Assignment help – Discussion: Sleep/Wake Disorders
It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015). Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Assignment help – Discussion, you consider how you might assess and treat the individuals based on the provided client factors.
Learning Objectives
Students will:
• Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disorders
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disorders
• Evaluate efficacy of treatment plans for clients presenting for sleep/wake therapy
• Apply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disorders
Case 1: Volume 2, Case #16: The woman who liked late-night TV
Post a response to the following:
• Provide the case number in the subject line of the Assignment help – Discussion.
• List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.
• Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
• Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
• List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake 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.
• If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
• Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.
PATIENT FILE The Case: The woman who liked late-night TV The Question: What to do when comorbid depression and sleep disorders are resistant to treatment The Dilemma: Continuous positive airway pressure (CPAP) may not be a reasonable option for treating apnea; polypharmacy is needed but complicated by adverse effects
• Patient evaluation on intake: 70-year-old female with a chief complaint of “being sad” Feels she had been doing well until her hearing began to diminish in both ears – Candidate for cochlear implants in the future, but this is a long way off – Despite the promise of improved hearing, she often has crying spells for no clear reason Psychiatric history • The patient has been without psychiatric disorder throughout her life • Has felt increasingly sad over the last year and these feelings were not triggered by an acute stressor • Lives alone with the help of a home aide – Her spouse died many years ago due to CAD – Despite her aide and her son who visits often, she is having a harder time coping with both instrumental and basic activities of daily living • She admits to full MDD symptoms – She is sad, has lost interest in things she used to enjoy, and is fatigued with poor focus and concentration – Denies feelings of guilt, worthlessness, or any suicidal thoughts – Appears mildly psychomotor slowed – Additionally states that sleep is “awful” ◦ Does not fall asleep easily as her legs “ache and jump”
• PATIENT FILE: Takes frequent naps during the day as a result ◦ She admits to snoring frequently • There is no evidence of cognitive decline or memory problems • She has a supportive son who accompanies her to all appointments and helps provide her care Social and personal history • Graduated high school, was married, and raised her children • Denied any academic issues, learning disability, or ADHD symptoms growing up • Having and maintaining friendships has been easy and successful over the years • At times, she is lonely at home • Her mobility has declined somewhat, which limits her going out • Participates in activities at a local elders’ center • No history of drug or alcohol problems Medical history • HTN • Hypothyroidism • CAD • Anemia • Environmental allergies • Obesity Family history • Reports AUD throughout her extended family • MDD reportedly suffered by her mother Medication history • Never taken psychotropic medications Psychotherapy history • Recently, has gone to a few sessions of outpatient supportive psychotherapy, but her hearing loss makes this modality almost impossible – Hearing aids have failed to help – May be a candidate for cochlear implants • She has a fax machine at home and states that she and her therapist often fax notes back and forth, which she finds helpful as receiving them brightens her mood – Perhaps this is “supportive facsimile therapy”
• PATIENT FILE: Patient evaluation on initial visit • Gradual onset of geriatric, first-episode MDD symptoms likely as a result of hearing loss and mobility loss • This caused interpersonal disconnectedness, loneliness, and onset of MDD • Suffers from daily crying spells and seems very tired • Has good insight into her illness and wants to get better • There appears to be no suicidal or safety concerns clinically • The fatigue and possible infirmities of strength and balance may be problematic if side effects compound these symptoms Current medications • Furosemide (Lasix) 40 mg/d • Lisinopril (Zestril) 40 mg/d • Levothyroxine (Synthroid) 100 mcg/d • Enteric-coated aspirin 325 mg/d • Fexofenadine (Allegra) 180 mg/d • Ferrous sulfate 1000 mg/d
• Attending physician’s mental notes: initial evaluation • Patient has her first MDE now • It appears chronic in nature, but essentially, has been untreated • It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling at this point • As this is an initial MDE and an initial foray into treatment with good family support, her prognosis is good • However, her older age of onset, loss of hearing, mobility, and marked medical comorbidity are concerning • Psychotherapy, especially IPT-based, would be clearly indicated but difficult to deliver adequately
• Attending physician’s mental notes: initial evaluation (continued) • This case seems easy in that she is untreated up to this point; therefore, any antidepressant has a chance of working • However, there is concern regarding her obesity and lethargy; thus, avoiding medications with high weight-gain side-effect burden is warranted • Sleep is also very disrupted – By initial insomnia, which may be caused by her depression – Perhaps by restless legs syndrome (RLS) – It is unclear if she snores and has OSA • Hearing loss and inability to communicate well is also problematic in providing her with good psychotherapy – Even delineating symptoms in the medication management session is a difficult task – Likely need to pressure and advocate for the cochlear implants acting as an antidepressant in order to advance this process Further investigation Is there anything else you would especially like to know about this patient? • She has marked fatigue; have medical causes been ruled out? – She is euthyroid and her anemia is stable with a normal hematocrit – Her cardiac function is stable and without compromise – If she has RLS, this could account for her fatigue and should be investigated – If she has OSA, this could account for her fatigue and should be investigated.
• PATIENT FILE Case outcome: first interim follow-up visits four weeks later • Citalopram (Celexa), an SSRI, was started at 10 mg/d and titrated to 20 mg/d • She appears less weepy and is in a partial response • Still is not sleeping well • Denies any typical side effects
Attending physician’s mental notes: second interim follow-up visit at two months • Despite being a little better, the patient is still suffering • She is crying less but there is now more of a need to improve her sleep and daytime fatigue issues • She has clinical risks for OSA (HTN, obesity, large neck size), and if this is a positive finding, CPAP treatment may be an excellent choice for her apnea and her depression residual symptoms • Her access to a sleep laboratory is limited and it may take months to have the study completed Case outcome: second interim follow-up visit at two months • Citalopram (Celexa) is increased gradually, given her age, to 30 mg/d – Historically, the QTc prolongation warning did not exist when this patient was prescribed this medication – Currently, use above 20 mg/d is discouraged in the elderly ◦ If a higher dose is needed clinically, it would make sense to obtain plasma levels and an EKG in the current era • Sleep electrophysiology is ordered to rule out OSA, RLS • She is placed on off-label tiagabine (Gabitril) as a hypnotic in order to avoid more respiratory suppressing, psychomotor impairing, sedativehypnotic BZ or BZRA agents – This agent has human sleep laboratory data suggesting it increases slow wave, restorative deep sleep – Its theoretical mechanism of action is GABA reuptake inhibition, selectively at the GAT1 transporter, making it an SGRI – She is allowed to titrate to 6 mg/d at bedtime – This agent, interestingly, is approved to treat epilepsy but came out with a warning, well after this patient utilized this “drug” therapy that tiagabine might actually induce seizures in non-epileptic patients • The patient subsequently shows moderate improvement in her affect • Experiences slightly less RLS • Is not initiating sleep any better • She is felt to be 20%–30% better globally, but is plagued by daytime fatigue as a chief complaint – This may actually be occurring due to the adverse effect profile of tiagabine (Gabitril)
Attending physician’s mental notes: second interim follow-up visit at two months (continued) • Cannot wait months for a sleep study • Her SSRI is at a reasonable, moderate dose, and has effectively treated the target symptom of sadness and dysphoria – Switching from this may cause a relapse • Adding a noradrenergic or dopaminergic agent may target her fatigue symptoms a little better • Adding a hypnotic may improve her sleep, and secondarily, her next day wakefulness, but need to watch for respiratory suppression and psychomotor impairment, especially if she has severe undiagnosed OSA Case outcome: interim follow-up visits through four months • The NDRI bupropion-XL(Wellbutrin-XL) is added to her SSRI and titrated to 300 mg/d – There is moderate improvement in her vegetative MDD symptoms and her drive and motivation improves slightly • Zaleplon (Sonata) 5 mg at bedtime is started in place of tiagabine (Gabitril) with improved sleep onset overall, but she still reports RLS
PATIENT FILE: Zaleplon is chosen as the shortest half-life (1 h) BZRA, and in theory, should have least impact on psychomotor impairment or respiratory suppression in this class of sleep-inducing agents • Further workup suggests she meets criteria for RLS. Sleep study is still pending • Cochlear implants are approved, and surgery scheduled
Case debrief :Over the next several months, the patient ultimately is maintained in an MDD-free state, RLS-free state, and the OSA fatigue is reduced by at least 50% by use of modafinil (Provigil), which clearly improves her quality of life • Her current regimen includes: – Citalopram (Celexa) 20 mg/d – Bupropion-XL (Wellbutrin-XL) 300 mg/d – Gabapentin (Neurontin) 600 mg/d – Modafinil (Provigil) 400 mg/d – Ramelteon (Rozerem) 16 mg/d • Modafinil had to be escalated to its full dose to allow for its sustained response (400 mg/d) • Ramelteon had to be doubled over the approved 8 mg dose for better effectiveness (16 mg at bedtime) • Citalopram was reduced to 20 mg/d as it was felt to be contributing to fatigue • Finally, after a physical rehabilitation stay, her need or desire to stay up late for TV watching diminished and her home health aide adjusted her schedule to arrive a bit later in the morning – These behavioral modifications seemed to improve her CRSD symptoms and improved her quality of life because her delayed phase shift was allowed to continue instead of being resisted ◦ Essentially, as her health aide could come later, the patient was allowed to sleep in and obtain more consecutive hours of sleep Take-home points • Geriatric depression is complicated given the psychosocial issues that must be navigated, medical comorbidities that are present, and the possibility of more pronounced side-effect burden in this age group • Sometimes treating the depression is simple, but treating the comorbidities require more effort or collaboration with other providers to optimize treatment – In this case, collaboration with otolaryngology, pulmonology–sleep medicine, primary care, physical medicine and rehabilitation, home healthcare, and the family often occurred Performance in practice: confessions of a psychopharmacologist • What could have been done better here? – Unlike other cases in this book, this patient was not escalated to the maximum higher dose monotherapy before combination therapy was started
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Free Essay Sample
Sleep/Wake Disorders Case Study
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Sleep/Wake Disorders Case Study
Case Number
The case number of the question is Case 1: Volume 2, Case #16: The woman who liked late-night TV.
Three Questions and Rationale
1. Do you feel sleepy during the day or experience sleep attacks and describe the quality of sleep on a normal night? For example, describe the hours of sleep?
The question is essential since lack of sleep can trigger depression and lead to other health problems (American Psychiatric Association, 2013).
2. Have you or any of your family members been diagnosed with depression?
The information is intended to understand whether there is any genetic depression in the family. It will help in the treatment of the patient using effective strategies. It will also help to understand their symptoms such as sleeping patterns.
3. Do you take anything to help you sleep? The question is essential to understand if the patient is using any drug or prescribed medication to trigger sleep.
The three questions are essential to assess the sleeping patterns of the patient and to guide the diagnosis (Stahl, 2013).
Relevant People
The relevant people who can provide further information about the patient’s condition include the home aide and the son.
Questions for the son: Do you have any history of depression in your family and whether you have noticed any behavior changed in the patient’s life?
Questions for the home aide: How can you describe the mood of the patient during your visits? Describe any noticeable changes in the patient that have developed since you started working together.
The questions to the relevant people are essential to measuring the severity of depression and the progression of the symptoms (Stahl, 2013). The questions will also guide the diagnosis.
Physical Exams and Diagnostic Tests
Actigraphy test will be essential to track the pattern of sleep of the patient for some time. The test involves a wrist-worn device that tracks movement to determine insomnia, movement disorders, and circadian rhythm disorders (American Psychiatric Association, 2013).
Mental health exam test is necessary to check for symptoms such as insomnia, anxiety or any mental health disorder. It also involves a mental status exam, a history of mental health, and other relevant psychological evaluations (Gebara et al., 2016).
Polysomnogram test is necessary to assess the activity of the patient during sleep. The test is used to determine if the patient has any abnormal behavior during sleep (Gebara et al., 2016).
Multiple sleep latency testing is important in assessing if a patient is suffering from excessive sleepiness during the day. The indications of sleeping during the day include sleep apnea, idiopathic hypersomnia, and narcolepsy (Gebara et al., 2016).
Differential Diagnosis
Insomnia – Insomnia is a sleep disorder characterized by difficulty to initiate sleep. The condition can be acute or chronic (American Psychiatric Association, 2013). It is associated with other health conditions such as depression, lack of exercise, and anxiety. It can also include waking up too early or experiencing poor quality of sleep (Bei et al., 2018). The sleep disturbance causes daytime fatigue which can negatively influence the quality of life. For example, a person experiencing insomnia is likely to have social distress or healthy participation in other daily activities (Bei et al., 2018). For example, a person may experience slowness in activity, headache or irritability.
Major Depressive Disorder (MDD) – Depression is a mental health disorder that causes loss of interest and a persistent feeling of sadness. Also known as clinical depression, the condition affects mood, behavior, and thoughts (Bei et al., 2018). It can trigger behavior and emotional problems. People with depression feel there is no worth in participating in daily activities. For example, depression can lead to suicide since individuals feel they are not worth living (Bei et al., 2018). The causes of depression include psychological, genetic, and environmental factors. One of the noticeable symptoms is two weeks of low mood in daily activities.
Restless Legs Syndrome (RLS) – The syndrome is a disorder that causes an uncontrollable urge to move the legs, especially while sitting or lying down. The persistent urge occurs to satisfy a specific urge in the body (Williams et al., 2016). It occurs mostly in the evening or during bedtime, causing sleep disturbance. In severe cases, the movement may include hands or other parts of the body (Williams et al., 2016). The syndrome leads to sleep deprivation, day time sleep, and falling asleep. It also causes fatigue and restlessness, which further interferes with sleep.
One of the possible conditions among the three is insomnia. The reason is that the patient has presented several symptoms of depression, insomnia co-exists with depression making it the most likely condition the patient is suffering from (Gebara et al., 2016).
Pharmacologic Agent
Eszopiclone 1mg daily orally – The drug is essential for the treatment of sleep problems, especially insomnia. The dose can be increased to 2mg is there is a partial response. It is effective in the treatment of chronic, primary, and transient insomnia (Gebara et al., 2016). It also causes inhibitory actions in sleep centers which trigger sedative hypotonic effects.
Trazodone 150mg daily – The drug is necessary to improve mood, behavior, and emotions. It is popular in reducing anxiety. Administration of the drug can be increased in 3 or 4 days depending on the patient outcomes. For example, 50mg can be increased daily with a maximum of 400mg for outpatient and 600mg for inpatient (Bei et al., 2018). Trazodone binds the 5-HT2 receptor thus acting as serotonin in high doses and an antagonist in low doses. It prevents serotonin reuptake at the presynaptic neural membrane.
Check Points
The patient responded positively to faxes from the respective therapies. She had a cochlea implant which makes it for her to hear other people. The device capability ends the frustration. The patient write my essay needs to engage with her peers to promote further recovery (Bei et al., 2018). Cognitive behavior therapy is also an effective strategy for depressed patients. Family-oriented therapies and social skills are also necessary including group therapy and case management (Bei et al., 2018). The checkpoints are necessary to track and enhance the treatment of the disorder.
Lessons Learned
The case study of the patient demonstrates the diagnosis and different pharmacologic agents for insomnia. The treatment of the condition requires critical analysis to identify the accurate condition and appropriate treatment. Another lesson is that it is essential to titrate the medication in case of partial response or persistent symptoms to achieve complete remission (American Psychiatric Association, 2013). It is also critical to consider various symptoms presented in the patient before prescribing any medication. An analysis of the condition helps in prescribing the right medication, achieving early recovery, and promoting better health conditions in the long-term. A clinician should also analyze pharmacologic agents, their reaction, and the ability to achieve remission depending on the dosage. Interaction of drugs is essential to reduce the risk of side effects. The lessons are important in improving responses to sleep and wake disorders among patients of different ages.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Pub.
Bei, B., Asarnow, L. D., Krystal, A., Edinger, J. D., Buysse, D. J., & Manber, R. (2018). Treating insomnia in depression: Insomnia related factors predict long-term depression trajectories. Journal of Consulting and Clinical Psychology, 86(3), 282.
Gebara, M. A., Karp, J., Kasckow, J., & Reynolds, C. F. (2016). Treatment-resistant depression and insomnia in older veterans: State of the science and planned clinical trial. The American Journal of Geriatric Psychiatry, 24(3), 88-89.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press.
Williams III, W. P., McLin III, D. E., Dressman, M. A., & Neubauer, D. N. (2016). Comparative review of approved melatonin agonists for the treatment of circadian rhythm sleep‐wake disorders. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 36(9), 1028-1041.
