep and immune function. Sleep Health, 3(4), 213-222.
• Li, P., et al. (2020). Pharmacogenetics of antidepressants in Asian populations. Pharmacogenomics Journal, 20(2), 243-251.
• Nel, K., et al. (2020). Actigraphy versus polysomnography to measure sleep in youth treated for craniopharyngioma. Behavioral Sleep Medicine, 18(5), 662-669.
• Walters, A. S., et al. (2017). Restless legs syndrome in older adults: Clinical features and management. Sleep Medicine Clinics, 12(4), 439–450.