1. Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today
with chief complaint of insomnia. Patient is 75 YO with PMH
of DM, HTN, and MDD. Her husband of 41 years passed away
10 months ago. Since then, she states her depression has gotten
worse as well as her sleep habits. The patient has no previous
history of depression prior to her husband’s death. She is
awake, alert, and oriented x3. Patient normally sees PCP once
or twice a year. Patient denies any suicidal ideations. Patient
arrived at the office today by private vehicle. Patient currently
takes the following medications:
• Metformin 500mg BID
• Januvia 100mg daily
• Losartan 100mg daily
• HCTZ 25mg daily
• Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
Insomnia is a disorder linked with difficulty in sleep
quality, initiating or maintaining sleep, along with substantial

2. distress and impairments of daytime functioning. Its prevalence
ranges from 10 to 15% among the general population, with
higher rates seen among females, divorced or separated
individuals, those with loss of loved ones, and older people
(Bollu & Kaur, 2019). Insomnia can simply be defined as a
sleep disorder where the patient has trouble falling asleep or
staying asleep. According to Krystal et al (2019), it is a
common condition that is linked with noticeable deterioration
in function and quality of life, mental and physical morbidity.
The complaints of insomnia are present in 60–90% of patients
with major depression, Complaints of disrupted sleep are very
common in patients suffering from depression, (Wichniak,
etal., 2017).
Questions you might ask the patient and rationale
The diagnosis and treatment of insomnia rely mainly
on a thorough sleep history to address the precipitating factors
as well as maladaptive behaviors resulting in poor sleep (Bollu
& Kaur, 2019).
What is your sleep pattern including how many hours of sleep
do you get at night prior to your husband’s demise and what it
has been in the 10 months since his death? Does she perform
certain rituals or do something special before she sleeps. This
assesses if the insomnia started before or after the husband’s
death. This provides a clue to insomnia that may be related to
bereavement.
What time do you go to bed every night and what is your
normal routine before going to bed? This is to check if the
patient is doing something differently which has disrupted her
normal routine and caused insomnia.
How often do you wake up to urinate at night? This question is
asked to assess for nocturia due to diabetes that may lead to

3. insomnia. Nocturia can prevent the patient from having a good
night’s sleep. , changes in blood glucose levels at night
causesto hypoglycemic and hyperglycemic episodes, nocturia
and associated depression and insomnia ( Khandelwal et al.,
2017).
Do you sleep during the day time. This provides information
that evaluates if day time sleeping may be affecting her ability
to sleep at night.
Are you taking your medications as prescribed? This patient
takes sertraline for depression. Did the insomnia start after the
pt started taking sertraline or after the death of her husband.
Identify people in the patient’s life you would need to speak to
or get feedback from to further assess the patient’s situation
Children
Are there are things that disrupts her sleep? for example,
music/TV noise or crying/playing children. This is important to
ascertain that her condition is not caused by environmental
factors. Epidemiologic research according to Johnson et al
(2018) has shown that social features of environments, family,
social cohesion, safety, noise, and neighborhood disorder can
cause changes in sleep patterns; and other factors like light,
noise, traffic, etc., can also affect sleep and is attributed to
sleep disorders among adults and children.
What does she do when she wakes up at night? does she eat,
drink coffee or smoke. This is to determine if midnight
activities may hinder her from falling asleep.
Does she complain of having a hard time falling asleep or
sleeping for a short period and waking up, unable to go back to
sleep? This assesses how sleep and rest she may be getting.

4. Who caters to the needs of this patient? This is to assess if she
is well cared for or if the patient is concerned about her self
care.
Relatives
Has the patient complained to you about difficulty falling
asleep?
Does the patient complain about waking up in the middle of the
night and finding it hard to go back to sleep?
Who does the patient leave with?
Friends
Does she complain of feeling tired because of not sleeping?
Does this patient communicate appropriately or is she
withdrawn when you see her?
When did you see the patient last?
Primary care physician
Has this patient complained about any sleep problems in the
past? This provides collaboration between health care providers
to ensure proper management and delivery of patient-centered
care.
Physical Exams
Psychiatric evaluation:
A mental health evaluation should be done to assess the
patient’s overall mental state including presenting symptoms,

5. thoughts, feelings, or behavior. PMHNP’s can use the Geriatric
Depression Scale (GDS) which is a self-reported measure of
depression in the older adult. Cornell Scale for Depression in
Dementia (CSDD). The CSDD focuses on an interview with a
family member or caregiver as well as with the patient and is
confirmed for use in patients with or without dementia. Also,
the Zung Self-Rating Depression Scale (SDS) which is used as
a screening tool, covering affective, psychological and somatic
symptoms associated with depression.
Polysomnogram ( sleep study):
can be performed to diagnose sleep disorders such as
insomnia
Sleep diary:
Evaluating the patient’s sleep patterns through a sleep diary
provides information on the patient’s sleep pattern and a
diagnosis of insomnia.
Epworth Sleepiness Scale:
This a questionnaire used to evaluate daytime sleepiness.
Thyroid function test:
Production of little or much thyroid hormone, can affect sleep.
HBA1C
: The patient has a history of diabetes, monitoring her HbA1C
is important. This is because Individuals with a diagnosis of
diabetes report higher rates of insomnia, poor sleep quality,
excessive daytime sleepiness ( Khandelwal et al., 2017).
Actigraphy:
is an objective measurement of sleep schedule, rest-activity
patterns used to help confirm insomnia.
Lab test:

6. such as random glucose test, liver function test, complete
blood count, Erythrocyte Sedimentation Rate, kidney function
test.
Differential diagnosis
Late-life spousal bereavement : bereavement is known to cause
depression and complicated grief ( Holm etal., 2019).
Late life depression (LLD) Predisposing factors include
previous clinical depression, persistent sleep difficulties,
female gender, being widowed or divorced ( Blackburn etal.,
2017). Complicated grief
Medicated-related insomnia
Sleep apnea. Sleep apnea is considered to be prevalent in more
in persons with diabetes ( Khandelwal et al., 2017).
The most likely differential diagnosis, in my opinion,
would be late-life spousal bereavement. (LLSB). The patient
was diagnosed with MDD, she lost her husband (died) ten
months ago, and she is still suffering from depression and
insomnia. Being widowed causes impairments in sleep (Monk
et al., 2008).
Pharmacologic Agents
Sertraline (SSRI) causes insomnia as a side effect. Augmenting
sertraline with a different medication in the elderly may lead to
polypharmacy. Therefore, switching sertraline with a
medication to help with MDD and insomnia will be more
helpful. I would choose to stop sertraline and start trazadone.
sedative antidepressants (such as trazadone 25-50mg) are a safe
when given in low doses and are given in patient groups where
hypnotics are contraindicated, e.g., in the elderly and patients

7. with sleep apnea (Wichniaketal., etal., 2017). Trazodone is an
antidepressant that functions by inhibiting serotonin transporter
and serotonin type 2 receptors. Trazodone in low doses
provides a sedative effect for sleep through antagonism of 5-
HT-2A receptor, H1 receptor, and alpha-1-adrenergic receptors
( Shin & Saadabadi., 2020). Trazodone also improves apnea
and hypopnea episodes in patients known to have with
obstructive sleep apnea (OSA), and it does not worsen
hypoxemic episodes. This patient can be started on trazadone
25- 50mg at bedtime.
A second drug choice is an antidepressant mirtazapine.
It is effective in managing major depressive disorder and has
sedative properties which is helpful in relieving sleep problems
like insomnia and can be used in the elderly. Mirtazapine is
known as an atypical antidepressant with an off label use for
insomnia. It works by exerting antagonist effects on the central
presynaptic alpha-2-adrenergic receptors, causing an elevated
release of serotonin and norepinephrine. Mirtazapine is also
sometimes called a noradrenergic and specific serotonergic
antidepressant (NaSSA). I would recommend starting the
patient on 15 mg of mirtazapine at bedtime. Mirtazapine is
known to treat MDD in patients that were no unresponsive to
SSRIs. I prefer to start this patient on trazadone, rather than
mirtazapine. Mirtazapine has side effects of increased appetite,
increased weight gain and this patient is already obese with
weigh 88kg, height 64 inches (bmi 34.4), increased cholesterol.
Further increase in weight would increase risk for
cardiovascular problems. Trazadone is quickly absorbed and
has a faster onset with hypnotic properties. This makes it more
appropriate for this patient.
Identify any contraindications to / Ethnicities
A consideration for administration of trazadone is the
age of this patient. The dose in the elderly should not be more

8. than 100 mg/day. There is a risk for orthostatic hypotension is
in the elderly, especially in the elderly with with pre-existing
heart conditions (hypertension) ( ( Shin & Saadabadi., 2020).
The metabolism of trazadone should also be considered in
different ethnicities as poor CYP2D6 metabolizers are known
to have therapeutic response. In the Asian ethnicity,
medications that metabolized by CYP2D6 should not be
prescribed (Kitada, 2003). Therefore, if this patient is Asian
increasing the dose of trazadone will be considered or choosing
a different medication to enable the patient get a full effect of
the drug. If the patient were of Asian descent, I would have to
decide on increasing the dose of Trazadone if they were a poor
metabolizer or choosing another medication that was not
affected by CYP2D6.
Check Points
Monitor the patient closely after changing her drug therapy.
Side effects of the medication should be clearly explained to
the patient and family importantly if hallucination is noted,
immediate report to the PMHNP for discontinuation of the
medication. The patient should be be monitored for suicide
ideation, especially at the beginning of the treatment or when
the dose is modified (Shin & Saadabadi., 2020). I would
observe how this patient will adjust to trazadone 25-50mg in 4
weeks to determine dose adjustment.
References
Blackburn, P., Wilkins-Ho, M., Wiese, B. (2017). Depression in
older adults: Adults and management
. BCMJ, 59
(3).
https://bcmj.org/articles/depression-older-adults-
diagnosis-and-management

9. Bollu, P., Kaur, H. ( 2019). Sleep Medicine: Insomnia and Sleep
. The Journal of Missouri State Medication Association, 116
(1), 68–75.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390785/
Khandelwal, D., Dutta, D., Chittawar, S., Kalra, S. (2017).
Sleep disorders in type 2 diabetes.
Indian Journal of Endocrinology and Metabolism, 21
(5), 758–761. doi: 10.4103/ijem.IJEM_156_17
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628550/
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 meaning of
bereavement following spousal loss: A qualitative study of
the experiences of older adults.
https://doi.org/10.1177/2158244019894273
https://journals.sagepub.com/doi/full/10.1177/21582440198942
73
Monk, T. H., Germain, A., & Reynolds, C. F. (2008). Sleep
disturbance in bereavement.

10. 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). Effects of Antidepressants on sleep.
Current Psychiatry Reports, 19
(9), 63. doi: 10.1007/s11920-017-0816-4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5548844/