Insomnia Response

Respond to at least two of your colleagues in one of the following ways:

·         If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.(Insomnia Response Discussion Example)

·         If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective. Read a selection of your colleagues’ responses and respond to at least two of your colleagues.

Please use at least two resources per response.

Claire

Questions  I Might ask the Patient if she were in my Office and Rationale for asking them

1.    How much coffee do you drink in a day? How often?

2.    Have you been taking your medication as instructed?

3.    Have you tried to talk to someone about your grieving process? If yes, who?

Rationale

The client’s chief complaint is insomnia. Therefore, it is essential to ask the patient about her caffeine intake since coffee increases the risk of insomnia. In addition, it is good to determine the client’s compliance with her medication. Sertraline is associated with increased sleeplessness in most clients. In this regard, it should be taken at least once daily (in the morning) to avoid such side effects. Non-compliance to Sertraline intake instructions can expose clients to an increased risk of suffering from such side effects. The third question is a high-yield screening question that I feel is important for this client. Grieving has many stages, and it is crucial for clients to get help for a successful recovery process. This client is still in the early stages of the grieving process, and it is vital for her to get the help she needs to successfully control her depression and issues such as insomnia.

People in the Patient’s Life I would need to Speak to or get Feedback from to Further Assess the Situation.

I would need feedback from the client’s close friends and family to further assess the situation. Below are some of the questions I would ask them.

1.    Have you noticed any changes in the mood and attention of your mom/sister/friend?

2.    Does she live alone? How often does she talk about the loss she experienced and what she is feeling?

3.    What kind of a person was she before and after the loss?

Asking these questions is necessary to assess the situation further. The first question can help determine whether there have been any observable common depressive symptoms from the client. The second question can help determine the client’s social support through her grieving process, and the third question can help create further understanding of the client, especially after the loss. Unquestionably, taking note of such details can help me understand the situation better for effective treatment interventions.

Physical Exams and Diagnostic Tests and How the Results would be Used

It is crucial o screen for depression in this situation. Siniscalchi et al. (2020) stipulate that screening for depression is crucial for adults based on an increased prevalence of the condition in recent years. The authors observe that 7.1% of all US adults are more likely to suffer from depressive episodes. In this case, I would use the PHQ-2 and PHQ-9 (The Patient Health Questionnaire) tools to screen for depression in this patient. PHQ-2 tests the frequency of depressed mood and anhedonia with scales from 0 (not at all) to 3 (nearly every day), while PHQ-9 tests the severity of depression in patients. PHQ-9 has nine items and scales of 5 (mild), 10 (moderate), 15 (moderately severe) and 20 (severe) (Siniscalchi et al., 2020). This tool’s results would help determine and implement an effective treatment intervention for the client. Notably, I would also use laboratory studies to rule out potential illnesses that sometimes present as depressive disorders.

Differential Diagnosis for the Patient

The differential diagnosis for the patient could be related to psychiatric disorders. In most cases, major depressive disorders are confused with other related mental issues (Zimmerman et al., 2018). The disorder may be confused with conditions such as dysthymia, bipolar disorder, and anxiety disorders. Dysthymia presents the same symptoms as a major depressive disorder but is not complex enough. At the same time, bipolar disorders have the same symptoms as major depressive disorder. The only difference between the two is hypomania which commonly occurs between depressive episodes. Patients with anxiety disorders are at a higher risk of developing depressive disorders, and it is essential to differentiate the two conditions for effective treatment (Zimmerman et al., 2018). Confusing major depressive disorder with other mental problems could cause inadequate treatment.

Pharmacologic Agents and their Dosing Appropriate for the Patient’s antidepressant Therapy based on Pharmacokinetics and Pharmacodynamics

The patient could switch to Buspirone (50 mg/day) with a combination of SSRI, and Aripiprazole, or continue taking sertraline with an increased dosage of not more than 200 mg qDay. Although Buspirone is identified as an antianxiety drug, it has antidepressant effects when combined with SSRIs (Riemann et al., 2020). The FDA has approved Aripiprazole as an effective treatment for major depressive disorders. Therefore, the patient can use 2 mg daily with a combination of the current Sertraline 100mg/day. Trazadone (25 mg) could also be sued as a treatment agent in this case since it has been associated with a tendency to increase sleep without effects such as daytime sleepiness.(Insomnia Response Discussion Example)

Contraindications to use the Drug Therapy Selected or Alterations in Dosing based on Ethical Prescribing

SSRIs may lead to induced hyponatremia in elderly and female patients. Notably, female patients taking antidepressants are at a higher risk of suffering from stroke; this might be more prominent in our patient, considering her age and the fact that she suffers from hypertension (Riemann et al., 2020). Therefore, alterations in dosage may be considered for this patient to promote ethical prescribing.

Checkpoints and Therapeutic Changes I Might Make Based on Possible Outcomes that May Happen Given the Treatment Options Chosen

I would visit the patient at least twice a month but communicate with her regularly over the phone. Keeping in touch with the client could help me identify changes and possible side effects from the drugs to make necessary alterations. After some time, I plan to reduce the dosage of Sertraline and take it back to 100mg/day and discontinue the usage of SSRIs to protect the patient from adverse health outcomes.

Insomnia Response Discussion Example- Solution

The topic of discussion this week is Insomnia. “Chronic Insomnia is said to affect 40 million people in the United States, with an additional 20 million suffering from episodic insomnia” (Stahl, 2021a, pg. 418). This case study is about an elderly widow who just lost their spouse she presents to my office was complaints of insomnia she’s 75 years old with a history of diabetes, hypertension, and major depressive disorder she recently lost her husband of 41 years, 10 months ago.  Since then, she states her depression has gotten worse, as well as her sleep habits she had no previous history of depression prior to her husband’s death. The initial assessment finds her awake, alert, and oriented times 3 she normally sees her primary care physician once or twice a year she denies any suicidal ideation she arrived today by private vehicle.(Insomnia Response Discussion Example)

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.    How long have you been unable to sleep? Knowing how long she has had difficulty sleeping, whether chronic or acute, will help determine her treatment.

2.    What was your sleep pattern like before developing this problem? I would like to know what time she goes to bed, what time she normally wakes up, how long she sleeps for does she normally wakes up during the night because this too, can give an idea of what she was like prior and if there is a chronic or an acute issue.(Insomnia Response Discussion Example)

3.    What time do you take the sertraline? Taking a “Selective serotonin reuptake inhibitor (SSRI) is associated with treatment-induced insomnia in approximately 20% of patients” (Winkelman, 202, para.8). Side effects can include irritability, wakefulness,  in the first couple of weeks, so would be good to know if insomnia started after she started taking the sertraline also it would help to know if she takes a Sertraline in the morning or at night because it’s often recommended to take the SSRI’s in the morning even though there have not been conclusive events to show it makes a difference one way or the other (Winkelman, 2023).(Insomnia Response Discussion Example)

Identify people in the patient’s life you would need to speak to or get feedback from to assess the patient’s situation further. Include specific questions you might ask these people and why.

People in the patient’s life I would like to ask questions of are any immediate family, such as a son or daughter, close family friends, or caretaker. Questions I would ask are:(Insomnia Response Discussion Example)

Does the patient snore when she sleeps?

Does she drink any alcohol?

Close family and friends would know her best. Her habits and what information she may be hiding from a stranger.

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

Winkelman (2023) states, “Treatment of insomnia in older adults requires careful attention to the role of medical, neurological, sleep, and psychiatric comorbidities. Vulnerability to side effects increases with age, and insomnia medication often exacerbates age-related impairments such as gait instability, sedation, cognitive dysfunction, urinary and bowel dysfunction, and cardiac arrhythmias. Older adults may have slower drug metabolism, and thus maximum and next day serum concentration will be increased” (sect. 7)(Insomnia Response Discussion Example). While running any diagnostic test is unnecessary, doing a physical exam to rule out any underlying medical conditions should be a standard (Anderson, 2018). Using a questionnaire such as the Pittsburg Sleep Quality Index (PSQI) scale or Insomnia Severity Index (ISI) can help in the initial assessment to diagnose the problem of Insomnia. Other test that could be considered diagnostic-wise is polysomnography (PSG), which is used to rule out narcolepsy, restless legs syndrome, or obstructive sleep apnea Act and a thyroid-stimulating hormone (TSH) (Stahl, 2021a).(Insomnia Response Discussion Example)

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

Insomnia

Restless legs Syndrome

Periodic limb movement disorder

Obstructive sleep Apnea (OSA)

Short sleeper

Poor Sleep hygiene.

I believe she has insomnia r/t the use of SSRI and is caused by her depression due to the death of her husband.(Insomnia Response Discussion Example)

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.

Two pharmacological agents that Could be used for this patient are Mirtazapine or Trazodone in addition to sertraline due to the patient’s complaints of worsening depression.(Insomnia Response Discussion Example)

Mirtazapine: “Mirtazapine or Remeron is a serotonin, norepinephrine receptor antagonist (SN-RAn), Initial dosage starts at 15mg at night, increasing every 1 to 2 weeks until desired effects are reached. The maximum dose is 45 mg/day, even though some people have gone as high 90 mg/day” (Stahl, 2021b, pg.511). “Mirtazapine has been demonstrated to have an earlier onset of action than SSRIs. Mirtazapine does not affect the CYP450 system and may be preferable in patients requiring concomitant medications” (Stahl, 2021b, pg. 513).(Insomnia Response Discussion Example)

Pharmacokinetics: “Half-life is 20 to 40 hours; substrate for CYP450 2D6, 3A4, and possibly also CYP450 1A2. Food does not affect absorption” (Stahl 2021b, pg.511).(Insomnia Response Discussion Example)

Pharmacodynamics: “Mirtazapine boosts neurotransmitters serotonin and norepinephrine/noradrenaline; blocks alpha 2 adrenergic presynaptic receptor, thereby increasing norepinephrine neurotransmission; it blocks alpha 2 adrenergic presynaptic receptors on serotonin neurons, thereby increasing serotonin neurotransmission; blocks 5HT2A, 5HT2C, and 5HT3 serotonin receptors, blocks H1 histamine receptors” ( Stahl, 2021b, pg. 509).(Insomnia Response Discussion Example)

Trazadone: “Trazadone or Desyrel is a serotonin receptor antagonist (S-MM), SARI (serotonin 2 antagonist/reuptake inhibitor); Antidepressant; hypnotic” (Stahl, 2021b, pg793).” For insomnia, the initial dose is Trazodone 25 to 50 milligrams at bedtime, increasing as tolerated, usually 50 to 100 milligrams per day. However, some patients may require up to the full antidepressant dose range” Stahl, 2021b, pg. 794)(Insomnia Response Discussion Example)

Pharmacokinetics: CYP450 3A4 metabolizes Trazodone; the half-life is biphasic; the first phase is approximately 3 to 6 hours; the second phase is approximately 5 to 9 hours (Stahl, 2021b)(Insomnia Response Discussion Example)

 Pharmacodynamics: “Trazodone works by blocking serotonin 2A receptors potently and blocks serotonin reuptake pump (serotonin transporter) less potently” (Stahl, 2021b, pg.793)(Insomnia Response Discussion Example)

Rationale: I would choose Mirtazapine over Trazadone at this. The patient is a diabetic and is on Metformin and Januvia. I know that Mirtazapine has the potential for significant weight gain, so we will have to monitor the patient’s weight and do an initial cholesterol panel on her. Trazadone. Trazadone has some side effects I prefer not to have her deal with, given her age, such as dizziness, sedation, fatigue, headache incoordination, tremors, hypotension, and syncope (Stahl, 2021b)(Insomnia Response Discussion Example)

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?

Due to the patient’s age, the patient might be more sensitive to the adverse effects of any drugs prescribed and may require lower starting doses. It is important to avoid polypharmacy, but in this patient’s case, if she has just been on the SSRI for 2 to 4 weeks, we need to give it more time to work. Often people have worsening symptoms before the medication starts to work properly. I feel that augmenting the Sertraline with the Mirtazapine will help her to treat the depression that she has due to her husband’s death and allow her to get some much need sleep to help her recover. Once her symptoms improve, we can titrate her off the Mirtazapine.(Insomnia Response Discussion Example)

As nurse practitioners, we must know the diseases we are treating the patient for and the best medication available to treat these patients. We must keep informed and learn. We must educate our patients so they can make informed decisions and consent to the best treatment course for them. Follow-up should occur 4 weeks after starting or increasing any medication unless otherwise indicated. For the Mirtazapine, I would want the patient to return in 1 to 2 weeks, increasing the dose until the desired effect is reached. Cost is a factor that needs to be considered because the patient may be on a limited income, and we want her to adhere to her treatment.(Insomnia Response Discussion Example)

Insomnia Response 

You have provided a compelling presentation on insomnia, including comprehensive potential patient assessment details. Insomnia is a common sleep disorder marked by trouble sleeping or falling asleep, staying asleep, and getting quality sleep, despite being in the right environment and time. People develop coping skills to deal with insomnia, including sticking to a sleep schedule, taking medications, and avoiding or limiting caffeine (Krystal et al., 2019). Therefore, when assessing the patient, asking about coping skills they adopt to deal with insomnia is critical. Inquiring about risk factors or potential contributors to insomnia is also essential.(Insomnia Response Discussion Example)

You identified the right questions to help assess the current state, including the amount and frequency of caffeine intake, medication adherence, and any contributing factors such as the current mental state. I like your rationale for the questions identified because they cover contributing factors, treatment, and coping mechanisms. Your rationale enhanced my understanding of the importance of the questions selected during clinical assessment. You also identified the client’s close friends and family as people you would involve in the assessment for further information about the client. Indeed close friends and family interact more with the patient and have a better understanding of the client’s current state. Their information could help disclose more than the patient might be willing to tell, helping develop a comprehensive patient assessment to guide the right diagnosis and treatment plan. It is vital to inquire about what they have noticed about the client recently and changes to the client’s health, social interaction, functionality, and decision-making (Kaur et al., 2022).(Insomnia Response Discussion Example)

Insomnia co-occurs with several mental health disorders and is considered a symptom of some mental conditions such as depression. I agree that it is vital to screen for depression, but you can also screen for other conditions like generalized anxiety disorder and post-traumatic stress disorder (Kaur et al., 2022). The PHQ-9 would help screen for depression, while GAD-7 could help screen for generalized anxiety disorder. I have gained valuable insights from your elaboration of pharmacological interventions to help treat the situation and the contradiction to consider during drug therapy to avoid undesired outcomes like drug interactions or adverse drug events. In this case, arranging for regular follow-ups is required to evaluate progress.(Insomnia Response Discussion Example)

References

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry: official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674

Kaur, H., Spurling, B. C., & Bollu, P. C. (2022). Chronic insomnia. In StatPearls [Internet]. StatPearls Publishing.

https://www.ncbi.nlm.nih.gov/