The selected case for this discussion is case number five which involves sleepy woman with anxiety.
The three questions to ask the patient
a. Does anxiety interfere with your ability to concentrate?
The choice for this question is based on the fact that anxiety can send one into a true tailspin of disruptive and irrational thinking which interferes with the ability to focus
b. Which medication did you use for narcolepsy?
The question will help in determining if the drugs used to treat past narcolepsy was effective to avoid possible onset.
c. Do you experience headache, dizziness, nausea, vomiting, constipation or dry mouth?
The question will help determine if the patient is responding positively to bupropion. These are some of the side effects of bupropion and therefore, persistent of these symptoms would mean the patient is not responding well to bupropion
The people in the patient’s life to speak to or get feedback from for further assessment of the patient’s situation
a. The husband: How do you describe the sleeping pattern of your wife?
The question will help in determining if the patient is having sleeping disorder, that is, excessive sleep.
b. Former class teacher: How do you describe the concentration of the patient while in class?
Lack of concentration is one of symptoms of sleep apnea and therefore, the question will determine if the patient has recurring sleep apnea.
The physical exams and diagnostic tests that would be appropriate for the patient and the use of the results
I will perform physical exam to look for signs and symptoms of anxiety such as nervousness, restlessness, panics, rapid heartrate and weakness and lethargy. The result will be used to determine severity of the anxiety disorder and consequently helps in selecting the most effective medication. I will also use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). I will also use polysomnography to monitors heart, lung and brain activity, breathing pattern to help in ruling the presence of absence of sleep apnea (Mokhlesi & Cifu, 2017).
The three differential diagnoses for the patient
The first differential diagnosis is anxiety disorder. The patient presents symptoms of anxiety such as excessive sleep during the day.
The second differential diagnosis could be sleep apnea. This order can make one to feel tired and unrefreshed. During the day, one may feel fatigued and experiencing difficulty concentrating or unintentionally fall asleep. Further, obstructive sleep apnea is the most likely differential diagnosis for this patient. This is because obstructive sleep apnea is associated with excessive daytime sleep just like evidenced in the patient.
The third differential diagnosis is narcolepsy. The past medical history of the patients showed that she had been diagnosed with narcolepsy and therefore, it is possible that the patient has another onset of narcolepsy.
Hypersomnia is another possible condition of the patient because she is having or excessive sleepiness. The patient has trouble staying awake during the day. Insomnia is another possible condition as the patient has daytime impairment related daytime sleepiness (Ardani et al. 2016).
Two pharmacologic agents and their dosing appropriate for the patient’s sleep/wake therapy
The first pharmacologic agent that would be appropriate for the patient’s sleep/wake therapy by considering that the patient has narcolepsy is to start initial dosage of amphetamines at 10 mg orally per day in divided doses. The medication will be used induce daytime alertness because the patient is experiencing excessive sleep which is a symptom of obstructive sleep apnea. The second pharmacologic agent that would be appropriate for the patient’s sleep/wake therapy is gabapentin. The medication is useful in patients with restless leg syndrome and insomnia just like the patient in the case study. The dosage for gabapentin would be 600 mg orally once daily together with food (Schroeck et al. 2016).
Therapeutic changes and check point
The following for this client based on amphetamines dosage, the daily dose will be raised in 10 mg increments at weekly intervals up to the point when the optimal response is achieved.
The “lessons learned” from the case study
One of the challenges in the case is to use effective drug to treat resistant anxious depression while taking into consideration excessive sleep symptoms. A comprehension of the electrophysiologic, as well as, neurochemical that correlates with the stages of sleep is necessary in defining sleep disorders. Just like evidenced in the patient, excessive daytime sleepiness is normally associated with disorders such as obstructive sleep apnea and depression.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
Ardani, A. R., Saghebi, S. A., Nahidi, M., & Zeynalian, F. (2016). Does abstinence resolve poor sleep quality in former methamphetamine dependents?. Sleep Science (sao Paulo, Brazil), 9, 3.
Schroeck, J. L., Ford, J., Conway, E. L., Kurtzhalts, K. E., Gee, M. E., Vollmer, K. A., & Mergenhagen, K. A. (November 01, 2016). Review of Safety and Efficacy of Sleep Medicines in Older Adults. Clinical Therapeutics, 38, 11, 2340-2372.
Mokhlesi, B., & Cifu, A. S. (2017). Diagnostic Testing for Obstructive Sleep Apnea in Adults. Jama, 318, 20, 2035.
Case 1: Volume 2, Case #16: The woman who liked late-night TV
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.
I would ask the following questions from the patient
How has your life changed after the death of your husband?
The case reveals that patient’s husband died many years ago. This is an open ended question to ask about changes in patient’s life after the death of her husband. May be she feels lonely, maybe she does not have someone to listen to her views. Spending such a life for years might have resulted in symptoms of depression. Social isolation affects behavioral health in elderly people. It contributes to depression and sleep disturbance (Choi, et al., 2015).
Do you feel stressful in your life?
Depression and sleep problems are often associated with stress. Sleep disturbances often occur during high-stress periods (Schlarb, et al., 2017). This question access if patient’s sadness and sleep issues are due to stress in her life. May be feels stressful about something in her life. May be to deal with stress she prefer to watch TC until late at night.
What do you feel about your cochlear implant?
The case reveal that patient has a chief complaint of being sad. She is also expected to have a cochlear implant in future. This question access if her sadness issue is related to her hearing issue. The answer to this question would reveal if patient’s hearing problem is the reason behind her sadness or there is something else.
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.
I would ask specific questions and would take specific feedback from patient’s son. The case reveal that patient has a son who visits him often but does not live with her. Patient is 70-year-old, is elderly and has hearing issues. Asking the following questions from her son would be helpful to understand her problem in detail
Other than your father’s death, has anything tragic happened in your mother’s life?
Have you notices anything notable in your mother’s behavior over the past six months?
Do you think your mother hearing and sadness problems are interrelated?
Why you do not keep your mother with yourself?
Does your mother ever insist to take her with you?
The above mentioned questions would provide useful insight to evaluate the health condition, past life condition and social life of the patient. I would indicate when the patient’s problem started.
Patient is an elderly and wants support from her love one still her son does not live with him. The other person caring for patient is her aide and I would also ask from questions from her to access patient’s condition and underlying problems more accurately.
Since when you have been caring for the patient?
How does the patient behaves with you?
Have you noticed any changes in patient’s behavior over the past few months?
What do you think might be the cause of her sleeping and sadness issues?
These questions would help analyze the relationship between patient and her aide. Patient is taken care by her aide. At this point we do not know the behavior of her aide. These questions are important to access if aide is caring for her in the right manner or she is not taking care of the patient.
Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
A complete physical exam would be performed for the patient. Patient has depression, sleeping problems and leg ache. Physical exam would help determine if physical problems or weakness are the underlying cause of these problems. An eye exam would also be performed during physical exam to access why the patient is having the issue of tears in her eyes. Her eye problem would be accessed and appropriate eye drops would be prescribed. Thyroid test would be important to access the level of thyroid hormone in the body. This is because thyroid hormonal level is found to have a relationship with depression (Dayan & Panicker, 2013). Iron level test would also be needed to identify if inadequate levels of iron in the body are causing of restless leg syndrome (Cochrane, 2016). DSM-5 criteria would be used to determine the patient’s mental health problem and diagnosis.
List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.
Based upon the signs and symptoms and patient’s condition revealed in the given case, following are the three differential diagnosis for the patient
Restless Legs Syndrome (RLS):
This condition also called Willis-Ekbom Disease causes unpleasant or uncomfortable sensations in the legs and an irresistible urge to move them. Symptoms commonly occur in the late afternoon or in evening hours, and are often most severe at night when a person is resting such as lying or sitting (Guo, et al., 2017). Symptoms may also occur when someone remains in an inactive position for a long period of time for instance when sitting in an airplane for long hour or watching a movie. The intensity of symptoms in increased during night time and therefore it is often difficult to sleep at night or return to sleep after waking up.
Restless leg syndrome is the most likely diagnosis for the patient. This is because patient has complaints of ‘ache and jump’ and due to this condition she is unable to fall asleep at night.
Insomnia is the most common sleep complaint. This condition occur when someone has trouble falling asleep or staying asleep even though he has the opportunity to get a full night of sleep. The symptoms, causes and severity of insomnia vary from person to person. Symptoms of the condition may include difficulty falling asleep; waking up too early in the morning; difficulty staying asleep throughout the night (Singh, 2016). In the current case, patient reports problem with sleeping, she has difficulty falling asleep at night. Therefore, the differential diagnosis for insomnia is included.
Obstructive Sleep Apnea (OSA):
This is a potentially serious sleep disorder. It causes breathing to repeatedly stop and start during sleep. There are several types of sleep apnea, but the most common type is obstructive sleep apnea. This condition occurs when the throat muscles intermittently relax and block the airway during sleep. A noticeable sign of obstructive sleep apnea is snoring (Foroughi, et al., 2016).
In the current case, patient might also be suffering from this disorder because she reported snoring during sleep.
At this point, it can be inferred that patient is having comorbid medical conditions including restless leg syndrome and obstructive sleep apnea. These two conditions are affecting her sleep pattern and due to lack of quality sleep she might be having depressive symptoms. Sleep problems often result in depressive problems (Luca et al., 2013)
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.
The two pharmacologic agents that would be appropriate for the patient include:
Modafinil is a wake-promoting agent approved for the treatment of excessive sleepiness associated with shift work disorder, obstructive sleep apnea (OSA) and narcolepsy (Stahl, 2014). This drug would be helpful for patient in controlling her problem of obstructive sleep apnea (OSA) that is causing her issues of snoring. The current dose of modafinil prescribed to the patient is 400 mg/day. This dose is the full dose. However, I would not prescribe full dose to the patient considering her age and possible side effects of the medicine at full dose.
Mirapex is prescribed for treatment of restless legs syndrome and Parkinson’s disease. The medicine can improve symptoms of restless legs syndrome and Parkinson’s disease and can improve sleep (Stahl, 2014). The medicine should be started at lowest dose (0.125 mg) and increased necessary every 5 to 7 days until symptoms are controlled (Stahl, 2014). Therefore, for the treatment of RLS, Mirapex would be prescribed to the patient.
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.
A potential mistake or medical prescription error I noted in the case was that at second interim follow up Celexa was increased to 30 mg/day. However, maximum dose of Celexa for elderly is 20 mg/day (Stahl, 2014). Considering the age of patient, I would have not increased the dose to 30 mg/day. Another issue that I noted in the case was that patient did not agree for CPAP in repeated visits. I would have researched for new generation CPAP equipment and would have motivated the patient for CPAP treatment.
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.
Through the case study I learnt how the symptoms of multiple conditions overlap and create difficulty for patient’s to cope up with the symptoms. This case also though to how to use polypharmacy for patients suffering from a number of sleep problems. In the current case, patient has suffering from restless leg syndrome and obsessive sleep apnea. For OSB, CPAP treatment was recommended for the patient which she denied. If I would be in a similar situation in my clinical practice, I would try to convince my patient for CPAP treatment. If however, patient would not agree then I would consider other treatment options.
Choi, H., Irwin, M. R., & Cho, H. J. (2015). Impact of social isolation on behavioral health in elderly: Systematic review. World Journal of Psychiatry, 5(4), 432-436. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4694557/
Cochrane. (2016). Iron for restless legs syndrome. Retrieved from https://www.cochrane.org/CD007834/MOVEMENT_iron-for-restless-legs-syndrome
Dayan, C. M., & Panicker, V. (2013). Hypothyroidism and depression. European Thyroid Journal, 2(3), 168-179. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017747/
Foroughi, M., Razavi, H., Malekmohammad, M., Naghan, P. A., & Jamaati, H. (2016). Diagnosis of Obstructive sleep apnea syndrome in adults: A brief review of existing data for practice in Iran. Tanaffos, 15(2), 70-80. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5127617/
Guo, S., Huang, J., Jiang, H., Han, C., Li, J., Xu, X., & Wang, T. (2017). Restless Legs Syndrome: From pathophysiology to clinical diagnosis and management. Frontiers in Aging Neuroscience, 9(1), 171-182. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454050/
Luca, A., Luca, M., & Calandra, C. (2013). Sleep disorders and depression: Brief review of the literature, case report, and nonpharmacologic interventions for depression. Clinical Interventions in Aging, 8(1), 1033-1042. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3760296/
Schlarb, A. A., Claßen, M., Grünwald, J., & Vögele, C. (2017). Sleep disturbances and mental strain in university students: Results from an online survey in Luxembourg and Germany. International journal of mental health systems, 11(1), 24-29. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5372247/
Singh, P. (2016). Insomnia: A sleep disorder: Its causes, symptoms and treatments. International Journal of Medical and Health Research, 2(10), 37-41.
Stahl, S. M. (2014). The prescriber’s guide. New York, NY: Cambridge University Press. Retrieved from https://stahlonline-cambridge-org.ezp.waldenulibrary.org/prescribers_drug.jsf?page=9781316618134c114.html.therapeutics&name=SERTRALINE&title=Therapeutics