Reference no: EM133468745

Sleep Disorders

The patient presented to the office with depression and sleep difficulties since her husband passed away ten months ago. When assessing the patient, I would ask what is your bedtime routine like? What time do you go to bed? How long does it take you to sleep, and can you shut off your mind? How many nighttime awakenings do you have, and how long do they last? What time do you awaken in the morning and feel rested? Do you snore? In asking these questions, we are assessing for depression, sleep apnea, anxiety, and any other medical conditions that may contribute to the patient's sleep. According to Luyster et al., "Insomnia can be a primary sleep disorder; however, in older adults, it is often co-morbid with medical and psychiatric illnesses and medications and other sleep disorders such as obstructive sleep apnea (OSA) and restless legs' syndrome (RLS)" (2015, p. 1). If the patient were married or had children living in the house, we would ask to speak to them to see if the patient snores, takes pauses of breathing during sleep, and any other symptoms they may notice.

The differential diagnosis for sleep disorders is Primary insomnia, depression, obstructive sleep apnea, and anxiety. I would diagnose the patient with major depressive disorder. The patient reports that her depression has worsened and is affecting her sleep. The grief from her husband's death is likely causing her depression and sleep disorder. According to Murphy & Peterson, improving sleep in a depressed patient can overall enhance the outcomes of their depression (2015). It is often hard to tell which precedes major depressive disorder or insomnia, but they feed into each other.

Two sleep agents I would use in this patient are trazodone and mirtazapine. Trazodone can improve depression and insomnia as it is an antidepressant. Due to the patient's age of 72, I would start at 25 mg PO at bedtime and increase as tolerated. The antidepressant range is 150 mg a day but would caution against rising to quickly with elderly patients (Stahl, 2021, p. 794). Pharmacokinetics are it is rapidly absorbed and metabolized by CYP450 3A4 (Stahl, 2021, p. 795). Pharmacodynamics is that it blocks the serotonin 2A receptors, including histamine and serotonin reuptake pump causing sedating effects (Stahl, 2021, p. 793). Mirtazapine is known to help with insomnia, depression, and anxiety. It is often used in the elderly or cancer/HIV patients. Mirtazapine 7.5 mg po daily qhs is what I would use (Stahl, 2021, p. 511). The pharmacokinetics of mirtazapine is the half-life is 20-40 hrs, food does not affect absorption, and it is a substrate for CYP450 2D6, 3A4, and 1A2 (Stahl, 2021, p. 511). Pharmacodynamics of mirtazapine is a potent antagonist of 5-HT2a, 5-HT3 receptors, and histamine H-1 receptors (Stahl, 2021, p. 509). Overall I would choose for this patient the mirtazapine over the trazodone due to knowing how this drug is tolerated in the elderly. Even though this patient is not underweight, it can help with depression and sleep. Monitoring the patient's weight would be beneficial as well.
There is no contraindication for this patient in particular, but for the Mirtazapine, I would start at a lower dose due to the patient's age, as recommended. If the patient had a renal, hepatic, or cardiac impairment, then this drug should be used with caution(Stahl, 2021, p. 512). For hepatic impairment, a lower dose should be considered (Stahl, 2021, p. 512). For Cardiac impairment, hypotension needs to be considered (Stahl, 2021, p. 512). This drug is not recommended in pregnancy or breastfeeding. With the elderly considering fall risk and mentation, lowering the dose should be highly considered initially to see how the patient tolerates it. I would reassess the patient again in 4 weeks to see how sleep has improved as well as depression. If it has partially improved, I would increase the mirtazapine to 15 mg po a day and reassess again in 4 weeks. If the patient is not tolerating, then I would switch to trazodone.

Discussion

o 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. Does she have feelings of emptiness and loss or more so the inability to anticipate happiness?
2.1 would attempt to find out which worsened first- did the insomnia cause increased depression or did the depression increase the insomnia? And is the sleep disrupted due to not being able to fall asleep or not being able to stay asleep?
3. Has there been alcohol involved?
o 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.
1. Any family or caregivers that are available. Is she eating appropriately? Is she involved in the same activities as she was prior to her husband's passing?
2. If she is in therapy, ask for permission to discuss her progress with her therapist, if she's not in grief counseling, I would recommend it.
o Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
1. Make sure her labs are recent, with current kidney and liver function, as well as the A1C. May also consider a thyroid panel.
2. Would do a routine physical exam
o List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
1. Major Depressive Episode
2. Insomnia due to other mental health diagnosis (depression)- I do believe this is most likely
3. Bereavement and loss
o 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.
1. Trazodone- low dose, start at 25 mg at bedtime. Trazodone reduces levels of neurotransmitters associated with arousal effects, such as serotonin, noradrenaline, dopamine, acetylcholine, and histamine (Shin & Saadabadi, 2022). This medication gives a sedative effect, which will help with insomnia. It also works to block serotonin reuptake to work with depression as well.
2. Doxepin- low dose, start at 3 mg at bedtime. Doxepin is a tricyclic antidepressant, increases serotonin and norepinephrine, assisting with insomnia
o 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?
1. For Doxepin, must keep the dose low. 6 mg and under due to the patient's age. A higher dose will increase the fall risk of the pt.
2. Will also need to ensure blood sugars and weight are continued to be monitored, as these medications can increase appetite, which may increase total sugar intake.
3. The medications should be given within 30 minutes before intended sleep.
4. May increase the risk of suicidal thoughts, although this risk is decreased for those over 65 years of age
o 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.
1. I would have her follow up in 1-2 weeks, with specific instructions to call if the depressive symptoms worsen, due to the increased risk of suicidal thoughts with both medications.
2. Repeat labs at 8 weeks
3. If there is no improvement, I would increase the doxepin to 6 mg or the Remeron to 50 mg.
4. Prior to any medication additions, I would strongly suggest a sleep diary and implementing a solid sleep hygiene routine.
5. Would also council to minimize alcohol or caffeinated beverages