Case study 4.rtfdTXT.rtfYou are doing an eight-week clerkship

Case study 4.rtfd/TXT.rtf
You are doing an eight-week clerkship in a family medicine
practice. You review the EMR (electronic medical record) for
the next patient, which identifies the patient as Mrs. Gomez, "a
65-year-old female who is here today reporting that she can't
sleep."
Dr. Lee, your preceptor, fills you in: "Mrs. Gomez has been a
patient here for several years. Difficulty sleeping is a new issue
for her. Her past medical history is significant for hypertension
and diabetes. Generally, she has been doing well, although I
notice that her last hemoglobin A1c has climbed to 8.7%."
SLEEP HYGIENE
TEACHING
Dr. Lee tells you, "Poor sleeping habits can also cause
insomnia. Here are some helpful tips to share with patients on
sleep hygiene. For some patients, simply correcting their sleep
habits by following these tips will correct their quality of
sleep."
TREATMENT OF INSOMNIA
Treatments for Primary Insomnia in the Elderly
Of the behavioral treatments, many of which may be of some
assistance in the elderly, only sleep restriction/sleep
compression therapy and multi-component cognitive-behavioral
therapy have met evidence-based criteria for efficacy.
Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is recommended as the first choice for most patients with
insomnia. CBT-I combines behavioral treatments, resulting in
improvements lasting up to two years. Recent guidelines
recommend CBT-I as the first-line therapy for insomnia in
adults. Examples include:
Sleep restriction therapy: The patient is told to reduce his or her
sleep/in-bed time to the average number of hours the patient has
actually been able to sleep over the last two weeks (as opposed
to the number of hours spent in bed (awake plus asleep)). As
sleep efficiency increases, time allowed in bed is increased
gradually by 15- to 20-minute increments approximately once
every five days (if improvement is sustained) until the
individual's optimal sleep time is obtained.
     
Relaxation therapy: Structured exercises designed to reduce
somatic tension (eg, abdominal breathing, progressive muscle
relaxation; autogenic training) and cognitive arousal (eg, guided
imagery training; meditation) that may perpetuate sleep
problems.
     
Agents evaluated in older patients:
Class
Agents
Improves
Strength of evidence
Considerations
Benzodiazepine Receptor Agonists
zolpidem (Ambien)
eszopiclone (Lunesta)
SOL
SOL, TST, WASO, sleep efficiency

low
Risks for falls and fractures, mood alteration
Short term use only
Use lower doses
Tricyclic Antidepressants
doxepin
SOL, TST, WASO
low to moderate
Anticholinergic effects, sedation, and orthostatic hypotension
Orexin Receptor Antagonist
suvorexant (Belsomra)
SOL, WASO
moderate
Decreased alertness and increased fatigue morning after use
Melatonin Receptor Agonist
ramelteon
SOL
low
Somnolence, mood alteration and dizziness
Abbr: SOL - sleep onset latency, TST - total sleep time, WASO
- wake after sleep onset
Benzodiazepines and orexin receptor antagonists can be
effective but have more complications and the additional risk of
addiction.
Antihistamines, antidepressants including trazodone (in the
absence of depression), anticonvulsants, and antipsychotics are
associated with more risks than benefits in older adults.
The evidence base for exercise as a treatment for insomnia is
less extensive. Despite this, there are many other reasons to
encourage regular physical activity in the elderly, assuming

there are no other contraindications to such activity.
There is limited research, particularly in the elderly, on
complementary therapies including melatonin, L-Tryptophan,
valerian, chamomile, kava, and wuling. What evidence that does
exist suggests that any potential benefit is equaled or exceeded
by potential adverse effects, particularly in the case of valeria n.
They are not recommended.
Family Medicine 03: 65-year-old female with insomnia
Author: William Hay, MD; Associate Editor: Martha P.
Seagrave RN, PA-C; Case Editor: William Hay, MD
INTRODUCTION
HISTORY
SLEEP HYGIENE
TEACHING
TREATMENT OF INSOMNIA
TEACHING
Question
Which treatments are recommended in the elderly?
Select all that apply.
The best option is indicated below. Your selections are
indicated by the shaded boxes.
A. Antidepressants
B. Antihistamines
C. Benzodiazepines

D. Cognitive behavioral therapy
E. Zolpidem
SUBMIT
Answer Comment
The correct answer is D.
TEACHING POINT
Treatments for Primary Insomnia in the Elderly
Of the behavioral treatments, many of which may be of some
assistance in the elderly, only sleep restriction/sleep
compression therapy and multi-component cognitive-behavioral
therapy have met evidence-based criteria for efficacy.
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is recommended as the first choice for most patients with
insomnia. CBT-I combines behavioral treatments, resulting in
improvements lasting up to two years. Recent guidelines
recommend CBT-I as the first-line therapy for insomnia in
adults. Examples include:
Sleep restriction therapy: The patient is told to reduce his or her
sleep/in-bed time to the average number of hours the patient has
actually been able to sleep over the last two weeks (as opposed
to the number of hours spent in bed (awake plus asleep)). As
sleep efficiency increases, time allowed in bed is increased
gradually by 15- to 20-minute increments approximately once
every five days (if improvement is sustained) until the
individual's optimal sleep time is obtained.
     
Relaxation therapy: Structured exercises designed to reduce
somatic tension (eg, abdominal breathing, progressive muscle

relaxation; autogenic training) and cognitive arousal (eg, guided
imagery training; meditation) that may perpetuate sleep
problems.
     
Agents evaluated in older patients:
Class
Agents
Improves
Strength of evidence
Considerations
Benzodiazepine Receptor Agonists
zolpidem (Ambien)
eszopiclone (Lunesta)
SOL
SOL, TST, WASO, sleep efficiency
low
Risks for falls and fractures, mood alteration
Short term use only
Use lower doses
Tricyclic Antidepressants
doxepin
SOL, TST, WASO
low to moderate
Anticholinergic effects, sedation, and orthostatic hypotension
Orexin Receptor Antagonist
suvorexant (Belsomra)
SOL, WASO
moderate
Decreased alertness and increased fatigue morning after use
Melatonin Receptor Agonist
ramelteon
SOL
low
Somnolence, mood alteration and dizziness

Abbr: SOL - sleep onset latency, TST - total sleep time, WASO
- wake after sleep onset
Benzodiazepines and orexin receptor antagonists can be
effective but have more complications and the additional risk of
addiction.
Antihistamines, antidepressants including trazodone (in the
absence of depression), anticonvulsants, and antipsychotics are
associated with more risks than benefits in older adults.
The evidence base for exercise as a treatment for insomnia is
less extensive. Despite this, there are many other reasons to
encourage regular physical activity in the elderly, assuming
there are no other contraindications to such activity.
There is limited research, particularly in the elderly, on
complementary therapies including melatonin, L-Tryptophan,
valerian, chamomile, kava, and wuling. What evidence that does
exist suggests that any potential benefit is equaled or exceeded
by potential adverse effects, particularly in the case of valerian.
They are not recommended.
icon-circle-expand-1.svg ¬DEEP DIVE
References
Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and
psychological treatments for chronic insomnia disorder in
adults: an American Academy of Sleep Medicine clinical
practice guideline. J Clin Sleep Med. 2021;17(2):255-62.

Flaxer JM, Heyer A, Francois D. Evidenced-Based Review and
Evaluation of Clinical Significance: Nonpharmacological and
Pharmacological Treatment of Insomnia in the Elderly. Am J
Geriatr Psychiatry. 2021;29(6):585-603.
Matheson E, Hainer BL. Insomnia: Pharmacologic Therapy. Am
Fam Physician. 2017;96(1):29-35.
Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD;
Clinical Guidelines Committee of the American College of
Physicians. Management of Chronic Insomnia Disorder in
Adults: A Clinical Practice Guideline From the American
College of Physicians. Ann Intern Med. 2016;165(2):125-33.
REASON FOR VISIT
After discussing these potential causes of insomnia with Dr.
Lee, you feel prepared to talk with Mrs. Gomez. You knock on
the exam room door and enter to find Mrs. Gomez, who is
accompanied by her daughter, Silvia. You introduce yourself
and ask if you may ask her a few questions, to which she agrees.
"What brings you to the clinic today?"
"Tell me more about this."
On further questioning, Mrs. Gomez reports no discomfort such
as pain or breathing problems disturbing her sleep. She reports
no snoring, apneic spells (a period of time during which
breathing stops or is markedly reduced), or physical restlessness
during sleep. Her daughter agrees that she has not seen these

problems. She rarely consumes alcohol or caffeine.
When you ask if anything like noise or an uncomfortable
sleeping environment might be bothering her, she replies that
this is not a problem - but her daughter interjects: "Yes, in fact
Mom's waking up the rest of us, walking around and turning on
the TV. My husband and I both work. So we all need our rest.
Mom came to live with us last year after Dad passed away.
We're her only family around here and we thought we should
help her."
RELATED HISTORY
You tell Mrs. Gomez,
"I'm sorry to hear about your husband."
"Do you find that you feel sad most of the time?"
Silvia states, "But Mom, you spend most of your time just
moping around the house." Turning to you she elaborates, "She
seems to be in slow motion most of the time. She doesn't even
go to church anymore. She used to go three to four times a
week. She used to read all the time, and she doesn't do that
anymore either."
Mrs. Gomez explains, "I haven't been reading as much as I used
to because I can't seem to focus and I end up reading the same
page over and over." She goes on to say, "And I don't seem to
have any energy to do anything. I'm not even able to help out
around the house. I feel bad about that; I should be helping out
more. I seem to spend a lot of time just watching TV and eating
junk food."

PAST MEDICAL HISTORY AND MEDICATIONS
HISTORY
You ask,
"Have you tried anything to help you sleep?"
"I'm not familiar with that product, but I'll mention it to Dr.
Lee. I'm glad you brought it up. It's important that your doctors
know about everything you are taking, whether it's prescription
medication or not. I'm sorry nothing seems to be helping you
sleep. We'll get to the bottom of this together."
You turn your attention to taking Mrs. Gomez's past medical
history. You learn:
Problem list:
Hypercholesterolemia
Type 2 diabetes
Hypertension
     
Surgical history:
Cholecystectomy
Hysterectomy (due to fibroids)
     
Medications:
For diabetes:

Glyburide (10 mg daily)
Metformin (1,000 mg bid)
     
For blood pressure:
Methyldopa (250 mg bid)
Lisinopril (10 mg daily)
     
For cholesterol:
Atorvastatin (80 mg daily)
     
For CHD prophylaxis:
Aspirin (81 mg daily)
     
For osteoporosis prevention:
Calcium citrate with vitamin D (600mg/400 IU bid)
     
Diphenhydramine is her only over-the-counter medication, and
she is taking no traditional or herbal medications beyond the
zapote tea.
Social History
She does not smoke, and drinks only small amounts of alcohol
on holidays.

DIFFERENTIAL DIAGNOSIS
CLINICAL REASONING
Given what you have heard from Mrs. Gomez and her daughter,
especially
Her inability to focus
Her lack of energy
The sense that she is in slow motion
She has stopped doing activities she previously enjoyed
     
You are concerned that her insomnia may be due to depression.
Depression may stem from environmental stressors such as her
husband's death and her loss of independence along with a
primary neurochemical imbalance. Her depression also could be
caused by another medical condition.
REVIEW OF SYSTEMS
HISTORY
Keeping in mind the disorders associated with depression, you
elicit a review of systems from Mrs. Gomez to help discover
what these indicate regarding her underlying illness.
Constitutional: Mrs. Gomez has gained about 10 lbs in the last
six months. She reports no fevers or dizziness. This makes you
less concerned about cancer or other systemic illness.
Respiratory: No shortness of breath, making cardio-respiratory
disease less likely.
Cardiac: No chest pains, palpitations or edema, decreasing the

likelihood of cardiovascular disease.
Gastrointestinal: No nausea, changes in bowel habits,
hematochezia or melena. This makes you less concerned about
gastrointestinal cancer or occult blood loss leadi ng to anemia.
Endocrinologic: No polydipsia or polyuria, decreasing the
likelihood of poorly controlled diabetes.
Neurologic: No acute neurologic changes or tremors. Her
daughter confirms that her mother has been alert, oriented, and
has had no episodes of confusion. So you are now less
concerned about cerebral infarction, intracranial tumors,
multiple sclerosis, and Parkinson disease.
Urologic: Normally urinates one to two times at night.
Once you have completed your review of systems, you excuse
yourself from the room for a moment while Mrs. Gomez
changes into a gown.
PHYSICAL EXAM
PHYSICAL EXAM
You perform a physical exam on Mrs. Gomez.
When you return to the exam room, after washing your hands,
you perform a physical exam on Mrs. Gomez.

Vital signs:
Pulse is 60 beats/minute and regular
Respiratory rate is 16 breaths/minute
Blood pressure is 128/78 mm Hg
Weight is 84 kg (186 lbs (up 10 lbs since last year))
Height is 163 cm (64 in)
     
Head, eyes, ears, nose and throat (HEENT): No thyrome galy,
adenopathy, or masses.
Cardiac: Regular rate and rhythm, no murmur or gallops. No
edema.
Respiratory: Clear to auscultation.
Abdominal: Soft, nontender, without organomegaly or masses.
Neurologic: Cranial nerves 3-12 intact. Normal strength and
light touch sensation in extremities. No tremors. Normal gait.
ASSESSING MENTAL HEALTH STATUS
PHYSICAL EXAM
You are afraid your next question may upset Mrs. Gomez, but
you know it is important to ask: "Mrs. Gomez, I have one more
question: When people are down, sometimes they wish they

would fall asleep and never wake up.
"Have you had any thoughts of dying or causing harm to
yourself?"
"Okay, thank you for your openness with me," you tell Mrs.
Gomez. "I would like to bring in Dr. Lee so she can also
perform a physical exam before you get dressed. We'll be back
in just a minute. Do you have any questions for me before I
go?"
Mrs. Gomez indicates she doesn't have any concerns, so you
exit the room.
DIAGNOSTIC CRITERIA
PHYSICAL EXAM
You present your concern that Mrs. Gomez is depressed.
You locate Dr. Lee and present the case to her, expressing your
concern that Mrs. Gomez is depressed. She suggests discussing
the evidence you found that Mrs. Gomez may have depression.
You tell Dr. Lee, "Mrs. Gomez has a depressed mood and seven
of the nine criteria."
TEACHING POINT

Major Depression Diagnostic Criteria
For a diagnosis of major depression, the patient must have at
least five of the following nine criteria for a minimum of two
weeks.
A least one of the symptoms must be either (1) depressed mood
or (2) loss of interest or pleasure.
     
Depressed Mood
(The eight remaining criteria can be remembered using the
mnemonic SIG E CAPS):
Sleep: Insomnia or hypersomnia nearly every day.
Interest (loss of): Anhedonia (loss of interest or enjoyment) in
usual activities.
Guilt: Feelings of worthlessness or excessive or inappropriate
guilt (which may be delusional) nearly every day (not merely
self-reproach or guilt about being sick).
Energy (decreased): Fatigue or loss of energy nearly every day.
Concentration (decreased, or crying): Diminished ability to
think or concentrate, or indecisiveness, nearly every day (either
by subjective account or as observed by others).
Appetite (increased or decreased): or significant weight loss
when not dieting or weight gain (e.g., a change of more than 5%

of body weight in a month).
Psychomotor retardation: Psychomotor agitation or retardation
nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down).
Suicidal ideation: Recurrent thoughts of death (not just fear of
dying), recurrent suicidal ideation without a specific plan, or a
suicide attempt or a specific plan for committing suicide.
DISCUSSING DIAGNOSIS
TEACHING
"You seem to have established that Mrs. Gomez meets the
criteria for a major clinical depression," says Dr. Lee, and goes
on to explain:
TEACHING POINT
Major Depressive Disorder versus Bereavement
The presence of certain symptoms that are not characteristic of
a "normal" grief reaction may be helpful in differentiating
bereavement from a Major Depressive Episode. The table below
adapted from the DSM V discusses some potential differences:
Major Depressive Episode
Bereavement (Grief)
Persistent depressed mood and inability to anticipate happiness
or pleasure
Feelings of emptiness and loss
Depression persistent, not tied to specific thoughts or
preoccupations

Depressed feelings often decrease in intensity over days to
weeks and occur in waves, associated with thoughts of the
deceased
Pervasive unhappiness and misery
Grief may be accompanied by positive emotions and humor
Self-critical or pessimistic ruminations
Preoccupation with thoughts and memories of the deceased
Feelings of worthlessness and self-loathing
Self-esteem is generally preserved. May be self-deprecating—
feeling they should have done more or told the deceased how
much he or she was loved
Suicidal ideation because of feeling worthless, undeserving of
life, or unable to cope with the pain of depression
Individual thinks about death and dying, generally focused on
the deceased and possibly about joining the deceased
TEACHING POINT
Risk factors for Late-life depression
Risk factors for late-life depression include:
Female sex
Social isolation
Widowed, divorced, or separated marital status
Lower socioeconomic status
Comorbid general medical conditions, e.g. stroke, heart disease
and cancer
Uncontrolled pain
Insomnia
Functional impairment
Cognitive impairment
     
TEACHING POINT
Depression in the Elderly
Depression is a very serious disease in the elderly:

Depression increases the risk of disabilities in mobility and the
activities of daily living by about 70% over the course of six
years.
Alcohol and drug abuse are very common comorbidities
complicating depression.
Completed suicide is more common in older depressed patients.
RISK ASSESSMENT
CARE DISCUSSION
You express to Dr. Lee your concern that by asking about
suicide you may have made the situation worse.
Dr. Lee reassures you: "Many people worry that bringing up the
subject of suicide will cause the patient to commit suicide. On
the contrary, talking about it allows the opportunity to intervene
and prevent a completed suicide."
TEACHING POINT
Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
Suicide Assessment Five-step Evaluation and Triage (SAFE-T)
1. RISK FACTORS
a. Suicidal behavior: history of prior suicide attempts, aborted
suicide attempts, or self-injurious behavior
b. Current/past psychiatric disorders: especially mood disorders,
psychotic disorders, alcohol/substance abuse, ADHD, TBI,
PTSD, Cluster B personality disorders, conduct disorders
(antisocial behavior, aggression, impulsivity) Co-morbidity and

recent onset of illness increase risk
c. Key symptoms: anhedonia, impulsivity, hopelessness,
anxiety/panic, global insomnia, and command hallucinations
d. Family history: of suicide, attempts, or psychiatric disorders
requiring hospitalization
e. Precipitants/stressors/Interpersonal: triggering events leading
to humiliation, shame, or despair (e.g, loss of relationship,
financial or health status—real or anticipated). Ongoing medical
illness (esp. CNS disorders, pain). Intoxication. Family
turmoil/chaos. History of physical or sexual abuse. Social
isolation
f. Change in treatment: discharge from psychiatric hospital,
provider or treatment change
g. Access to firearms
2. PROTECTIVE FACTORS Protective factors, even if present,
may not counteract significant acute risk
a. Internal: ability to cope with stress, religious beliefs, and
frustration tolerance
b. External: responsibility to children or beloved pets, positive
therapeutic relationships, and social supports

3. SUICIDE INQUIRY Specific questioning about thoughts,
plans, behaviors, and intent
a. Ideation: frequency, intensity, duration—in last 48 hours,
past month, and worst ever
b. Plan: timing, location, lethality, availability, and preparatory
acts
c. Behaviors: past attempts, aborted attempts, rehearsals (tying
noose, loading gun) versus non-suicidal self injurious actions
d. Intent: extent to which the patient (1) expects to carry out the
plan and (2) believes the plan/act to be lethal versus self-
injurious.
e. Explore ambivalence: reasons to die versus reasons to live
›For Youths: ask parent/guardian about evidence of suicidal
thoughts, plans, or behaviors, and changes in mood, behaviors,
or disposition
›Homicide Inquiry: when indicated, esp. in character disordered
or paranoid males dealing with loss or humiliation. Inquire in
four areas listed above

4. RISK LEVEL/INTERVENTION
a. Assessment of risk level is based on clinical judgment, after
completing steps 1–3
b. Reassess as patient or environmental circumstances change
5. DOCUMENT Risk level and rationale; treatment plan to
address/reduce current risk (e.g., medication, setting,
psychotherapy, E.C.T., contact with significant others,
consultation); firearms instructions, if relevant; follow -up plan.
For youths, treatment plans should include roles for
parent/guardian.
SCREENING TOOLS
Mrs. Gomez fills out a Mini-Cog exam.
Entering the room with you, Dr. Lee greets Mrs. Gomez and her
daughter, and thanks them for allowing you to interview them.
She tells Mrs. Gomez, "I understand that you've been having
trouble sleeping - not unusual given your recent stresses. These
can also lead to feelings of depression. I'd like to look into this
by going over a short questionnaire with you."
Dr. Lee goes over the questions on the Geriatric Depression
Scale - Short Form (GDS-SF) with Mrs. Gomez. Her score
equals 9. This confirms depression, as a score of > 5 is

consistent with the diagnosis of depression.
Dr. Lee then performs a Mini-Cog exam to screen for dementia,
explaining to Mrs. Gomez that in cases like this, checking out
the patient's memory and concentration can help to rule out
other disorders and can assist in planning treatment. She scores
in the normal range.
TEACHING POINT
Screening for Depression
The U.S. Preventive Services Task Force (USPSTF)
recommends screening all adults for depression, but especially
patients with chronic diseases like diabetes, as they are at high
risk for depression.
The PHQ-2 is a simple screen that is 97% sensitive and 59%
specific as a depression screen:
"Over the past two weeks, have you often been bothered by
either of the following problems?"
Little interest or pleasure in doing things.
Feeling down, depressed, or hopeless.
     
If positive, it should be followed up by a diagnostic instrument
such as:
PHQ-9Geriatric Depression Scale - Short Form (GDS-SF) (.pdf)
     
TEACHING POINT

Screening for Dementia in Geriatric Patients with Depression
While screening for dementia in asymptomatic individuals is not
recommended (I statement), screening is important in geriatric
patients with depression because the Geriatric Depression Scale
is less sensitive in patients experiencing dementia.
Two dementia screening tools are:
The Mini-Cog exam
The Mini-Mental State Exam (MMSE)
     
The Mini-Cog exam is faster and more sensitive and specific
than the MMSE.
Sensitivity
Specificity
Mini-Cog
99%
93%
MMSE
91%
92%
TEACHING POINT
Patient Health Questionnaire, Two-Item Version (PHQ-2)
The U.S. Preventive Services Task Force (USPSTF)
recommends screening all adults for depression when staff-
assisted depression care supports are in place to assure accurate
diagnosis, effective treatment, and follow-up. Many family
physicians and students are familiar with the nine-item
depression survey from the Patient Health Questionnaire (PHQ-
9), which has been demonstrated to be useful in diagnosis and
tracking the severity of symptoms among patients with major

depression. The length of the questionnaire has been a barrier to
its use as a screening tool in primary care, where physicians are
under considerable time pressure and face competing demands.
More recently, a shortened two-item version (PHQ-2) has been
developed and validated in primary care. The PHQ-2 asks
patients, "Over the last two weeks, how often have you been
bothered by any of the following problems?" The two symptoms
are "little interest or pleasure in doing things" and "feeling
down, depressed, or hopeless." For each question the patient can
answer:
Not at all (0 points)
Several days (1 point)
More than half the days (2 points)
Nearly every day (3 points)
     
The score from the two symptom questions are then added
together into a final score.
MEDICATIONS AND MECHANISMS OF ACTION
TEACHING
"Now that we know Mrs. Gomez is depressed," states Dr. Lee,
"Let's talk about the different groups of antidepressant
medications and how they work."
TEACHING POINT
Antidepressant Medications
Most antidepressants work by improving the levels of the
neurotransmitters norepinephrine (NE), serotonin (5HT), and
dopamine (DA). There are four major classes of antidepressants:

Others
Class
Mechanism
Examples
Selective serotonin reuptake inhibitors (SSRIs)
Selectively block reuptake of serotonin, potentiating serotonin's
effect on the postsynaptic neuron
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
Escitalopram (Lexapro)
Tricyclic antidepressants (TCAs)
Block reuptake of norepinephrine and serotonin, potentiating
their effects on the postsynaptic neuron
Nortriptyline (Pamelor)
Amitriptyline
Clomipramine (Anafranil)
Doxepin (Sinequan)
Monoamine oxidase (MAO) inhibitors
Block presynaptic catabolism of norepinephrine and serotonin
(rarely used today)
Phenelzine (Nardil)
Tranylcypromine (Parnate)
Serotonin and norepinephrine reuptake inhibitors
Block reuptake of norepinephrine and serotonin, increasing
their concentration/availability
Venlafaxine (Effexor) and Duloxetine (Cymbalta)
Others
Norepinephrine and dopamine reuptake inhibitors
Bupropion (Wellbutrin)
Serotonin antagonist and reuptake inhibitors
Nefazodone (Serzone) and Trazodone (Desyrel)

Norepinephrine and serotonin antagonist, antihistaminic effects
Mirtazapine (Remeron)
Serotonin partial agonist and reuptake inhibitor
Vilazodone (Viibryd)
TREATMENT OF CHOICE 1
CLINICAL REASONING
Question
Which of the following would be considered treatment(s) of
choice in this clinical scenario?
Select all that apply.

The best options are indicated below. Your selections are
indicated by the shaded boxes.
A. Amitriptyline - a tricyclic antidepressant
B. Cognitive-behavioral therapy
C. Electroconvulsive therapy (ECT)
D. Exercise
E. Sertraline - a selective serotonergic reuptake inhibitor (SSRI)
SUBMIT
Answer Comment
The correct answers are B, D, E.
Dr. Lee concludes, "In the elderly, the chance of spontaneous
remission of depression is much lower than in younger patients,
so it's best we start some form of therapy. I agree that an SSRI
and/or psychotherapy would be a good choice for Mrs. Gomez.
Also, the death of her husband and moving into a new
environment proved to be stressful for her. Cognitive therapy
can help her cope with these life changes."
TEACHING POINT
Management of Depression
When treating patients with major depression disorder, a
biopsychosocial approach should be considered. "Bio" refers to
pharmacotherapy; "psycho" refers to psychotherapy; and
"social" refers to the identification of life stressors.
While either medication or counseling can be effective when
used alone, using the two treatment modalities concurrently
offers the patient the most beneficial and comprehensive
therapy, and is associated with the highest rates of remission.

Medication:
In a first episode of depression, it's usually recommended that
the patient take the medication for nine to 12 months, as
stopping any sooner runs a high risk for recurrence. Recurrent
episodes of depression are treated for two to three years. With
multiple recurrences and - in the elderly, who experience
increased rates of recurrence - continuous therapy should be
considered.
SSRIs, such as sertraline, and SNRIs are generally considered
safe and effective drugs for depression. They have lower rates
of side effects compared to the older tricyclics and, unlike the
tricyclics, have little risk of overdose. A tricyclic such as
amitriptyline would not be a first-line approach because of its
multiple side effects including anti-cholinergic effects and
sedation.
Psychotherapy:
Psychotherapy, most notably cognitive behavior therapy and
interpersonal therapy, have been found as effective as
psychotropic medications. It can be especially useful for
patients who want to avoid medication.
Exercise:
Trials of mixed exercise indicated a small but statistically
significant positive effect favoring exercise for the treatment of
mild to moderate depression and, similarly to combining

psychotherapy and medication, may have an additive effect
when used in combination with other modalities.
Avoidance of other substances:
Additionally, avoidance of recreational drugs and excessive
alcohol use is a necessary part of any treatment regimen.
ECT:
While ECT is not an appropriate treatment for an initial episode
of major depression, it is a safe and effective therapy that can
be useful in patients with psychotic depression or severe
nonpsychotic depression unresponsive to medications or
psychotherapy and seems to improve mild cognitive impairment
in depressed elderly.
TREATMENT OF CHOICE 2
THERAPEUTICS
"What are the differences between the various SSRIs, and how
do I choose which to use?" you ask Dr. Lee.
TEACHING POINT
Antidepressant Profiles
Effectiveness:
The selective serotonin reuptake inhibitors (SSRIs) and
serotonin-norepinephrine reuptake inhibitors (SNRIs) are all
equally effective in geriatric patients but recent analysis s hows

SNRIs have a higher rate of adverse reactions. While matching
the patient's symptoms with the drug's profile, keep in mind that
each patient's reaction to a medication is different and the final
selection needs to be individualized.
Cost:
Cost is another strong consideration. There are now generic
preparations of many antidepressants, making them more
affordable.
Drug-drug interactions:
Also, antidepressants have a wide variety of drug-drug
interactions, most prominently through the P450 system.
Side effects
While antidepressants are relatively safe, there are potential
side effects that vary in frequency and intensity between
medications and the individual patient.
Profiles
Drug
Comments
Fluoxetine (Prozac)Unusually long half life (two to four days),
so effects can last for weeks after discontinuation.

Most problematic (but uncommon) side effects include
agitation, motor restlessness, decreased libido in women, and
insomnia.  
Sertraline (Zoloft)In addition to being a frequently used SSRI in
pregnancy and breastfeeding, approved specifically for
obsessive-compulsive, panic, and posttraumatic stress
disorders. 
More gastrointestinal side effects than the other SSRIs. 
Paroxetine (Paxil)Side effects can include significant weight
gain, impotence, sedation, and constipation. 
Due to its short half-life, paroxetine is most likely of all the
SSRIs to cause antidepressant discontinuation syndrome.  
Paxil is Pregnancy Category D 
Fluvoxamine (Luvox)Particularly useful in obsessive-
compulsive disorder. 
Greater frequency of emesis compared to other SSRIs. 
Citalopram (Celexa)Most common side effects include nausea,
dry mouth, and somnolence. 
Maximum recommended dose: 20 mg per day for patients 60
years of age due to concerns of QT interval prolongation. 
Escitalopram (Lexapro)Approved specifically for Generalized
Anxiety Disorder. 
Overall, fewer side effects than citalopram. 
ALTERNATIVE THERAPIES
You discuss alternative therapies with Dr. Lee.
"I'm glad Mrs. Gomez mentioned trying out a traditional herbal
treatment," Dr. Lee tells you, "This is the sort of thing you don't
want to miss. Do you know anything about zapote?"
You quickly search a drug program on your smartphone and an

online database and identify a couple of websites that discuss
zapote and its suggested uses, but not much else.
TEACHING POINT
Complementary and Alternative Therapies
When obtaining a medication history, health care providers
should ask routinely about herbal and other supplements - as
well as over-the-counter medications and nutritional
supplements. Patients frequently will not mention the use of
complementary and alternative medical treatment unless they
are asked about them. Be respectful when patients discuss
alternative therapies, even if you are unfamiliar or skeptical
about a particular treatment.
Herbs and similar supplements are a concern because of their
potential to interact with conventional medications or produce
side effects, just like conventional drugs. Even where they were
obtained is important, as supplements have repeatedly been
found to be contaminated with other herbs, heavy metals, and
even prescription drugs. Only a few herbs have been
scientifically studied, so information on their effectiveness is
limited. St. John's Wort has been shown possibly to be effective
for short-term treatment of mild to moderate depression but data
from trials is mixed.
DISCUSSING THE PLAN
CARE DISCUSSION
When you re-enter the exam room, Dr. Lee sits down to talk
with Mrs. Gomez, "I would like to do a few tests to rule out any
medical problem that might be causing your symptoms. But it
looks as though you may be suffering from depression, which is
completely understandable given the recent changes in your life.

"This may also explain the increase in your blood sugar:
Depression takes away your energy and motivation, so it's hard
to summon the effort to stick to a diet or even remember to take
your medication regularly."
After discussing the options for treatment and the various
SSRIs, Mrs. Gomez agrees to try sertraline (Zoloft). Dr. Lee
writes a prescription for sertraline 25 mg daily, which is well
tolerated and available in a generic form. She tells Mrs. Gomez,
"Possible side effects include headache, nausea, diarrhea,
sleepiness, and (infrequently) insomnia. Because of your age
and other medical problems, I'm starting with a moderate dose,
but we may increase it later if you don't have an adequate
response."
Dr. Lee is also worried that Mrs. Gomez's methyldopa may be
aggravating her depression, so she substitutes amlodipine 5 mg
daily. This would also be in line with current blood pressure
research.
Next, she suggests,
"Mrs. Gomez, another treatment that is very effective for
depression is talking with a therapist."
You recommend Mrs. Gomez try to get some exercise, possibly
walking at the local mall. She agrees to try this. And you give
Mrs. Gomez and her daughter a handout about the diagnosis of
depression and a list of community resources for people
struggling with depression.

Dr. Lee reviews the plan with Mrs. Gomez and her daughter:
"We will order the blood tests to make sure there are no other
medical conditions causing your symptoms. I will order a
hemoglobin A1c to see how your diabetes is doing. We may
need to adjust your diabetes medicine."
"Do you have any other questions?" Dr. Lee asks Mrs. Gomez
and her daughter. They shake their heads no.
Dr. Lee then concludes the visit: "It will probably take four to
six weeks before the medication becomes effective, but it is best
if I see you before then - let's say in two weeks - to monitor
your progress and discuss any problems or side effects; we will
also review your tests and see if anything else needs to be done.
Please feel free to call or come in sooner than that if you have
concerns, feel worse, or experience side effects that prevent you
from continuing to take your medication."
FOLLOW-UP VISIT 1
HISTORY
On a return visit to Dr. Lee's office two months later, you see
Mrs. Gomez is on the schedule. It is her first visit to the clinic
since your previous encounter. Her daughter is in the waiting
room.
When you ask how she's been doing, she says, "Just terrible. I
still can't sleep, and now I find that I'm crying all the time." She
admits that she never started her sertraline and didn't get the lab
tests. She was worried that people would think she's crazy. She
also felt that she should be able to handle her feelings without
using drugs.

You ask her what she thinks is wrong with her. She replies she
simply thinks she is grieving the loss of her husband. She's been
trying to use prayer to overcome it, but this hasn't worked so
far.
ASSESSING LIVING SITUATION
Mrs. Gomez describes her stressful situation.
"I worry about my daughter," Mrs. Gomez says tearfully
through the interpreter. "She's just so angry all the time." At
this point, Mrs. Gomez starts to cry. You attempt to comfort her
for a moment, and then retrieve Dr. Lee for assistance.
Dr. Lee offers Mrs. Gomez a tissue and holds her hand. After a
moment, she asks,
"Mrs. Gomez, can you tell me why you are worried about your
daughter?"
Dr. Lee responds,
"I have to ask, has your daughter ever hurt you or threatened
you?"
A quick exam finds no bruises or other signs of abuse.
Dr. Lee explains to Mrs. Gomez that you and she are going to
talk with Silvia and will be back in a moment.

CONVERSATION WITH DAUGHTER
Silvia is interviewed alone.
You and Dr. Lee interview Sylvia alone. She admits finding the
demands of caring for her mother increasingly draining.
Assuring her that it is common for adult children to find
themselves caring for both their parents and their own children
(a situation sometimes referred to as the "Sandwich
Generation"), Dr. Lee directs Silvia to a website
(http://www.familyaware.org/) for families dealing with
depression. The website includes:
Lay-oriented educational materials on depression
Resources on how to deal with their own emotional reactions to
the illness
Lists of support groups
     
When you have answered all of her questions, you excuse
yourselves from the room.
Dr. Lee states that she doesn't feel that there is much risk for
abuse in this case, although it's something a provider should
keep an eye open for in such taxing situations.
TEACHING POINT
Elder Abuse
Early research indicates the following risk factors for abuse:

Dementia.
Shared living situation of elder and abuser (except in financial
abuse).
Caregiver substance abuse or mental illness.
Heavy dependence of caregiver on elder. Surprisingly, the
degree of an elder's dependency and the resulting stress has not
been found to predict abuse.
Social isolation of the elder from people other than the abuser.
PHARMACEUTICAL TREATMENT
THERAPEUTICS
You and Dr. Lee return to speak with Mrs. Gomez about her
depression.
"I can appreciate your concern about the diagnosis of
depression," says Dr. Lee. "I hope it will help to know that
these feelings you are having are very common: More than 14
million Americans experience depression in any given year. I
see lots of people who are depressed in this clinic, and they are
not 'crazy.' Depression is not a weakness of character that you
should try to deal with on your own. It's a medical condition
just like your diabetes. And just like you take medication to
help control your diabetes, we have medication to help with
depression. This can be a severe problem, and is unlikely to
clear up anytime soon without appropriate help."
"But I am afraid I won't have the same feelings if I take
medication," Mrs. Gomez interjects, "I don't want to change
who I am."
Dr. Lee explains, "I am glad you shared your concern with me. I

want to assure you that the medication won't change who you
are; in fact, I believe that this medication will be helpful in
allowing you to be more like you normally are. I also know you
are concerned about Silvia and how she's dealing with her own
stress. This is the best thing you can do, not only for yourself,
but also for your family."
Mrs. Gomez replies, "Well, I suppose it can't hurt to give the
medicine a try. I don't seem to be getting better on my own."
Dr. Lee then replies, "Great. I know this is hard for you to do,
but I think you will find it helpful. Once you start taking the
medication, you may start feeling better as quickly as within a
week. But you probably won't feel the full effects for about two
months. Try not to get discouraged. Depression can be very
frustrating. It will take time for your depression to go away."
Dr. Lee re-prescribes the sertraline and Mrs. Gomez gives her
assurance that she will try it this time. Dr. Lee also reorders the
lab tests and refers Mrs. Gomez to the local government
Department of Aging to see if there are any support services
they might provide.
THERAPEUTIC CHALLENGES
TEACHING
After Mrs. Gomez and her daughter leave, Dr. Lee advises you,
"It is common to have difficulty getting an older adult to adhere
to an antidepressant regimen."
TEACHING POINT
Adherence to Antidepressant Medication in the Elderly
Providers note that adherence to depression treatment in older

adults occurs only about half the time. The reasons are
understandable and include:
Inability to afford the medication
Concerns about side effects
Worry about the stigma of the diagnosis
Not understanding how to take the medication properly
     
The important thing is not to blame the patient, but to educate
them about the recommendations, allowing the patient to ask
questions and fully express any concerns.
FOLLOW-UP VISIT 2
Mrs. Gomez is feeling much improved.
You see Mrs. Gomez and her daughter again about two months
later when you return to Dr. Lee's clinic.
"So nice to see you, Mrs. Gomez!"
"How are you feeling?"
Today her score on the Geriatric Depression Scale is 4, which is
in the normal range.
Silvia adds, "Mom has made new friends at church and has
become involved with a group of women there that she spends
time with several days a week. It's nice to see her taking an
interest in things again. It actually takes a huge weight off my

shoulders, as well. Thank you for all of your help."
This is the final page of the case. We value your perspective on
the learning experience. After completing three required
feedback ratings you can finish the case and access the case
summary.
__MACOSX/Case study 4.rtfd/._TXT.rtf
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Discussion Mental Health
This discussion assignment provides a forum for discussing
relevant topics for this week based on the course competencies
covered. For this assignment, make sure you post your initial
response to the Discussion Area by the due date assigned.
To support your work, use your course textbook readings and
the South University Online Library. As in all assignments, cite
your sources in your work and provide references for the
citations in APA format.
Start reviewing and responding to the postings of your
classmates as early in the week as possible. Respond to at least
two of your classmates’ initial postings. Participate in the
discussion by asking a question, providing a statement of
clarification, providing a point of view with a rationale,
challenging an aspect of the discussion, or indicating a
relationship between two or more lines of reasoning in the
discussion. Cite sources in your responses to other classmates.
Complete your participation for this assignment by the end of
the week.

For this assignment, you will complete a Aquifer case study
based on the course objectives and weekly content. Aquifer
cases emphasize core learning objectives for an evidence-based
primary care curriculum. Throughout your nurse practitioner
program, you will use the Aquifer case studies to promote the
development of clinical reasoning through the use of ongoing
assessments and diagnostic skills and to develop patient care
plans that are grounded in the latest clinical guidelines and
evidence-based practice.
The Aquifer assignments are highly interactive and a dynamic
way to enhance your learning. Material from the Aquifer cases
may be present in the quizzes, the midterm exam, and the final
exam.
Learn how to access and navigate Aquifer.
This week, complete the Aquifer case titled “Family Medicine
03: 65-year-old woman with insomnia”
Apply information from the Aquifer Case Study to answer the
following discussion questions:
Discuss the Mrs. Gomez’s history that would be pertinent to her
difficulty sleeping. Include chief complaint, HPI, Social, Family
and Past medical history that would be important to know.
Describe the physical exam and diagnostic tools to be used for
Mrs. Gomez. Are there any additional you would have liked to
be included that were not?
Please list 3 differential diagnoses for Mrs. Gomez and explain
why you chose them. What was your final diagnosis and how
did you make the determination?
What plan of care will Mrs. Gomez be given at this visit,
include drug therapy and treatments; what is the patient
education and follow-up?

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Case study 4.rtfdTXT.rtfYou are doing an eight-week clerkship