Psychopharmacology Approach To Treatment . 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.
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 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 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.
Read a selection of your colleagues’ responses.
Respond to at least two of your colleagues on two different days in one of the following ways:
• If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
• If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
Joseph ay answer
Three questions to ask the patient
• What brought you here today? It is always good to begin interviews with patients with open-ended questions because it always gives a patient chance to be so available to the healthcare provider.
• Do you drink caffeine? Because this can prevent the patient’s chance of getting good sleep if the patient drinks caffeine, especially near bedtime.
• Did you have any history of gastro-esophageal Reflux Disease (GERD)? This usually leads to Insomnia in most older patients.
All these questions are essential for nurse practitioners to determine the conditions while evaluating patients with open-ended questions.
Peoples in patient live
The significant people in the patient’s life that would be asked the questions are children and caregivers. The question is: Is there a recent change in the patient’s appetite, mood, energy/interest? Providing all this information to the nurse practitioner would help to treat/diagnose the patient correctly, which is all relevant to patient care.
Physical Exam
In this scenario, the patient reported a lack of sleep (Insomnia). Both physical exam and blood work can be done on this patient to determine if there is any thyroid problem. Hyperthyroidism can result in nervousness from the inactivity of the hormone, and the symptom is insomnia (Van Straten A. et al. 2018). The Hamilton Anxiety Rating Scale is essential to measure the patient’s anxiety level. The HAM-A results can be used to treat insomnia, provided it is related to anxiety. Another scan can be used in the Hamilton Depression Rating Scale, which focuses on assessing a patient’s feelings of guilt, suicidal thought, and insomnia.
Diagnosis
This patient has been diagnosed with depression, and the differential diagnosis will be generalized anxiety disorder next to her husband’s death.
Pharmacologic Agents
Temazepam belongs to the benzodiazepine class that FDA has approved for insomnia, and the patient can be benefited from treating insomnia (Miller, C. B. et al. 2017). Temazepam is also used to treat anxiety and acute mania as an off label. Temazepam restricts GABA’s activity and is metabolized in the liver in the absence of CYP450. Trazodone is another suitable medication used to treat insomnia, which the FDA also approves to treat depression. Still, it is an off label to treat anxiety caused by insomnia. HT2C inhibits the Serotonin 5-HT2A and reuptake of Serotonin. Trazodone can cause daytime sleepiness and dizziness, but it is used through CYP3A4.
Contraindications
I prefer to treat the patient with temazepam because it has no active antibodies, a short half-life, and no drug interactions. The patient is already on medications to treat diabetes, HTN, and depression, so temazepam must be given with caution when administered with other drugs to prevent drug-drug interactions.
Check Point
It is always a good decision to start with a lower dose when prescribing medication, especially with elderly patients (Abad, V. C., & Guilleminault, C. (2018). 7.5mg is the lower dose of Temazepam that we should start this patient on. For example, start the patient on 7.5 mg tab PO at Bedtime for the next four weeks. The patient should be able to sleep effectively and see reduced anxiety after the medication starts. Otherwise, Temazepam should be increased to 15mg tab PO at Bedtime. The patient should be checked at eight weeks, and the maximum dose to be prescribed is 30 mg PO at bedtime, and caution should be taken when increasing the amount.
References
Abad, V. C., & Guilleminault, C. (2018). Insomnia in elderly patients: recommendations for pharmacological management. Drugs & aging, 35(9), 791-817.
Miller, C. B., Valenti, L., Harrison, C. M., Bartlett, D. J., Glozier, N., Cross, N. E., … & Marshall, N. S. (2017). Time trends in the family physician management of insomnia: the Australian experience (2000-2015). Journal of Clinical Sleep Medicine, 13(6), 785-790.
Sateia, M. J., & Buysse, D. (Eds.). (2016). Insomnia: Diagnosis and treatment. CRC Press.
Van Straten, A., van der Zweerde, T., Kleiboer, A., Cuijpers, P., Morin, C. M., & Lancee, J. (2018). Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis. Sleep medicine reviews, 38, 3-16
Three questions to ask the patient
• Can you describe your sleep patterns and habits? Understanding the patient’s sleep patterns and habits can give an insight into their sleep-wake cycle and help in identifying any sleep disturbances.
• What changes have you noticed since your husband passed away? It is important to understand the patient’s emotional state, and the impact of her husband’s death on her life, which could be related to her insomnia and depression.
• What are your typical daily activities? Knowing the patient’s daily activities, including exercise and dietary habits, can help determine if any changes need to be made to improve her sleep and overall health.
People in patient’s life
In the patient’s life, it would be appropriate to speak to her children or any close relatives to get feedback on her behavior and activities since her husband’s death. The questions that can be asked include:
• How has the patient been coping with her husband’s death?
• Has the patient shown any changes in behavior, mood, or sleep patterns?
• Has the patient been engaging in activities she used to enjoy before her husband’s death?
Physical Exam and Diagnostic Tests
A thorough physical exam including a neurologic exam and vital signs is important to rule out any medical causes of insomnia such as sleep apnea or restless leg syndrome.
A depression screening test such as the Beck Depression Inventory (BDI) or the Patient Health Questionnaire (PHQ-9) can be used to assess the patient’s depression symptoms. The results of these tests can help determine the severity of the patient’s depression and guide the course of treatment.
Differential Diagnosis
The differential diagnosis for this patient could be major depressive disorder, adjustment disorder with depressed mood, and bereavement. The most likely diagnosis in this case is major depressive disorder as the patient has reported worsening symptoms of depression since her husband’s death and has a history of depression.
Pharmacologic Agents
Two pharmacologic agents that could be appropriate for the patient’s antidepressant therapy are sertraline and venlafaxine.
Sertraline is a selective serotonin reuptake inhibitor (SSRI) with a mechanism of action that involves increasing the levels of serotonin in the brain. It is well tolerated and has a low risk of side effects, making it a good option for elderly patients. The recommended starting dose for sertraline is 25mg daily and can be increased up to 200mg daily.
Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) with a mechanism of action that involves increasing the levels of both serotonin and norepinephrine in the brain. It is also well tolerated but may cause more side effects compared to SSRIs, particularly in the elderly. The recommended starting dose for venlafaxine is 37.5mg daily and can be increased up to 225mg daily.
Contraindications and Alterations in Dosing
In elderly patients, it is important to consider the potential for increased risk of falls and cognitive impairment with the use of both sertraline and venlafaxine. The dose should be titrated slowly and monitored for adverse effects, particularly in patients with a history of falls or cognitive impairment.
Checkpoints and Therapeutic Changes
It would be appropriate to schedule follow-up appointments with the patient at Week 4, 8, and 12 to monitor the patient’s response to the antidepressant therapy and make any necessary therapeutic changes. If the patient is not responding to the therapy, a switch to a different antidepressant medication could be considered. It is also important to monitor the patient’s blood pressure, as some antidepressant medications can cause an increase
