Traciep
Treatment for A Patient with A Common Condition
Questions to ask
- How many hours of sleep do you have in a night? This is important to assess the number of hours and establish the extent of insomnia.
- Do you consume caffeinated drinks? This is because caffeine is a stimulant and hence its consumption may cause sleep disturbance (Chaudhary et al., 2021).
- Have you been experiencing symptoms of worthlessness and hopelessness? These are some of the most common symptoms of depression, which is also associated with sleep disorders including insomnia.
People to get feedback from
The family members as well as her friends and her caretaker. Important questions will include any changes that the individual has noticed in the patient including how she has been interacting with people, as this will help identify any instances of withdrawal or loss of interest in activities that she once enjoyed, which are common symptoms of depression (Park & Zarate, 2019). Physical Exams and Diagnostic Tests
Psychological assessments can be used to further evaluate symptoms of depression and to monitor the treatment progress. These include questionnaires such as the Hamilton Rating Scale for Depression (HAM-D) and the Beck Depression Inventory (BDI)
The Differential Diagnosis for The Patient
Major depressive disorder (MDD), is a serious and potentially debilitating mental health condition that affects an individual’s mood, thoughts, physical health, and behavior
It is characterized by a persistent feeling of sadness, loss of interest or pleasure in usual activities, and other symptoms that significantly interfere with the person’s ability to function in daily life (Park & Zarate, 2019).
Two Pharmacological Agents and Their Dosing
Sertraline- starting dosage is 25 mg/day
Nortriptyline- starting dosage is 25mg/day
Contraindications of the drugs
Nortriptyline is a tricyclic antidepressant medication contraindicated in children under the age of 12, patients with histories of seizures, patients with mania or bipolar disorder, kidney or liver impairment, cardiac conditions, as well as those with suicide ideation (Merwar et al., 2022).
Sertraline on the other hand is contraindicated in patients with cardiac issues, liver disorders, pregnant or breastfeeding patients, taking monoamine oxidase inhibitors, or those with a history of suicidal ideation (Singh & Saadabadi, 2022).
Checkpoints
After therapy, there is a need for follow-up every four weeks. Based on the outcomes, there can be alterations in the dosage to address the issues that come up.
References
Chaudhary, N.S., Taylor, B. V., Grandner, M. A., Troxel, W. M., & Chakravorty, S. (2021). The effects of caffeinated products on sleep and functioning in the military population: A focused review. Pharmacology, Biochemistry, and Behavior, 206, 173206. https://doi.org/10.1
Initial Discussion Post
Depression and insomnia frequently cooccur in the elderly population, with one diagnosis often being the cause of the other (Brouwer et al., 2022). Some disruption to sleep is an expected aspect of aging, such as going to bed or waking up earlier, but compounding sleep disturbances can drastically affect one’s physical and emotional health (Rani et al., 2019). Like the patient in the case study, the elderly frequently cite grief or worry as their perceived primary reason for insomnia (Rani et al., 2019). In addition to depression or anxiety, poor sleep hygiene can also be a factor in why a patient is experiencing poor sleep (Rani et al., 2019).
Three questions that I believe would be beneficial during an interview with an elderly patient with sleep disturbances would be:
- Do you nap throughout the day?
- Could you give me an example of your daily routine?
- Do you feel afraid or unsafe at night?
The first question is useful in assessing how often, if any, the patient is sleeping during the day. If the patient takes frequent naps throughout the day, we can discuss strategies to improve her sleep hygiene, such as being more active. The second question follows this thinking of determining what adjustments can be made to her lifestyle to promote better sleep at night. Light exercises or community activities throughout the day could have the dual benefit of breaking up the patient’s day and making her more tired in the evenings. Finally, the third question will help determine if the insomnia is due to a social determinant of health and/or if there is some underlying anxiety about being alone.
If the patient does report feeling unsafe, it would be prudent to involve family members in the discussion. Questions that would be appropriate to ask the family members are:
- Is there someone who could stay with the patient at night?
- Have you ever discussed getting a home security system for her?
I believe this patient is experiencing insomnia due to depression since her symptoms have worsened along with her depression. It also appears that the sertraline she previously prescribed is ineffective and should be discontinued. I believe that this patient would benefit from adding either trazodone or mirtazapine to her nightly medication regime.
Trazodone is an SSRI that is frequently used off-label for the treatment of insomnia (Shin & Saadabadi, 2022). I would anticipate beginning trazodone 50mg PO QHS for insomnia and depression while decreasing the sertraline to 50mg PO daily for five days, then discontinuing. Slowly tapering down the sertraline will help reduce any withdrawal symptoms the patient may experience (Keks et al. 2016). Geriatric patients have an increased risk of developing hyponatremia while taking trazodone, so we would need to monitor her BMP while on the medication. I anticipate seeing her again in one-to-two weeks to evaluate whether we need to increase the trazodone to 100mg PO QHS.
Mirtazapine is a tetracyclic antidepressant frequently used off-label for treating insomnia (Jilani et al., 2022). I would titrate the patient’s sertraline the same as above and begin mirtazapine 15mg PO QHS for insomnia and depression (Jilani et al., 2022). Mirtazapine can cause weight gain and increase serum cholesterol and triglycerides (Jilani et al., 2022). The patient’s weight, blood sugar, and lipid panels must be monitored periodically to address any increases. I would want to see the patient within two weeks to assess the effectiveness of the mirtazapine. Her dose could be increased to 30mg PO QHS if ineffective.
In conclusion, the cause of insomnia in elderly patients can involve many different factors. Patient and family questioning can be invaluable in identifying the underlying cause and developing a treatment plan. Trazodone and mirtazapine are both antidepressants that excel at treating symptoms of insomnia (Shin & Saadabadi, 2022; Jilani et al., 2022).
References
Brouwer, A., van de Ven, P. M., Kok, A., Snoek, F. J., Beekman, A. T. F., & Bremmer, M. A. (2022). Symptoms of depression and insomnia in older age: A within‐individual analysis over 20 years. Journal of the American Geriatrics Society, 70(7), 2051–2059. https://doi.org/10.1111/jgs.17765Links to an external site.
