An Elderly Widow Who Just Lost Her Spouse

An Elderly Widow Who Just Lost Her Spouse

An Elderly Widow Who Just Lost Her Spouse

The case scenario is about a 75-year-old female reporting insomnia. She has a history of hypertension, diabetes, and major depressive disorder. Her depressive symptoms have progressively worsened after her husband died 10 months ago. This paper will discuss the additional questions for the patient, appropriate physical and diagnostic tests, differential diagnosis, and pharmacologic therapy.

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Questions I Might Ask the Patient

1. How is your mood most of the time? The question will establish the patient’s mood to determine depression.
2. How have your current mood and sleep symptoms affected your daily life? To identify if the symptoms have impaired her occupational and social functioning (Tolentino & Schmidt, 2018).
3. What challenges do you experience when carrying out your daily activities? To identify any challenges in ADLs contributed by the current symptoms.

People in the Patient’s Life I Would Need to Speak To

I would need to speak with the patient’s primary caregiver since they interact daily. I would ask the caregiver:

1. What changes in the patient’s mood and interactions have you noted in the past weeks? The response will help identify signs of a mood disorder that the patient may not have revealed (Tolentino & Schmidt, 2018).
2. Does the patient often express feelings of inappropriate guilt? Inappropriate guilt is a feature of depression that often leads to self-harm ideations.
3. Does the patient engage in risky behaviors? This will identify any signs of self-harm.

Physical Exam and Diagnostic Tests Appropriate For the Patient

1. Head-to-toe physical exam: The exam will identify signs of underlying abnormalities that may cause depression or insomnia symptoms and complications from diabetes.
2. Thyroid-stimulating Hormone (TSH) Test to assess for Hypothyroidism, which often presents with features of depression (Avasthi & Grover, (2018)
3. Hemoglobin A1c- The patient has a history of diabetes, and the test will establish if glycemic control has been achieved.
4. Depression screening using Patient Health Questionnaire (PHQ)-9 to assess the severity of the depression symptoms (Avasthi & Grover, (2018).

Differential Diagnosis

Major depressive disorder (MDD): MDD presents with a depressed/sad mood, decreased pleasure or interest in activities, or both. Other features include changes in appetite and weight, fatigue, sleep disturbances, indecisiveness, feelings of guilt and worthlessness, and recurrent suicidal ideations or attempt (Tolentino & Schmidt, 2018). MDD is the most likely diagnosis based on the patient’s positive symptoms of depression and insomnia and the history of depression.

Pharmacologic Agents

Duloxetine 30 mg PO once daily. Duloxetine is a serotonin-norepinephrine reuptake inhibitor (SNRI) that plays an essential role as a 2^nd-line agent in individuals with no adequate SSRI response (Muscatello et al., 2019). The patient has been on Sertraline, an SSRI, which has not helped reduce the depressive symptoms.

Amitriptyline 25 mg PO at bedtime.  Amitriptyline is a Tricyclic antidepressant (TCA), which has a long record of efficacy in treating depression (Tolentino & Schmidt, 2018).

I would choose Duloxetine over Amitriptyline because it is safe and tolerable for older adults and has fewer side effects (Muscatello et al., 2019). On the other hand, Amitriptyline is less desirable due to its strong anticholinergic and sedative effects. Contraindications in using Duloxetine include simultaneous administration with Monoamine oxidase inhibitors (MAOIs).

Check-Points

The patient will be followed up four weeks after initiation of treatment to evaluate response to treatment. She would be assessed for the severity of depression and insomnia symptoms after four weeks to determine if the treatment has been effective or there will be a need to increase dosing or change the drug.

Conclusion

Additional questions will seek to identify other symptoms of depression and their impact on the patient’s functioning. The patient’s presumptive diagnosis is MDD according to her history of MDD and symptoms of worsening depression and insomnia. Duloxetine would be an ideal treatment since it is recommended for patients who do not respond to SSRI treatment.

References

Avasthi, A., & Grover, S. (2018). Clinical Practice Guidelines for Management of Depression in Elderly. Indian journal of psychiatry, 60(Suppl 3), S341–S362. https://doi.org/10.4103/0019-5545.224474

Muscatello, M., Zoccali, R. A., Pandolfo, G., Mangano, P., Lorusso, S., Cedro, C., Battaglia, F., Spina, E., & Bruno, A. (2019). Duloxetine in Psychiatric Disorders: Expansions Beyond Major Depression and Generalized Anxiety Disorder. Frontiers in psychiatry, 10, 772. https://doi.org/10.3389/fpsyt.2019.00772

Tolentino, J. C., & Schmidt, S. L. (2018). DSM-5 criteria and depression severity: implications for clinical practice. Frontiers in psychiatry, 9, 450. https://doi.org/10.3389/fpsyt.2018.00450

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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
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.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
RUBRIC
Response to the Discussion question is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
40 (40.00%) – 44 (44.00%)
Thoroughly responds to the Discussion question(s).
Is reflective with critical analysis and synthesis representative of knowledge gained from the course readings for the module and current credible sources.
No less than 75% of post has exceptional depth and breadth.
Supported by at least three current credible sources.
NOTE:
APA format
3 References not more than 5 years old