course material

1. Post- Lynae
Respond of your colleagues who were assigned to a different case than you. Explain how
you might apply knowledge gained from your colleagues’ case studies to you own practice
in clinical settings. Main Post Sleep/Wake
DisordersThe patient is an obese 70-year-old female with a chief complaint of “being sad.”
Her husband passed away several years ago due to coronary artery disease (CAD). She lives
at home alone and has a home health aide help her. Her son comes to visit her often. She
was feeling well until her hearing began to diminish in both ears. Her mobility has declined,
so she has not been able to get out as much. She is often lonely at home. She has daily crying
spells, is often very tired, has good insight to her illness, and wants to get better. Three
Questions to Ask the Patient and Why The case study mentioned that the patient is a
candidate for cochlear implants, but it is a long way off. Thus, my first question to ask the
patient is what is preventing her from getting cochlear implants? She began experiencing
sadness when she began to lose her hearing and mobility. Therefore, regaining her hearing
may help decrease the depression. If its financial reasons, maybe there are resources that
can help her. Finding out the reason the patient isn’t getting the implants can help the
provider and patient find solutions. The patient also mentioned that her sleep was
“awful”, stating her legs “ache and jump”, she takes frequent naps during the day, and
admits to snoring frequently. Thus, the second question I would ask is what are her sleeping
habits like? Individuals who have good sleep habits sleep better. Getting better sleep can be
obtained by being consistent by going to bed at the same time each night and waking up the
same time each day (Centers for Disease Control and Prevention, [CDC], 2016). Individuals
can make sure the room is dark, quiet, and cool (CDC, 2016). Additionally, remove
electronic devices, avoid large meals, caffeine, and alcohol can help with getting better sleep
(CDC, 2016). My third question would be what do you do when you are sad?
Individuals who are depressed often have a negative view of the world and often think of
themselves as worthless (This Way Up, n.d.). They often blame themselves when something
bad happens and feel like they are unlucky (This Way Up, n.d.). Thus, helping individuals
identify negative thinking and reframe the way they think about life can help improve
depressive symptoms (This Way Up, n.d.). People to Speak to with Specific Questions to
Ask The first person I would want to speak to is the patient’s son. The case study states the
son visits her often so he should know the patient’s habits. First, I would ask him the same
questions I asked the patient such as what is preventing the patient from getting cochlear
implants, what are her sleep habits, and what does she do when she is sad? By asking the

2. son the same questions, insight can be shown on how the son views things and how the
patient views things. I would also him when he began to notice her depressive symptoms
because that will help provide a timeline as to when it all began. The second person I
would talk to is her home health aide because she is familiar with the patient. I would ask
her what the patient’s home life is like such as how is she maintaining her house? Is she able
to clean up after herself? How is she doing with activities of daily living? These questions
can provide insight on the severity of the patient’s depressive symptoms. Physical Exams
and Diagnostic Tests and How Results Would Be Used The first diagnostic test I would
want to perform on the patient is the 9-item Patient Health Questionnaire (PHQ-9). The
PHQ-9 is a screening tool for major depression (Na et al., 2018). The test is a reliable and
valid measurement of depressive symptoms that also asks about the individual’s thoughts
of death or self-injury within the last two weeks (Na et al., 2018). The results would be used
to determine the severity of her depression. Another diagnostic test that can be performed
on this patient is a polysomnography. A polysomnography is a sleep study that helps
providers diagnose sleep apnea, periodic limb movement disorder, restless leg syndrome
(RLS), insomnia, and nighttime behaviors (National Sleep Foundation, n.d.). The results
would be used to can help determine the cause of her daytime sleepiness such as sleep
apnea or RLS. I would also want to run a complete blood count (CBC) with differential on
the patient. I would specifically want to obtain a red blood cell count (RBC) and white blood
cell count (WBC). Thus, a CBC with differential would help determine if the patient is
fatigued due to anemia or an underlying infection. Three Differential Diagnosis and WhyThe
three potential differential diagnoses include:Major Depressive DisorderPersistent
Insomnia Disorder Obstructive Sleep Apnea Hypopnea The most likely differential diagnosis
is major depressive disorder (MDD). The diagnostic criteria for MDD is five or more
symptoms during the same 2-week period and a change from previous functioning
(American Psychiatric Association, 2013). The symptoms include: depressed mood most of
the day, marked diminished interest or pleasure in all or almost all activities most of the
day, significant weight loss or weight gain, insomnia or hypersomnia neatly every day,
psychomotor agitation or retardation nearly every day, fatigue or loss of energy nearly
every day, feelings of worthlessness or excessive or inappropriate guilt nearly every day,
diminished ability to concentrate, and recurrent thoughts of death (American Psychiatric
Association, 2013). The patient fits this diagnosis as evidence by depressed mood,
diminished interest in activities she used to enjoy, fatigue, diminished ability to concentrate,
and psychomotor retardation.Two Pharmacological Agents and Dosing and Why One
pharmacologic agent that can be tried is doxepin 3 mg at bedtime for insomnia. Doxepin
works by boosting serotonin and norepinephrine by blocking the serotonin reuptake pump
and norepinephrine reuptake pump (Stahl, 2017). At hypnotic doses, doxepin blocks
histamine-1 receptors, which promotes sleep (Stahl, 2017). Doxepin is a substrate for
CYP450 2D6 and has a half-life of 8-24 hours (Stahl, 2017). In the elderly, the recommended
dose for insomnia is 3 mg per day (Stahl, 2017). Another pharmacologic agent that I
would like to start the patient on is bupropion (extended release) XL 150 mg daily in the
morning. Bupropion is used to treat MDD and works by boosting norepinephrine and
dopamine by blocking the norepinephrine reuptake pump and dopamine reuptake pump

3. (Stahl, 2017). Bupropion inhibits CYP450 2D6, has a parent half-life of 10-14 hours, and a
metabolite half-life of 20-27 hours (Stahl, 2017). Thus, since bupropion blocks the
dopamine reuptake pump and norepinephrine reuptake pump, this medication is beneficial
in improving symptoms of loss of happiness, joy, interest, pleasure, energy, enthusiasm,
alertness, and self-confidence (Stahl, 2013). Thus, because of bupropion’s mechanism of
action and the patient’s symptoms, I would want this patient to try this medication. Lessons
Learned Lessons learned during this case study is that geriatric depression can be difficult
to treat. They often have multiple comorbidities with the possibility of more pronounced
side-effects (Stahl, 2008). Additionally, medications can have contraindications that do not
previously exist prior to the patient being put on medication. Thus, providers must be
aware of new and old warnings on medications in the event there are changes made to
medications. I will apply this information when I am in practice by paying close attention to
dosages, side effects, and potential contraindications when providing medication to the
geriatric population. ReferencesAmerican Psychiatric Association.
(2013). Diagnostic and statistical manual od mental disorders (5th ed.). Washington, DC:
Author. Centers for Disease Control and Prevention. (2016). Tips for better sleep. Retrieved
from https://www.cdc.gov/sleep/about_sleep/sleep_hygiene.htmlNa, P. J., Yaramala, S. R.,
Kim, J. A., Kim, H., Goes, F. S., Zandi, P. P.,…Bobo, W. V. (2018). The PHQ-9 item 9 based
screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ-9)-9
item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS). Journal of Affective
Disorders, 232, 34-40. doi: https://doi.org/10.1016/j.jad.2018.02.045National Sleep
Foundation. (n.d.). Sleep apnea. Retrieved from https://www.sleepfoundation.org/sleep-
apneaThis Way Up. (n.d.). How do you feel? Retrieved from https://thiswayup.org.au/how-
do-you-feel/sad/Stahl, S. M. (2008). Essential psychopharmacology online. Retrieved from
https://stahlonline-cambridge-
org.ezp.waldenulibrary.org/viewPdf?page=csEP_16.pdf&vol=2Stahl, S. M. (2013). Stahl’s
essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.).
New York, NY: Cambridge University Press. Stahl, S. (2017). Stahl’s essential
psychopharmacology: Prescriber’s guide (6th ed.). San Diego, CA: Cambridge University
Press.