Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult Essay

Assessing and Treating Patients With Sleep/Wake Disorders -Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult Essay

Assessing and Treating Patients with Sleep/Wake Disorders

Insomnia is a sleep disorder whereby individuals have trouble falling asleep, maintaining sleep, or getting good quality sleep. Persistent insomnia usually significantly impacts a person’s quality of life. This is because it limits a person’s occupational functioning, affects mood, and causes social problems (Ng & Cunnington, 2021). Insomnia is associated with anxiety, stress, depression, physical health conditions, some medications, and poor sleep hygiene. The purpose of this assignment is to analyze the case of a patient with insomnia and discuss treatment interventions.

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Introduction to the case

The case concerns a 31-year-old man who presents with complaints of insomnia that has gradually worsened in the past six months. He has never been a “great sleeper,” but he reports experiencing trouble falling asleep and maintaining sleep. The sleeping problem started about six months ago after his fiancé died. The insomnia has affected his job output because he sometimes falls asleep at work after failing to sleep adequately at night. The client previously used diphenhydramine to promote sleep but stopped due to the morning side effect. In addition, he has an opiate abuse history, which occurred after he started taking acetaminophen for pain following an ankle fracture during a skiing accident. However, he has not been prescribed an opiate analgesic in the last four years. His MSE is unremarkable.

The factors that should be considered when prescribing treatment for a patient with insomnia include age, current medications, the risk of drug dependency, tolerance and abuse, substance abuse history, and existing physical and mental health illnesses. Ng & Cunnington (2021) explain that a risk–benefit assessment should be conducted when prescribing medications for insomnia, with special care for the elderly. Besides, drugs can interact with other medications and substances that cause sedation, including alcohol.

Decision #1

Trazodone: 50–100 mg daily at bedtime.

Why did I select this decision?

Trazodone was selected because it is an antidepressant used off-label at low doses to treat insomnia due to its hypnotic effect. Wang et al. (2020) explain that Trazodone effectively improves nocturnal sleep maintenance and is not associated with the morning hangover effect because it has a relatively short half-life of 3–6 hours. Yi et al. (2018) found that Trazodone has a good tolerance for short-term insomnia treatment.

Why did I not select the other two options?

Zolpidem was not selected because it is associated with a risk of drug dependency, tolerance and abuse, and strange nighttime behaviors (Campbell et al., 2021). Therefore, it was not ideal because of its abuse potential since the patient has a history of opiate abuse. Hydroxyzine is not ideal because it contains sedating H-1 antihistamines, usually, diphenhydramine, that usually induces increased daytime sleepiness and cognitive impairment that persists in the morning after nighttime use (Pagel et al., 2018). The patient had previously used diphenhydramine and did not like the side effects.

What was I hoping to achieve by making this decision?

The PMHNP hoped that Trazodone would improve the client’s sleep quality by inducing sleep and reducing nighttime awakening. Yi et al. (2018) found that Trazodone effectively maintained sleep maintenance by minimizing early awakenings, significantly improving perceived sleep quality. Wang et al. (2020) found that Trazodone enhanced sleep continuity and t slow-wave sleep ratio.

How ethical considerations may impact the treatment plan and communication

The PMHNP must consider ethical factors of beneficence and respect for autonomy, which can affect the treatment plan and communication. Beneficence affects the treatment plan since the PMHNP has to assess the treatment options and select the one associated with the best outcomes for the specific patient population. Besides, the PMHNP must obtain consent from the patient before initiating treatment, which respects the right to autonomy but can affect communication.

Decision #2

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

Why did I select this decision?

It was crucial to explain to the patient the erection associated with Trazodone, which abates over time. This was to promote medication adherence since the patient reported a positive impact of the drug on improving insomnia.   Krystal et al. (2019) explain that Trazodone may induce priapism, but this is safe and well tolerated.

Why did I not select the other two options?

The option to stop Trazodone and initiate Suvorexant was not selected because the client reported that Trazodone effectively reduced insomnia. Besides, Suvorexant is associated with a dose-related next-day somnolence in age groups, making it less ideal for this patient. Decreasing Trazodone to 25 mg daily was also not ideal because the recommended dose to treat insomnia is 50 to 150 mg. Thus, reducing the dose may reduce the drug’s efficacy in reducing insomnia.

What was I hoping to achieve by making this decision?

The PMHNP hoped to explain that the erection associated with Trazodone would encourage medication adherence. Besides, continuing the current Trazodone dose would further improve the patient’s sleep quality by helping to induce and maintain sleep. In Yi et al. (2018) study, patients with primary and secondary insomnia who received Trazodone reported more benefits in sleep quality.

How ethical considerations may impact the treatment plan and communication

Ethical factors like nonmaleficence may impact the treatment since the practitioner has to assess for drug side effects and modify or change medication if severe side effects are reported. Confidentiality may impact communication since the PMHNP has to assure the patient that confidentiality will be maintained.

Decision #3

Continue dose. Explain to the patient that he may split the 50 mg tablet in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks.

Why did I select this decision?

This option was selected because the patient reported that the Trazodone dose produced next-day drowsiness. Krystal et al. (2019) explain that Trazodone is associated with dose-dependent drowsiness, and reducing the dose helps to alleviate this side effect.

Why did I not select the other two options?

It was not ideal to stop Trazodone and start Sonata because Trazodone effectively improved the patient’s sleep quality. Besides, Sonata is documented to cause dose‐dependent sedation and psychomotor impairment and has an abuse potential, which can cause a relapse of the patient’s opiate abuse. Furthermore, the option to stop Trazodone and initiate hydroxyzine was not selected because hydroxyzine is associated with increased daytime sleepiness and cognitive impairment (Pagel et al., 2018).

What was I hoping to achieve by making this decision?

The PMHNP hoped that reducing the dose by half would reduce the dose-dependent next-day drowsiness. According to Krystal et al. (2019), a lower Trazodone dose is similarly effective in promoting sleep maintenance without next-day drowsiness since it has a short half-life.

How ethical considerations may impact the treatment plan and communication

            Ethical considerations of beneficence impacted the treatment plan since the PMHNP had to modify Trazodone to reduce the dose-dependent drowsiness and improve sleep quality. Communication was impacted by patient autonomy since the PMHNP had to involve the patient in developing the treatment plan and respect the client’s decisions.

Conclusion

The patient’s factors that may influence his treatment include age, current medications, the risk of drug dependency, tolerance and abuse, substance abuse history, and existing physical and mental illnesses. The client was initiated on Trazodone 50 mg. The drug’s efficacy in alleviating sleep difficulties and good tolerance made it an ideal drug for this patient Wang et al. (2020). Zolpidem was not ideal because it is associated with strange nighttime behaviors and has an abuse potential that may trigger a relapse of opiate abuse in the patient (Campbell et al., 2021). Hydroxyzine was not selected due to its sedating H-1 antihistamine properties that cause increased daytime sleepiness and cognitive impairment (Pagel et al., 2018). The patient expressed concerns that Trazodone caused an erection of about 15 minutes. He was informed that this did not meet the priapism criteria and would abate with time. The patient was continued on Trazodone 50 mg, but he later reported that it caused next-day drowsiness. The PMHNP instructed the client to split the dose in half to reduce the drowsiness (Krystal et al., 2019). Trazodone is associated with dose-dependent drowsiness and sedation, which decrease when the dose is reduced.

References

Campbell, R., Chabot, I., Rousseau, B., Bridge, D., Nicol, G., & Meier, G. (2021). Understanding the unmet needs in insomnia treatment: a systematic literature review of real-world evidence. International Journal of Neuroscience, 1-15. https://doi.org/10.1080/00207454.2021.1995383

Ng, L., & Cunnington, D. (2021). Management of insomnia in primary care. Australian prescriber, 44(4), 124–128. https://doi.org/10.18773/austprescr.2021.027

Pagel, J. F., Pandi-Perumal, S. R., & Monti, J. M. (2018). Treating insomnia with medications. Sleep Science and Practice, 2(1), 1-12. https://doi.org/10.1186/s41606-018-0025-z

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on Sleep Quality and Cognitive Function in Arteriosclerotic Cerebral Small Vessel Disease Comorbid With Chronic Insomnia. Frontiers in psychiatry, 11, 620. https://doi.org/10.3389/fpsyt.2020.00620

Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., Zhang, Y. Q., Zhang, L., & Zhou, X. Y. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep medicine, 45, 25–32. https://doi.org/10.1016/j.sleep.2018.01.010

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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

· 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

· 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

· 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

· 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

· 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.

CASE STUDY

https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_11/index.html