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/
