100 word reply due tomorrow at 9 am


Case: An antiquated widow who righteous lost her colleague. 

Subjective:  A resigned gives to your first circumspection duty today following a while pre-eminent  complaint of insomnia. Resigned is 75 YO following a while PMH of DM, HTN, and MDD.  Her mate of 41 years passed separate 10 months ago. Since then, she  states her degradation has gotten worse as courteous-mannered-mannered as her repose habits. The  resigned has no preceding narrative of degradation preceding to her mate’s  death. She is reanimate, lively, and oriented x3. Resigned regularly sees PCP  once or twice a year. Resigned denies any suicidal ideations. Resigned  arrived at the duty today by not-public bearing. Resigned currently takes  the followingcited medications: 

•           Metformin 500mg BID 

•           Januvia 100mg daily 

•           Losartan 100mg daily 

•           HCTZ 25mg daily 

•           Sertraline 100mg daily 

 Current consequence: 88 kg

Current climax: 64 inches

Temp: 98.6 degrees F

BP: 132/86 

             Insomnia is a guess-work linked following a while awkwardness in repose sort,  initiating or maintaining repose, concurrently following a while corporeal pain and  impairments of dayera exerciseing. Its power ranges from 10 to 15%  unarranged the public population, following a while remarkable rates seen unarranged womanishs,  divorced or separated race, those following a while damage of preservationd-for ones, and  older race (Bollu & Kaur, 2019). Insomnia can balean be defined as  a repose guess-work where the resigned has perplexity flux arepose or  staying heedless. According to Krystal et al (2019), it is a contemptible  condition that is linked following a while noticeable reward in exercise and  sort of conduct, invisible and tangible morbidity. The mournts of  insomnia are give in 60–90% of resigneds following a while elder degradation,  Complaints of disrupted repose are very contemptible in resigneds indisposition from  depression, (Wichniak, etal., 2017).

Questions you force ask the resigned and rationale

             The peculiarity and composition of insomnia lean largely on a thoroughgoinggoing repose  narrative to harangue the precipitating factors as courteous-mannered-mannered as maladaptive  behaviors resulting in insufficient repose (Bollu & Kaur, 2019).

What  is your repose exemplar including how manifold hours of repose do you get at  extinction preceding to your mate’s fall and what it has been in the 10  months since his failure? Does she discharge positive rituals or do bigwig  special precedently she reposes. This assesses if the insomnia agoing precedently  or following the mate’s failure. This provides a elimination to insomnia that may  be cognate to loss.

What  era do you go to bed entire extinction and what is your regular settlement  precedently going to bed? This is to bung if the resigned is doing bigwig  differently which has disrupted her regular settlement and principled insomnia. 

How  often do you summon up to urinate at extinction? This inquiry is asked to  assess for nocturia due to diabetes that may carry to insomnia. Nocturia  can obviate the resigned from having a good-natured-natured extinction’s repose. ,  changes in  class glucose levels at extinction principlesto hypoglycemic and hyperglycemic  episodes, nocturia and associated degradation and insomnia ( Khandelwal  et al., 2017).

Do  you repose during the day era. This provides notification that evaluates  if day era reposeing may be forcible her power to repose at extinction.

Are  you  taking your medications as prescribed? This resigned takes  sertraline for degradation. Did the insomnia initiate following the pt agoing  taking sertraline or following the failure of her mate.   

Identify race in the resigned’s conduct you would insufficiency to talk to or get feedtail from to elevate assess the resigned’s situation


Are  there are things that disrupts her repose?  for model, music/TV sound  or crying/playing conclusion. This is relevant to aspositive that her  condition is not principled by environinvisible factors. Epidemiologic elimination  according to Johnson et al (2018) has shown that political features of  environments, extraction, political cohesion, security, sound, and neighborhood  guess-work can principle changes in repose exemplars; and other factors approve  light, sound, commerce, etc., can besides influence repose and is attributed to  repose guess-works unarranged adults and conclusion.

What  does she do when she summons up at extinction? does she eat, quaff coffee or  smoke. This is to individualize if midextinction activities may above her from  flux heedless.

Does  she mourn of having a solid era flux arepose or reposeing for a  short duration and early up, feeble to go tail to repose? This assesses  how repose and cessation she may be getting.

Who  caters to the insufficiencys of this resigned? This is to assess if she is courteous-mannered-mannered  cared for or if the resigned is solicitous encircling her headstrong circumspection.


Has the resigned mourned to you encircling awkwardness flux heedless?

Does the resigned mourn encircling early up in the intermediate of the extinction and judgment it solid to go tail to repose?

Who does the resigned concession following a while?


Does she mourn of contact wearied beprinciple of not reposeing?

 Does this resigned divulge justly or is she following a whiledrawn when you see her?

When did you see the resigned definite?

Primary circumspection physician

Has  this resigned mourned encircling any repose problems in the late? This  provides collaboration between soundness circumspection providers to determine fair  management and exhibition of resigned-centered circumspection.

Physical Exams

Psychiatric evaluation: A  invisible soundness evaluation should be produced to assess the resigned’s overall  invisible specify including giveing symptoms, thoughts, contacts, or  behavior. PMHNP’s can use the Geriatric Degradation Scale (GDS) which is a  self-reported gauge of degradation in the older adult. Cornell Scale  for Degradation in Dementia (CSDD). The CSDD focuses on an confabulation following a while  a extraction portion or circumspectiongiver as courteous-mannered-mannered as following a while the resigned and is  confirmed for use in resigneds following a while or following a whileout dementia. Also, the   Zung  Self-Rating Degradation Scale (SDS) which is used as a screening instrument,  covering influenceive, metaphysical and somatic symptoms associated following a while  depression.

Polysomnogram ( repose consider):  can be dischargeed  to diagnose repose guess-works such as insomnia

Sleep diary:  Evaluating the resigned’s repose exemplars through a repose diary provides  notification on the resigned’s repose exemplar and a peculiarity of insomnia.

Epworth Sleepiness Scale: This a inquirynaire used to evaluate  dayera reposeiness.

Thyroid exercise proof: Production of petty or ample thyroid hormone, can influence  sleep.

HBA1C:  The resigned has a narrative of diabetes, monitoring her HbA1C is  important. This is beprinciple Race following a while a peculiarity of diabetes  description remarkable rates of insomnia, insufficient repose sort, inordinate dayera  sleepiness ( Khandelwal et al., 2017).

Actigraphy:  is an concrete gaugement of  repose register,  rest-activity exemplars used to acceleration establish insomnia.

Lab proof: such as vague glucose proof,  liver exercise proof, adequate class enumerate, Erythrocyte Sedimentation Rate, consanguinity exercise proof.

Differential peculiarity

 Late-conduct spousal loss : loss is public to principle  degradation and perplexed trouble ( Holm etal., 2019).

Late  conduct degradation (LLD) Predisposing factors embrace preceding clinical  depression, perpetual repose difficulties, womanish gender,  entity widowed  or divorced ( Blackburn etal., 2017). Perplexed trouble

Medicated-cognate insomnia

 Sleep apnea. Repose apnea is considered to be customary  in further in individuals following a while diabetes ( Khandelwal et al., 2017).

             The most approvely divergential peculiarity, in my conviction, would be  late-conduct spousal loss. (LLSB). The resigned was diagnosed following a while  MDD, she lost her mate (died) ten months ago, and she is quiescent  indisposition from degradation and insomnia.  Being widowed principles  impairments in repose (Monk et al., 2008).

Pharmacologic Agents

Sertraline  (SSRI) principles insomnia as a party chattels. Augmenting sertraline following a while a  divergent medication in the antiquated may carry to polypharmacy. Therefore,  switching sertraline following a while a medication to acceleration following a while MDD and insomnia  achieve be further accelerationful. I would pick-out to bung sertraline and initiate  trazadone. tranquillizing antidepressants (such as trazaproduced 25-50mg) are a  safe  when eager in low doses and are eager in resigned groups where  hypnotics are contraindicated, e.g., in the antiquated and resigneds following a while  repose apnea (Wichniaketal., etal., 2017). Trazoproduced is an antidepressant  that exercises by inhibiting serotonin transporter and serotonin enjoyness 2  receptors. Trazoproduced in low doses provides a tranquillizing chattels for repose  through animosity of 5-HT-2A receptor, H1 receptor, and  alpha-1-adrenergic receptors ( Shin & Saadabadi., 2020). Trazoproduced  besides improves apnea and hypopnea episodes in resigneds public to feel   following a while alien repose apnea (OSA), and it  does not worsen hypoxemic  episodes. This resigned can be agoing on trazaproduced 25- 50mg at bedtime.

             A prevent garbage select is an antidepressant mirtazapine. It is chattelsive  in managing elder depressive guess-work and has tranquillizing fairties which  is accelerationful in relieving repose problems approve insomnia and can be used in  the antiquated. Mirtazapine is public as an atypical antidepressant following a while an  off letter use for insomnia. It works by exerting enemy chattelss on  the mediate presynaptic alpha-2-adrenergic receptors, causing an  elevated loose of serotonin and norepinephrine. Mirtazapine is besides  sometimes determined a noradrenergic and specific serotonergic  antidepressant (NaSSA). I would applaud initiateing the resigned on 15 mg  of mirtazapine at bedtime. Mirtazapine is public to write MDD in resigneds  that were no unresponsive to SSRIs. I promote to initiate this resigned on  trazadone, rather than mirtazapine. Mirtazapine has party chattelss of  increased tendency, acceptiond consequence produce and this resigned is already  obese following a while prove 88kg, climax 64 inches (bmi 34.4), acceptiond  cholesterol. Elevate acception in consequence would acception abandon for  cardiovascular problems. Trazaproduced is undeviatingly eager and has a faster  onset following a while anodyne fairties. This makes it further expend for this  patient.

Identify any contraindications to / Ethnicities

             A consequence for government of trazaproduced is the age of this  patient. The dose in the antiquated should not be further than 100 mg/day.  There is a  abandon for orthostatic hypotension is in the antiquated,  in-particular in the antiquated following a while following a while pre-existing hardihood stipulations  (hypertension) ( ( Shin & Saadabadi., 2020). The metabolism of  trazaproduced should besides be considered in divergent ethnicities as insufficient  CYP2D6 metabolizers are public to feel curative defense.  In the  Asian ethnicity, medications that metabolized by CYP2D6 should not be  prescribed (Kitada, 2003). Therefore, if this resigned is Asian  increasing the dose of trazaproduced achieve be considered or choosing a  divergent medication to strengthen the resigned get a liberal chattels of the  drug. If the resigned were of Asian descent, I would feel to run on  increasing the dose of Trazaproduced if they were a insufficient metabolizer or  choosing another medication that was not influenceed by CYP2D6.

Check Points

Monitor  the resigned air-tight following changing her garbage therapy. Party chattelss of  the medication should be perspicuously explained to the resigned and extraction  importantly if derangement is renowned, present description to the PMHNP for  discontinuation of the medication. The resigned should be   be monitored  for suicide ideation, in-particular at the rise of the composition or  when the dose is mitigated (Shin & Saadabadi., 2020).  I would  observe how this resigned achieve adrighteous to trazaproduced 25-50mg in 4 weeks to  individualize dose disposement. 


Blackburn, P., Wilkins-Ho, M., Wiese, B. (2017). Degradation in older adults: Adults and management. BCMJ, 59 (3).


Bollu, P., Kaur, H. ( 2019). Repose Medicine: Insomnia and Sleep. The Journal of Missouri Specify   Medication Association, 116(1), 68–75.


Khandelwal, D., Dutta, D., Chittawar, S., Kalra, S. (2017). Repose guess-works in enjoyness 2 diabetes.       Indian Journal of Endocrinology and Metabolism,  21(5), 758–761. doi:    10.4103/ijem.IJEM_156_17


Kitada M. (2003) Genetic polymorphism of cytochrome P450 enzymes in Asian populations:

            Focus on CYP2D6. International Journal of Clinical Pharmacological

            Research,23(1),31-5. https://pubmed.ncbi.nlm.nih.gov/14621071/

Holm,  N. Severinsson, E., Berland, A. (2019). The import of loss  aftercited spousal     damage: A necessary consider of the experiences of  older adults. https://doi.org/10.1177/2158244019894273


Monk, T. H., Germain, A., & Reynolds, C. F. (2008). Repose restlessness in loss.

            Psychiatric Annals, 38(10), 671–675. https://doi.org/10.3928/00485713-20081001-06

Shin, J., Saadabadi., A. (2020). Trazodone. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK470560/

Wichniak, A., Wierzbicka, A., Walęcka, M., Jernajczyk, W. (2017). Proceeds of Antidepressants    on repose. Current Psychiatry Reports, 19 (9), 63. doi: 10.1007/s11920-017-0816-4