answer this discussion based on this:
Critique your colleague’s
indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
References at least 2-3 no more than 5 years ago.
In reviewing the case study of this 75-year-old female who recently lost her 41-year-old spouse, the following three questions may arise: (1) How have you been doing with the Sertraline medication? Although it is unclear how long this medication has been prescribed, the case study reveals that the spouse died ten months ago. Major Depressive Disorder has been diagnosed in the patient (MDD). This information will be used to determine whether or not the medication is taken as prescribed; depression and insomnia are known to coexist, but it is unclear which comes first, “depression or insomnia” (Brouwer et al., 2022). In addition, Sertraline has a known side effect of insomnia (Sertraline: MedlinePlus Drug Information, n.d.). (2) A second question of interest is “how frequently are alcoholic beverages consumed?” A study of over 9,000 participants (over 5000> age 60) on the use of alcohol, MDD, and grief found that changes in alcohol use, whether an increase or decrease, contributed to insomnia in bereaved individuals from a few months to a few years after bereavement (Aoyama et al., 2020). (3) It is critical to ask the individual, “What are your current sleep patterns; do you have difficulty falling or staying asleep?” It is not uncommon for an individual who sleeps most of the day to be restless during the night; the question is, why?
A child, caregiver, and a close friend or grief counselor with privileged information may be able to provide insight into this patient’s condition. These people may be able to offer insight into the patient’s cognitive functioning as well as coping mechanisms related to her spouse’s death. Close family and friends may also be aware of other complaints that the provider is unaware of that are affecting this patient’s ability to sleep. It would be useful to know what behaviors these individuals have observed, as well as the individual’s appetite. The importance of speaking with others in this individual’s circle is to determine if any other medical, physiological, or psychological conditions that have not been previously disclosed may be affecting this individual’s sleep.
A good history of current illness, including any heart and lung issues, substance use, pain condition, and psychiatric history, past or present, would be beneficial in determining the cause of this individual’s sleep disturbance. An initial lab screen should include a CBC, CMP, urinalysis, sedimentation rate, thyroid tests, and A1C check. The preliminary lab results could reveal whether the condition is caused by an infection or inflammation, which may or may not be related to pain, other drug use, or another medical condition causing insomnia (Collins, 2017).
Prolonged grief, insomnia, nocturia, substance use, Gastrointestinal Esophagus Reflux Disease, depression, and osteoarthritis are all possible diagnoses for this individual’s sleep disturbance. Although all of the noted differential diagnoses may have an impact on one’s ability to sleep, Garg (2018) believes the patient’s condition is Insomnia Disorder due to unresolved depression related to the loss of a spouse.
Cymbalta, a Serotonin and Norepinephrine Reuptake Inhibitor (SNRI), is a pharmacologic agent that is appropriate for the patient’s antidepressant therapy. Cymbalta’s exact mechanism of action is unknown. Its applications, however, include the treatment of Major Depressive Disorders (MDD) and the relief of pain. Cymbalta has anti-anxiety properties and may increase serotonergic and noradrenergic brain activity. Cymbalta will be started at 30 mg daily for two weeks and may be increased after a follow-up visit if no or minimal improvement is noted and medication is tolerated; no age adjustment is required for the elderly patient with this medication (Cymbalta (Duloxetine Delayed-Release Capsules), n.d.).
Tofranil, a Tricyclic Antidepressant, is another antidepressant drug that could be used to treat this patient (TCA). Tofranil, like Cymbalta, has an unknown mechanism of action, but it is known to stimulate the central nervous system and is effective in treating MDD. Tofranil’s initial starting dose will be 30 mg daily, with a lower dose (recommended 30-40 mg/day for elderly patients). Tofranil (Imipramine Hydrochloride), n.d.
Given the choice between Cymbalta and Tofranil, this writer would choose Cymbalta because it has no drug interactions with medications the patient is already taking and will effectively treat the patient’s condition; unlike Tofranil, which interacts with medications the patient is already taking. Tofranil has synergistic effects that interact with Metformin and Januvia, potentially increasing the effects of both drugs (Drug Interactions Checker – Medscape Drug Reference Database, n.d.). It is also worth noting that the medication Tofranil is contraindicated in anyone who has recently (within the last 14 days) or is currently using a Monoamine Oxidase Inhibitor (MOAI); use may result in an extremely high temperature and seizure. Tofranil may interact with other drugs that affect the enzyme Cytochrome P450, requiring lower doses. Tofranil may also aggravate cardiac disease (Tofranil (Imipramine Hydrochloride), n.d.). Cymbalta, like Tofranil, is contraindicated if a MOAI’s prior or current use is noted. Furthermore, the medication Cymbalta may cause hyponatremia, as well as an increase in blood pressure and glucose; regular monitoring is advised (Cymbalta (Duloxetine Delayed-Release Capsules), n.d.), which is especially important in this patient with diabetes and hypertension. The desired outcome for this patient is to effectively treat depression while also improving insomnia and overall quality of life. If this patient is not already receiving grief counseling, he or she will benefit from it.
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