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Insomnia and Depression in the older adult
Presenting is a 75 year-old female who presents with worsening depression and new onset insomnia since the death ten months ago of her husband of 41-years. The patient presents alert and oriented X3 spheres, arrived VIA private vehicle, denies suicidal ideations at this time and traditionally sees her PCP up to twice yearly. Patient reports taking metformin, januvia, losartan, HCTZ, and sertraline. Patients medical conditions are not listed, but based on chart review of medications and age, patient is assumed to have diabetes type 2 and high blood pressure. Patients BP at clinic visit is 132/86 (managed). No additional complaints made at this time.
-List three questions you might as the patient if she were in your office.
What does depression mean to you? What would be the items you would identify if someone asked you why you felt depressed?
-Depression can be caused by many different things. The patient reported the loss of her husband of 41 years less than one year from this visit, and it is possible that the patient has not made it past a certain point of grieving. It is unknown of what type of relationship they had, and it is possible that the patient’s husband was her primary caregiver, and without him she may be having greater difficulty managing living on her own, which could increase the patient’s depression. Furthermore, the patient may not have children or other family to be there to support or talk to her, and it is possible her late spouse was the only person that she had. Having support through grief, especially those that were close to both the patient and the loved one who has passed can help in the patient in their grieving process (Pdq, 2020). Grief can increase levels and feelings of depression within the already depressed patient, and lead them into a depressed episode, as well as lead to problems with sleep either with too much sleep or inability to fall or stay asleep (Parkes, 1998). The patient could feel depressed due to worsening health concerns, or just out of missing her husband or no longer doing the activities that they may have once shared together.
What are your current sleeping habits? When did your sleeping habits change? What were your sleeping habits before the noticed change?
-It is important to understand the patient’s current complaint of insomnia, and what insomnia means to them, and it should be clearly defined on what issue the patient is having such as the inability to fall or stay asleep or is her mind racing leading her to being unable to fall asleep. Is she having changes in diet which is leading her to have increased trips to urinate throughout the night? Having type two diabetes, the patient is at risk for higher blood sugars leading to increased urination throughout the night, and with increased aged comes possible decreased muscle tone and lower tolerance to hold larger amounts of urine. Furthermore, it has been found that women were most likely to stress eat during bereavement periods than men, and with possibly increasing caloric intake, especially if now only cooking meals for one may not be as healthy and could be leading to increased insulin levels (Oliveira, Rostila, Saarela & Lopes, 2014). It is a possibility that the patient has never slept a night in her life since marriage until the death of her spouse, which may lead to sleep being something that is uncomfortable for her as well. And furthermore, it could warrant the question to ask if the husband passed at home, as it could also be that the patient has not resolved that her husband may have passed in their bed/home. Lastly, the patient may be experiencing anticipatory fear of possibly passing herself, since the death of her husband has happened and the reality that death is imminent may be at play, possibly leading to racing thoughts which should be explored if that is present.
Has the patient stopped doing things she once enjoyed since the loss of her husband?
Grief is complicated and not everyone who experiences the loss of a loved one is able to cope with that loss. By moving on with life, and continuing to be in a environment where one is reminded of the lost loved one, it can make coming to terms with the loss even more difficult. Grief can lead to isolation, especially when experiencing depression, and can lead to the lack of motivation, desire, or will to do things or see people or do things that she once enjoyed. By isolating ones self, it can further lead to depression and complicate the patients current condition. By isolating ones self, and no longer placing yourself in the situations of which used to bring happiness, the patient voids themselves of happy or positive experiences, leading to further increases in depression, thus the need for interaction and support from others is crucial in helping combat grief and depression, which could also in turn help insomnia concerns (Pitman, King, Martson, & Osborn, 2020).
-List three people in the patients life that you would need to speak to or get feedback from to further assess patient.
The three people in the patients life I would want to speak to would be any close children that may have further insight into the patients life, any close friends that may see the patient on a day to day basis, as well as her primary care provider. Any adult child that has a relationship with the patient would be a good resource to speak with. Background information could be obtained about the details of the passing of the patients husband, and if the patient had any challenges before the death such as being his primary care provider until death, or if the passing was slow and painful. Children would have known the patient prior to the death of husband as well as current, and would be helpful in identifying any changes in behavior. Furthermore, the patients children may have insight into the patients depression prior to death of husband, and can assert what patterns have negatively gotten worse, or if there are things that the patient is not forthcoming about. Close friends who the patient consents to speaking with would be a good resource as well as friends generally confide in one another, and may be able to offer some insight of any comments or concerns that the patient may have raised that she did not mention in the current visit. The patient may feel comfortable speaking to a friend versus a child about thoughts of death, or possible thoughts of suicide as to not scare their child (who recently just lost a parent) and my feel that the friend has insight as they may have experienced something similar. The patients primary care provider would be a good resource we well due to the patient seeing them once or twice a year, and questions about medication management/compliance could be loosely assessed. Further, speaking with the PCP, it could be explored if the patient has made any comments related to depression or grief since the passing of her husband, and if there have been any noticeable changes at any recent appointments. Additionally, by speaking with the PCP, it could be asked if the patient has been showing signs of depression and if it has gotten worse since visit with PCP prompting to come to psychiatry, and was the PCP the one who started her on Zoloft and why that course of medication was chosen, including if any side effects were noticed during any course of treatment and if that was the first medication tried, or is that one that she has just seen noticeable changes on?
-Diagnostics
Due to the patient having hypertension, getting a baseline EKG is always a good idea to check for any cardiac conduction abnormalities that could eliminate certain medications from treatment (Stern, Fava, Wilens, & Rosenbaum, 2016). Conducting a rating scale using the Hamilton Depression rating scale gives a baseline on patient’s current depressive symptoms, and will help evaluate at future appointments the effectiveness of medication changes at this visit (Williams, 1988). CBC, CMP, prolactin levels (due to some antipsychotics increasing prolactin levels), weight for baseline measurement, baseline blood sugar, baseline blood pressure, as well as fasting lipid panel as antipsychotics are known to have a metabolic side effect profile and the patient is already a known diabetic (Freudenreich, Goff, & Henderson, 2016).
-Differential Diagnosis
Prolonged Grief Disorder- Prolonged Grief Disorder can be diagnosed as earlier as 6 month post the death of someone that has severely impacted that patients life, leading to the patient to possibly experience emotional pain or grief, loss of routine social activities, lack of ADLs and adherence to routines, feelings of emptiness, increased depression and isolation (Killikelly & Maercker, 2018).
Major Depressive disorder- The patient carries a diagnosis of depression, and that may have further been pushed into a depressive episode with the death of her husband, of which she has been unable to lighten those feelings. Grief and the loss of a loved one, especially one that the patient lived with and most likely confided in everything, may be experiencing the loss of more than just a loved one, therefore adding to the depression with the inability to confide their sadness to (Jacobsen, Zhang, Block, Maciejewski, & Prigerson, 2010).
Insomnia- The patient is experiencing disruption in sleep patterns, assumed to be decreased sleep. Insomnia can be caused due to depression or grief, and can subside on its own, or can prolong and be debilitating and cause disruptions in the patient’s daily life, including leading to isolation due to irritability and frustration (Krystal, Prather, & Ashbrook, 2019).
PTSD- The patient may be suffering from post-traumatic stress disorder depending on the nature of her husband’s death, but has been minimalizing her current symptoms. PTSD can cause depressive symptoms to worsen, decreased sleep, and disruptions in daily patterns of life that could further complicate depression, and furthermore lead to thoughts that she could have done something different and could carry sadness (Mann & Marwaha, 2021).
-Pharmacological Agents
-Quetiapine- Seroquel was found in a study to have improved satisfaction and overall improvement in depression when used in combination with sertraline. Studies showed that HAM-D scores improved when Seroquel was used as an adjunct therapy with sertraline, figuring that the combination targeted multiple specific mood receptors, and furthermore increased quality of sleep in these patients (Daly & Trivedi, 2007). Also, due to being loosely bound to D2 receptors, the likelihood of experiencing EPS effects from Seroquel are significantly lower (Daly & Trivedi, 2007). In recent studies conducted on women over the age of 65 with a current diagnosis of MDD, Seroquel was started at a low dose of 25 mg oral daily and saw that not only was Seroquel tolerated without effects with sertraline, but that it decreased depressive symptoms, and carried a side effect of sedation which would be beneficial in our current patient (Carta, Zairo, Mellino, Hardoy, 2007). Because of no negative interactions with sertraline, I would continue sertraline at the current dose and augment with adding Seroquel 25 mg oral at bedtime with the hope that she will experience decreased depressive symptoms and increased sleep.
-Olanzapine- Olanzapine was found to have fewer reactions with EPS effects, decreased drug interactions, as well as providing satisfactory reduction in depressive symptoms that were formerly unresolved with other antidepressant therapy and is tolerated well in the geriatric population (Madhusoodanan, Brenner, Suresh, Concepcion, et al, 2000). Furthermore, olanzapine has a sedative side effect which may be beneficial in also helping with the patients current complaint of insomnia, and for this reason should be dosed at night (Madhusoodanan, Brenner, Suresh, Concepcion, et al, 2000). This medication would be my second choice in medication therapy. I would titrate the Zoloft down over a course of two weeks, and then start the patient on low dose olanzapine to avoid the possibility of a rare side effect of irregular heart rhythm as the patient is taking a current SSRI (Madhusoodanan, Brenner, Suresh, Concepcion, et al, 2000). Because the patient is a geriatric patient, elimination concerns should be taken into consideration, and the patient should be started on a low dose in order to evaluate the response. Because of this, I would start the patient on low dose 5 mg oral daily at bedtime once titrated off Zoloft.
-Checkpoints
Four Week Follow up
Seroquel
At the patients four week follow up, I would conduct a HAM-D assessment to assess in changes in depressive symptoms to assess if medication change has been beneficial to patient. At this time, assessing for oversedation would be a priority, and if the patient has experienced any anticholinergic side effects (Freudenreich, Goff, & Henderson, 2016). Assuming that this medication adjustment has been beneficial to the patient, at the eight week follow up I would assess weight changes, and at twelve weeks I would conduct all Assessments that were done at baseline of treatment.
Olanzapine
At the patients four week follow up, I would conduct a HAM-D assessment to assess for any changes in depressive symptoms to evaluate current medication therapy, as well as assess for continued insomnia or if the current dose causes unwanted excess sedation (Freudenreich, Goff, & Henderson, 2016). Assuming that this course of treatment is beneficial to patient, at eight weeks I would checks weight and at twelve weeks I would assess for EPS effects, weight change, prolactin levels, fasting blood sugar, fasting lipids, and blood pressure (Freudenreich, Goff, & Henderson, 2016). I would expect the patient to experience increased sleep absent of daytime grogginess, with decreased depressive symptoms.
References
Carta, M. G., Zairo, F., Mellino, G., & Hardoy, M. C. (2007). Add-on quetiapine in the treatment of major depressive disorder in elderly patients with cerebrovascular damage. Clinical practice and epidemiology in mental health : CP & EMH, 3, 28. https://doi.org/10.1186/1745-0179-3-28
Daly, E. J., & Trivedi, M. H. (2007). A review of quetiapine in combination with antidepressant therapy in patients with depression. Neuropsychiatric disease and treatment, 3(6), 855–867. https://doi.org/10.2147/ndt.s1862
Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry : official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674
Madhusoodanan S, Brenner R, Suresh P, Concepcion NM, Florita CD, Menon G, Kaur A, Nunez G, Reddy H. Efficacy and tolerability of olanzapine in elderly patients with psychotic disorders: a prospective study. Ann Clin Psychiatry. 2000 Mar;12(1):11-8. doi: 10.1023/a:1009018809174. PMID: 10798821.
Mann SK, Marwaha R. Posttraumatic Stress Disorder. [Updated 2021 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559129/
Oliveira, A. J., Rostila, M., Saarela, J., & Lopes, C. S. (2014). The influence of bereavement on body mass index: results from a national Swedish survey. PloS one, 9(4), e95201. https://doi.org/10.1371/journal.pone.0095201
Parkes C. M. (1998). Bereavement in adult life. BMJ (Clinical research ed.), 316(7134), 856–859. https://doi.org/10.1136/bmj.316.7134.856
PDQ Supportive and Palliative Care Editorial Board. Grief, Bereavement, and Coping With Loss (PDQ®): Health Professional Version. 2020 Dec 3. In: PDQ Cancer Information Summaries [Internet]. Bethesda (MD): National Cancer Institute (US); 2002-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK66052/
Pitman, A. L., King, M. B., Marston, L., & Osborn, D. (2020). The association of loneliness after sudden bereavement with risk of suicide attempt: a nationwide survey of bereaved adults. Social psychiatry and psychiatric epidemiology, 55(8), 1081–1092. https://doi.org/10.1007/s00127-020-01921-w
Jacobsen, J. C., Zhang, B., Block, S. D., Maciejewski, P. K., & Prigerson, H. G. (2010). Distinguishing symptoms of grief and depression in a cohort of advanced cancer patients. Death studies, 34(3), 257–273. https://doi.org/10.1080/07481180903559303
T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics. Elsevier.
Williams JBW. A Structured Interview Guide for the Hamilton Depression Rating Scale. Arch Gen Psychiatry. 1988;45(8):742–747. doi:10.1001/archpsyc.1988.01800320058007
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