6 hours ago
Case #16: The woman who liked late-night TV
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The patient is an obese 70-year-old female with a chief complaint of “being sad.” Her husband passed away several years ago due to coronary artery disease (CAD). She lives at home alone and has a home health aide help her. Her son comes to visit her often. She was feeling well until her hearing began to diminish in both ears. Her mobility has declined, so she has not been able to get out as much. She is often lonely at home. She has daily crying spells, is often very tired, has good insight to her illness, and wants to get better.
Three Questions to Ask the Patient and Why
The case study mentioned that the patient is a candidate for cochlear implants, but it is a long way off. Thus, my first question to ask the patient is what is preventing her from getting cochlear implants? She began experiencing sadness when she began to lose her hearing and mobility. Therefore, regaining her hearing may help decrease the depression. If its financial reasons, maybe there are resources that can help her. Finding out the reason the patient isn’t getting the implants can help the provider and patient find solutions.
The patient also mentioned that her sleep was “awful”, stating her legs “ache and jump”, she takes frequent naps during the day, and admits to snoring frequently. Thus, the second question I would ask is what are her sleeping habits like? Individuals who have good sleep habits sleep better. Getting better sleep can be obtained by being consistent by going to bed at the same time each night and waking up the same time each day (Centers for Disease Control and Prevention, [CDC], 2016). Individuals can make sure the room is dark, quiet, and cool (CDC, 2016). Additionally, remove electronic devices, avoid large meals, caffeine, and alcohol can help with getting better sleep (CDC, 2016).
My third question would be what do you do when you are sad? Individuals who are depressed often have a negative view of the world and often think of themselves as worthless (This Way Up, n.d.). They often blame themselves when something bad happens and feel like they are unlucky (This Way Up, n.d.). Thus, helping individuals identify negative thinking and reframe the way they think about life can help improve depressive symptoms (This Way Up, n.d.).
People to Speak to with Specific Questions to Ask
The first person I would want to speak to is the patient’s son. The case study states the son visits her often so he should know the patient’s habits. First, I would ask him the same questions I asked the patient such as what is preventing the patient from getting cochlear implants, what are her sleep habits, and what does she do when she is sad? By asking the son the same questions, insight can be shown on how the son views things and how the patient views things. I would also him when he began to notice her depressive symptoms because that will help provide a timeline as to when it all began.
The second person I would talk to is her home health aide because she is familiar with the patient. I would ask her what the patient’s home life is like such as how is she maintaining her house? Is she able to clean up after herself? How is she doing with activities of daily living? These questions can provide insight on the severity of the patient’s depressive symptoms.
Physical Exams and Diagnostic Tests and How Results Would Be Used
The first diagnostic test I would want to perform on the patient is the 9-item Patient Health Questionnaire (PHQ-9). The PHQ-9 is a screening tool for major depression (Na et al., 2018). The test is a reliable and valid measurement of depressive symptoms that also asks about the individual’s thoughts of death or self-injury within the last two weeks (Na et al., 2018). The results would be used to determine the severity of her depression.
Another diagnostic test that can be performed on this patient is a polysomnography. A polysomnography is a sleep study that helps providers diagnose sleep apnea, periodic limb movement disorder, restless leg syndrome (RLS), insomnia, and nighttime behaviors (National Sleep Foundation, n.d.). The results would be used to can help determine the cause of her daytime sleepiness such as sleep apnea or RLS.
I would also want to run a complete blood count (CBC) with differential on the patient. I would specifically want to obtain a red blood cell count (RBC) and white blood cell count (WBC). Thus, a CBC with differential would help determine if the patient is fatigued due to anemia or an underlying infection.
Three Differential Diagnosis and Why
The three potential differential diagnoses include:
Major Depressive Disorder
Persistent Insomnia Disorder
Obstructive Sleep Apnea Hypopnea
The most likely differential diagnosis is major depressive disorder (MDD). The diagnostic criteria for MDD is five or more symptoms during the same 2-week period and a change from previous functioning (American Psychiatric Association, 2013). The symptoms include: depressed mood most of the day, marked diminished interest or pleasure in all or almost all activities most of the day, significant weight loss or weight gain, insomnia or hypersomnia neatly every day, psychomotor agitation or retardation nearly every day, fatigue or loss of energy nearly every day, feelings of worthlessness or excessive or inappropriate guilt nearly every day, diminished ability to concentrate, and recurrent thoughts of death (American Psychiatric Association, 2013). The patient fits this diagnosis as evidence by depressed mood, diminished interest in activities she used to enjoy, fatigue, diminished ability to concentrate, and psychomotor retardation.
Two Pharmacological Agents and Dosing and Why
One pharmacologic agent that can be tried is doxepin 3 mg at bedtime for insomnia. Doxepin works by boosting serotonin and norepinephrine by blocking the serotonin reuptake pump and norepinephrine reuptake pump (Stahl, 2017). At hypnotic doses, doxepin blocks histamine-1 receptors, which promotes sleep (Stahl, 2017). Doxepin is a substrate for CYP450 2D6 and has a half-life of 8-24 hours (Stahl, 2017). In the elderly, the recommended dose for insomnia is 3 mg per day (Stahl, 2017).
Another pharmacologic agent that I would like to start the patient on is bupropion (extended release) XL 150 mg daily in the morning. Bupropion is used to treat MDD and works by boosting norepinephrine and dopamine by blocking the norepinephrine reuptake pump and dopamine reuptake pump (Stahl, 2017). Bupropion inhibits CYP450 2D6, has a parent half-life of 10-14 hours, and a metabolite half-life of 20-27 hours (Stahl, 2017). Thus, since bupropion blocks the dopamine reuptake pump and norepinephrine reuptake pump, this medication is beneficial in improving symptoms of loss of happiness, joy, interest, pleasure, energy, enthusiasm, alertness, and self-confidence (Stahl, 2013). Thus, because of bupropion’s mechanism of action and the patient’s symptoms, I would want this patient to try this medication.
Lessons learned during this case study is that geriatric depression can be difficult to treat. They often have multiple comorbidities with the possibility of more pronounced side-effects (Stahl, 2008). Additionally, medications can have contraindications that do not previously exist prior to the patient being put on medication. Thus, providers must be aware of new and old warnings on medications in the event there are changes made to medications. I will apply this information when I am in practice by paying close attention to dosages, side effects, and potential contraindications when providing medication to the geriatric population.
American Psychiatric Association. (2013). Diagnostic and statistical manual od mental disorders (5th ed.). Washington, DC: Author.
Centers for Disease Control and Prevention. (2016). Tips for better sleep. Retrieved from https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.html
Na, P. J., Yaramala, S. R., Kim, J. A., Kim, H., Goes, F. S., Zandi, P. P.,…Bobo, W. V. (2018). The PHQ-9 item 9 based screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ-9)-9 item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS). Journal of Affective Disorders, 232, 34-40. doi: https://doi.org/10.1016/j.jad.2018.02.045
National Sleep Foundation. (n.d.). Sleep apnea. Retrieved from https://www.sleepfoundation.org/sleep-apnea
This Way Up. (n.d.). How do you feel? Retrieved from https://thiswayup.org.au/how-do-you-feel/sad/
Stahl, S. M. (2008). Essential psychopharmacology online. Retrieved from https://stahlonline-cambridge-org.ezp.waldenulibrary.org/viewPdf?page=csEP_16.pdf&vol=2
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide (6th ed.). San Diego, CA: Cambridge University Press.