Discussion: Sleep\/Wake Disorders
\nIt 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 Assessment. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors.
\nLearning Objectives
\nStudents will:
\n\u2022\tAssess client factors and history to develop personalized therapy plans for clients with sleep\/wake disorders
\n\u2022\tAnalyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep\/wake disorders
\n\u2022\tEvaluate efficacy of treatment plans for clients presenting for sleep\/wake therapy
\n\u2022\tApply knowledge of providing care to adult and geriatric clients presenting for sleep\/wake disorders<\/p>\n
Case 1: Volume 2, Case #16: The woman who liked late-night TV
\nPost a response to the following:
\n\u2022\tProvide the case number in the subject line of the Discussion.
\n\u2022\tList 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.
\n\u2022\tIdentify people in the patient\u2019s life you would need to speak to or get feedback from to further assess the patient\u2019s situation. Include specific questions you might ask these people and why.
\n\u2022\tExplain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
\n\u2022\tList three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
\n\u2022\tList two pharmacologic agents and their dosing that would be appropriate for the patient\u2019s 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.
\n\u2022\tIf your assigned case includes \u201ccheck points\u201d (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.
\n\u2022\tExplain \u201clessons learned\u201d from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.<\/p>\n
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
\n\u2022\tPatient Assessment on intake: 70-year-old female with a chief complaint of \u201cbeing sad\u201d Feels she had been doing well until her hearing began to diminish in both ears \u2013 Candidate for cochlear implants in the future, but this is a long way off \u2013 Despite the promise of improved hearing, she often has crying spells for no clear reason Psychiatric history \u2022 The patient has been without psychiatric disorder throughout her life \u2022 Has felt increasingly sad over the last year and these feelings were not triggered by an acute stressor \u2022 Lives alone with the help of a home aide \u2013 Her spouse died many years ago due to CAD \u2013 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 \u2022 She admits to full MDD symptoms \u2013 She is sad, has lost interest in things she used to enjoy, and is fatigued with poor focus and concentration \u2013 Denies feelings of guilt, worthlessness, or any suicidal thoughts \u2013 Appears mildly psychomotor slowed \u2013 Additionally states that sleep is \u201cawful\u201d \u25e6 Does not fall asleep easily as her legs \u201cache and jump\u201d
\n\u2022\tPATIENT FILE: Takes frequent naps during the day as a result \u25e6 She admits to snoring frequently \u2022 There is no evidence of cognitive decline or memory problems \u2022 She has a supportive son who accompanies her to all appointments and helps provide her care Social and personal history \u2022 Graduated high school, was married, and raised her children \u2022 Denied any academic issues, learning disability, or ADHD symptoms growing up \u2022 Having and maintaining friendships has been easy and successful over the years \u2022 At times, she is lonely at home \u2022 Her mobility has declined somewhat, which limits her going out \u2022 Participates in activities at a local elders\u2019 center \u2022 No history of drug or alcohol problems Medical history \u2022 HTN \u2022 Hypothyroidism \u2022 CAD \u2022 Anemia \u2022 Environmental allergies \u2022 Obesity Family history \u2022 Reports AUD throughout her extended family \u2022 MDD reportedly suffered by her mother Medication history \u2022 Never taken psychotropic medications Psychotherapy history \u2022 Recently, has gone to a few sessions of outpatient supportive psychotherapy, but her hearing loss makes this modality almost impossible \u2013 Hearing aids have failed to help \u2013 May be a candidate for cochlear implants \u2022 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 \u2013 Perhaps this is \u201csupportive facsimile therapy\u201d
\n\u2022\tPATIENT FILE: Patient Assessment on initial visit \u2022 Gradual onset of geriatric, first-episode MDD symptoms likely as a result of hearing loss and mobility loss \u2022 This caused interpersonal disconnectedness, loneliness, and onset of MDD \u2022 Suffers from daily crying spells and seems very tired \u2022 Has good insight into her illness and wants to get better \u2022 There appears to be no suicidal or safety concerns clinically \u2022 The fatigue and possible infirmities of strength and balance may be problematic if side effects compound these symptoms Current medications \u2022 Furosemide (Lasix) 40 mg\/d \u2022 Lisinopril (Zestril) 40 mg\/d \u2022 Levothyroxine (Synthroid) 100 mcg\/d \u2022 Enteric-coated aspirin 325 mg\/d \u2022 Fexofenadine (Allegra) 180 mg\/d \u2022 Ferrous sulfate 1000 mg\/d
\n\u2022\tAttending physician\u2019s mental notes: initial Assessment \u2022 Patient has her first MDE now \u2022 It appears chronic in nature, but essentially, has been untreated \u2022 It seems more than an adjustment disorder as it is pervasive, lasting over time, and clearly disabling at this point \u2022 As this is an initial MDE and an initial foray into treatment with good family support, her prognosis is good \u2022 However, her older age of onset, loss of hearing, mobility, and marked medical comorbidity are concerning \u2022 Psychotherapy, especially IPT-based, would be clearly indicated but difficult to deliver adequately
\n\u2022\tAttending physician\u2019s mental notes: initial Assessment (continued) \u2022 This case seems easy in that she is untreated up to this point; therefore, any antidepressant has a chance of working \u2022 However, there is concern regarding her obesity and lethargy; thus, avoiding medications with high weight-gain side-effect burden is warranted \u2022 Sleep is also very disrupted \u2013 By initial insomnia, which may be caused by her depression \u2013 Perhaps by restless legs syndrome (RLS) \u2013 It is unclear if she snores and has OSA \u2022 Hearing loss and inability to communicate well is also problematic in providing her with good psychotherapy \u2013 Even delineating symptoms in the medication management session is a difficult task \u2013 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? \u2022 She has marked fatigue; have medical causes been ruled out? \u2013 She is euthyroid and her anemia is stable with a normal hematocrit \u2013 Her cardiac function is stable and without compromise \u2013 If she has RLS, this could account for her fatigue and should be investigated \u2013 If she has OSA, this could account for her fatigue and should be investigated.
\n\u2022\tPATIENT FILE Case outcome: first interim follow-up visits four weeks later \u2022 Citalopram (Celexa), an SSRI, was started at 10 mg\/d and titrated to 20 mg\/d \u2022 She appears less weepy and is in a partial response \u2022 Still is not sleeping well \u2022 Denies any typical side effects
\nAttending physician\u2019s mental notes: second interim follow-up visit at two months \u2022 Despite being a little better, the patient is still suffering \u2022 She is crying less but there is now more of a need to improve her sleep and daytime fatigue issues \u2022 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 \u2022 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 \u2022 Citalopram (Celexa) is increased gradually, given her age, to 30 mg\/d \u2013 Historically, the QTc prolongation warning did not exist when this patient was prescribed this medication \u2013 Currently, use above 20 mg\/d is discouraged in the elderly \u25e6 If a higher dose is needed clinically, it would make sense to obtain plasma levels and an EKG in the current era \u2022 Sleep electrophysiology is ordered to rule out OSA, RLS \u2022 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 \u2013 This agent has human sleep laboratory data suggesting it increases slow wave, restorative deep sleep \u2013 Its theoretical mechanism of action is GABA reuptake inhibition, selectively at the GAT1 transporter, making it an SGRI \u2013 She is allowed to titrate to 6 mg\/d at bedtime \u2013 This agent, interestingly, is approved to treat epilepsy but came out with a warning, well after this patient utilized this \u201cdrug\u201d therapy that tiagabine might actually induce seizures in non-epileptic patients \u2022 The patient subsequently shows moderate improvement in her affect \u2022 Experiences slightly less RLS \u2022 Is not initiating sleep any better \u2022 She is felt to be 20%\u201330% better globally, but is plagued by daytime fatigue as a chief complaint \u2013 This may actually be occurring due to the adverse effect profile of tiagabine (Gabitril)
\nAttending physician\u2019s mental notes: second interim follow-up visit at two months (continued) \u2022 Cannot wait months for a sleep study \u2022 Her SSRI is at a reasonable, moderate dose, and has effectively treated the target symptom of sadness and dysphoria \u2013 Switching from this may cause a relapse \u2022 Adding a noradrenergic or dopaminergic agent may target her fatigue symptoms a little better \u2022 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 \u2022 The NDRI bupropion-XL(Wellbutrin-XL) is added to her SSRI and titrated to 300 mg\/d \u2013 There is moderate improvement in her vegetative MDD symptoms and her drive and motivation improves slightly \u2022 Zaleplon (Sonata) 5 mg at bedtime is started in place of tiagabine (Gabitril) with improved sleep onset overall, but she still reports RLS
\nPATIENT 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 \u2022 Further workup suggests she meets criteria for RLS. Sleep study is still pending \u2022 Cochlear implants are approved, and surgery scheduled
\nCase 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 \u2022 Her current regimen includes: \u2013 Citalopram (Celexa) 20 mg\/d \u2013 Bupropion-XL (Wellbutrin-XL) 300 mg\/d \u2013 Gabapentin (Neurontin) 600 mg\/d \u2013 Modafinil (Provigil) 400 mg\/d \u2013 Ramelteon (Rozerem) 16 mg\/d \u2022 Modafinil had to be escalated to its full dose to allow for its sustained response (400 mg\/d) \u2022 Ramelteon had to be doubled over the approved 8 mg dose for better effectiveness (16 mg at bedtime) \u2022 Citalopram was reduced to 20 mg\/d as it was felt to be contributing to fatigue \u2022 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 \u2013 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 \u25e6 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 \u2022 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 \u2022 Sometimes treating the depression is simple, but treating the comorbidities require more effort or collaboration with other providers to optimize treatment \u2013 In this case, collaboration with otolaryngology, pulmonology\u2013sleep medicine, primary care, physical medicine and rehabilitation, home healthcare, and the family often occurred Performance in practice: confessions of a psychopharmacologist \u2022 What could have been done better here? \u2013 Unlike other cases in this book, this patient was not escalated to the maximum higher dose monotherapy before combination therapy was started<\/p>\n
——
\nFree Essay Sample<\/p>\n
Sleep\/Wake Disorders Case Study<\/p>\n
Student\u2019s Name
\nInstitutional Affiliation
\nCourse
\nProfessor\u2019s Name
\nDate<\/p>\n
Sleep\/Wake Disorders Case Study
\nCase Number
\nThe case number of the question is Case 1: Volume 2, Case #16: The woman who liked late-night TV.
\nThree Questions and Rationale
\n1.\tDo 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?
\nThe question is essential since lack of sleep can trigger depression and lead to other health problems (American Psychiatric Association, 2013).
\n2.\tHave you or any of your family members been diagnosed with depression?
\nThe 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.
\n3.\tDo 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.
\nThe three questions are essential to assess the sleeping patterns of the patient and to guide the diagnosis (Stahl, 2013).
\nRelevant People
\nThe relevant people who can provide further information about the patient\u2019s condition include the home aide and the son.
\nQuestions for the son: Do you have any history of depression in your family and whether you have noticed any behavior changed in the patient\u2019s life?
\nQuestions 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.
\nThe 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.
\nPhysical Exams and Diagnostic Tests
\nActigraphy 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).
\nMental 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 Assessments (Gebara et al., 2016).
\nPolysomnogram 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).
\nMultiple 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).
\nDifferential Diagnosis
\nInsomnia \u2013 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.
\nMajor Depressive Disorder (MDD) \u2013 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.
\nRestless Legs Syndrome (RLS) \u2013 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.
\nOne 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).<\/p>\n
Pharmacologic Agent
\nEszopiclone 1mg daily orally \u2013 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.
\nTrazodone 150mg daily \u2013 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.
\nCheck Points
\nThe 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.
\nLessons Learned
\nThe 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.<\/p>\n
References
\nAmerican Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5\u00ae). American Psychiatric Pub.
\nBei, 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.
\nGebara, 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.
\nStahl, S. M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press.
\nWilliams 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\u2010wake disorders. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 36(9), 1028-1041.<\/p>\n","protected":false},"excerpt":{"rendered":"
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