Questions and Rationale

The first question that I might ask the Patient is, “what brings you in today?”. By this question, you are forming a rapport with the Patient and making it for her to share his/her feelings openly. By asking an open-ended question, the Patient is more willing to share information with the provider (Stern, 2016). The second question that would be of beneficial knowledge during the interview is, “do you consume caffeine?” If so, how much caffeine do you consume in a day? Since caffeine consumption close to bedtime contributes significantly to insomnia. Lastly, “do you suffer from Gastro-Esophageal Reflux Disease (GERD)?”. GERD is a contributing factor to insomnia in elderly patients. The provider can rule out environmental factors by asking the above questions while assessing the Patient’s concerns with open-ended questions. (Farazdaq et al., 2018).

People in the Patient’s life, Questions, and feedback

The People in the Patient’s life that could help and give further information are her children or caretakers. Since they are in close contact with the Patient before admission to your office, questions that would be appropriate to ask the Patient’s children or caretaker would be, “Is there a recent decrease in her appetite, energy, mood, or interests?” By asking about these questions, external information will be provided, and further assessment that the Patient might be withholding or unaware of.

Appropriate Physical Examinations and Diagnostic Tests

A physical exam could be performed with the order of blood testing to rule out thyroid problems. Hyperthyroidism results in nervousness from the overactivity of this hormone, and insomnia is often a symptom. Administering the Hamilton Anxiety Rating Scale would assess the severity of the Patient’s anxiety. The HAM-A results would aid with further treatment of the Patient’s insomnia if related to anxiety. Also, insomnia relies heavily on self-report for a diagnosis (Levenson et al., 2015). Another appropriate scale to administer to this Patient is the Hamilton Depression Rating Scale. HDRS is an assessment that focuses on feelings of guilt, mood, suicidal ideation, activities, weight, various stages of insomnia, and many more critical areas (Hamilton, 1960) appropriate to the Patient’s condition.

Differential and Likely Diagnosis

The Patient has a previous diagnosis of depression. The differential diagnosis for this Patient is Generalized Anxiety Disorder (GAD), secondary to the husband’s death. There are many possible changes within the dynamics of life, such as financial stress, fear of being alone, fear of death, and sudden sleep alone. Generalized Anxiety Disorder (GAD) is characterized by persistent and excessive worry about several things. People with GAD may anticipate disaster and be overly concerned about money, health, family, work, or other issues. Individuals with GAD find it difficult to control their worries. They may worry more than seems warranted about actual events. This differential diagnosis fits the Patient given in the scenario. Changes within this Patient’s routine may be a cause of reported insomnia.

Appropriate Pharmacologic Agents

The two pharmacological agents appropriate for the Patient’s antidepressant therapy are Trazodone and Temazepam.

Trazodone is widely used for insomnia. It Is FDA approved for the treatment of major depression and used off-label for insomnia and anxiety. Trazodone inhibits serotonin reuptake, alpha-1 adrenergic receptor antagonist, and serotonin 5-HT2A and 5-HT2C receptor antagonist and is metabolized primarily through CYP3A4 to active metabolite mCPP, that is metabolized by 2D6, inducing P-glycoprotein. Trazodone, however, carries the side effect of daytime somnolence and dizziness (Cook et al., 2018).

Another good sleep aid choice is Temazepam. It is also FDA approved for insomnia and used off-label for anxiety disorders, acute mania, psychosis, and catatonia (Puzantian & Carlat, 2020). It is generally effective in the treatment of insomnia by enhancing the widespread inhibitory activity of GABA (Levenson et al., 2015). Temazepam is metabolized through the liver without CYP450. Temazepam is used to help people get to sleep. It is habit-forming and should not be used for more than seven to ten nights in a row but is safer in elderly patients, which suits the Patient in the scenario given. Although, trazodone is mainly used for its sleep-inducing effects (an off-label indication) rather than as an antidepressant. Only generic forms are available, which makes it a lot cheaper than some other sleep-inducing alternatives, and it is not classified as a controlled substance.

Contraindications and Patient Factors

The favorable medication for this Patient is Temazepam. Temazepam is a safer medication for elderly patients because of its lack of active metabolites, short half-life, and absence of drug interactions (Puzantian & Carlat, 2020). The Patient is currently taking Metformin, Januvia, Losartan, HCTZ, and Sertraline. The Patient is being treated for diabetes mellitus, hypertension, and depression based on the current medications. Adding Temazepam to the Patient’s medication regimen would not result in toxicity of other medications. Sleep is heritable and regulated by numerous genes. A genome broad association study found numerous single-nucleotide polymorphisms significantly associated with insomnia symptoms. The most significant SNPs occurred within genes involved in neuroplasticity, stress reactivity, neuronal excitability, and mental health.

Checkpoints and Therapeutic Changes.

The starting dose of Temazepam is lower in the elderly population (Puzantian & Carlat, 2020). The proper dose to begin with this Patient is Temazepam 7.5mg tab PO QHS. At the 4-week checkup, the expected outcome would be an increased ability to sleep and reduced anxiety. If these results have not been achieved, Temazepam 15mg tab PO Q HS would be ordered. Temazepam does have the risk of weakness and dizziness, so great care and caution would need to be taken when increasing the dose. There needs to be an evaluation of the effects at week 8, or sooner if needed. The maximum dose of Temazepam is 30mg PO Q HS, and even lower in the elderly (Cook et al., 2018).

Lessons Learned and Therapeutic Application

The lesson I’ve learned from the given case study is that depression and sleep have a bidirectional relationship. This means that poor sleep can contribute to the development of depression and that having depression makes a person more likely to develop sleep issues. Sleep problems often accompany most people who have experienced depression. At the same time, sleep problems can exacerbate depression, leading to a negative cycle between depression and sleep that can be challenging to break, not only to elderly patients but in all types of life development from kids to adolescents, adults up to elderly patients. Depression and sleep are closely intertwined and must be prioritized, and should not be taken lightly. I could apply this in my practice by giving health teachings, counseling, or educating patients about the basic knowledge on depression. Not to be scared to talk about their feelings to others, their healthcare provider, doctors, and families. Patients with this kind of situation are most likely to feel better after they open up their situation.

References:

Cook, B., Creedon, T., Wang, Y., Lu, C., Carson, N., Jules, P., Alegría, M. (2018). Examining racial/ethnic differences in patterns of benzodiazepine prescription and misuse. Drug and Alcohol Dependence, 187, 29-34. DOI: 10.1016/j.drugalcdep.2018.02.011

 

 

 

Farazdaq, H., Andrades, M., & Nanji, K. (2018, December 31). Insomnia and its correlates among elderly patients presenting to family medicine clinics at an academic center. Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6382090/

 

https://adaa.org/understanding-anxiety/generalized-anxiety-disorder-gad

 

Hamilton, M. (1960). Hamilton Rating Scale for Depression. PsycTESTS Dataset, 23, 56-62. https://doi.org/10.1037/t04100-000

 

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