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IHuman Case Study: 65-Year-Old Female Patient Presenting with Trouble Sleeping (Class 6531) - Week #9
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Course: Class 6531 – Week # Case Focus: Insomnia & Emotional Distress
“I haven’t been sleeping well for the past few months.”
Ears:
“I haven’t been sleeping well for the past few months.”
# Diagnosis Reasoning 1 Adjustment Disorder with Depressed Mood (F43.21) Strong psychosocial stressor (loss of close friend), emotional withdrawal, sadness, but symptoms do not meet full MDD criteria. Sleep disturbance consistent with diagnosis. 2 Major Depressive Disorder (MDD) Possible due to flat affect and low mood; however, lacks core symptoms like anhedonia, appetite/weight change, suicidal ideation. PHQ-9 screening needed to rule in/out. 3 Generalized Anxiety Disorder (GAD) May contribute to sleep onset difficulty, but patient does not report excessive worry or physical signs of anxiety. GAD- 7 screening suggested. 4 Obstructive Sleep Apnea (OSA) Unlikely: no snoring, no daytime sleepiness, no obesity or witnessed apneas. Not the primary pattern of sleep complaint. 5 Grief Reaction (Uncomplicated Bereavement) Significant emotional loss present, but patient is not incapacitated; functioning is intact. Symptoms suggest adjustment disorder more than isolated bereavement. 6 Restless Legs Syndrome (RLS) No symptoms like leg discomfort or urge to move at rest; ruled out based on detailed sleep history.
Primary Insomnia (G47.00)
Patient: Diana Walters (65-year-old female) Case: Week #9 – i-Human Case (Insomnia & Emotional Distress)
Test Reason Result Interpretation CBC (Complete Blood Count) Rule out anemia or infection as a cause of fatigue Normal No anemia or infection contributing to symptoms TSH (Thyroid Stimulating Hormone) Evaluate for hypothyroidism (a common cause of fatigue and sleep issues) Within normal limits Thyroid dysfunction ruled out Vitamin B Rule out deficiency that may cause fatigue or cognitive effects Normal No neurological/vitamin deficiency impact Vitamin D Fatigue and mood regulation Low- Normal Not severely deficient, but could benefit from supplementation PHQ- 9 (Depression Screen) Assess for Major Depressive Disorder Mild depression range (score ~6–9) Suggestive of Adjustment Disorder rather than MDD GAD-7 (Anxiety Screen) Evaluate for anxiety component Low score (0–4) Anxiety is not a significant contributor
Test Reason Status Polysomnography (Sleep Study) To rule out OSA or parasomnias Not indicated — no snoring, apnea, or daytime hypersomnolence MMSE or MoCA (Cognitive Testing) Rule out early dementia in older patients Not indicated — no memory or cognitive complaints Serum Iron, Ferritin To assess for restless legs syndrome Not indicated — no RLS symptoms present
If Present Action Suicidal ideation, severe depression Immediate referral to mental health services or crisis intervention unit Medication overdose or reaction Emergency services; monitor for confusion, dizziness, hypotension Acute sleep deprivation causing falls, confusion Immediate safety plan, remove fall hazards, monitor vitals, consider short-term supervised care Emergency not currently present , but patient should be instructed to report:
Pharmacologic: Drug Dose Use Notes Trazodone 25 – 50 mg PO at bedtime Short-term sleep aid Sedating antidepressant; preferred in elderly due to low abuse potential Acetaminophen 500 mg PRN Mild knee pain May improve sleep if pain is contributing factor Avoid benzodiazepines, diphenhydramine, zolpidem in older adults (Beers Criteria risk: falls, confusion, dependence) Non-Pharmacologic:
Plan Component Detail Follow-Up Visit In 4 weeks to assess sleep, mood, medication effect, therapy engagement Monitoring Watch for depression worsening (repeat PHQ-9), medication tolerance, or new symptoms Adjustments Taper medication if sleep improves Switch or escalate if no benefit from trazodone Lab Results Review CBC, TSH, B12, Vit D — address deficiencies if found Mental Health Referral If PHQ-9 increases or patient expresses distress, refer to psychiatry for co-management
Diagnosis:
Patient: Diana Walters, 65-year-old female Concern: Chronic insomnia and emotional distress
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Course: Class 6531 Case Study: Week #9 – Diana Walters (65 y/o Female with Insomnia) Student: [Your Name] Date: [Insert Date]
This case deepened my understanding of how insomnia in older adults often stems from complex biopsychosocial factors—not just sleep behaviors. I learned how grief, emotional distress, and lifestyle habits can influence sleep, and how insomnia may present as the primary symptom of adjustment disorder or even unrecognized depression. Importantly, I saw the role of non-pharmacologic approaches such as Cognitive Behavioral Therapy for Insomnia (CBT-I), as well as the need for caution in prescribing medications to older adults due to fall and cognitive risks.
Initially, I leaned too heavily on pharmacologic treatment without first prioritizing behavioral interventions , which are the true first-line treatment for chronic insomnia. I also realized I needed to ask more about functional impact , such as whether insomnia was affecting safety (e.g., driving or falls), which is critical in elderly patients. Next time, I would also explore the grief process more deeply , as bereavement can mask depressive symptoms and complicate sleep.
This case reminded me to always approach insomnia holistically— never treat sleep complaints in isolation. I will screen all older patients with insomnia for emotional distress, depression, anxiety, and grief. I also gained confidence in choosing safer pharmacological alternatives for elderly clients and in counseling on sleep hygiene in practical, empathetic terms. I’ll be more deliberate in recommending CBT-I as a gold standard therapy and in identifying when specialist referrals (mental health, sleep medicine) are appropriate.
Insomnia is not just a nighttime problem — it is often a daytime reflection of unresolved emotions, poor habits, or unrecognized illness. Compassionate listening, cautious prescribing, and evidence-based behavioral therapy are key.