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. 

            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.

Insomnia is the inability to fall asleep, stay asleep, or wake up early. To be diagnosed with insomnia disorder, an individual must exhibit symptoms at least three times per week for a minimum of three months (Riemann et al., 2020). Insomnia is associated with bereavement. Bereaved individuals are more likely to experience sleep problems. Sleep disturbances are more prevalent during the first few months following a loss, but they can improve over time (Lancel et al., 2020). A 75-year-old woman who recently lost her 41-year-old husband presented to the client with a complaint of insomnia. The patient stated that her depression and sleep habits have gotten worse since her husband died.

 

List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions. 

1. Is your depression interfering with your day-to-day activities, or have you lost interest in formerly enjoyed pursuits? Do you have any family members or friends who can lend a hand? If depression is not addressed promptly, it might progress to suicidal or homicidal ideas. When a depressed person begins to give up beloved possessions to others, the person may experience feelings of hopelessness and worthlessness, as well as the inability to perform tasks that were formerly valued. This may lead to self-harm. Depression can be reduced and behavioral therapy can be improved with the help of family or social support.

How many hours do you get to sleep at night? 2. Has it been difficult for you to fall asleep or to stay awake? In order to develop a treatment plan and determine the type of medications to be delivered, it is necessary to determine the number of hours that one sleeps at night. Being aware of the patient’s sleep pattern assists the health care practitioner in making an accurate diagnosis and encouraging the patient to sleep in a peaceful atmosphere in order to promote sleep.

3. What is the length of time you have been taking Sertraline 100 mg orally for depression? Do you take any type of sleeping medicine? What medications do you take over the counter, and if so, what is the name of the medication that you take? Do you know how long you’ve been taking the medications? What is the frequency with which you take your medications? Have you seen any side effects or symptoms as a result of taking the medications? Do you have any sensitivities to foods, medications, or seasonal changes? It is vital to determine whether or not the patient is complying with her meds, whether or not the medications are effective, whether or not a change in medication is necessary, and whether or not the medication should be titrated or discontinued. The answers to these questions are critical in order to provide appropriate treatment.

• 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.

When dealing with a patient’s disease process, it is critical that she maintains her confidentiality. Because she is attentive and oriented, the patient’s power of attorney should be the most appropriate person with whom to discuss the patient’s health issues, with or without the patient’s knowledge or authorization. The second individual could be one of the patient’s children, if they are present at the time of the assessment. It is possible that the third person is one of the patient’s siblings, if any are present. If the patient’s family members have seen any behavioral changes in the individual, it is necessary to inquire about the drugs that the patient is taking, the patient’s food, and whether the patient’s vital signs have been consistent or irregularly fluctuating. How many pharmacies does the patient utilize for her meds? Is the patient taking her scheduled pills as prescribed by the health care provider? Is the patient in the process of giving up her most prized possessions to others? Has she expressed concern about dying? Have they observed any signs of the patient engaging in self-injurious behavior? Have any of your relatives had depression, diabetes, hypertension, or insomnia as a result of their medical or mental history? Obtaining the following information from the patient’s loved ones will allow the health care practitioner to be aware of the patient’s activities at home, which will aid in the delivery of effective treatment therapy.

• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used. 

To detect gray matter decrease in the frontal lobes of the brain, magnetic resonance imaging (MRI) studies can be performed. Complete blood count (CBC) and complete metabolic panel (CMP) tests can be performed on a regular basis to detect abnormalities. A Consensus Sleep Diary with specific questions can be used to get extra information about a patient’s sleep history. Environmental elements such as the temperature of the bedroom, the intensity of the light, and the sound level should be considered. The patient should have an insomnia evaluation, which includes a medical history and physical examination to rule out medical and psychological conditions that can cause insomnia. When it comes to treating insomnia, behavioral and cognitive behavioral therapies can be advised as first-line therapeutic choices (Patel et al., 2018).

ORDER A PLAGIARISM FREE-PAPER HERE

• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.

The differential diagnosis for this patient includes insomnia, which is secondary to depression because the patient is grieving the loss of her husband and may not be able to sleep as a result of this.

• 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.

The patient was taking sertraline 100 mg orally once a day for the treatment of depression. This medication was causing this patient to have greater depression and insomnia; as a result, the prescription should be shifted to a different type of medication. For this treatment, the drugs Trazodone (Antidepressant – Serotonin-2 Antagonist-Reuptake Inhibitors (SARIs) and Mirtazapine (Antidepressant – Alpha-2 Receptor Antagonists (NaSSAs) are used to treat depression and anxiety. Patients suffering from mental illnesses such as serious depression are treated with sedating antidepressants such as Trazodone and Mirtazapine to alleviate the symptoms of sleep disruptions. These drugs are not authorized for the treatment of insomnia that is not accompanied by a mental illness (Riemann et al., 2020). The patient can be started on Trazodone 50 mg orally daily at bedtime for insomnia and Mirtazapine 15 mg orally daily at bedtime for depression, and the dose can be increased or decreased depending on the effectiveness of the medication. Besides exerting an alpha-adrenergic blocking activity, trazodone also has a minor histamine blocking effect, which results in a sleepy effect. It can also suppress the vasopressor response to norepinephrine, which decreases blood pressure (Jones & Bartlett, 2018). (Jones & Bartlett, 2018). Mirtazapine has been shown to raise neuronal serotonin and norepinephrine levels, as well as to improve mood. After 2 weeks of treatment, Mirtazapine showed a substantial improvement in sleep latency, sleep efficiency, and awakenings after sleep onset, whereas Trazodone did not show a significant change in any of these variables. It only has sedative effects because it inhibits the activity of histamine receptors (Patel et al., 2018).

•   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?

Mirtazapine should be used with caution in senior patients, and patients should be continuously monitored for suicidal thoughts, particularly when therapy is initiated or dose changes are made, because depression may temporarily worsen (Jones & Bartlett, 2018). Because of the patient’s advanced age, medication should be taken in the manner advised by the health care practitioner to avoid injury to the patient.

• 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.

On a weekly basis, it is necessary to check on the patient’s health state, symptoms, and any bad responses. It is necessary to receive an updated report on the patient’s sleep pattern and depression.

References

Jones & Bartlett. (2018). Nurse’s Drug Handbook (17th ed.). Burlington, MA: Jones & Bartlett Learning.

Lancel, M., Stroebe, M., & Eisma, M. C. (2020). Sleep disturbances in bereavement: A systematic review. Sleep Medicine Reviews, 53, 101331. https://doi.org/10.1016/j.smrv.2020.101331

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: A Review. Journal of Clinical Sleep Medicine: JCSM : Official Publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172

Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and depression. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 45(1), 74–89. https://doi.org/10.1038/s41386-019-0411-y

Discussion: Treatment for a Patient With a Common Condition
Insomnia is one of the most common medical conditions you will encounter as a PNP. 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 PNP, 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.
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

ORDER A PLAGIARISM FREE-PAPER HERE

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.
By Day 6 of Week 7
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

MEDICATION RESOURCES
https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm