For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
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
The case of an elderly widow who just lost her spouse and presents with insomnia and worsening depression provides a complex clinical scenario that requires a thorough assessment and consideration of various therapy approaches. Here’s how you might approach the assessment, diagnosis, and treatment:
1. Initial Assessment:
- Patient History: Begin by taking a detailed medical and psychosocial history. The patient’s past medical history (DM, HTN, and MDD), as well as the recent loss of her spouse, are crucial factors.
- Depression Evaluation: Assess the patient’s depressive symptoms by using standardized scales like the PHQ-9 (Patient Health Questionnaire-9). This will help in diagnosing and quantifying the severity of her depression.
- Insomnia Assessment: Evaluate the nature and severity of her insomnia using a validated tool like the Insomnia Severity Index (ISI) or Pittsburgh Sleep Quality Index (PSQI).
- Medication Review: Review her current medications, including the dosage and side effects. Ensure she is adhering to her medications and not experiencing any adverse drug interactions.
- Vital Signs: Continue monitoring vital signs, including blood pressure and temperature, to assess for any physical health concerns.
2. Diagnosis:
- Depression: The patient’s history of Major Depressive Disorder (MDD) and the worsening of symptoms after her husband’s death indicate a likely diagnosis of complicated grief and depression. You may also need to rule out bereavement-related depression and differentiate it from the pre-existing MDD.
- Insomnia: Given the patient’s sleep disturbances, she may have comorbid insomnia, which can be related to her depressive symptoms or other factors. The use of standardized sleep assessment tools can help diagnose the severity of her insomnia.
- Medical Conditions: Ensure that her diabetes (DM) and hypertension (HTN) are well-managed and not contributing to her depressive or sleep symptoms.
3. Treatment Options:
- Psychotherapy: Consider referring the patient for psychotherapy, such as Cognitive-Behavioral Therapy (CBT) or Grief Counseling. Psychotherapy can help her cope with her loss, manage her depressive symptoms, and improve her sleep patterns.
- Medication: The patient is already taking sertraline, an antidepressant commonly used to treat depression and anxiety. Depending on the severity of her depressive symptoms and the diagnosis, you may consider adjusting her medication or exploring other options, like adding a sedative for her insomnia.
- Grief Support Groups: Suggest joining a grief support group where she can connect with others who have experienced similar losses. This can provide her with emotional support and a sense of community.
- Lifestyle Modifications: Encourage healthy lifestyle changes, such as regular exercise, maintaining a balanced diet, and ensuring good sleep hygiene to help with her insomnia.
- Regular Follow-Up: Schedule regular follow-up appointments to monitor her progress, medication adherence, and response to treatment.
- Collaborative Care: Collaborate with specialists in psychiatry, geriatrics, or sleep medicine, as needed, to address her complex healthcare needs.
Remember to consider the patient’s unique circumstances and preferences when developing a treatment plan. Treating the depression and insomnia while addressing the grief and loss is essential for her overall well-being and quality of life. Additionally, it’s important to provide emotional support and empathy throughout the treatment process.