Case An elderly widow who just lost her spouse Subjective A patient presents to

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 

             Insomnia is a disorder linked with difficulty in sleep quality,  initiating or maintaining sleep, along with substantial distress and  impairments of daytime functioning. Its prevalence ranges from 10 to 15%  among the general population, with higher rates seen among females,  divorced or separated individuals, those with loss of loved ones, and  older people (Bollu & Kaur, 2019). Insomnia can simply be defined as  a sleep disorder where the patient has trouble falling asleep or  staying asleep. According to Krystal et al (2019), it is a common  condition that is linked with noticeable deterioration in function and  quality of life, mental and physical morbidity. The complaints of  insomnia are present in 60–90% of patients with major depression,  Complaints of disrupted sleep are very common in patients suffering from  depression, (Wichniak, etal., 2017).

Questions you might ask the patient and rationale

             The diagnosis and treatment of insomnia rely mainly on a thorough sleep  history to address the precipitating factors as well as maladaptive  behaviors resulting in poor sleep (Bollu & Kaur, 2019).

What  is your sleep pattern including how many hours of sleep do you get at  night prior to your husband’s demise and what it has been in the 10  months since his death? Does she perform certain rituals or do something  special before she sleeps. This assesses if the insomnia started before  or after the husband’s death. This provides a clue to insomnia that may  be related to bereavement.

What  time do you go to bed every night and what is your normal routine  before going to bed? This is to check if the patient is doing something  differently which has disrupted her normal routine and caused insomnia. 

How  often do you wake up to urinate at night? This question is asked to  assess for nocturia due to diabetes that may lead to insomnia. Nocturia  can prevent the patient from having a good night’s sleep. ,  changes in  blood glucose levels at night causesto hypoglycemic and hyperglycemic  episodes, nocturia and associated depression and insomnia ( Khandelwal  et al., 2017).

Do  you sleep during the day time. This provides information that evaluates  if day time sleeping may be affecting her ability to sleep at night.

Are  you  taking your medications as prescribed? This patient takes  sertraline for depression. Did the insomnia start after the pt started  taking sertraline or after the death of her husband.   

Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation

Children

Are  there are things that disrupts her sleep?  for example, music/TV noise  or crying/playing children. This is important to ascertain that her  condition is not caused by environmental factors. Epidemiologic research  according to Johnson et al (2018) has shown that social features of  environments, family, social cohesion, safety, noise, and neighborhood  disorder can cause changes in sleep patterns; and other factors like  light, noise, traffic, etc., can also affect sleep and is attributed to  sleep disorders among adults and children.

What  does she do when she wakes up at night? does she eat, drink coffee or  smoke. This is to determine if midnight activities may hinder her from  falling asleep.

Does  she complain of having a hard time falling asleep or sleeping for a  short period and waking up, unable to go back to sleep? This assesses  how sleep and rest she may be getting.

Who  caters to the needs of this patient? This is to assess if she is well  cared for or if the patient is concerned about her self care.

Relatives

Has the patient complained to you about difficulty falling asleep?

Does the patient complain about waking up in the middle of the night and finding it hard to go back to sleep?

Who does the patient leave with?

 Friends

Does she complain of feeling tired because of not sleeping?

 Does this patient communicate appropriately or is she withdrawn when you see her?

When did you see the patient last?

Primary care physician

Has  this patient complained about any sleep problems in the past? This  provides collaboration between health care providers to ensure proper  management and delivery of patient-centered care.

Physical Exams

Psychiatric evaluation: A  mental health evaluation should be done to assess the patient’s overall  mental state including presenting symptoms, thoughts, feelings, or  behavior. PMHNP’s can use the Geriatric Depression Scale (GDS) which is a  self-reported measure of depression in the older adult. Cornell Scale  for Depression in Dementia (CSDD). The CSDD focuses on an interview with  a family member or caregiver as well as with the patient and is  confirmed for use in patients with or without dementia. Also, the   Zung  Self-Rating Depression Scale (SDS) which is used as a screening tool,  covering affective, psychological and somatic symptoms associated with  depression.

Polysomnogram ( sleep study):  can be performed  to diagnose sleep disorders such as insomnia

Sleep diary:  Evaluating the patient’s sleep patterns through a sleep diary provides  information on the patient’s sleep pattern and a diagnosis of insomnia.

Epworth Sleepiness Scale: This a questionnaire used to evaluate  daytime sleepiness.

Thyroid function test: Production of little or much thyroid hormone, can affect  sleep.

HBA1C:  The patient has a history of diabetes, monitoring her HbA1C is  important. This is because Individuals with a diagnosis of diabetes  report higher rates of insomnia, poor sleep quality, excessive daytime  sleepiness ( Khandelwal et al., 2017).

Actigraphy:  is an objective measurement of  sleep schedule,  rest-activity patterns used to help confirm insomnia.

Lab test: such as random glucose test,  liver function test, complete blood count, Erythrocyte Sedimentation Rate, kidney function test.

Differential diagnosis

 Late-life spousal bereavement : bereavement is known to cause  depression and complicated grief ( Holm etal., 2019).

Late  life depression (LLD) Predisposing factors include previous clinical  depression, persistent sleep difficulties, female gender,  being widowed  or divorced ( Blackburn etal., 2017). Complicated grief

Medicated-related insomnia

 Sleep apnea. Sleep apnea is considered to be prevalent  in more in persons with diabetes ( Khandelwal et al., 2017).

             The most likely differential diagnosis, in my opinion, would be  late-life spousal bereavement. (LLSB). The patient was diagnosed with  MDD, she lost her husband (died) ten months ago, and she is still  suffering from depression and insomnia.  Being widowed causes  impairments in sleep (Monk et al., 2008).

Pharmacologic Agents

Sertraline  (SSRI) causes insomnia as a side effect. Augmenting sertraline with a  different medication in the elderly may lead to polypharmacy. Therefore,  switching sertraline with a medication to help with MDD and insomnia  will be more helpful. I would choose to stop sertraline and start  trazadone. sedative antidepressants (such as trazadone 25-50mg) are a  safe  when given in low doses and are given in patient groups where  hypnotics are contraindicated, e.g., in the elderly and patients with  sleep apnea (Wichniaketal., etal., 2017). Trazodone is an antidepressant  that functions by inhibiting serotonin transporter and serotonin type 2  receptors. Trazodone in low doses provides a sedative effect for sleep  through antagonism of 5-HT-2A receptor, H1 receptor, and  alpha-1-adrenergic receptors ( Shin & Saadabadi., 2020). Trazodone  also improves apnea and hypopnea episodes in patients known to have   with obstructive sleep apnea (OSA), and it  does not worsen hypoxemic  episodes. This patient can be started on trazadone 25- 50mg at bedtime.

             A second drug choice is an antidepressant mirtazapine. It is effective  in managing major depressive disorder and has sedative properties which  is helpful in relieving sleep problems like insomnia and can be used in  the elderly. Mirtazapine is known as an atypical antidepressant with an  off label use for insomnia. It works by exerting antagonist effects on  the central presynaptic alpha-2-adrenergic receptors, causing an  elevated release of serotonin and norepinephrine. Mirtazapine is also  sometimes called a noradrenergic and specific serotonergic  antidepressant (NaSSA). I would recommend starting the patient on 15 mg  of mirtazapine at bedtime. Mirtazapine is known to treat MDD in patients  that were no unresponsive to SSRIs. I prefer to start this patient on  trazadone, rather than mirtazapine. Mirtazapine has side effects of  increased appetite, increased weight gain and this patient is already  obese with weigh 88kg, height 64 inches (bmi 34.4), increased  cholesterol. Further increase in weight would increase risk for  cardiovascular problems. Trazadone is quickly absorbed and has a faster  onset with hypnotic properties. This makes it more appropriate for this  patient.

Identify any contraindications to / Ethnicities

             A consideration for administration of trazadone is the age of this  patient. The dose in the elderly should not be more than 100 mg/day.  There is a  risk for orthostatic hypotension is in the elderly,  especially in the elderly with with pre-existing heart conditions  (hypertension) ( ( Shin & Saadabadi., 2020). The metabolism of  trazadone should also be considered in different ethnicities as poor  CYP2D6 metabolizers are known to have therapeutic response.  In the  Asian ethnicity, medications that metabolized by CYP2D6 should not be  prescribed (Kitada, 2003). Therefore, if this patient is Asian  increasing the dose of trazadone will be considered or choosing a  different medication to enable the patient get a full effect of the  drug. If the patient were of Asian descent, I would have to decide on  increasing the dose of Trazadone if they were a poor metabolizer or  choosing another medication that was not affected by CYP2D6.

Check Points

Monitor  the patient closely after changing her drug therapy. Side effects of  the medication should be clearly explained to the patient and family  importantly if hallucination is noted, immediate report to the PMHNP for  discontinuation of the medication. The patient should be   be monitored  for suicide ideation, especially at the beginning of the treatment or  when the dose is modified (Shin & Saadabadi., 2020).  I would  observe how this patient will adjust to trazadone 25-50mg in 4 weeks to  determine dose adjustment. 

References

Blackburn, P., Wilkins-Ho, M., Wiese, B. (2017). Depression in older adults: Adults and management. BCMJ, 59 (3).

            https://bcmj.org/articles/depression-older-adults-diagnosis-and-management

Bollu, P., Kaur, H. ( 2019). Sleep Medicine: Insomnia and Sleep. The Journal of Missouri State   Medication Association, 116(1), 68–75.

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390785/

Khandelwal, D., Dutta, D., Chittawar, S., Kalra, S. (2017). Sleep disorders in type 2 diabetes.       Indian Journal of Endocrinology and Metabolism,  21(5), 758–761. doi:    10.4103/ijem.IJEM_156_17

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628550/

Kitada M. (2003) Genetic polymorphism of cytochrome P450 enzymes in Asian populations:

            Focus on CYP2D6. International Journal of Clinical Pharmacological

            Research,23(1),31-5. https://pubmed.ncbi.nlm.nih.gov/14621071/

Holm,  N. Severinsson, E., Berland, A. (2019). The meaning of bereavement  following spousal     loss: A qualitative study of the experiences of  older adults. https://doi.org/10.1177/2158244019894273

            https://journals.sagepub.com/doi/full/10.1177/2158244019894273

Monk, T. H., Germain, A., & Reynolds, C. F. (2008). Sleep disturbance in bereavement.

            Psychiatric Annals, 38(10), 671–675. https://doi.org/10.3928/00485713-20081001-06

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

Wichniak, A., Wierzbicka, A., Walęcka, M., Jernajczyk, W. (2017). Effects of Antidepressants    on sleep. Current Psychiatry Reports, 19 (9), 63. doi: 10.1007/s11920-017-0816-4

            https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548844/