Discussion: Insomnia Disorder Case Study

NURS 6630 Week 8 Assignment 2 Assessing and Treating Patients with Sleep/Wake Disorders Example

Sleep/wake disorders are the various conditions associated with the ability to fall asleep, maintain sleep and get back to sleep after waking up. Sleep disorders can be symptoms of other psychiatric conditions or result from the disorder. In addition, sleep disorders such as insomnia can be a side effect caused by psychiatric and other treatments. Care providers are responsible for administering different treatment therapies to sleep disorders patients, managing the symptoms over time, and deciding whether to change the current medication or therapy to ensure the desired health outcome. They should also consider the medications’ various side effects, thus making decisions to address or reduce them.

Insomnia is characterized by difficulty falling asleep, persistent awakening and finding it challenging to go back to sleep, and a complete lack of sleep. Insomnia can negatively affect an individual’s physical and mental aspects and quality of life, especially when it is long-term. Therefore, avoiding other related effects such as diabetes, weight gain, and hypertension requires immediate attention. This paper analyzes a patient with insomnia, the treatment options available, the most appropriate decisions, and the changes made after interacting with the patient at different points, considering the patient’s pharmacokinetic and pharmacodynamics processes.

The case involves a 31-year-old male who has been diagnosed with insomnia. He reports that the condition has been progressively worsening in the last six months. He states that it began after he suddenly lost his fiancé. He also mentions that the condition is affecting his productivity at the workplace. He has used diphenhydramine in the past but does not like how it makes him feel in the morning. Also, his medical record has a history of opiate abuse.in addition, he mentions using alcohol to help him sleep, approximately four beers before bedtime. The patient maintains eye contact and is alert and oriented to place, time, and person. He has dressed appropriately and denies suicidal ideations and hallucinations. His judgment, reality, and insight are intact.

Decision point One

The first decision is to begin Trazodone 50mg PO daily before bedtime. Trazodone is an antidepressant medication that belongs to the medication class of Serotonin-Antagonist and Reuptake Inhibitors. It works by inhibiting both serotonin transporter and serotonin type 2 receptors. Trazodone is FDA-approved and is one of the most effective medications used to treat sleep disorders, specifically helping maintain sleep and addressing the issue of difficulty in falling asleep. The decision was selected due to its effectiveness. Despite being used for treating depressive disorders, Trazodone can be used in low doses to effectively treat primary and secondary insomnia (Shin & Saabadadi,2022). Shin and Saabadadi note that Trazodone has been found effective in reducing nightmare episodes and improving sleep habits.

Zolpidem 10mg daily at bedtime was not selected due to its adverse side effects and the sleep-related eating disorder. Zolpidem is an FDA-approved drug used to treat short-term insomnia in patients with difficulty falling asleep and improve sleep quality for patients with chronic insomnia. It is a non-benzodiazepine receptor modulator. It works by increasing GABA inhibitory effects, leading to sedation.

However, it has adverse side effects, such as changes in behavior and abnormal thinking, memory loss, central nervous system depression, and withdrawal. Given the patient’s current quality of life, the medications were avoided to prevent these side effects. In addition, the patient initially reports alcohol use to help him sleep, whereby he uses at least four beers before bedtime. According to Bouchette, Akhondi & Quick (2022), administering Zolpidem to patients with alcohol or drug toxicity may experience visual and auditory hallucinations associated with strange behavior changes and agitation. Therefore, Zolpidem is not the best medication for the patient since he is more likely to experience these side effects.

Beginning Hydroxyzine 50mg daily at bedtime was the other option. It was not selected since it is an antihistamine used to treat allergic reactions. The medication has a sedative effect that usually takes 4-6 hours. Therefore, it cannot be the best treatment option for insomnia. The patient reports using diphenhydramine in the past. Hydroxyzine is in the same class as diphenhydramine. Thus, administering it would mean changing therapy with medications from the same class, placing the patient at a higher risk for severe side effects. In addition, the patient reports developing counter-reactions from the intake of antihistamines. Thus, Hydroxyzine is not the best treatment therapy for him due to the possibility of severe side effects. More so, the medication is not approved for treating insomnia.

The important ethical considerations, in this case, include non-maleficence and beneficence. The selected treatment therapy ensured minimal harm to the patient and maximum benefit. The side effects of each medication were also considered to avoid adverse side effects. Also, the most appropriate medication was selected, which is Trazodone. It was expected to produce a desirable health outcome with minimal side effects.

Decision point two

After some time, the care provider evaluates the previous medication/ treatment therapy based on the side effects present and the effectiveness of the medication in treating the symptoms. Thus, a decision on whether to make changes is made. The second decision is to reduce the Trazodone dose to 25mg daily. This medication was retained, being the best decision for the patient because the patient reported an improvement in the resolution of the symptoms. However, he complained of severe side effects, including an unpleasant erection lasting up to about 15 minutes, thus affecting his daily activities, such as making it difficult for him to get ready for work. It was, therefore, important to reduce the dosage to 25mg daily and see how the patient responded to it within the next two weeks.

Continuing with the trazodone 50mg daily was not selected despite the patient responding well to it since he also presented with unpleasant side effects. The side effects could, however, be managed by reducing the dosage. Research shows that lower doses of Trazodone are effective in less presentation of side effects and improving the quality of sleep and the sleep cycle (Wichniak, Wierzbicka, & Jarema, 2021). Due to the present side effects, the current dosage could not be maintained.

Changing the medication and introducing Hydroxyzine or Suvorexant was not selected since the patient was already positively responding to the current medication. These two are also used for insomnia treatment but are usually associated with severe side effects such as addiction, compromising physical and mental capabilities, and Priapism (Olson et al., 2021). The patient is already experiencing priapism, which mines a medication such as Hydroxyzine would make it worse.

The ethical principles considered in making the second decision were informed consent and beneficence. The patient was informed on why the change in dose reduction was made and the implications of the change. The decision also intended to benefit the patient by reducing the side effects and addressing the symptoms.

Decision Point Three

The third decision after a two-week follow-up clinic was to continue the dose of Trazodone 25mg daily before bedtime for four weeks and to encourage sleep hygiene. The decision was selected because the patient is already positively responding to the medication. The symptoms are partially resolved, and the patient denies presenting adverse side effects such as auditory/visual hallucinations. However, the patient reported that the 25mg daily dose was insufficient to help him sleep through the night. Therefore, the decision included advice on sleep hygiene to ensure that even with the small dose, he can sleep through the night.

The discontinuation of Trazodone was not selected since the patient had not experienced complete symptom resolution. More so, no severe side effects were reported during the second clinic. It is safe to use Trazodone long-term to ensure that the patient heals completely (Vgontzas et al., 2020).

Changing the medication to either Ramelteon or Hydroxyzine was also not selected since, at this point, the patient was already showing a positive response to the current medication. In addition, the current dose of Trazodone has demonstrated efficacy in improving the patient’s sleep quality and sleep cycle. It also reduced the patient’s symptoms considerably, as well as the manifestation of the side effects such as priapism.

The beneficence ethical principle was considered to ensure patient safety and protect the patient from more harm. Continuing the dose and initiating sleep hygiene advice aims to improve the patient’s condition further, reduce side effects, and provide the desired health outcome.

Conclusion

Insomnia is a sleep disorder that can affect the patient’s physical and mental abilities, reducing their quality of life. Long-term insomnia requires immediate medical attention. In this case, the most appropriate decisions for the patient were beginning Trazodone 50mg PO daily, reducing the dose to 25mg, and continuing with the dosage for at least four weeks on the first, second, and third points, respectively. Despite the patient presenting with undesirable side effects during the second clinic, the dosage reduction enhanced a regression and helped improve sleep quality and sleep patterns.

In addition, given that the patient had used antihistamines in the past and presented with adverse side effects, Hydroxyzine could not be used. An analysis and evaluation of medications from different points of interaction with the patient enable the care provider to make changes where necessary to ensure the best outcomes are achieved. It is vital to consider ethical principles while making medication decisions and involve the patient actively in every change.

References

Bouchette D, Akhondi H, Quick J. Zolpidem. [Updated 2022 Oct 1]. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK442008/

Olson, C., Jhawar, A., Elfessi, Z., & Doyle, R. (2021). Hydroxyzine-induced priapism. The American Journal of Emergency Medicine, 48, 375-e5. https://doi.org/10.1016/j.ajem.2021.03.066

Shin J.J, & Saadabadi A. Trazodone. [Updated 2022 Jul 10]. In: StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK470560/

Vgontzas, A. N., Puzino, K., Fernandez-Mendoza, J., Krishnamurthy, V. B., Basta, M., & Bixler, E. O. (2020). Effects of Trazodone versus cognitive behavioral therapy in the insomnia with short sleep duration phenotype: a preliminary study. Journal of Clinical Sleep Medicine, 16(12), 2009-2019. https://doi.org/10.5664/jcsm.8740

Wichniak, A., Wierzbicka, A. E., & Jarema, M. (2021). Treatment of insomnia – effect of Trazodone and hypnotics on sleep. Psychiatria Polska, 55(4), 743–755. https://doi.org/10.12740/PP/125650

Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders Instructions

Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life.

Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.

Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sle…

TO PREPARE FOR THIS ASSIGNMENT:

Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders. Discussion: Insomnia Disorder Case Study

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THE ASSIGNMENT: 5 PAGES

Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

Insomnia – 31-year-old Male Case Study

BACKGROUND

This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

SUBJECTIVE

Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company.

The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One

Select what you should do:

Zolpidem: 10 mg daily at bedtime

Trazodone 50 mg po at bedtime

Hydroxyzine: 50 mg daily at bedtime

Trazodone 50 mg po at bedtime

Decision Point 1: Trazodone 50 mg po at bedtime

RESULTS OF DECISION POINT ONE

Patient returns to clinic in 2 weeks
Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking
Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
Patient denies auditory/visual hallucinations and is future oriented

Decision Point Two

Select what you should do next:

Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose

Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

Decrease trazodone to 25 mg daily at bedtime

Decision Point Two

Decrease trazodone to 25 mg daily at bedtime

RESULTS OF DECISION POINT TWO

Patient returns to clinic in 2 weeks
Patient states trazodone is very effective for sleep
Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night
Patient denies auditory/visual hallucinations and is future oriented

Decision Point Three

Select what you should do next:

Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks

Decision Point Three

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.

LEARNING RESOURCES

Required Readings

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disordersLinks to an external site.(5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry ReportsLinks to an external site., 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. ChestLinks to an external site., 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/
Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEPLinks to an external site., 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf
Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEPLinks to an external site., 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf
Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep MedicineLinks to an external site., 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470
Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of MedicineLinks to an external site., 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Medication Resources

S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugsLinks to an external site.. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Links to an external site.

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

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