Scenario Summary
An elderly widow who just lost her spouse presents to the primary care office today with the chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and Major Depressive Disorder (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 has no previous history of depression before her husband’s death. She is awake, alert, and oriented x3. The patient normally sees the PCP once or twice a year. The patient denies any suicidal ideations.
Questions to Ask the Patient
The first question is whether the patient has observed any patterns in her insomnia. Identifying potential triggers for the condition and establishing a diagnosis is necessary. Question two is whether the woman has other symptoms, such as loss of appetite or concentration problems. They may be signs of significant mental disorders, including depression. Thirdly, clarifying whether the patient’s daily routine has changed since her husband’s passing is essential.
This question involves identifying additional stressors, like a new routine or social isolation, that may negatively impact her condition. Moreover, to obtain a more accurate clinical picture, it is necessary to contact family members, such as children, and the patient’s PCP. The main question in both cases is: “Have you noticed any significant changes in the patient’s health or behavior since the death of her husband?”
Physical Examination
Given the woman’s age and the increased risk of associated symptoms, a comprehensive physical examination should be performed. In older adults, insomnia can be a symptom of various diseases, including diabetes, hypertension, and cardiovascular disease (CVD) (Brewster et al., 2022). The woman has diabetes, as evidenced by taking Januvia and metformin, and has CVD and is taking Losartan. Therefore, these assessments are necessary to rule out a relationship between insomnia and these diseases.
Differential Diagnoses
If the patient had not previously experienced insomnia, it is likely a symptom of a mental disorder (Abbott, 2016). Potential diagnoses for a woman include adjustment disorder with depressed mood and MDD. MDD is the most likely diagnosis because of persistent depression manifestations caused by a significant life shock. The optimal pharmacological agents in this case may be Sertraline (increasing the dose to 150 mg daily) and Escitalopram (10 mg daily with the possibility of increasing the dose to 20 mg) (Riemann et al., 2020).
Drug Therapy
However, the choice of Sertraline as a drug treatment makes more sense due to its familiarity and the lack of reported side effects. Contraindications may include the presence of CVD and the use of other medications incompatible with the selected agent. Although the patient’s previous experience did not show critical side effects, increasing the dosage of Sertraline should occur under the constant supervision of a physician.
References
Abbott, J. (2016). What’s the link between insomnia and mental illness? Science Alert.
Brewster, G. S., Riegel, B., & Gehrman, P. R. (2022). Insomnia in the Older Adult. Sleep Medicine Clinics, 17(2), 233–239.
Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and depression. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 45(1), 74–89.