Comprehensive Assessment and Treatment Plan for Insomnia and Depression in an Elderly Widow

Posted: July 7th, 2022

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
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” (Le., 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.

Comprehensive Assessment and Treatment Plan for Insomnia and Depression in an Elderly Widow

Introduction:
This article presents a case of an elderly widow who recently lost her spouse and is experiencing insomnia and worsened symptoms of depression. The patient’s history, current medications, and vital signs have been provided. In order to develop an appropriate treatment plan, several essential steps need to be taken, including thorough questioning, gathering feedback from people in the patient’s life, conducting physical exams and diagnostic tests, considering a differential diagnosis, and selecting suitable pharmacologic agents. This article will address each of these components to provide a comprehensive approach to the patient’s care.

Questions for the Patient and Rationale:
a) How has your sleep pattern changed since your husband’s passing?
Rationale: Understanding the patient’s sleep patterns will help assess the severity of her insomnia and its correlation with her husband’s death, enabling a more accurate diagnosis.
b) Have you noticed any changes in your appetite or interest in activities you used to enjoy?
Rationale: This question will help evaluate the patient’s depressive symptoms and determine whether they are associated with major depressive disorder or a normal reaction to bereavement.

c) How are you coping with the loss of your husband, and have you discussed your feelings with anyone?
Rationale: Exploring the patient’s coping mechanisms and social support will provide insight into her emotional state and potential risk factors for further deterioration.

Gathering Feedback from People in the Patient’s Life:
a) Family Members: Speaking to family members can provide valuable information about the patient’s behavior, mood, and any changes noticed after her husband’s death.
b) Close Friends: Friends can offer additional perspectives on the patient’s emotional well-being and her social interactions post-bereavement.

c) Caregivers or Home Health Aides: These individuals may observe the patient’s daily activities and provide valuable insights into her sleep patterns and depressive symptoms.

Physical Exams and Diagnostic Tests:
a) Physical Exam: A comprehensive physical examination is essential to rule out any underlying medical conditions that might contribute to the patient’s insomnia and depression.
b) Diagnostic Tests: Laboratory tests such as a complete blood count (CBC), thyroid function tests, and blood glucose levels can help identify potential physiological causes for the patient’s symptoms.

Differential Diagnosis:
The patient’s symptoms could be attributed to:
a) Major Depressive Disorder (MDD): Considering the patient’s loss and the duration of her depressive symptoms, MDD is a primary consideration.

b) Adjustment Disorder: The patient’s symptoms might be a normal reaction to her husband’s death, but the duration and intensity of her symptoms warrant consideration of a more persistent condition like MDD.

c) Grief Response: It’s important to differentiate normal grief from clinical depression to tailor appropriate interventions.

Most Likely Diagnosis: Major Depressive Disorder (MDD)

Pharmacologic Agents for Antidepressant Therapy:
a) Selective Serotonin Reuptake Inhibitors (SSRIs) – Escitalopram: Starting dose of 10 mg daily, titrating up to 20 mg daily if needed.
Rationale: SSRIs have shown efficacy in treating depression in the elderly and have a favorable side effect profile.
b) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) – Venlafaxine: Starting dose of 37.5 mg daily, titrating up to 150 mg daily if needed.
Rationale: SNRIs can be considered for patients who do not respond well to SSRIs or have comorbid pain conditions.

Contraindications and Ethical Considerations:
a) Escitalopram: Contraindicated if the patient is taking monoamine oxidase inhibitors (MAOIs) due to the risk of serotonin syndrome.
Ethical Consideration: Prescribers should assess the patient’s medication history to avoid potential drug interactions and adverse effects.
b) Venlafaxine: Caution should be exercised in patients with uncontrolled hypertension due to the risk of increasing blood pressure.
Ethical Consideration: Regular monitoring of blood pressure is necessary to ensure patient safety during treatment.

Follow-up and Treatment Adjustments:
Check Points: Follow-up at Weeks 4, 8, and 12, and as needed based on symptom improvement or worsening.
Treatment Adjustments: If there is an inadequate response or intolerable side effects with the initial medication, consider switching to an alternative agent or adjusting the dose based on the patient’s tolerance and clinical response.
Conclusion:
Effective management of insomnia and depression in an elderly widow requires a comprehensive approach, involving detailed patient questioning, feedback from relevant individuals, appropriate physical exams, and diagnostic tests. A differential diagnosis is essential to ensure accurate identification of the patient’s condition. Selecting the appropriate antidepressant therapy, considering pharmacokinetics and pharmacodynamics, and accounting for contraindications and ethical considerations are vital steps in providing safe and effective treatment. Regular follow-ups and timely adjustments will ensure optimal outcomes and improved quality of life for the patient.

References:

Anderson, C. M., & Brown, C. (2016). The Pharmacologic Management of Insomnia. The Journal of the American Osteopathic Association, 116(8), 520-527.

Gartlehner, G., Wagner, G., Matyas, N., Titscher, V., & Greimel, J. (2018). Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews. BMJ Open, 8(5), e022890.

Markowitz, J. C. (2017). Psychotherapy for Depression in Older Adults: A Review. Harvard Review of Psychiatry, 25(6), 278-289.

Warden, D., Rush, A. J., Trivedi, M. H., Fava, M., & Wisniewski, S. R. (2017). The STAR*D Project results: a comprehensive review of findings. Current Psychiatry Reports, 19(7), 1-13.