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NURS 6630 WEEK 5 IP CASE STUDY 1/ NURS 6630: PSYCOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCOPATHOLOGY
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NURS 6630 WEEK 5 IP CASE STUDY 1/ NURS 6630: PSYCOPHARMACOLOGIC APPROACHES TO TREATMENT OF PSYCOPATHOLOGY
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Week 5 Case 1IP Case Study 1, Case
#16 the woman who like
late NIGHT TV
COLLAPSE
NURS 6630:
Psychopharmacologic
Approaches to Treatment of
Psychopathology
, Case Study 1: Volume 2, Case #16: The
woman who liked late-night TV
The three questions that would be asked to the patient are:
• How long have you had trouble sleeping? This would be asked to get a
better understanding of the timeframe that symptoms have developed.
• How long does it take you to fall asleep? How often do you wake at
night? This would be asked to obtain further assessment and evaluation
of the sleep pattern/disturbance.
• Do you feel tired when you awake? How many hours do you sleep a
night? This would be asked to get an estimate of hours and to see if a
pattern has developed.
The individuals of the patient’s life I would need to speak with and get
feedback and further assess would be the patient’s son, home aide and
PCP. The questions asked to the son would be, How often do you see
your mom? Do you know of any possible triggers or stressors that
would cause her sleep deprivation? When did you notice your mother
wasn’t sleeping much? Any particular behaviors? The questions asked
to the home aide would be, How often do you assist in care? Are there
any change in behavior that you noticed? Does she sleep frequently
throughout the day? How has she described her sleep to you? Does she
sleep frequently throughout the day? These questions asked will be
beneficial to the treatment plan and medication regimen.
,A physical exam would be completed, obtaining medical and sleep
history as well as conducting sleep disorder test. A sleep study would be
conducted to evaluate oxygen levels, body movements and brain wave
that may disrupt sleep patterns
Three differential diagnoses: insomnia, depression stress. Insomnia, the
most common sleep disorder, is the perception or complaint of
inadequate or poor-quality sleep because of one or more of the
following conditions: difficulty in falling asleep, frequent waking up
during the night with difficulty for returning to sleep, waking up too
early in the morning, or unrefreshing sleep (Haile, Alemu, & Habtewold,
2017). Many cases of insomnia are caused by underlying but very
treatable causes (Varghes & Elangovan, 2014). While emotional issues
such as stress, anxiety, and depression can cause insomnia, the most
common causes in seniors are a poor sleep environment and poor sleep
and daytime habits (Varghes & Elangovan, 2014). The patient does not
fall asleep easily due to her RLS, takes frequent naps throughout the
day, and snores frequently. The patient also presents with an
underlying factor of depression.
The two pharmacologic agents chosen would be Doxepin 3mg at
bedtime and Trazodone 25mg at bedtime. Pharmacokinetics is based
on absorption, distribution, metabolism and excretion. Psychodynamics
will be due to the patient being 70 years old, with underlying disorders
and medications that may counteract against what is prescribed,
causing the medication not to work effectively. Low-dose doxepin (3–6
mg/day) has been studied and found effective for insomnia in elderly
patients; recommended dose is 3 mg/day (Stahl, 2013). The patient was
started on Zaleplon which was ineffective, and while on Ambien she fell
asleep at table and fell and fractured arm.
Doxepin binds with high specificity and affinity to the histamine H1
receptor compared with other receptors. Therefore, at low doses,
doxepin selectively antagonises H1 receptors, which is believed to
, promote the initiation and maintenance of sleep. Doxepin was found to
be safe and effective in treating primary insomnia in elderly patients
(Doxepin, 2009). Doxepin is a tricyclic antidepressant which is known to
have anxiolytic properties at higher doses (Doxepin, 2009). Trazodone
blocks postsynaptic serotonin receptors and weakly inhibits serotonin
reuptake (Flint, 1998). It has a strong sedating effect which can result in
daytime drowsiness, falls and impaired cognitive functioning (Flint,
1998). Trazodone also blocks a1-adrenergic receptors and, thus, can
cause orthostatic hypotension (Flint, 1998). Doxepin would be chosen
over Trazodone due to improving sleep, appetite, energy level and
sense of well-being. The patient will follow up every 4 weeks until a
therapeutic response has been shown if needed. The dose may increase
or decreased depending on the follow up visit.
Lessons learned would be important to know that as aging occurs body
produces lower levels of growth hormone likely to experience a
decrease in slow wave or deep sleep (Varghes & Elangovan, 2014).
When this happens body produce less melatonin, and often experience
more fragmented sleep (more rapid sleep cycles) and more awakenings
between sleep cycles (Varghes & Elangovan, 2014). It is also important
to pay attention to other developing disorders such as depression,
heart disease, and obesity in which causes the secondary symptoms.
This would be applied to my own practice due to being mindful of the
age of the patient and knowing what medications that would be
harmful and least effective. Also to follow up, be involved to help build
a therapeutic rapport with the patient and her son.
References:
Doxepin improves sleep in elderly adults. (2009). Brown University
Geriatric Psychopharmacology Update, 13(1) , 4.
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