An 80-year-old man presents to his primary care physician’s office complaining of low back pain, fatigue, decreased appetite, and trouble falling asleep for the past several months. The patient suffered a spinal injury when he worked as a construction worker approximately 20 years ago, and he has been retired since then. He received multiple spinal surgeries and is currently seeing pain management. He is taking high dose gabapentin, and he uses a transcutaneous electrical nerve stimulation device. He recently was able to wean off hydrocodone-acetaminophen that he had used for about 2 years. He reports his trouble falling asleep has now affected his daily life to the point where he prefers to stay on his couch and rest. He has skipped multiple family events as well. He asks about medication to help him with sleep.
Which of the following is the most appropriate next step in management?
- A) Call his daughter to obtain more information
- B) Obtain basic labs including complete blood count, complete metabolic panel, and urinalysis
- C) Prescribe hydrocodone-acetaminophen at previous dosing
- D) Prescribe zolpidem
- E) Screen for depression
E) Screen for depression
Depression is one of the most common mental health diseases diagnosed in adult patients. The most commonly used screening tools are the Patient Health Questionnaire (PHQ)–2 and PHQ-9. PHQ-9 is a more comprehensive tool that objectifies degree of a patient’s depression severity which includes questions such as loss of interest, feeling down or hopeless, trouble falling asleep or staying sleep, feeling tired, change in appetite, trouble concentrating, and thoughts of suicidal ideation. Patients who suffer from chronic pain are at increased risk for depression which may manifest as trouble falling sleep and somatic pain associated with sad mood.
Answer choice A: Call his daughter to obtain more information, is incorrect.
Answer choice B: Obtain basic labs including complete blood count, complete metabolic panel, and urinalysis, is incorrect. Basic labs may be considered if the patient’s history and physical exam suggest further workup for causes such as an acute infection, anemia, hematological disorders or uremia.
Answer choice C: Prescribe hydrocodone-acetaminophen, is incorrect. Prescribing hydrocodone-acetaminophen for this patient could worsen his depressive symptoms and wouldn’t make sense since he was able to wean off this medication.
Answer choice D: Prescribe zolpidem, is incorrect. Prescribing zolpidem or other hypnotics increase the risk of delirium, falls, and fractures in elderly patients while providing minimal improvement in sleep latency and duration
Key Learning Point
The United States Preventive Services Task Force (USPSTF) recommends screening for depression in the general adult population. The PHQ-9 can be used as a tool. Remember that patients who suffer from chronic pain is at an increased risk for depression and should be screened for signs and symptoms, such as the insomnia and possible anhedonia seen in this patient.
Dr. Raj Dasgupta