- Give three questions that you could ask the patient if she was in your office. Give reasons why you would ask the questions.
a. Which number of hours sleep per night do you average? – To determine the severity of the patient’s insomnia and whether it meets diagnostic criteria. b. Is it possible to feel refreshed after waking up in the morning? – To understand if the patient is experiencing any symptoms of sleep deprivation. c. Are you familiar with any other sleep aids and remedies that may be available? – To assess the effectiveness of any previous treatments and to determine if any non-pharmacological approaches have been tried.
- 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 the specific questions and reasons you would ask them.
a. Family members or close friends – To obtain additional information about the patient’s sleep habits, behavior, and mood before and after the loss of her husband. b. The patient’s primary care provider – To obtain additional information about the patient’s medical history, current medications, and any previous treatments for insomnia or depression. c. A mental health provider – To determine if the patient would benefit from counseling or therapy to address her depression and insomnia.
- Explain to the patient what diagnostic tests and physical examinations would be most appropriate and the use of the results.
A physical exam may be appropriate to rule out any underlying medical conditions that could be causing or contributing to the patient’s insomnia. To diagnose any sleep disorder, diagnostic tests such as a sleeping study may prove useful. They would be able to help the patient decide the most effective treatment.
- You can list a variety of diagnoses for this patient. Name the most probable and give reasons.
An elderly person may have multiple diagnoses of insomnia, including major depressive disorder and anxiety disorders, as well as substance abuse disorder and medical conditions like sleep apnea. The most likely diagnosis in this case is major depressive disorder, as the patient’s insomnia and depression began after the loss of her husband and she has no previous history of depression.
- List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. Explain why, from the perspective of the mechanism of action, you would choose one over another.
Two pharmacologic agents that may be appropriate for the patient’s antidepressant therapy are selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Sertraline (the SSRI currently being used by the patient) may have its dose increased to 100mg or 150-200mg daily. Duloxetine (a SNRI) may also be started at a 30 mg per day starting dose and then increased as needed. These agents can increase brain levels of neurotransmitters, which may help with depression symptoms and sleep improvement.
- For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. What would make this dangerous for people from other races?
No known contraindications exist to the use SSRIs and SNRIs based upon ethnicity. It is vital to recognize the potential differences between ethnicities in drug metabolisms and side effects. Some studies suggest that Asians are more likely to experience sexual dysfunction as side effects from SSRIs.
- Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc