Fluent Essays

Sleep/Wake DisordersIt 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 Discussion, you consider how you might assess and treat the individuals based on the provided client factors.Review this weeks Learning Resources and reflect on the insights they provide.Go to the Stahl Online website and examine the case study you were assigned.Take the pretest for the case study.Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.Review the posttest for the case study.Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the Post to Discussion Question link and then select Create Thread to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!By Day 3Post a response to the following:Provide the case number in the subject line of the 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.Case study is attached :Case 1: Volume 2, Case #16: The woman who liked late-night TV the_woman_who_liked_late_night_tv.pdf Unformatted Attachment Preview 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 Pretest self-assessment question (answer at the end of the case) Which of the following hypnotic agents is less likely to be addictive, impair psychomotor function, or cause respiratory suppression? A. B. C. D. E. F. G. Ramelteon (Rozerem) Zolpidem (Ambien) Doxepin (Silenor) Temazepam (Restoril) A and C B and D None of the above 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” 227 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 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” 228 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 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 Question Interpersonal approaches to psychotherapy would suggest that social disconnection and loss of role function causes depression, and treating this patient by changing the way she thinks, feels, and acts in problematic relationships may help. Does this make sense for this particular patient? • Yes, this approach is evidence based in terms of providing IPT • Yes, this approach clinically fits this patient’s precipitating events prior to developing MDD • Yes, for the reasons noted. However, her inability to hear well might render IPT difficult to apply and outcomes difficult to achieve 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 229 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Question Which of the following would be your next step? • • • • • • • Start an SSRI such as citalopram (Celexa) Start an SNRI such as duloxetine (Cymbalta) Start an NDRI such as buporpion-XL (Wellbutrin-XL) Start an NaSSA such as mirtazapine (Remeron) Start a SPARI such as vilazodone (Viibryd) Start a SARI such as trazodone-ER (Oleptro) Start a multimodal serotonin receptor modulating antidepressant with geriatric depression/cognition data, such as vortioxetine (Brintellix) 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 230 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Case outcome: first interim follow-up visit 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 Question Would you increase her current SSRI medication? • Yes • Yes, only if it appears that she is partially better and her response has reached a plateau in this partial response range • No, she is a partial responder with only four weeks of treatment. Longer treatment may allow for remission • No, addition of a sleeping pill may treat insomnia and result in improved energy and concentration, thus facilitating a better overall response via polypharmacy • No, citalopram carries cardiac warnings, especially in geriatric MDD patients 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 231 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE • • • • – 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) Question What would you do next? • • • • Continue escalating her SSRI to a higher dose Switch or augment with a more stimulating antidepressant Augment with a formal stimulant Add a formal hypnotic agent to better improve sleep 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 232 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. 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 Question What would you do next? • Increase the bupropion-XL (Wellbutrin-XL) to the approved maximum 450 mg/d • Increase the citalopram (Celexa) further above the geriatric approved maximum dose • Increase zaleplon (Sonata) toward the approved maximum of 20 mg/d (10 mg/d in the elderly) • As she is a partial responder, make no changes until her cochlear implants are in place and her sleep study is performed Attending physician’s mental notes: interim follow-up visits through four months • Fairly good resolution of dysphoria is reported but insomnia and fatigue are still a major problem • It will still be a while for her to obtain a sleep study and she likely has OSA clinically, thus markedly increasing a sedative at night is worrisome • RLS is now more concerning to the patient, and she admits she likes to stay up watching late-night TV – The initial insomnia may be more of a circadian rhythm sleep disorder (CRSD) in that she is choosing to stay up late and then has to get up early when her home health aide arrives – She is inappropriately awake in the early morning hours and inappropriately tired during the daytime. A circadian delayed phase shift has occurred • Perhaps a “win–win” situation exists where her RLS and initial insomnia could be treated with one medication – This was attempted with tiagabine (Gabitril) ◦ This helped the RLS ◦ Did not improve her sleep onset ◦ Left her more fatigued in the morning ◦ Could consider using another off-label antiepileptic medication, given her partial RLS response to tiagabine and hope for less daytime fatigue 233 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE • A literature search suggests that gabapentin (Neurontin) does have a limited evidence base showing effectiveness in RLS – Otherwise, an option would be to choose a formal RLS-approved dopaminergic medication such as pramipexole (Mirapex) or ropinirole (Requip) – These D2 receptor agonists have some data suggesting they may provide antidepressant response but fatigue is a key side effect – It might help fatigue at night, but the daytime fatigue may be a problem Case outcome: interim follow-up visits through nine months • Gabapentin (Neurontin) is titrated to 300 mg twice a day as patient also has RLS symptoms intermittently through the day as well • Zaleplon (Sonata) 5 mg at bedtime is still allowed, but only as needed for severe insomnia • SSRI (citalopram [Celexa]) and NDRI (bupropion-XL [Wellbutrin-XL]) are continued at the same doses, 30 mg/d and 300 mg/d, respectively • There is remission of MDD symptoms • RLS resolves and she sleeps better with minimal morning fatigue • However, she still seems to go to bed after midnight due to watching TV – Patient and family educated about sleep hygiene and behavioral management of sleep initiation – It is not possible to ask the home health aide to arrive later due to her schedule, so the patient cannot sleep late to allow for an adequate number of hours of sleep • Her sleep study shows moderate OSA – She is fitted for a CPAP mask, which causes discomfort and claustrophobia and she declines to wear it • Medications with known sedation side effects are moved to afternoon or dinner-time to avoid iatrogenic sedation in the morning Attending physician’s mental notes: interim follow-up visits through 12 months • Patient has been doing very well on moderate dose of two antidepressants and a hypnotic agent used as needed • RLS is well treated with a low-dose antiepileptic • Cochlear implants are implanted and work very well. She is able to hear and converse, which has helped lower her social isolation and likely has helped her depression • There are minimal to no side effects and she agrees to maintain these medications • Compliance and family support are excellent 234 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE Case outcome: interim follow-up visits through 18 months • There is a resurgence of insomnia and daytime fatigue • Zaleplon (Sonata) is increased to a 10 mg dose at bedtime, which is used more routinely, but is ineffective – This is discontinued and she is allowed to take the next longest half-life BZRA hypnotic, zolpidem (Ambien) up to 10 mg at bedtime • Sleep improves some, but sometimes she still chooses to watch TV and go to bed late – One morning she falls asleep at the breakfast table in front of her home health aide – She later falls and fractures her arm and requires inpatient physical rehabilitation – While there, develops panic attacks and is treated by the inpatient physician successfully with the BZ anxiolytic, alprazolam (Xanax), in low doses (0.25 mg as needed) • Upon returning home, she discontinues the alprazolam anxiolytic – Is not depressed but her insomnia and fatigue continue – Still refuses CPAP treatment and behavioral modification measures fail to help – It becomes clear that at night, her sleep patterns and use of her zolpidem (Ambien) are erratic • Instead of trying to induce sleep to improve daytime fatigue, which is likely due to OSA, the patient and son agree to approach her case with regard to providing more daytime wakefulness with a stimulant medication – Starts modafinil (Provigil) as it is approved for OSA fatigue and likely has fewer cardiac and blood pressure adverse effects than true stimulant-class medications • Given her fall on full-dose zolpidem (Ambien) and her OSA, it is agreed to remove sedative-type medications • However, providing better sleep initiation is still needed – Ramelteon (Rozerem), an MT1/MT2 receptor agonist hypnotic agent, is started ◦ This should provide for better sleep onset without the risk of much respiratory suppression or falls ◦ This combination should allow better daytime alertness with a relative absence of morning fatigue side effects and likely less risk for developing ataxia, psychomotor impairment, and fall potential 235 Downloaded from http://stahlonline.cambridge.org by IP 100.111.251.218 on Sun Jan 05 12:01:39 UTC 2020 Stahl Online © 2020 Cambridge University Press. All rights reserved. Not for commercial use or unauthorized distribution. PATIENT FILE 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 (Roze ... Purchase answer to see full attachment