reply to discussion post

Case: An elderly widow who just lost her spouse.

Three questions to ask the patient and a rationale for asking these questions.

The three questions I will ask the patient are: 1) Have you ever had any past history of depression. 2) How do you cope day by day after the loss of yours? 3) Do you regularly take your medication? The reasons for asking those questions are because: It’s important to know what the patient’s mental health has been like before her husband’s death or if the patient may be experiencing recurrent depression. It’s equally important to know if the patient has any support system after her husband. Because the lonely she becomes the more difficult it is for the patient to find comfort or have better coping mechanisms. The reason for asking if the patient regularly takes her medication is to find out how much the patient is affected by the actual situation of “mourning her husband”. Because people who experience difficult situations such as mourning, depending on the relationship they have, the window may end up losing interest in everything including taking the daily medication. It is also important to know if he is physically incapacitated

People in the patient’s life to speak to or get feedback from to further assess the patient

I would elicit this information first and also find out if she has any children and or possibly a guardian. Depending on this information and whom; I would want more information and clarification on her living situation, socioeconomic status. I would ask about a support network- does she have friends/family, someone to talk to. I would ask her about her sleep habits, does she nap during the day? What does she do before going to bed?

Physical and diagnostic tests

The type of physical exam that would be appropriate for the patient would include a heart rhythm check, an assessment of the eye, and her oxyhemoglobin saturation. Diagnostic checks suitable for the patient would include actigraphy tests and polysomnography tests. The main aim of these tests will be to measure the sleeping patterns of the patient. polysomnography test looks into the patient’s sleep pattern while actigraphy measures total sleep time, sleep latency, and sleep patterns.

Differential diagnoses for the patient

The patient’s differential diagnoses include generalized anxiety disorder, major depressive disorder (MDD), and restless leg syndrome. MDD would likely explain why the patient is currently experiencing insomnia. Some key takeaways would be difficulty in concentration, loss of appetite, and hopelessness (Keller et al., 2019). If these symptoms would be available, then she would be diagnosed with insomnia. After her husband’s death, the patient might have developed depression and later affected her sleeping pattern. Patients that are experiencing sleeping disorders are likely to be diagnosed with sleeping disorders (Bollu & Kaur, 2019).

Pharmacologic agents and their dosing

Selegiline The transdermal patch would be administered with the patient being advised to take a 6mg daily dose applied every day. If she doesn’t improve, then an increase of dosage by 3 mg daily for two weeks will be prescribed till the total dosage reaches 12 mg daily. The purpose of Selegiline The transdermal patch will be to inhibit the monoamine Oxidase-B isoenzyme (Puttrevu et al., 2020).

Eszopiclone with a dosage of 3 mg administered orally before the patient goes to bed is prescribed. The drug is recommended for the fight against insomnia as it reacts with the gamma-aminobutyric acid (GABA) receptors at the allosterically binding sites at the benzodiazepine receptors. The drug method of action is to slow down brain activities hence allowing sleep i.e., induce sedation and hypnosis to allow sleep (Rösner et al., 2018).

Drug therapy contraindications

One of the contradictions of using Selegiline The transdermal patch would be the increased risk of serotonin syndrome i.e., taking selective serotonin reuptake inhibitors, mirtazapine, and other vasoconstrictors and analgesics (Puttrevu et al., 2020).

Checkpoints

The patient will be assessed after a four-week interval to determine if the symptoms have improved. If the symptoms have not improved after four weeks, selegiline transdermal will be increased by 3mg for four weeks until 12mg which is termed as the maximum dosage. If within the first four weeks the symptoms would have changed positively, then the dosage is maintained till the patient completes the dosage in which the sleep problem would be effectively managed.

References

Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri medicine, 116(1), 68–75.

Keller, A. S., Leikauf, J. E., Holt-Gosselin, B., Staveland, B. R., & Williams, L. M. (2019). Paying attention to attention in depression. Translational psychiatry, 9(1), 279. https://doi.org/10.1038/s41398-019-0616-1

Puttrevu, S. K., Arora, S., Polak, S., & Patel, N. K. (2020). Physiologically Based Pharmacokinetic Modeling of Transdermal Selegiline and Its Metabolites for the Evaluation of Disposition Differences between Healthy and Special Populations. Pharmaceutics, 12(10), 942. https://doi.org/10.3390/pharmaceutics12100942

Rösner, S., Englbrecht, C., Wehrle, R., Hajak, G., & Soyka, M. (2018). Eszopiclone for insomnia. The Cochrane database of systematic reviews, 10(10), CD010703. https://doi.org/10.1002/14651858.CD010703.pub2