Applying Knowledge Gained from Case Studies to Clinical Practice in the Treatment of Sleep/Wake Diso

Three Questions to Ask the Client

ASSIGNMENT EXPLAIN HOW YOU MIGHT APPLY KNOWLEDGE GAINED FROM CASE STUDIES ANALYSIS 1 AND 2 BELOW TO YOU OWN PRACTICE IN CLINICAL SETTINGS. PROVIDE 3 REFERENCES FOR YOUR RESPONSE CASE STUDY 1(200 WORDS AND 3 REFERENCES) Sleep/Wake Disorders Three Questions The first question that

I would ask this client is how is the insomnia affecting you?

It is essential to find out when she is unable to sleep does, she lay there trying to meditate to go back to bed, or is she laying there in distress. This can guide the treatment options appropriate for her, whether she is experiencing recurrent worrying thoughts, and if this is a constant occurrence. The second question I would ask her is what is your sleep routine like?

What are the types of things she is doing before falling asleep can play a role in why she is having difficulty sleeping. She needs to create a peaceful routine before sleep, such as turning off electronics at least an hour before bedtime, reading a book, going to bed every night at the same time, and avoiding caffeine a few hours before bed. The sleep patterns of older adults natural change as they get older, so this is something that she needs to be aware of and address to help with her sleep hygiene. The third question I would ask her is what are your thoughts on getting a pet?

Pets play a unique role in people suffering from depression; studies have shown that pet owners create an extraordinary bond with their pet both through walking and just living with them. The client’s hearing impairment is one of the reasons she expresses feelings of depression. Animals can often help people get over or avoid feelings of loneliness and sadness. Animals can provide an amount of emotional and social support that is important to a healthy mind. This is an option that she can consider to help her cope with her depression. People in Life The people who would be able to provide insight regarding her condition would be the people she interacts with regularly, which would be her home aide and her son. I would ask what does her schedule consist of during the day?

What is she doing before bedtime? Are there particular activities that she seems to enjoy?

How long does she sleep for during the day? Has the client ever expressed feeling of sadness or loneliness?

People in Life

How much time do you spend with her? When did you first notice the symptoms of depression?

These questions will provide an understanding of the extent of how her symptoms are affecting her daily activities. It is one thing to have the client describe her symptoms, but when a person sees it firsthand and can provide that information, it brings it into a better perspective on how it impacts her. The questions above will also give a clearer picture of the extent of how her symptoms are affecting her life.

The questions will help to devise a treatment plan regarding teaching her healthy sleep habits. It can also help her to understand the importance of having a healthy support system during the course of treatment. Physical Exams/Diagnostic Test The testing that would be appropriate for this client is to order a recent thyroid level to see if there are any changes to her TSH levels. She is currently on Levothyroxine 40mg; the dose may need to be adjusted. Thyroid function can affect a person’s mood relating to depression. A sleep study to rule out obstructive sleep apnea since she reports snoring and poor sleep habits can be a depression factor.

According to Richards et al. (2018), “ Finding and treating the underlying cause of the sleep disturbance is critical to effective management” (p.17). There is a significant correlation between depression symptoms and insomnia, which can also play a role in the symptoms she is experiencing. A blood test to check iron deficiency since restless leg syndrome is based on central nervous system iron deficiency. A referral for her to see a neurologist rule out restless leg syndrome would be appropriate since this a significant complaint contributing to her not being able to sleep well. Patient education on discontinuing Allegra medication is advisable since this drug can worsen the symptoms of restless leg syndrome.

Three Differential Diagnosis The three differential diagnoses are major depressive disorder, obstructive sleep apnea and narcolepsy. Depression and insomnia are associated with that insomnia is a symptom of depression. As Becker et al. (2017) concluded, “An older person’s lack of good sleep quality is probably associated with depressive symptoms” (p. 890).

The majority of clients who have depression have an insomnia complaint. This would be a probable diagnosis. The client reports insomnia and reports symptoms of depression. Major depressive disorder is a mood disorder that impacts sleep, causing insomnia, difficulty staying asleep, or sleeping too much. The symptoms of depression can also include feelings of sadness, decreased energy, changes in eating habits. This would be the most likely diagnosis. Obstructive sleep apnea is correlated with obesity, loud snoring, and apnea episodes at night, resulting in low sleep quality for these patients. The client reports loud snoring and frequent naps during the day would suggest the diagnosis of OSA. Patients with OSA sleep have symptoms of daytime tiredness, trouble concentrating, sleep disturbance, which is also associated with depression.

Physical Exams/Diagnostic Test

The client has not had a sleep study for a definitive diagnosis to rule this out. The third diagnosis would be narcolepsy, a disorder that impairs the sleep-wake cycle, leading to frequent lapses into sleep and elements of sleep elements while a person is awake. Patients experience daily sleepiness, cataplexy, inability to move at the end or start of sleep, vivid hallucinations, or fragmented sleep. This diagnosis would be unlikely since she denies hallucinations, muscle weakness triggered by strong emotions, sleep paralysis, or waking up during the night. Two Pharmacologic Agents The two pharmacologic agents appropriate for this client to treat her sleep/wake therapy would be Ramelteon or Mirtazapine. The first medication would be Ramelteon (Rozerem), which is a melatonin receptor agonist sedative-hypnotic that mimics melatonin receptors as an agonist. Shroeck et al. (2016) noted, “Ramelteon is distinguishable from other common competition in the insomnia market in that it does not cause general CNS sedation” (p. 2345).

She complained of difficulty falling asleep, which this drug is safer for her to use and help with initiating sleep. Aging influences the pharmacokinetics of medications in the older adult population, altering the absorption rate, which needs to be considered when prescribing medications. Ramelteon prescribed at 8 mg taken at night would be the starting dose. It has about an 8-hour duration when used. This drug would be the best one to initiate treatment due to her complaints and probable diagnosis of OSA, which has been safe to use with this condition. Melatonin is a hormone secreted by the pineal gland and is secreted at night to regulate sleep. There are two types of melatonin receptors, MT1, and MT2 receptors it will not depress CNS improves the quality of sleep. Ramelteon is known to act on MT1 and MT2 receptors. It will induce sleep, so no rebound insomnia occurs, and no withdrawal symptoms (Perumal et al., 2011, p. 55).

The adverse effects are fatigue and dizziness, increased prolactin secretion, and a decrease in testosterone levels. The active metabolite metabolizes it by cytochrome system. It does interact with certain drugs. The second medication would be Mirtazapine (Remeron), which is an atypical antidepressant. This drug causes sedation and weight gain. It does not have significant drug to drug interactions and best used as an augmenting agent with other antidepressants. This medication does not have monoamine reuptake inhibition properties. It is a serotonergic and noradrenergic antidepressant. The drug has a half-life of 20-40 hours and does not have active metabolites. Mirtazapine is a histamine one antagonist that is linked to sedation, increased appetite, and dry mouth (Stimmel et al. 2012, p. 4). This medication would be an excellent option to treat her insomnia and depression, but it does have the potential for weight gain. This would not be the best treatment option for her, since she is has history of obesity. The dose that would be prescribed to her is 15 mg at night, titrated up to 45mg.

Medications such as Mirtazapine, Trazadone, Doxepin have sedating quality long half-lives. They have adverse effects on daytime cognitive effects such as sleepiness and possible memory impairment and confusion. Check Points The checkpoints indicated at four weeks indicated partial response, so titrating upward may be an option and adding an augmenting agent to treat her insomnia. Sleeping better improves mood disturbance more and faster when people are sleeping well. At the two month mark, she is still complaining of inability to sleep; at this point, testing should be done to rule out conditions that might be attributed to her insomnia, such as the OSA and RLS. At this point, incorporating cognitive behavioral therapy should be initiated. The client should also be addressing her hearing impairment with a specialist since this is also playing a role in her symptoms of depression, affecting her quality of life.

The four-month mark should be focused on her medical conditions and making sure they are being resolved. At this point psychotherapy and teaching proper sleep hygiene is important. The months nine and beyond should include proper educating on the importance of wearing the CPAP mask and her understanding its benefits on her mental and overall health. The client continues to complain of restless leg syndrome, so I would address incorporating more physical activity such as swimming or possibly physical therapy. Lesson learned The lessons learned from this case study are the important role sleep has on clients struggling with mental health disorders. Clients who are depressed have various patterns in their sleep.

The goal that I would like to implement in my practice is to help clients understand that creating good sleep habits is essential and that adequate time is needed to make sure clients are prescribed a maximum tolerated dose. References Richards, K., Demartini, J., Xiong, G. (2018).