Question A patient presents to your primary care office today with a chief complaint of insomnia. The patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse, as well as her sleep habits. The patient had no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. The patient normally sees PCP once or twice a year. The patient denies any suicidal ideations. The patient arrived at the office today by private vehicle. The patient currently takes the following medications: Case- An Elderly Widow Who Just Lost her Spouse Case- An Elderly Widow Who Just Lost her Spouse Metformin 500mg BID Januvia 100mg daily Losartan 100mg daily HCTZ 25mg daily Sertraline 100mg daily Current weight: 88 kg Current height: 64 inches Temp: 98.6 degrees F, BP: 132/86 List three questions you might ask the patient if she were in your office. Provide a rationale for why y

Case- An Elderly Widow Who Just Lost Her Spouse

Firstly, I will ask the patient whether or not she adheres to her treatment plan. This is relevant because some of her medications increase the risk of insomnia. For instance, about 20 percent of patients taking sertraline report insomnia. Secondly, I will ask the patient whether or not she takes caffeinated drinks and the frequency of her intake. This is relevant because caffeinated drinks increase the likelihood of insomnia. Thirdly, I will ask the patient to describe her depressive symptoms and her prognosis since she started taking sertraline. This is relevant because inadequately controlled depression increases the likelihood of insomnia.

The patient’s children or caretakers will provide additional information to facilitate patient assessment. They are relevant because they monitor the patient’s progress and daily activities. As such, they are likely to identify key details to facilitate the diagnosis or optimize the management of the patient. To begin with, I will ask them if the patient adheres to her treatment plan. Also, I will ask them if they have noted changes in the patient’s mood, orientation, or attention. Furthermore, I will inquire whether or not they have noted any phobias, panic, or anxiety in the patient.

A physical examination will be used to rule out medical conditions that increase the likelihood of depression. For instance, a head and neck examination will rule out insomnia related to sleep apnea (Riemann et al., 2022). Enlarged neck, tonsils, and a low-lying soft palate are associated with sleep apnea hence insomnia (Riemann et al., 2022). Subsequently, the Patient Health Questionnaire-9 is a screening tool that would be used to monitor the severity of the patient’s depression.

Various differential diagnoses can be formulated for the patient. In this context, the patient reports that her depression and sleeping disorder worsened after the loss of her husband 10 months ago. Potential differential diagnoses include dissociative disorders, illness anxiety disorder, hypopituitarism, schizoaffective disorder, somatic symptom disorder, generalized anxiety disorder, and adjustment disorders (Riemann et al., 2022). The most likely diagnosis is a generalized anxiety disorder. This is because the patient’s symptoms have lasted more than 6 months and were exacerbated by a stressor (the death of her husband) (DeMartini et al., 2019).

The pharmacological agents that would be appropriate for the patient’s antidepressant therapy are citalopram and escitalopram. The dosing of escitalopram among geriatrics is 10 mg orally daily (de Bardeci et al., 2023). On the other hand, the dosing of citalopram in geriatrics is 20 mg orally daily (de Bardeci et al., 2023). Citalopram requires an increase in the dose to achieve optimal outcomes. However, high doses are associated with a high risk for QTc- -prolongation (de Bardeci et al., 2023). I would select escitalopram because it has a low risk for QTc-prolongation and antihistaminic effects. It is efficacious at low doses (de Bardeci et al., 2023).

The potential contraindications to the use of escitalopram include known hypersensitivity and concomitant use with pimozide and monoamine inhibitors. Concomitant use with pimozide increases the risk of QTc interval prolongation (de Bardeci et al., 2023). When administered to a patient with known hypersensitivity, the severity of the hypersensitive reactions is worsened and predisposes the patient to death. Concomitant use of monoamine inhibitors increases the likelihood of serotonin syndrome (de Bardeci et al., 2023).

The use of escitalopram in this patient necessitates continuous follow-up. To begin with, the patient’s electrolyte levels should be monitored monthly (after every four weeks). Notably, sodium levels should be closely monitored because the drug increases the risk of hyponatremia (Hsu et al., 2022). Notably, if serum sodium levels fall below 110mmol/L, the drug should be discontinued (de Bardeci et al., 2023). Also, the patient should report any adverse effects such as headache, nausea, diarrhea, and somnolence (de Bardeci et al., 2023).

References

de Bardeci, M., Greil, W., Stassen, H., Willms, J., Köberle, U., Bridler, R., Hasler, G., Kasper, S., Rüther, E., Bleich, S., Toto, S., Grohmann, R., & Seifert, J. (2023). Dear Doctor Letters regarding citalopram and escitalopram: guidelines vs real-world data. European Archives of Psychiatry and Clinical Neuroscience, 273(1), 65–74. https://doi.org/10.1007/s00406-022-01392-x