NURS 6630 Treatment for a Patient With a Common Condition

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

Do you drink caffeinated drinks? If yes, how many do your drink a day and at what time?

Rationale: Caffeine is a stimulant. Individuals who drink caffeine during the day cause a reduction in 6-sulfatoxymelatonin (the main metabolite of melatonin) at night, which leads to sleep disturbance (O’Callaghan et al., 2018). The lack of sleep affects cognitive functioning and psychomotor response (O’Callaghan et al., 2018).

How many hours of sleep are you getting each night?

Rationale: According to Levenson et al., when a person is living with unpleasant thoughts or worrying excessively, it can lead to sleep disturbances (2015). The decreased sleep can cause the person to worry about not getting enough sleep, leading to more anxiety and insomnia (Levenson et al., 2015).

Have you had any feelings of depression, hopelessness, or feeling down in the past month?

Rationale: Individuals who have suffered a significant loss are at high risk for depression. Individuals with depression often experience insomnia. This question is one of two that can be used to assess a patient for depression and determine if further treatment is warranted (Assessment of Depression in Adults in Primary Care, 2020). The patient’s husband died ten months ago in the given scenario. If the patient responds positively to this question, it is critical to also assess for suicide risk.

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.

It would be important to gain information from outside sources such as family, friends, and caretakers familiar with the patient’s daily life. If possible, individuals who have been around the patient from before her husband passed until now. You could ask the patient how she got to the appointment and if someone brought her, you could ask if she would be OK with you speaking with them. There are several questions you could ask.

Have you noticed a change in her interest in doing things?

Have you she seemed down or hopeless?

How has she been eating?

Do you know if she is taking her medications or noticed any side effects from her medications?

Have you noticed any anxiety or changes in memory?

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

Upon the initial interview, it is possible to screen the patient for depression. There are several ways this can be done. Practitioners can use the Mini-Mental State Exam MMSE), Geriatric Depression Scale Short Form (SGDS), or the Cornell Scale for Depression in Dementia (CSDD) (Brown et al., 2015). It is important to note that older adults with depression can also have dementia, so screening for dementia would also be important (Brown et al., 2015). The CSDD can detect depression in individuals with cognitive impairment. The SGDS is used because it is fairly easy and short and can detect depression in older adults (Brown et al., 2015). Laboratory testing is also important as many organic illnesses can lead to insomnia and depression. Baseline lab work should include glucose, liver function, complete blood count, Erythrocyte Sedimentation Rate, urea, creatinine, electrolytes, B-12, and Iron studies.

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

A differential diagnosis for depression in an elderly patient could be Vascular Depression. It is found in adults over 60 years of age and with no prior history of depression (Small, 2009). It can be found in patients with hypertension or a history of vascular disease believed to cause inflammation within the vascular system leading to the release of cytokines, especially after a stressful event (Jeon & Kim, 2018). When reviewing the patient’s medications, she is taking bother Losartan and hydrochlorothiazide to manage her hypertension, so the differential diagnosis of Vascular Depression is possible.

List two pharmacologic agents and their dosing that would be appropriate for the patient’s anti-depressant 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 is currently taking Sertraline 100mg daily. If the patient takes the medication as prescribed, the patient should see improvement in depressive symptoms. The scenario does not state how long the patient has been taking Sertraline. One side effect of SSRIs is that they can cause insomnia. At this time, it is appropriate to consider augmenting the Sertraline with a low dose TCA like trazodone. Research suggests that short-term use of a TCA can improve sleep as soon as the first dose (Wichniak et al., 2017). It is important to remember that when the patient’s depression symptoms improve, the TCA should be lowered or discontinued because it can cause oversedation (Wichniak et al., 2017).

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Sertraline makes it difficult to keep blood sugar stable. It can also be recommended to switch the anti-depressant to Bupropion. Studies have shown that in patients with diabetes, burproprione successfully treats depression and controls blood sugar levels (Darwish et al., 2018). It would be necessary to monitor the patient’s blood pressure as bupropion can elevate blood pressure (Darwish 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?

Sertraline is contraindicated in patients taking thioridazine, pimozide, or monoamine oxidase inhibitors, including linezolid or methylene blue, and it should not be taken with other serotonergic medications (Singh & Saadabad, 2020). Buspirone is contradicted in patients with kidney and liver disease as the drug’s effects may increase due to slow kidney or liver removal. Trazadone is contraindicated for anyone taking an MAOI or has taken an MAOI in the past 14 days (Shin & Saadabadi, 2020).

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.

It would be necessary to follow up with the patient in four weeks to see if adding Trazadone improves the patient’s sleep. If there is no improvement in the patient’s sleep or depressive symptoms, it would be time to consider changing the patient’s medication to buspirone.

References

Assessment of depression in adults in primary care [PDF]. (2020). Best Practice Medicine Journal New Zealand. https://bpac.org.nz/magazine/2009/Adultdep/docs/bpjse_adult_dep_assess_pages8- 12.pdf

Brown, E., Raue, P. J., & Halpert, K. (2015). Evidence-based practice guideline: Depression detection in older adults with dementia. Journal of Gerontological Nursing, 41(11), 15– 21. https://doi.org/10.3928/00989134-20151015-03

Darwish, L., Beroncal, E., Sison, M., & Swardfager, W. (2018). Depression in people with type 2 diabetes: Current perspectives. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy, Volume 11, 333–343. https://doi.org/10.2147/dmso.s106797

Jeon, S., & Kim, Y.-K. (2018). The role of neuroinflammation and neurovascular dysfunction in major depressive disorder. Journal of Inflammation Research, Volume 11, 179–192. https://doi.org/10.2147/jir.s141033

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

O’Callaghan, F., Muurlink, O., & Reid, N. (2018). Effects of caffeine on sleep quality and daytime functioning. Risk Management and Healthcare Policy, Volume 11, 263–271. https://doi.org/10.2147/rmhp.s156404

Park, L. T., & Zarate, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine, 380(6), 559–568.https://doi.org/10.1056/nejmcp1712493

Shin, J., & Saadabadi, A. (2020). Trazadone. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK470560/

Singh, H. K., & Saadabad, A. (2020). Sertraline. StatPearls. https://doi.org/https://www.ncbi.nlm.nih.gov/books/NBK547689/

Small, G. W. (2009). Differential diagnoses and assessment of depression in elderly patients. The Journal of Clinical Psychiatry, 70(12), e47. https://doi.org/10.4088/jcp.8001tx20c

Wichniak, A., Wierzbicka, A., Walęcka, M., & Jernajczyk, W. (2017). Effects of antidepressants on sleep. Current Psychiatry Reports, 19(9). https://doi.org/10.1007/s11920-017-0816-4

Overly, in the case where a client is on medications, it is good to confirm whether the client is compliant to the prescribed medications. It also gives the reasons as to why the patient might present with a given chief complaint. In this case, the client complains about insomnia and is currently taking antihypertensive and even taking sertraline which is a selective serotonin reuptake inhibitor and it triggers insomnia as a side effect (Bickley et al., 2020). Additionally, it would be good to inquire whether the patient takes caffeinated drinks since they also cause insomnia. The last question is meant to assess the presence of depression and it is part of the mental health screening questions.

People who could offer feedback about the patient in the case presentation

The patient currently stays with her children and would be closest people to offer feedback on whether the patient is compliant with the prescribed medications. The question would be important in identifying the differential diagnosis for the patient. In this case, the question would be whether the patient is compliant to the prescribed medications (Bickley et al., 2020). Additionally, the patient’s guardian can be questioned about whether he or she noted any changes on the patient’s speech, mood or attention as well as changes in memory, insight or orientation. Lastly, the question could deduce observations made on patient’s phobias, ritualistic behavior, anxiety and panic. Others would confirm if the patient has dementia or delirium (Carlo et al., 2021).

NURS 6630 Treatment for a Patient With a Common Condition

Diagnostics

The patient Health questionnaire which has got nine questions is used to screen the patient. Some of the questions include whether the patient is depressed and whether in the past one month the patient has been feeling hopeless, helpless or depressed. overly, the given questions could achieve a sensitivity of 97% and a specificity rated as 67%. Others include Zung Self –Rating depression scale and the last one which would be performed by a qualified professional include the Hamilton Depression rating scale where a score above 20 would be regarded as moderately severe (Bickley et al., 2020). A normal score would fall within 0 to 7. Since she is an older patient, a geriatric depression scale would also be viable. It has got 30 items. However, it has got a complex interpretation of the results. Lastly, to assess dementia, a Cornell Scale for Depression in Dementia would be used and it determine both the category as well as the severity. There are other useful laboratory studies that are done in cases of major depressive disorder such as alcohol levels in blood. arterial blood gas, dexamethasone suppression test meant for Cushing disease and cosynthropin stimulation test meant for Addison disease. Neuroimaging is also done to assess the nature of the neurological illnesses that the patient presents with (Kopel, 2021).

Differential diagnoses

Major Depressive disorder. This is the most possible condition in this case since the patient indicates that her depression worsened when her husband died. Therefore, the assessment should be focused on identifying the symptoms of depression such as hopelessness, helplessness and having depressive episodes (Hogan-Quigley & Palm, 2021). The patient has altered sleep pattern or insomnia which might be as a result of major depression.

Schizophrenia: This is a possible diagnosis where the patient presents with compulsive behavior, delusions, slowness in activities, depression, frenzied kind of thinking as well as memory impairment (Hogan-Quigley & Palm, 2021). Patients might also be active and have insomnia. In this case, however, the patient only has insomnia and does not meet the exact criteria used to diagnose schizophrenia.

Illness anxiety disorder: this is also referred to as hypochondria. It usually develops mostly during adulthood and would be characterized by intense fear that they have got some serious condition and at times get worried when they present with minor symptoms (Hogan-Quigley & Palm, 2021).

Pharmacological treatment

Zyprexa (Olanzapine): It is an atypical antipsychotic that is mostly used to manage patients with bipolar symptoms or schizophrenia. It is also used to manage patient who have had depression that is resistant to treatment. The dosage includes 10 mg per day given orally. It is metabolized through the liver and would be interfered with if the liver is affected (Carlo et al., 2021).

Buspirone: It is regarded as an antianxiety drug but also has got antidepressant effects. Its dosage is given as 45mg per day. However, the dosage may increase if combined with selective serotonin reuptake inhibitors or Tricyclic antidepressants especially among patient who have treatment-resistant depression. Its anxiolytic effects usually last for two to three weeks (Kopel, 2021).

Any contraindications to use or alterations in dosing

Monitor the patient closely since she is elderly and would be at a higher risk of having hyponatremia (Bickley et al., 2020). This is triggered by use of SSRIs especially among the elderly and other possible factors that need to be assessed include tumors, low body weight, smoking, central nervous system illness or any previous episodes of hyponatremia that the patient states.

Check points

A two-week follow up is necessary to rule out any drug interactions especially anti-depressant induced hyponatremia as well as stroke which may occur as a result of use of depression among patients with hypertension.

References

Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2020). Bates’ pocket guide to physical examination and history taking. Lippincott Williams & Wilkins.

Carlo, A. D., Basu, A., & Unützer, J. (2021). Associations of common depression treatment metrics with patient-centered outcomes. Medical Care, 59(7), 579-587. https://doi.org/10.1097/mlr.0000000000001540

Hogan-Quigley, B., & Palm, M. L. (2021). Bates’ nursing guide to physical examination and history taking. Lippincott Williams & Wilkins.

Kopel, J. (2021). Zyprexa. Encyclopedia of Autism Spectrum Disorders, 5256-5257. https://doi.org/10.1007/978-3-319-91280-6_102100

NURS 6630 Treatment for a Patient With a Common Condition