Treatment for a Patient With a Common Condition

Treatment for a Patient With a Common Condition

By Day 3 of Week 7

By Day 6 of Week 7

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1. Questions for the Patient:

a. What is your usual bedtime, and how many hours of sleep do you get at night?
– This inquiry aims to assess the patient’s sleep patterns, as inadequate sleep, especially in the elderly, can have both medical and psychological repercussions (Patel et al., 2019).

b. Are you consistently taking your prescribed medication as directed?
– This question is crucial to determine if irregular medication intake might be contributing to her symptoms or exacerbating her condition, particularly in cases of depression.

c. Do you have a strong support system through family or friends?
– Inquiring about the presence of a support network is essential, as individuals lacking social support are more prone to depression, which can subsequently lead to sleep disturbances like insomnia.

2. People to Consult and Specific Questions:

a. Children:
– What noticeable changes have you observed in her daily routine?
– Have you noticed any alterations in her sleep patterns?
– How many meals does she typically consume in a day?
– These questions will provide insight into the patient’s overall well-being and potential changes in her lifestyle and eating habits.

b. Friends:
– Have you been in regular contact with her?
– Have you observed any significant changes in her behavior or mood?
– Friends can provide valuable information about the patient’s social interactions and any noticeable shifts in her emotional state.

c. Relatives:
– Have you maintained regular communication with her?
– Do you have any concerns about her well-being that you would like to discuss privately?
– Relatives may offer insights into family dynamics and any specific worries they have regarding the patient’s health.

d. Driver:
– Does she frequently request rides or prefer to stay at home?
– Information from a driver can shed light on the patient’s mobility and social engagement outside her residence.

3. Appropriate Physical Exams and Diagnostic Tests:

a. Sleep Study/Diary:
– This examination allows for the assessment of sleep patterns and can provide valuable information about her insomnia.

b. Mini Mental State Exam (MMSE):
– Administering this test can help evaluate any cognitive impairment that may be contributing to her symptoms.

c. Geriatric Depression Scale (GSD):
– The GSD can assist in assessing the severity of her depression and provide insights into her mental health status.

d. Blood Work (if indicated):
– Specific blood tests may be considered to assess for any changes in relevant biochemical markers that could be contributing to her condition.

4. Differential Diagnosis:

– Possible diagnoses include insomnia and recurrent depression. The most likely diagnosis appears to be insomnia, given the patient’s reported sleep disturbances and the presence of depression symptoms.

5. Pharmacologic Agents for Antidepressant Therapy:

a. Trazodone, 15 mg at bedtime (HS):
– This medication can address both depression and insomnia.

b. Mirtazapine, 15 mg at bedtime (HS):
– Mirtazapine can treat depression and insomnia while also stimulating appetite. It is favored over Trazodone due to its potential to address appetite concerns.

6. Contraindications and Ethical Considerations:

– Mirtazapine, 15 mg at HS: Patients with high cholesterol or those taking MAOIs should inform their healthcare provider before starting this medication. Mirtazapine carries a black box warning due to its potential to paradoxically cause depression, anxiety, and suicidal ideation. Additionally, anti-depressants, including Mirtazapine, have a black box warning regarding increased mortality in elderly patients (Crock et al., 2017).

7. Follow-up and Therapeutic Changes:

– The patient will have follow-up appointments every four weeks to assess treatment efficacy. Therapeutic adjustments will be considered based on observed changes in symptoms, always with appropriate tapering procedures.

References:

Crocco, E. A., Jaramillo, S., Cruz-Ortiz, C., & Camfield, K. (2017). Pharmacological Management of Anxiety Disorders in the Elderly. Current treatment options in psychiatry, 4(1), 33–46. https://doi.org/10.1007/s40501-017-0102-4

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the Elderly: A Review. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine, 14(6), 1017–1024. https://doi.org/10.5664/jcsm.7172