Treatment of a patient with Insomnia

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 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.

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf

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). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org

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Treatment of a patient with Insomnia
Question 1
Three Questions.
What brings you today? This question is open-ended in nature. By asking this question, the patient will be in position to willingly share information with the healthcare provider (Stern, 2016).
Have you ever consumed caffeine? If so, what amount in a day? This question will be of great benefit during the interview. This is because consumption of caffein close to bed time contributes greatly to insomnia.
Do you suffer from Gastro Esophageal Reflux Disease (GERD)? GERD contributes to insomnia among the elderly patients. This question helps the healthcare provider to rule out environmental factors and at the same time evaluate the concerns of the patient through open-ended questions.
Question 2
Caretakers and children are people in the patient’s life that could give more information about the patient.
Question to be asked: Is there any recent disease in her appetite, energy, mood or interest? Through asking this question, the healthcare provider will get external information that the patient may not be willing to give or simply unaware of (Levenson et al, 2015).
Question 3
Insomnia disease mainly relies on self-report for the purposes of diagnosis. Performing of the physical exam could also be done through blood testing to rule out thyroid cases. Hyperthyroidism brings about nervousness from overactivity of the hormone. Insomnia is usually a symptom in such a case. Administering Hamilton Anxiety Rating Scale would help in evaluating the seriousness of the anxiety of the patient. Hamilton Anxiety Rating Scale outcome would help in further treatment of insomnia in case it is related to anxiety (Stern, 2016).
Question 4
Differential diagnosis for the patient is Generalized Anxiety Disorder (GAD) as a result of depression that was occasioned by the death of the husband. The occurrence of death brought about changes such as financial burdens, fear of own death among other factors. These changes are the reasons for insomnia (Stern, 2016).
Question 5 and 6
Temazepam is approved by FDA for insomnia. It is used off-label for anxiety disorder and is generally effective in the treatment of insomnia. Trazodone is also approved by FDA for insomnia and other major depression effects (Rajib, 2020). I would choose Temazepam because it is safer to use among the elderly patients. This because it lacks active metabolites.
Question 7
Starting a dose of Temazepam is lower among the elderly population. The proper dose would be 7.5mg tab PO QHS. After 4 weeks, the expected result would be an increase in the ability to sleep and reduced levels of anxiety. In case this does not give positive outcome, Temazepam 15mg tab PO QHS would then be ordered. Dizziness and weakness are not some of the side effects of Temazepam therefore they need for great care when increasing the dose (Puzantian, & Carlat, 2020). Assessing the effect at week 8 or earlier would be necessary. The maximum dose would be 30gm PO Q HS and lower among the elderly.

References
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The Pathophysiology of Insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
Puzantian, T., & Carlat, D. J. (2020). Medication fact book for psychiatric practice. Carlat Publishing, LLC.
Rajib, D. (2020). Do genes matter in sleep? -A comprehensive update. Journal of Neuroscience and Neurological Disorders, 4(1), 014–023.
Stern, T. A. (2016). Massachusetts General Hospital: psychopharmacology and neurotherapeutics (1st ed.). Elsevier.