Case: An elderly widow who just lost her spouse. 

Subjective: A patient presents to your primary care office today with chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and 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 prior to her husband’s death. She is awake, alert, and oriented x3. Patient normally sees PCP once or twice a year. Patient denies any suicidal ideations. Patient arrived at the office today by private vehicle. Patient currently takes the following medications: 

• Metformin 500mg BID 
• Januvia 100mg daily 
• Losartan 100mg daily 
• HCTZ 25mg daily 
• Sertraline 100mg daily 

Current weight: 88 kg

Current height: 64 inches

Temp: 98.6 degrees F

BP: 132/86 

• List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
• 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.
• Explain what, if any, physical exams, and diagnostic tests would be appropriate for the patient and how the results would be used.
• List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
• List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant 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.
• For the drug therapy you select, identify any contraindications to use or alterations in dosing that may need to be considered based on ethical prescribing or decision-making. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals based on ethical prescribing guidelines or decision-making?
• Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.

ANSWER

Comprehensive Assessment and Management of an Elderly Widow with Insomnia and Depression

Introduction

This case involves an elderly widow who recently lost her spouse and is presenting with insomnia and worsening depression. As a primary care provider, it is essential to conduct a thorough assessment, involve relevant individuals, and formulate an appropriate treatment plan.

Three Questions for the Patient

1. How has your sleep pattern changed since your husband’s passing, and do you find it difficult to fall asleep or stay asleep? This question helps assess the nature and severity of the patient’s insomnia.
2. Have you noticed any changes in your appetite or interest in activities you used to enjoy since your husband’s death? This question probes for additional depressive symptoms.
3. Are you comfortable discussing your feelings with friends or family? This question evaluates the patient’s social support system and willingness to seek help.

Rationale for the Questions

These questions provide insights into the patient’s sleep disturbances, depressive symptoms, and social support. Understanding the extent of her insomnia and depression helps guide treatment decisions.

People to Involve and Relevant Questions

1. Friends and Family: Inquire about the patient’s social interactions, changes in behavior, and expressions of sadness. Ask if they have observed any changes in her mood, sleep, or appetite.
2. Grief Support Group: Ask about her participation in any support groups to assess her engagement in activities that could alleviate depression and improve coping.

Physical Exams and Diagnostic Tests

1. Physical Exam: A thorough physical exam to assess overall health, including vital signs, weight, and height.
2. Depression Screening: Administer a validated depression screening tool like PHQ-9.
3. Sleep Study: Consider a sleep study to evaluate the extent of insomnia and rule out other sleep disorders.

Differential Diagnosis and Likely Diagnosis

Differential Diagnosis: Major Depressive Disorder, Adjustment Disorder, Insomnia Disorder.
Likely Diagnosis: Major Depressive Disorder, given the presence of significant depressive symptoms following her husband’s death and a lack of previous history of depression.

Pharmacologic Agents and Rationale

1. Selective Serotonin Reuptake Inhibitors (SSRIs), such as Sertraline: SSRIs are commonly used in elderly patients due to their favorable side effect profile and effectiveness in treating depression. Sertraline’s once-daily dosing is convenient.
2. Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs), such as Venlafaxine: Venlafaxine may be considered if the patient has inadequate response to an SSRI. However, it has a higher risk of hypertension and discontinuation syndrome.

Contraindications and Alterations in Dosing

For Sertraline: Caution is needed in patients with cardiac issues due to potential QT interval prolongation. Dose adjustments may be required in patients with impaired renal or hepatic function.

Therapeutic Follow-Up and Changes

Week 4: Assess for improvement in mood, sleep, and appetite using validated tools. If no significant improvement, consider dose adjustment or switching to an alternative antidepressant.
Week 8: Continue monitoring response and side effects. Consider involving a mental health specialist for further evaluation and recommendations if needed.

Conclusion

Addressing the complex needs of an elderly widow with insomnia and depression requires a holistic approach. By asking appropriate questions, involving relevant individuals, performing necessary assessments, and choosing suitable pharmacotherapy, healthcare providers can guide the patient toward improved mental and emotional well-being. Regular follow-up and adjustments in treatment ensure optimal outcomes.