Answer to this post: Elderly Female With MDD And New-Onset Of Insomnia And Worsening Depression

Answer to this post: Elderly Female With MDD And New-Onset Of Insomnia And Worsening Depression…

Elderly Female With MDD And New-Onset Of Insomnia And Worsening Depression

List Three Questions To Ask This Patient And Provide Rationales

Pertinent information would be to compassionately ask her if she is adhering to the sertraline regimen and if she is experiencing any untoward side effects.  Who prescribed the medication and how long has she been on sertraline? Additionally, I would ask the patient how long she has been experiencing her insomnia. She may be unable to fall asleep, unwillingly awakening at a certain time, or a combination of both.  Taking into consideration how long she has been on sertraline can be a determinant of whether or not this may be an inadequate response, as the trial period is four to twelve weeks (Stern, et al., 2016). Evidence points to less favorable results in antidepressive medications for those patients with other medical and psychiatric issues (p. 33). As this new onset of insomnia is distressful and concerning to the patient, I would like to earn her trust by obtaining a thorough history of that and other clinical symptoms to relieve her of her suffering and avoid an undue relapse. Per Levenson et al, (2015), the functional impairment insomnia can have on the patient regardless of the length of time is significant.

Whom Else Would I Speak To In Order To Collect Data?

I would like to speak to her PCP, along with the prescriber of the sertraline, assuming they are not the same person. I could gather medical as well as any psychiatric information available. Recent diagnostics, lab tests, and most importantly, how many prescriptions for sertraline have been dispensed to the patient. Additionally, I would like to speak to any close family or friends that may be involved in her care to uncover any hidden concerns or barriers.

Explain Any Diagnostics/Physical Exams or Lab Tests Appropriate

A neurologic exam including cranial nerve function would be appropriate in my novice opinion, as well as memory recall and cognitive functioning exams to explore the degree of any deficit if that is the case. My thought process at this time is to possibly augment her current therapy, so I would like to obtain a recent CBC, full thyroid panel, CMP, as well as folate level.  Recent evidence provides certain rationales for adding certain augmentation therapy for major depression (to be discussed further) when patients are taking SSRIs or SNRIs (Ginsberg, et al., 2011). As the PMHNP caring for this elderly patient, it is in her best interest for me to explore all avenues possible to avoid adding another medication with the resultant effects of polypharmacy.

List A Differential Diagnosis And Provide Rationale

My initial thoughts were that maybe this elderly woman is not functioning at capacity due to inadequate thyroid function.  Therefore, a differential diagnosis could be subclinical hypothyroidism. (Also considered were a mood disorder and possibly low folate levels). The prevalence of this hypothyroidism is estimated at four to ten percent and adds to the burdens of major depression (Airaksinen, et al., 2021).

List Two Pharmacologic Agents, Dosing With Pharmacokinetics and Pharmacodynamics. From an MOA Perspective, Provide Rationales

As this is an elderly patient with multiple significant comorbidities, already on polypharmaceuticals, I would like to augment her therapy based on lab results indicating low thyroid function and limit the possibility of side effects. I would also like her to adhere to the prescribed regimen, and given the nature of the safety and efficacy of adding triiodothyronine (T3), I think this may be a logical beginning to treatment.  Nine hundred milligrams once daily is the recommended dose for augmentation therapy (Stern, et al., 2016). The STAR D study concluded that this drug has the benefit of remission as augmentation therapy in roughly twenty-four percent of patients (Howland, 2008). Patients aged 65 to 79 have significant decreases in all thyroid hormones, particularly T3 (Xiong, et al., 2020). However, if her thyroid function was not an issue, and her folate levels were subpar, I would consider the addition of L-methyl folate therapy, as low folate levels are significantly associated with mood disorders (Ginsberg, et al., 2011). Appropriate dosing according to their study is 7.5 to 15mg daily (p. 21). Decreases in rates of insomnia and agitation in the patients studied were promising (p. 25).

List Contraindications Or Any Concerns That Would Be Problematic

Treatment for hypothyroidism in the elderly is controversial (Xiong, et al., 2020), I would be concerned that this might not solve her problem quickly enough, or at all.  There are limited sources of scientific evidence to use this as a long-term therapy (Stern, et al., 2016). L-methyl folate therapy may also not work as quickly as hoped for in terms of relieving insomnia, and dosing is currently at a fair range as mentioned earlier. My concern is that I would have to add another pharmaceutical agent such as bupropion or mirtazapine to possibly obtain faster relief from her troublesome symptoms.  Adding these medications to an elderly patient already on multiple medications creates the problem of dizziness and increases the risk of falls.

What Check Points Would I Include?

I would like to start the patient on augmentation therapy with Cytomel and follow up in 4 weeks.  However, if the patient experienced a further decrease in functioning, I would instruct her to contact me to seek other alternatives in her care. If she experienced worsening depression or insomnia, I would reevaluate her pharmacologic regimen and discuss the addition of bupropion or mirtazapine with her primary care physician to obtain the best but the safest course of action for her.

References

Airaksinen, J., Komulainen, K., García-Velázquez, R., Määttänen, I., Gluschkoff, K., Savelieva, K., & Jokela, M. (2021). Subclinical hypothyroidism and symptoms of depression: Evidence from the national health and nutrition examination surveys (nhanes). Comprehensive Psychiatry, 109, 152253. https://doi.org/10.1016/j.comppsych.2021.152253

Ginsberg, Oubre, & Daoud. (2011). Innovations in clinical neuroscience. Innovations in clinical neuroscience. Retrieved March 28, 2022, from https://web.s.ebscohost.com/ehost/pdfviewer/pdfviewer?vid=5&sid=145e2763-0e47-42e7-8bb0-5cd1823a4bda%40redis

Howland, R. H. (2008). Sequenced treatment alternatives to relieve depression (star*d)–part 2: Study outcomes. Journal of Psychosocial Nursing and Mental Health Services, 46(10), 21–24. https://doi.org/10.3928/02793695-20081001-05

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617

Stern MD, Theodore A., Maurizio, F. M., Wilens MD, Timothy E., & Rosenbaum MD, Jerrold F. (2016). Massachusetts general hospital psychopharmacology and neurotherapeutics (1st ed.). Elsevier.

Xiong, J., Liu, S., Hu, K., Xiong, Y., Wang, P., & Xiong, L. (2021). Correction: Study of reference intervals for free triiodothyronine, free thyroxine, and thyroid-stimulating hormone in an elderly chinese han population. PLOS ONE, 16(6), e0253359. https://doi.org/10.1371/journal.pone.0253359

Hi Julia,
Mental health practitioners and psychiatrists define insomnia as the inability to fall asleep or remain asleep, leading to sleeplessness that causes the individual distress or significantly interferes with their daily activities. A persistent insomnia disorder (PID) is diagnosed if this happens at least three nights in a week and lasts not less than days. Bjorvatn et al. (2021) posit that reaching a PID diagnosis requires sleep pattern-specific rescribed medications and the duration of the sleeplessness. It would also be prudent to inquire if the patient had changed her sleep pattern, the type of meals she takes before bedtime, and the activities that preceded her bedtime. The answers to these questions would prove useful in crafting an insomnia prevention plan that is not medication-based to reinforce the medications.
The primary care provider and the prescribing physician are bound to have a rich history pertinent to the history of the presenting illness. It is also important to ask the family caregiver or the home-based caregiver who attends to this elderly woman because the information available could help collaborate the patient’s account and facilitate the generation of the 3P model of care. The three P’s are factors that predispose the individual to insomnia, the factors that precipitated the acute episode of insomnia, and the factors that perpetuate insomnia from acute to chronic (Krystal et al., 2019).

I also concur with your post on recommending a neurological exam for the patient since treatment and management of insomnia whose cause is an underlying neurological condition must primarily address the condition/ disease first to alleviate insomnia. According to Mayer et al. (2021), secondary insomnia may stem from neurodegenerative, inflammatory, or traumatic damage hence the need to rule out possible causes. Other tests like a CBC, CMP and a full thyroid panel are also spot-on as they rule out organic or physiological causes of the PID.
The differential diagnoses of hypothyroidism, a mood disorder, or low folate levels could also make do with other questions to help exclude other sleep disorders that present with insomnia like obstructive sleep apnea and the circadian rhythm sleep-wake disorders (Krystal et al., 2019). It is also important to consider that several pharmacotherapy options currently exist where randomized, double-blind place- controlled trials in patients with insomnia with o demonstrated efficacy AS such, benzodiazepine medications like triazolam, flurazepam, and others with demonstrated therapeutic effects would be recommended.

References
Bjorvatn, B., Jernelöv, S., & Pallesen, S. (2021). Insomnia is a heterogenic disorder often comorbid with psychological and somatic disorders and diseases: a narrative review focusing on diagnostic and treatment challenges. Frontiers in Psychology, 289.
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337-352.
Mayer, G., Happe, S., Evers, S., Hermann, W., Jansen, S., Kallweit, U., … & Young, P. (2021). Insomnia in neurological diseases. Neurological Research and Practice, 3(1), 1-12.