Treatment For A Patient With A Common Condition Discussion

Treatment For A Patient With A Common Condition Discussion

Research studies have shown that nocturia is an independent predictor of insomnia and reduced sleep quality. According to Leslie et al., (2022), increased sleep awakenings worsen the sleep quality and are common in the elderly. Patients taking naps during the day may reduce the sleep drive in the evening. Caffeine is a psychoactive stimulant thus intake before sleeping results in sleep related effects such insomnia. Obstructive sleep apnea is commonly seen in the elderly and obese and it causes blockage of the airway when sleeping thus interrupting the sleeping patterns (Arnold et al., 2017)Treatment For A Patient With A Common Condition Discussion. Inquiring about childhood trauma is important since they have an impact throughout adulthood. With the worsening symptoms of depression, it is essential to rule out suicide or self-harm ideations. Inquiring when the symptoms began since use of sertraline is associated with insomnia.

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Information from people living with the patient is important to identify any mood or behavioral changes and anything the patient might be withholding from. Thyroid disorder such as hyperthyroidism is often associated with insomnia. Sleep disturbances also affect the rate of metabolism and therefore various hormones are involved.

Obstructive sleep apnea is most common in obese and the elderly and involves cessation of breathing with repeated episodes of upper airway collapse during sleep. It is mostly associated with excessive daytime sleep and fatigue (Arnold et al., 2017). Post-traumatic stress disorder occur secondary to traumatic incidences such as loss of a loved one or from prolonged exposure to trauma such as sexual abuse in childhood (Sukhmanjeet Kaur Mann & Marwaha, 2022). In this case, anxiety is an accompanying symptom in this case and requires further assessment to rule it in as a diagnosis.

References

Arnold, J., Sunilkumar, M., Krishna, V., Yoganand, S., Kumar, Ms., & Shanmugapriyan, D. (2017). Obstructive sleep apnea. Journal of Pharmacy and Bioallied Sciences, 9(5), 26. https://doi.org/10.4103/jpbs.jpbs_155_17

Leslie, S. W., Sajjad, H., & Singh, S. (2022, February 14). Nocturia. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK518987/

‌ Sukhmanjeet Kaur Mann, & Marwaha, R. (2022, February 7). Posttraumatic Stress Disorder. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK559129/ Treatment For A Patient With A Common Condition Discussion

‌First student response 6630N

The patient’s daytime schedule should be obtained. For example if the patient takes a nap during the day may decrease sleep drive in the evening and may be a target for intervention. Environmental factors such as excess light, noise and extreme temperatures often interfere with sleep and therefore it is important to assess the surrounding conditions of a patient living with insomnia (Krystal et al., 2019)Treatment For A Patient With A Common Condition Discussion. Identifying the patient’s social support is essential as it is directly related to anxiety and depression.

People surrounding the patient can help in providing information or noting behavioral changes that the patient is unaware of or holding back. There is a close association between insomnia with depression which is most likely related to the underlying pathophysiological mechanism for sleep and mood regulation that predispose an individual to both.

A sleep diary is essential in assessing the sleep patterns. According to (Krystal et al., 2019), it is considered as the gold standard for subjective sleep assessment as it helps characterize the specific sleeping problem. Sleep is essential in regulating metabolic processes thus metabolic disorders are prevalent in cases of insomnia. The hospital anxiety and depression scale is a self-assessment scale that is reliable for assessing the state and severity of depression and anxiety.

I disagree with insomnia since according to Krystal et al., (2019), if insomnia is explained by another underlying psychiatric disorder in this case increased depression. Anxiety may also be a symptom of worsening depression. The probable differential is post-traumatic stress disorder secondary to the loss of her husband.

Introducing trazodone is recommended due to its dual mechanism of action in treating depression and insomnia (Jaffer et al., 2017)Treatment For A Patient With A Common Condition Discussion. If the symptoms still persist or worsen, the dosage may be adjusted.

References

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in Clinical Neuroscience, 14(7-8), 24–34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337–352. https://doi.org/10.1002/wps.20674

‌Week 7 Discussion Class 6630

Questions you would ask the patient.

Does the patient experience cessation of breathing while asleep? Sleep disorders such as obstructive sleep apnea (OSA) are common in obese and elderly patient according to (Slowik & Collen, 2022)Treatment For A Patient With A Common Condition Discussion. From her BMI, the patient is at risk of OSA. Does the patient take caffeine before sleeping? Intake of caffeine may result in sleep related effects such as insomnia symptoms or cause sleep disruption as it is a psychoactive stimulant (O’Callaghan et al., 2018). Does the patient have symptoms of acid reflux when lying down? GERD and sleep disturbances are often correlated since it leads to coughing and choking sensation thus causing one to wake up from sleep resulting in interrupted sleeping patterns.

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People in the patient’s life.

The patient’s children and home care giver can provide further information. Ask about mood or behavioral changes, weight loss or appetite. This will help in obtaining information that the patient might be unaware of or withholding. Also ask about compliance to medications since more often than not, non-compliance results in worsening of symptoms.

Diagnostic tests

Hamilton depression rating scale is used to evaluate the severity of patients already diagnosed with depressive disorder and assess the effectiveness of medications given. Thyroid function tests is useful in ruling out thyroid disease specifically hyperthyroidism that can cause insomnia.

Differential diagnosis

Post-traumatic stress disorder (F43.1): a disorder that results from exposure from a traumatic event such as losing someone, threatened death/injury, and sexual assault. The disease is associated with cognitive and functional impairment (Miao et al., 2018).it mainly occurs with other disorders such as GAD and major depressive disorder.

Pharmacological agents

PO trazodone 50mg 24hourly (nocte). An FDA approved drug used in treatment of depression and as an off-label in treating anxiety and insomnia (Jaffer et al., 2017). It decreases the level of serotonin, dopamine, histamine and noradrenaline which are responsible for the arousal effects.
PO fluraxepam 15mg 24hourly (nocte). According to (Flurazepam, 2017), it is a benzodiazepine that enhances sleep by their positive allosteric modulation of GABA type A receptor.

Trazodone is the most preferable due to its dual mechanism of action in managing insomnia and depression (Jaffer et al., 2017).Flurazepam on the other hand is not commonly used in the elderly due to its long-acting metabolites, associated with increased fall rates.

Contraindications of Trazodone

Increases the risk of discontinuation syndrome. It is not recommended in patients with compliance symptoms since suddenly stopping the drug results in withdrawal symptoms.

Follow up after one week to monitor the patient’s progress and assess the need for dose adjustment. If the symptoms are improving, one might consider tapering off the drug Treatment For A Patient With A Common Condition Discussion.

References

Flurazepam. (2017, January 24). Nih.gov; National Institute of Diabetes and Digestive and Kidney Diseases. https://www.ncbi.nlm.nih.gov/books/NBK548683/

Miao, X.-R., Chen, Q.-B., Wei, K., Tao, K.-M., & Lu, Z.-J. (2018). Posttraumatic stress disorder: from diagnosis to prevention. Military Medical Research, 5(1). https://doi.org/10.1186/s40779-018-0179-0

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404

Slowik, J. M., & Collen, J. F. (2022, February 10). Obstructive Sleep Apnea. Nih.gov; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459252/

‌Insomnia is one of the most common medical conditions you will encounter as a PMHNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PMHNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and their sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being Treatment For A Patient With A Common Condition Discussion.

_{Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental-illness#:~:text=Sleep%20problems%20such%20as%20insomnia%20are%20a%20common,bipolar%20disorder%2C%20and%20attention%20deficit%20hyperactivity%20disorder%20%28ADHD%29}

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: Treatment For A Patient With A Common Condition Discussion

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.

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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 Treatment For A Patient With A Common Condition Discussion

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