NURS 6630 Assessing and Treating Patients With Sleep Disorders
NURS 6630 Assessing and Treating Patients With Sleep Disorders
The case scenario provided is of a 31year old male whose chief complaint is insomnia that has been worse in the past 6 months. Previously, he reports enjoying restful sleep although for the past 6months he has experienced both difficulties in falling and staying asleep. He even associates the onset of these sleep problems with the loss of his fiancé consequently leading to the loss. During the interview with the clinic, he explains that the problem is a bother because it has interfered with his job where because he experiences sleepiness during the day thus affecting his concentration and productivity at the workplace. He reports recent dependence on alcohol to help him fall asleep. The mental status examination performed on him revealed no abnormality in the orientation appearance, insight, and judgment.
A comprehensive assessment of this case study shows that the patient’s insomnia might be related to his psychological dysfunction resulting from the loss of his fiancé 6months ago. The sudden loss of a dear one triggers a myriad of psychiatric conditions even if the individual has no prior history of psychiatric conditions (Seiler et al., 2020). One of these psychiatric conditions is depression which is especially triggered by
complicated grief. The affected individual would therefore present with low mood, intense sadness, low energy, and loss of interest in activities of pleasure. They may also report sleep disturbances with insomnia being more common than hypersomnolence (Hasin et al., 2018). Managing the depression through medications or psychotherapy would help to relieve the patient’s symptoms such as insomnia that is suspected to arise from depression. The objective of this paper is to discuss how the patient in the case study was managed by describing the therapeutic options at Decision points 1, point 2, and point 3.
Decision Point One
For the initial management of the patient, I would prescribe 50mg of trazodone to be taken orally at bedtime daily. Trazodone is a drug that acts in the brain by reducing the reuptake of different neurochemicals in the brain such as serotonin but antagonizing the alpha-1-adrenergic and histamine receptors in the brain (Cuomo et al., 2019). By so doing, the serotonin levels in the brain are increased as well as the intensity of their action. Given depression results from an imbalance of brain neurochemicals such as serotonin and norepinephrine, increased serotonin levels resulting from trazodone use can lead to improved serotonergic actions thus treating depression and its symptoms (Hasin et al., 2018). When trazodone is therefore prescribed, the symptoms of depression including insomnia, appetite changes, and mood changes are corrected (Wang et al., 2020). It would therefore be the first-line medication for this patient.
At decision point one, the foregone options are the 10mg zolpidem taken daily at bedtime or 50mg hydroxyzine taken daily at bedtime. Although zolpidem is effective in the management of insomnia by promoting the action of gamma-aminobutyric acid (GABA) in the brain, its side effect profile which includes drowsiness, complex sleep-related behavior and volition usually limit its use as a first-line medication for insomnia (Edinoff et al., 2021). Hydroxyzine has also been foregone because of its anticholinergic effects such as xerophthalmia and xerostomia (Hasin et al., 2018). Further, neither of these drugs is effective for the management of depression that has been linked with the patient’s insomnia.
The ethical principles require that the health care providers do not harm the patient. At point one, increasing the pill burden by prescribing the antidepressants separately from the drugs addressing insomnia would pose the risk of adverse drug reactions as well as increase the incidence of poor drug compliance (Bipeta, 2019). The ethical principle of non-maleficence would therefore require for prescription of a single agent that could manage both depressive illness and insomnia (Seiler et al., 2020). As such, trazodone is the preferred medication to the other provided options.
Decision Point Two
After 2 weeks of therapy with 50mg of trazodone at bedtime daily, the patient reports experiencing a prolonged erection in the morning that lasts 15 minutes but is undesired and affects his morning preparation for work although his sleeping has improved. At this point, the choice is to be made on how to address the prolonged erection. My decision at this step would be to explain to the patient that this prolonged erection is not priapism and would resolve over time. Thereafter, the current drug dose could be continued for patient care.
One of the undesired side effects of trazodone use is the prolonged erection caused. Through its α-adrenergic antagonism, the drug can lead to dilatation of vessels in the penis thus resulting in prolonged erection (Cuomo et al., 2019). The patient in the case study reports such prolonged undesired erection that lasts for approximately 15 minutes and thus cannot be considered priapism which usually lasts for up to 4hours (Hasin et al., 2018). However, the patient requires reassurance about the side effect profile of the drug, especially with the emphasis that the symptoms would dissipate with time (Cuomo et al., 2019). This would enhance adherence to therapy despite the drug’s side effects.
The other options at decision point 2 were either to discontinue trazodone and initiate 10mg suvorexant daily therapy or to decrease the dose of trazodone to 25mg daily at bedtime. The negative side effect of suvorexant includes daytime drowsiness thus its contraindication for this patient who operates a forklift. On the other hand, decreasing the dose of trazodone to 25mg daily may not be adequate to correct insomnia (Seiler et al., 2020). Patient education on the drug’s side effects, as well as reassurance, would therefore be opted for at this step.
At this decision point 2 where the patient reports the drug’s side effects, it would be ethical to truthfully educate him on the drug’s side effects to anticipate. Medications may be discontinued if necessary to prevent more harm to the patient (Bipeta, 2019). These honor ethical principles of beneficence and non-maleficence.
Decision Point Three
2 weeks after reassuring and educating the patient on the side effects of trazodone, he now reports that the priapism has resolved although he now experiences increased drowsiness during the next day. His insomnia has also resolved at 50mg of trazodone. At this step, I would continue the patient therapy at 50mg although the dose is split in half, and the patient is reassessed after a month.
As had been alluded to, trazodone is associated with increased drowsiness that may limit its use although the occurrence of such side effects is either rare or mild. However, when such drowsiness occurs, a reduction of the drug dose by 50% may be necessary as this may result in a reduction in drowsiness (Cuomo et al., 2019). The patient should however be adequately educated on how to split the drug dose so that the required drug dose is maintained. Further, patient follow-up within 4weeks would also be indicated to help in reassessing the effectiveness of the drug as well as the persistence of the drowsiness at 50% of the dose (Wang et al., 2020).
The other options provided at decision point 3 included either discontinuing trazodone and initiating sonata at 10mg nightly or replacing trazodone with 50mg of hydroxyzine at bedtime. Both of these options are not appropriate as they involved replacing trazodone that the patient has shown partial response to. Further, both sonata and hydroxyzine have worse side effect profile that limits their administration in this patient (Hasin et al., 2018).
At this decision point, the ethical principle of patient autonomy may affect further care. For instance, the patient may prefer either sonata or hydroxyzine to the in-use trazodone thus they can be prescribed despite their side effect profile (Bipeta, 2019). Such prescription seeks to promote the role of patients in their treatment.
Conclusion
Individuals presenting with any signs and symptoms at the clinic should be suspected and examined for any underlying conditions responsible for such presentation. For instance, a patient with insomnia may have underlying anxiety or depression. In managing these patients, the drugs prescribed should aim at correcting the underlying psychological disorder instead of addressing the signs and symptoms such as insomnia. specifically for this patient whose insomnia was thought to result from depression due to complicated grief, trazodone which is an antidepressant was prescribed at decision point one because of its effectiveness in managing insomnia (Cuomo et al., 2019). When he returns to the clinic with complaints of prolonged erection, the patient would be reassured with the emphasis that the symptoms would disappear with time. The patient would also be adequately educated on the adverse effects of the drugs to encourage drug compliance as they would be anticipating these side effects (Hasin et al., 2018). Thereafter, when he comes complaining of drowsiness, the drug dose would be reduced by 50% to resolve the symptoms. At either of the steps, the drugs’ side effects profile, as well as effectiveness, are compared before an effective drug with the least side effects is prescribed.
References
Bipeta, R. (2019). Legal and ethical aspects of mental health care. Indian Journal of Psychological Medicine, 41(2), 108–112. https://doi.org/10.4103/IJPSYM.IJPSYM_59_19
Cuomo, A., Ballerini, A., Bruni, A. C., Decina, P., Di Sciascio, G., Fiorentini, A., Scaglione, F., Vampini, C., & Fagiolini, A. (2019). Clinical guidance for the use of trazodone in major depressive disorder and concomitant conditions: pharmacology and clinical practice. Rivista Di Psichiatria, 54(4), 137–149. https://doi.org/10.1708/3202.31796
Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and side effects for insomnia. Health Psychology Research, 9(1), 24927. https://doi.org/10.52965/001c.24927
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry (Chicago, Ill.), 75(4), 336. https://doi.org/10.1001/jamapsychiatry.2017.4602
Seiler, A., von Känel, R., & Slavich, G. M. (2020). The psychobiology of bereavement and health: A conceptual review from the perspective of Social Signal Transduction Theory of Depression. Frontiers in Psychiatry, 11, 565239. https://doi.org/10.3389/fpsyt.2020.565239
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
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/sleep-disorders/symptoms-causes/syc-20354018
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.
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.
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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.
To promote a comprehensive understanding of the treatment of a patient with insomnia, this discussion examines the case of a 31-year-old male patient diagnosed with insomnia. The patient reports being used to getting inadequate sleep most of his life. However, ever since he lost his fiancé about 6 months ago, he has been finding it hard to fall and stay asleep. Previously, the patient was using diphenhydramine to manage his insomnia but stopped due to the side effects experienced upon waking up. His work requires very high concentration levels which are greatly impacted by his inability to get enough sleep at night. The patient even reports that he has been falling asleep at work recently. As reported by the patient’s previous physician, he has a history of opiate abuse, which was developed when he was prescribed hydrocodone/APAP (acetaminophen) for managing pain associated with his broken ankle from skiing. The patient however denies use of opioid analgesics for the past 4 years. He however reports drinking alcohol every night to help him sleep. Mental status examination reveals no possibilities of comorbidities.
Several medications have been proven to be effective in the management of insomnia among adults. However, the choice of which medication to prescribe depends on several patient factors. For the patient in this discussion, such factors include his age, gender, and insomnia diagnosis. His previous use of diphenhydramine but with undesirable side effects will also be considered. His social history of losing his fiancé, history of opiate abuse, and use of alcohol will also play a significant role in determining the most effective drug choice. The purpose of this paper is to illustrate the decisions made in prescribing medication for the treatment of young adult patients with insomnia, in addition to the ethical consideration at each decision point.
Decision #1
Selected Decision and Rationale
Out of the provided alternatives, starting the patient on trazodone 50mg once daily at bedtime seems to be the most appropriate decision. Trazodone is an antidepressant with a complex mode of action primarily associated with the inhibition of the serotonin pathway (Martsenkovskyi & Napryeyenko, 2019). The drug is frequently prescribed off-label for the management of chronic insomnia high tolerance levels and effectiveness in initiating and maintaining sleep (Winkelman, 2015; Grandner & Perlis, 2019). The initial dose of the drug for adults with insomnia usually ranges from 25 to 50mg once daily, but the dose may range to up to 150mg once daily depending on the treatment outcome (Sateia et al., 2017). The drug is administered orally with a rapid absorption rate that promotes a short onset of action with peak plasma concentration being attained within 30 minutes to 1 hour. It is metabolized primarily via the CYP2D6 and CYP3A4 pathways with reduced risks of toxicity and adverse events.
Zolpidem can be used in the management of insomnia but is associated with increased risks of life-threatening sleep behaviors hence should only be recommended in case there is no other safer alternative (Sateia et al., 2017). On the other hand, it was not appropriate to prescribe hydroxyzine, given it belongs to a similar class of drugs to diphenhydramine (antihistamines) which already displayed undesirable side effects which made the patient discontinue using the drug (Martsenkovskyi & Napryeyenko, 2019; Yi et al., 2018).
Expected Outcome
In about four weeks, the patient is expected to report to the hospital with significantly improved sleeping patterns (Sateia et al., 2017). He should be able to sleep adequately through the night, and exhibit improved concentration and energy levels the following morning (Grandner & Perlis, 2019).
Ethical Considerations
When treating adult patients, the PMHNP needs to uphold the patient’s privacy and confidentiality. Consequently, the patient’s decision must be respected to uphold his autonomy.
Decision #2
Selected Decision and Rationale
Looking at the reported treatment outcome after four weeks, it was necessary to reduce the trazodone dose to 25 mg orally at bedtime. The decision was mainly based on the reported side effect of prolonged erection the following morning (Madari et al., 2021). The patient displayed a positive outcome of the drug in managing his insomnia which is an indication of potential effectiveness (Sateia et al., 2017; Akinnusi & El Solh, 2019). Studies show that when used at low doses, the risks of potential side effects of trazodone such as priapism are normally reduced (Winkelman, 2015; Martsenkovskyi & Napryeyenko, 2019). Additionally, it has been reported that in case of self-limiting side effects like prolonged erection, reducing the dose will promote the side effect disappearing within a shorter time, hence promoting the patient’s tolerance to the medication (Yi et al., 2018).
Explaining to the patient that the reported side effect is not priapism and will resolve with time, without altering the dose was not necessary as this would promote worsening of the side effect (Grandner & Perlis, 2019; Yi et al., 2018). Consequently, stopping trazodone and starting suvorexant was also inappropriate given that the patient’s response within the two weeks displayed great adherence to the medication with only one self-limiting side effect, which does not qualify termination of the treatment therapy (Martsenkovskyi & Napryeyenko, 2019).
Expected Outcome
The reported side effects of prolonged erection in the morning are expected to diminish within the next 4 weeks upon reducing the dose to 25mg once daily (Sateia et al., 2017). The patient’s sleeping pattern is also expected to improve even further within this time (Yi et al., 2018).
Ethical Considerations
With the obligation of preventing harm to the patient and respecting their autonomy, the PMHNP needed to consider the patient’s discomfort with the reported side effects of the drug (Grandner & Perlis, 2019). As such, it was necessary to observe ethical principles such as justice and nonmaleficence in promoting clinical decision which promotes using a lower dose of the drug, which is still effective to elicit desired effects (Madari et al., 2021).
Decision #3
Selected Decision and Rationale
Looking at the available options in line with the reported outcome from the initial intervention, the last decision was to continue using the same drug, at the same frequency and dose and encourage sleep hygiene. The patient has displayed great adherence and tolerance to trazodone, as the previously reported side effect diminished (Winkelman, 2015). However, the dose was quite low, hence sometimes failing to help the patient sleep through the night. Studies show that at low doses, trazodone can take up to 8 to 12 weeks to completely help patients sleep through the night (Grandner & Perlis, 2019). Consequently, to avoid side effects associated with the use of several pharmacological agents, evidence supports the use of nonpharmacological interventions such as appropriate sleep hygiene to promote treatment outcomes (Sateia et al., 2017; Yi et al., 2018).
Replacing trazodone with ramelteon, which is a hypnotic was not necessary as the already displayed great tolerance and adherence to trazodone, and the latter is also associated with undesired cardiovascular side effects which might compromise the patient’s health (Martsenkovskyi & Napryeyenko, 2019). As stated earlier, replacing trazodone with hydroxyzine was also inappropriate as hydroxyzine being an antihistamine would only lead to undesired side effects which might affect the patient’s compliance with the medication (Grandner & Perlis, 2019).
Expected Outcome
At this point, the patient is expected to attain an adequate amount of sleep every night with the adoption of appropriate sleep hygiene (Winkelman, 2015). No side effects are expected. Patient productivity at work is expected to improve due to improved quality of sleep (Yi et al., 2018).
Ethical Considerations
Adult patients have the legal right of making sound decisions concerning their health. As such, the PMHNP must ensure that the patient is adequately acknowledged of the available treatment options, and the benefits and limitations of each choice (Grandner & Perlis, 2019). Respecting patient autonomy is also crucial in promoting trust and a positive care outcome (Martsenkovskyi & Napryeyenko, 2019).
Conclusion
Several drugs have been recommended for the management of insomnia among adults. However, the decision on which medication to prescribe greatly depends on several patient-specific factors. The provided case demonstrates a young adult male patient with worsening insomnia. The patient was initially taking phenylhydrazine for the management of his insomnia but did not like the way it made him feel the following morning. Out of the available options, the first decision was to start the patient on trazodone 50mg orally every night. The drug has been approved by the FDA for the management of depression, but due to its tolerance and great effectiveness in the management of chronic insomnia, it is frequently prescribed doff label (Winkelman, 2015). Zolpidem and hydroxyzine were thus neglected due to their increased risks of toxicity (Martsenkovskyi & Napryeyenko, 2019). After two weeks, the patient came back to the hospital complaining of prolonged erection the following morning, but with well-managed insomnia (Akinnusi & El Solh, 2019). This outcome led to the second decision which was to reduce the dose of the drug to 25 mg every night (Yi et al., 2018). Discontinuing the drug and initiating suvorexant instead was not appropriate due to associated safety risks (Madari et al., 2021).
The patient reported that the side effect diminished after 2 weeks, but the dose was quite low to keep him asleep through the night. As such, the final decision was to continue using the same drug at the same dose and consider sleep hygiene to promote the treatment outcome (Sateia et al., 2017). In each decision process, the PMHNP was forced to observe several ethical principles including justice, autonomy, nonmaleficence, and observing the patient’s privacy and confidentiality (Grandner & Perlis, 2019). The patient was also adequately informed about each decision process, in terms of all the available options with their benefits and limitations.
References
Akinnusi, M., & El Solh, A. A. (2019). Drug treatment strategies for insomnia in patients with post-traumatic stress disorder. Expert Opinion on Pharmacotherapy, 20(6), 691–699. https://doi.org/10.1080/14656566.2019.1574745
Grandner, M. A., & Perlis, M. L. (2019). Pharmacotherapy for Insomnia Disorder in Older Adults. JAMA Network Open, 2(12), e1918214. https://doi.org/10.1001/jamanetworkopen.2019.18214
Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological Management of Insomnia. Neurotherapeutics. https://doi.org/10.1007/s13311-021-01010-z
Martsenkovskyi, D., & Napryeyenko, O. (2019). P.818 Adjunctive therapy with trazodone for insomnia in adolescents with post-traumatic stress disorder and depression. European Neuropsychopharmacology, 29, S543–S544. https://doi.org/10.1016/j.euroneuro.2019.09.682
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 Medicine, 13(02), 307–349. https://doi.org/10.5664/jcsm.6470
Winkelman, J. W. (2015). Insomnia Disorder. New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/nejmcp1412740
Yi, X., Ni, S., Ghadami, M. R., Meng, H., Chen, M., Kuang, L., Zhang, Y., Zhang, L., & Zhou, X. (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