The Critical Evaluation Of The Case Of Insomnia Discussion

The Critical Evaluation Of The Case Of Insomnia Discussion

Rahmot Raji
Initial post
COLLAPSE
An Elderly Widow Who Just Lost Her Spouse

The first question would be: do you often wake up feeling out of breath or gasping? This would provide a quick assessment of the functional, cognitive, and cardio-cerebrovascular condition of the patient (Jacobson, 2014). The second question would be: do you use substances, like caffeine, tobacco, and/or alcohol? These stimulants disrupt sleep in the evenings (Jacobson, 2014). And, lastly, do you have a current (besides your husband’s demise) or new stresses, perhaps in your personal life or other areas of your life? Increased stress levels worsen sleep disorders (Garg, 2018). In order to further assess the patient’s situation, I will speak to her caregiver or the older adult in the family. I will ask him/her questions that would somehow determine his/her capability to provide continuous care, such as: do you have children or other dependents at home; do you have a partner, if yes, is s/he supportive? The Critical Evaluation Of The Case Of Insomnia Discussion

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Appropriate physical exams that will be carried out will look for cardio-respiratory disease, thyroid disease, lymphadenopathy, and pallor. This is to rule out any physical cause(s) of the patient’s insomnia and depression (Garg, 2018). Blood tests and sleep evaluation (a comprehensive sleep history) are the diagnostic tests that will be carried out. The findings will be used to determine if psychotherapy, alongside pharmacologic medications, would be beneficial (Jacobson, 2014)The Critical Evaluation Of The Case Of Insomnia Discussion .

Some key differential diagnoses are endocrine (hyperthyroidism, diabetes), pulmonary (asthma), cardiovascular (arrhythmia, congestive heart failure), sleep apnea, and depression (Mai & Buysse, 2008). The most likely is depression as numerous of insomnia’s daytime symptoms (e.g. mood changes, poor concentration) overlap with depression’s symptoms (Victor, Garg, & Gupta, 2019). Two pharmacologic agents that would be most appropriate for the patient are Citalopram (Celexa)— 20 mg/d— and Sertraline (Zoloft)— 200 mg/d. These two are the safest drugs for older adults suffering from MDD symptoms and chronic diseases (e.g. diabetes, hypertension). However, I would choose Citalopram over Sertraline since studies show that it works faster than Sertraline in improving depressive symptoms (Jacobson, 2014)The Critical Evaluation Of The Case Of Insomnia Discussion .

One contraindication with Citalopram is that it could exacerbate suicidal tendencies and behavior that are not included in the original presenting symptoms (Jacobson, 2014). Hence, the patient’s family must regularly keep in touch with the PMHNP in case there would any sudden behavioral changes. The patient must be closely monitored for suicidal tendencies, clinical worsening, and changes in behavior; this must be carried out throughout the first 1-2 months of dosage adjustments and therapy (Garg, 2018)The Critical Evaluation Of The Case Of Insomnia Discussion .

References

Garg, H. (2018). Role of optimum diagnosis and treatment of insomnia in patients with hypertension and diabetes: a review. Journal of Family Medicine and Primary Care, 7(5), 876-883.

Jacobson, S. (2014). Clinical manual of geriatric psychopharmacology. American Psychiatric Publication.

Mai, E. & Buysse, D. (2008). Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Sleep Medicine Clinics, 3(2), 167-174.

Victor, R., Garg, S., & Gupta, R. (2019). Insomnia and depression: how much is the overlap? Indian Journal of Psychiatry, 61(6), 623-629.

I appreciate the critical evaluation of the case. The patient has insomnia. It is important that the questions included other things that could cause the insomnia such as use of stimulants. Cardiovascular causes can bring about paroxysmal nocturnal dyspnea therefore, it was key to ask of gasping during sleep (Krystal et al, 2019)The Critical Evaluation Of The Case Of Insomnia Discussion . Asking of quality of sleep such as snoring and frequent awakenings can help exclude obstructive sleep apnea. Identifying other stressors will help in laying out a treatment plan by eliminating some stressors if possible. I think it would be useful to ask if the patient has chronic illness like diabetes and hypertension. This would help influence the choice of medication given to ensure minimal drug interactions.

It is right to have the most probable diagnosis as depression. Insomnia can present as an underlying symptom of major depressive disorder as the patient just lost her spouse. Identification of this relationship is useful, as treatment of the depressive disorder will result to better sleep outcomes (Krystal et al, 2019)The Critical Evaluation Of The Case Of Insomnia Discussion . The physical examination and diagnostic tests chosen are appropriate, as they would help in ruling out the differential diagnoses.

The choice of citalopram over sertraline will be beneficial to the patient as it has faster mode of action. Citalopram also has better efficacy and will have minimal drug interactions in case the patient uses other drugs.

Use of Cognitive behavioral therapy (CBT) should also be included in the management of comorbid insomnia and depression (Cunningham & Shapiro, 2018)The Critical Evaluation Of The Case Of Insomnia Discussion . A technique that can be used concurrently with drugs such as citalopram. It will help patient to recognize any thoughts or beliefs that worsen their sleep habits and replace them. It includes relaxation and meditation techniques. CBT is a good in-person therapy that will manage both insomnia and depression.

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Reference

Cunningham, J., & Shapiro, C. (2018). Cognitive Behavioural Therapy for Insomnia (CBT-I) to treat depression: A systematic review. Journal Of Psychosomatic Research, 106, 1-12. https://doi.org/10.1016/j.jpsychores.2017.12.012

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337-352 The Critical Evaluation Of The Case Of Insomnia Discussion