Case An elderly widow who just lost her spouse. Insomnia Case – Discussion Solution

Case: An elderly widow who just lost her spouse, Insomnia Discussion Forum and Decision Tree. Our therapeutic focus for this week will be on Schizophrenia and Insomnia. The patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. 

Insomnia Case – Discussion

For this Discussion, review the case below. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.  Please keep in mind this is a Pharmacology course and Pharmacology should be your main point of emphasis in the discussion.

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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 (Wednesday) 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 the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.

Read a selection of your colleagues’ responses.

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Insomnia Case – Discussion Case An elderly widow who just lost her spouse. Insomnia Case – Discussion Solution

Introduction

Sleep disorders are a significant cause of concern among the elderly population yet remain one of the most commonly underdiagnosed health complications in this population. According to Abbad  & Guilleminault (2018), a host of factors that include but are not limited to retirement, health problems, death of family members or spouse, and changes in circadian rhythm contribute sleep disturbances among geriatrics. While changes in sleep patterns may constitute part of the normal aging process, if related to pathological processes should not be regarded as part of aging but necessitate therapeutic measures. The therapeutic modalities herein entail psychological/ behavioral therapies, medications, or both, aiming to alleviate the client’s quality of life.

Questions to Patient

1. How long per night do you sleep soundly?
2. Do you find it challenging to fall asleep when you go to bed, or do difficulties arise if you are awakened in the night?
3. Are there meals or drinks that seem to exacerbate the lack of sleep?
4. Do physiological symptoms related to your medical conditions of MDD and T2DM worsen the symptoms of sleeplessness?
5. Besides the prescribed medications, what nonpharmacological measures and interventions do you practice at home?

These questions are necessary for establishing the patient-specific risk factors for medical conditions of DM and HTN. Petrie et al. (2018) note that the risk factors for the two conditions are similar and could inform the identification of the protective factors the provider could tap into in creating an intervention plan. Likewise, it is vital to identify the risk factors and protective factors for MDD. Recognition of the alleviating and exacerbating factors could help craft the most effective intervention plans.

Questions to Caregivers

Family members constitute the largest group of caregivers attending to the elderly with multiple conditions at home and therefore have a rich history of the patient and can therefore collaborate with the patient’s information (Ploeg et al., 2020). Additionally, PCPs play a key role in supporting caregivers in geriatrics by offering patient and family education and assisting in managing the patient’s comorbidities (Karp et al., 2021).

1. Living children of the woman.
2. At what age was your mother diagnosed with DM, HTN, and MDD?
3. How effective are the prescribed therapeutic interventions in treating and managing each condition?
4. If she is not being cared for by family, the geriatric caregiver who attends to her, a nursing home, or any of its other alternatives.
5. What specific challenges does this patient adhere to the prescribed treatment and management plans?
6. The primary care provider whom she visits once or twice a year.
7. What referrals like psychiatric assessment and screening have you conducted with the patient over the last ten months, and what are their findings?
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Physical Exams and Diagnostic Tests (Paragraph form)

1. The A1C test for diabetes- confirm T2DM diabetes and monitor the blood sugar levels
   1. ECG- to evaluate the presence of left venti hypertrophy
   1. Thyroid Stimulation hormone- to determine the level of activity of the thyroid gland and rule out physiological causes to symptoms that could mimic MDD
   1. Beck Depression Inventory (BDI)- the 21 questions multiple choice self-report would measure the severity of depressive symptoms and feelings.

Differential Diagnosis For The Patient  

1. 6B42 Prolonged Grief Disorder (confirmed). -The symptoms were not present before and were triggered by the loss of her husband ten months earlier. No other psychiatric function is affected ( Killikelly & Maercker, 2017).
2. F33.1 MDD-(Refuted) – while both MDD and PCBD can manifest through Insomnia- MDD is associated with feelings of guilt not related to grief. (Maurer et al., 2018).
3. F20.9 Schizophrenia, unspecified (Refuted) – A schizophrenic patient has symptoms involving delusions, hallucinations or impaired speech, and highly disorganized behavior, which is not the case for the patient (McCutcheon et al., 2020).

Pharmacological Agents and Mechanism of Action

1. Naltrexone 50mg daily(PO)
2. Citalopram

According to Gang et al. (2021), it is a partial inverse agonist and is thought to work on serotonin, thus promoting sleep. Citalopram was avoided because if taken with other drugs like Bupropion, it increases the risk of seizures as a side effect.

Drug Therapy- Contraindications or Alterations in Dosing

Asian Americans have a higher than average population prevalence of Asp40 carriers and experience greater alcohol-induced (Ray et al., 2012). Their study found that Asp40 carriers experienced more significant alcohol sedation and lower alcohol cravings when Naltrexone was administered. The double-blinded study offer reinforcement to the study of naltrexone pharmacogenetics in Asian Americans. It is contraindicated in other ethnic because the average frequency of Asp40 in African Americans is 0.004, 0.16 in SW American Indians, and 0.14 in Hispanics. Most importantly, beta-endorphins have been found to have a 3- fold higher binding affinity at the Asp40 mutated receptor than at the receptor encoded by the Asn40 Allele. Therefore, it would cause individuals in these communities (Oroszi et al., 2009).

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Checkpoints and Follow-Up

Gang et al. (2021) report that the primary outcome measures on the difference in prolonged grief disorder were measured using Prolonged Grief -13 Revised (PG-13-R) administered every week for the next 12 weeks (1-12). A Structured Clinical Interview was also administered during weeks 1-4 and 8). The PG-13-R is a self-rated scale. The researchers demonstrated that PG-13 R has good internal consistency in three study samples (Gang et al., 2021).

Lessons Learned

I have learned that some gene mutations are more prevalent in ethnic communities like the Asp40 among Asian Americans. This might prove advantageous in some psychoactive drugs like Naltrexone. Asp40 polymorphism (DNA sequence variation common in a specific ethnic population) might render a drug more effective in some patients and not in others, hence its contraindication in patients from ethnic communities like African Americans and Caucasians.

References

Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: recommendations for pharmacological management. Drugs & Aging, 35(9), 791-817.

Gang, J., Kocsis, J., Avery, J., Maciejewski, P. K., & Prigerson, H. G. (2021). Naltrexone treatment for prolonged grief disorder: study protocol for a randomized, triple-blinded, placebo-controlled trial. Trials, 22(1), 1-15.

Karp, J. F., Hamm, M. E., de Abril Cameron, F., Lightfoot, M., Maher, R., Kincman, J., & Reynolds III, C. F. (2021). Improving Effective Mental Health Consultation for Rural Older Adults Living With Depression and Pain: Learning From the Experiences of Rural Primary Care Physicians. The Primary Care Companion for CNS Disorders, 23(2), 29380.

Killikelly, C., & Maercker, A. (2017). Prolonged grief disorder for ICD-11: the primacy of clinical utility and international applicability. European Journal of Psychotraumatology, 8(sup6), 1476441.

Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: screening and diagnosis. American family physician, 98(8), 508-515.

McCutcheon, R. A., Marques, T. R., & Howes, O. D. (2020). Schizophrenia—an overview. JAMA Psychiatry, 77(2), 201-210.

Oroszi, G., Anton, R. F., O’Malley, S., Swift, R., Pettinati, H., Couper, D., … & Goldman, D. (2009). OPRM1 Asn40Asp predicts response to naltrexone treatment: a haplotype‐based approach. Alcoholism: Clinical and Experimental Research, 33(3), 383-393.

Pantell, M. S., Prather, A. A., Downing, J. M., Gordon, N. P., & Adler, N. E. (2019). Association of social and behavioral risk factors with earlier onset of adult hypertension and diabetes. JAMA network open, 2(5), e193933-e193933.

Petrie, J. R., Guzik, T. J., & Touyz, R. M. (2018). Diabetes, hypertension, and cardiovascular disease: clinical insights and vascular mechanisms. Canadian Journal of Cardiology, 34(5), 575-584.

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Ploeg, J., Garnett, A., Fraser, K. D., Baird, L. G., Kaasalainen, S., McAiney, C., … & Dufour, S. (2020). The complexity of caregiving for community-living older adults with multiple chronic conditions: A qualitative study. Journal of Comorbidity, 10, 2235042X20981190.

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