Insomnia and Depression in the older adult

Presenting is  a 75 year-old female who presents with worsening depression and new  onset insomnia since the death ten months ago of her husband of  41-years. The patient presents alert and oriented X3 spheres, arrived  VIA private vehicle, denies suicidal ideations at this time and  traditionally sees her PCP up to twice yearly. Patient reports taking  metformin, januvia, losartan, HCTZ, and sertraline. Patients medical  conditions are not listed, but based on chart review of medications and  age, patient is assumed to have diabetes type 2 and high blood pressure.  Patients BP at clinic visit is 132/86 (managed). No additional  complaints made at this time. 

-List three questions you might as the patient if she were in your office.

1. What does depression mean to you? What would be the items you would identify if someone asked you why you felt depressed? 

-Depression  can be caused by many different things. The patient reported the loss of  her husband of 41 years less than one year from this visit, and it is  possible that the patient has not made it past a certain point of  grieving. It is unknown of what type of relationship they had, and it is  possible that the patient’s husband was her primary caregiver, and  without him she may be having greater difficulty managing living on her  own, which could increase the patient’s depression. Furthermore, the  patient may not have children or other family to be there to support or  talk to her, and it is possible her late spouse was the only person that  she had. Having support through grief, especially those that were close  to both the patient and the loved one who has passed can help in the  patient in their grieving process (Pdq, 2020). Grief can increase levels  and feelings of depression within the already depressed patient, and  lead them into a depressed episode, as well as lead to problems with  sleep either with too much sleep or inability to fall or stay asleep  (Parkes, 1998). The patient could feel depressed due to worsening health  concerns, or just out of missing her husband or no longer doing the  activities that they may have once shared together. 

1. What are  your current sleeping habits? When did your sleeping habits change? What  were your sleeping habits before the noticed change? 

-It is  important to understand the patient’s current complaint of insomnia, and  what insomnia means to them, and it should be clearly defined on what  issue the patient is having such as the inability to fall or stay asleep  or is her mind racing leading her to being unable to fall asleep. Is  she having changes in diet which is leading her to have increased trips  to urinate throughout the night? Having type two diabetes, the patient  is at risk for higher blood sugars leading to increased urination  throughout the night, and with increased aged comes possible decreased  muscle tone and lower tolerance to hold larger amounts of urine.  Furthermore, it has been found that women were most likely to stress eat  during bereavement periods than men, and with possibly increasing  caloric intake, especially if now only cooking meals for one may not be  as healthy and could be leading to increased insulin levels (Oliveira,  Rostila, Saarela & Lopes, 2014).  It is a possibility that the  patient has never slept a night in her life since marriage until the  death of her spouse, which may lead to sleep being something that is  uncomfortable for her as well. And furthermore, it could warrant the  question to ask if the husband passed at home, as it could also be that  the patient has not resolved that her husband may have passed in their  bed/home. Lastly, the patient may be experiencing anticipatory fear of  possibly passing herself, since the death of her husband has happened  and the reality that death is imminent may be at play, possibly leading  to racing thoughts which should be explored if that is present. 

1. Has the patient stopped doing things she once enjoyed since the loss of her husband? 

• Grief  is complicated and not everyone who experiences the loss of a loved one  is able to cope with that loss. By moving on with life, and continuing  to be in a environment where one is reminded of the lost loved one, it  can make coming to terms with the loss even more difficult. Grief can  lead to isolation, especially when experiencing depression, and can lead  to the lack of motivation, desire, or will to do things or see people  or do things that she once enjoyed. By isolating ones self, it can  further lead to depression and complicate the patients current  condition. By isolating ones self, and no longer placing yourself in the  situations of which used to bring happiness, the patient voids  themselves of happy or positive experiences, leading  to further  increases in depression, thus the need for interaction and support from  others is crucial in helping combat grief and depression, which could  also in turn help insomnia concerns (Pitman, King, Martson, &  Osborn, 2020).  

-List three people in the patients life that you would need to speak to or get feedback from to further assess patient. 

       The  three people in the patients life I would want to speak to would be any  close children that may have further insight into the patients life, any  close friends that may see the patient on a day to day basis, as well  as her primary care provider. Any adult child that has a relationship  with the patient would be a good resource to speak with. Background  information could be obtained about the details of the passing of the  patients husband, and if the patient had any challenges before the death  such as being his primary care provider until death, or if the passing  was slow and painful. Children would have known the patient prior to the  death of husband as well as current, and would be helpful in  identifying any changes in behavior. Furthermore, the patients children  may have insight into the patients depression prior to death of husband,  and can assert what patterns have negatively gotten worse, or if there  are things that the patient is not forthcoming about. Close friends who  the patient consents to speaking with would be a good resource as well  as friends generally confide in one another, and may be able to offer  some insight of any comments or concerns that the patient may have  raised that she did not mention in the current visit. The patient may  feel comfortable speaking to a friend versus a child about thoughts of  death, or possible thoughts of suicide as to not scare their child (who  recently just lost a parent) and my feel that the friend has insight as  they may have experienced something similar. The patients primary care  provider would be a good resource we well due to the patient seeing them  once or twice a year, and questions about medication  management/compliance could be loosely assessed. Further, speaking with  the PCP, it could be explored if the patient has made any comments  related to depression or grief since the passing of her husband, and if  there have been any noticeable changes at any recent appointments.  Additionally, by speaking with the PCP, it could be asked if the patient  has been showing signs of depression and if it has gotten worse since  visit with PCP prompting to come to psychiatry, and was the PCP the one  who started her on Zoloft and why that course of medication was chosen,  including if any side effects were noticed during any course of  treatment and if that was the first medication tried, or is that one  that she has just seen noticeable changes on?

-Diagnostics

   Due to the  patient having hypertension, getting a baseline EKG is always a good  idea to check for any cardiac conduction abnormalities that could  eliminate certain medications from treatment (Stern, Fava, Wilens, &  Rosenbaum, 2016). Conducting a rating scale using the Hamilton  Depression rating scale gives a baseline on patient’s current depressive  symptoms, and will help evaluate at future appointments the  effectiveness of medication changes at this visit (Williams, 1988). CBC,  CMP, prolactin levels (due to some antipsychotics increasing prolactin  levels), weight for baseline measurement, baseline blood sugar, baseline  blood pressure, as well as fasting lipid panel as antipsychotics are  known to have a metabolic side effect profile and the patient is already  a known diabetic (Freudenreich, Goff, & Henderson, 2016). 

-Differential Diagnosis

• Prolonged  Grief Disorder- Prolonged Grief Disorder can be diagnosed as earlier as  6 month post the death of someone that has severely impacted that  patients life, leading to the patient to possibly experience emotional  pain or grief, loss of routine social activities, lack of ADLs and  adherence to routines, feelings of emptiness, increased depression and  isolation (Killikelly & Maercker, 2018).  
• Major  Depressive disorder- The patient carries a diagnosis of depression, and  that may have further been pushed into a depressive episode with the  death of her husband, of which she has been unable to lighten those  feelings. Grief and the loss of a loved one, especially one that the  patient lived with and most likely confided in everything, may be  experiencing the loss of more than just a loved one, therefore adding to  the depression with the inability to confide their sadness to  (Jacobsen, Zhang, Block, Maciejewski, & Prigerson, 2010).  
• Insomnia-  The patient is experiencing disruption in sleep patterns, assumed to be  decreased sleep. Insomnia can be caused due to depression or grief, and  can subside on its own, or can prolong and be debilitating and cause  disruptions in the patient’s daily life, including leading to isolation  due to irritability and frustration (Krystal, Prather, & Ashbrook,  2019).  
• PTSD-  The patient may be suffering from post-traumatic stress disorder  depending on the nature of her husband’s death, but has been  minimalizing her current symptoms. PTSD can cause depressive symptoms to  worsen, decreased sleep, and disruptions in daily patterns of life that  could further complicate depression, and furthermore lead to thoughts  that she could have done something different and could carry sadness  (Mann & Marwaha, 2021).  

-Pharmacological Agents

             -Quetiapine- Seroquel was found in a study to have improved satisfaction  and overall improvement in depression when used in combination with  sertraline. Studies showed that HAM-D scores improved when Seroquel was  used as an adjunct therapy with sertraline, figuring that the  combination targeted multiple specific mood receptors, and furthermore  increased quality of sleep in these patients (Daly & Trivedi, 2007).  Also, due to being loosely bound to D2 receptors, the likelihood of  experiencing EPS effects from Seroquel are significantly lower (Daly  & Trivedi, 2007). In recent studies conducted on women over the age  of 65  with a current diagnosis of MDD, Seroquel was started at a low  dose of 25 mg oral daily and saw that not only was Seroquel tolerated  without effects with sertraline, but that it decreased depressive  symptoms, and carried a side effect of sedation which would be  beneficial in our current patient (Carta, Zairo, Mellino, Hardoy, 2007).  Because of no negative interactions with sertraline, I would continue  sertraline at the current dose and augment with adding Seroquel 25 mg  oral at bedtime with the hope that she will experience decreased  depressive symptoms and increased sleep. 

-Olanzapine-  Olanzapine was found to have fewer reactions with EPS effects, decreased  drug interactions, as well as providing satisfactory reduction in  depressive symptoms that were formerly unresolved with other  antidepressant therapy and is tolerated well in the geriatric population  (Madhusoodanan, Brenner, Suresh, Concepcion, et al, 2000). Furthermore,  olanzapine has a sedative side effect which may be beneficial in also  helping with the patients current complaint of insomnia, and for this  reason should be dosed at night (Madhusoodanan, Brenner, Suresh,  Concepcion, et al, 2000). This medication would be my second choice in  medication therapy. I would titrate the Zoloft down over a course of two  weeks, and then start the patient on low dose olanzapine to avoid the  possibility of a rare side effect of irregular heart rhythm as the  patient is taking a current SSRI (Madhusoodanan, Brenner, Suresh,  Concepcion, et al, 2000). Because the patient is a geriatric patient,  elimination concerns should be taken into consideration, and the patient  should be started on a low dose in order to evaluate the response.  Because of this, I would start the patient on low dose 5 mg oral daily  at bedtime once titrated off Zoloft. 

-Checkpoints

    Four Week Follow up

• Seroquel 
• At  the patients four week follow up, I would conduct a HAM-D assessment to  assess in changes in depressive symptoms to assess if medication change  has been beneficial to patient. At this time, assessing for  oversedation would be a priority, and if the patient has experienced any  anticholinergic side effects (Freudenreich, Goff, & Henderson,  2016). Assuming that this medication adjustment has been beneficial to  the patient, at the eight week follow up I would assess weight changes,  and at twelve weeks I would conduct all evaluations that were done at  baseline of treatment.  
• Olanzapine 
• At  the patients four week follow up, I would conduct a HAM-D assessment to  assess for any changes in depressive symptoms to evaluate current  medication therapy, as well as assess for continued insomnia or if the  current dose causes unwanted excess sedation (Freudenreich, Goff, &  Henderson, 2016). Assuming that this course of treatment is beneficial  to patient, at eight weeks I would checks weight and at twelve weeks I  would assess for EPS effects, weight change, prolactin levels, fasting  blood sugar, fasting lipids, and blood pressure (Freudenreich, Goff,  & Henderson, 2016). I would expect the patient to experience  increased sleep absent of daytime grogginess, with decreased depressive  symptoms.  

References

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Daly,  E. J., & Trivedi, M. H. (2007). A review of quetiapine in  combination with antidepressant therapy in patients with depression. Neuropsychiatric disease and treatment, 3(6), 855–867. https://doi.org/10.2147/ndt.s1862

Freudenreich,  O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In  T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674

Madhusoodanan  S, Brenner R, Suresh P, Concepcion NM, Florita CD, Menon G, Kaur A,  Nunez G, Reddy H. Efficacy and tolerability of olanzapine in elderly  patients with psychotic disorders: a prospective study. Ann Clin  Psychiatry. 2000 Mar;12(1):11-8. doi: 10.1023/a:1009018809174. PMID:  10798821.

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Oliveira,  A. J., Rostila, M., Saarela, J., & Lopes, C. S. (2014). The  influence of bereavement on body mass index: results from a national  Swedish survey. PloS one, 9(4), e95201. https://doi.org/10.1371/journal.pone.0095201

Parkes C. M. (1998). Bereavement in adult life. BMJ (Clinical research ed.), 316(7134), 856–859. https://doi.org/10.1136/bmj.316.7134.856

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