ASSESSING AND TREATING PATIENTS WITH SLEEP/WAKE DISORDERS

ASSESSING AND TREATING PATIENTS WITH SLEEP/WAKE DISORDERS

 

Assessing and Treating Patients with Sleep/Wake Disorders

 

 

Assessing and Treating Patients with Sleep/Wake Disorders

Insomnia is a sleep disorder characterized by poor sleep quantity or quality. Sleep disorders impair various aspects of individuals, including quality of life and cognition. They contribute to interpersonal difficulties, work-related problems, risk of psychiatric disease, substance abuse, and increased proneness to accidents. The purpose of this paper is to describe treatment interventions for a patient with a sleep/wake disorder.

Introduction to the Case

The case study portrays a 31-year-old man presenting with insomnia. He mentions that insomnia has increasingly worsened in the past six months. He currently experiences trouble falling asleep and remaining asleep at night. The sleep disturbance started roughly six months ago after his fiancé’s death. It affects his job performance because he often falls asleep when at work since he did not have adequate sleep the previous night. He had used diphenhydramine to aid sleep, but it has a morning after-effect. The patient has an opiate abuse history. He states that he has not been given an opioid prescription for the past four years. He reports taking four beers before bed to aid in falling asleep. His MSE is unremarkable.

Both pharmacological and psychotherapy interventions are indicated in managing insomnia in adult patients. When the pharmacotherapy option is selected, the choice of the drug should be directed by: Insomnia symptom pattern; Patient’s past treatment response; Treatment goals; Patient preference; Medication cost; Comorbid conditions;  Drug contraindications; Concurrent medication interactions; Potential adverse effects (Pagel et al., 2018). Therefore, the factors that may impact treatment decisions for this patient include his insomnia pattern, past response to diphenhydramine, and opiate abuse history.

Decision Point One

Trazodone 50 mg P.O. at bedtime.

Why I Selected This Decision

Trazodone was selected because it is widely prescribed off-label to manage insomnia. It is a sedative antidepressant that wields its antidepressant effect by antagonizing and inhibiting serotonin reuptake (Madari et al., 2021). Zheng et al. (2022) found that trazodone markedly improved total sleep time (TST) and non-rapid eye movement stage 3 (N3). It also markedly reduces latency to the onset of persistent sleep, frequency of awakenings, and waking time following persistent sleep onset.

Why I Did Not Select the Other Two Options Provided

Zolpidem was not ideal due to its associated abuse potential, psychomotor impairment, and complex sleep behaviors (Earl et al., 2020). Hydroxyzine was not also ideal due to its strong sedative properties that cause drowsiness, which causes intolerance to the drug (Krystal et al., 2019). Besides, limited data support Zolpidem’s efficacy and safety in treating insomnia.

What I Was Hoping To Achieve By Making This Decision

The practitioner hoped that Trazodone would improve the patient’s reported sleep quality by reducing nighttime awakenings and aiding in sleep (Hassinger et al., 2020). Zheng et al. (2022) explain that trazodone plays an essential role in improving the internal structure of sleep, such as reducing non-rapid eye movement stage 1 and the number of awakenings and increasing non-rapid eye movement stage 3.

How Ethical Considerations May Impact the Treatment Plan

Ethical factors of beneficence may affect treatment since the practitioner had to select the medication established to have the most benefits in improving insomnia. Respect for patient autonomy may affect communication since the practitioner must involve the patient in treatment decisions.

Decision Point Two

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

Why I Selected This Decision

Priapism is a known side effect of Trazodone. It is reported that prolonged, dysfunctional penile erection is most likely to happen within the first 28 days of trazodone treatment, typically 150 mg/day or less (Earl et al., 2020). The current dose was maintained because it led to a positive response in reducing insomnia. Continuing the dose would likely improve the patient’s sleep quality (Hassinger et al., 2020).

Why I Did Not Select the Other Two Options Provided

Changing the drug to Suvorexant was not ideal since it has side effects of daytime somnolence, motor and driving impairment, abnormal dream pattern, and unconscious nighttime activity like sleepwalking (Earl et al., 2020). The trazodone dose was not lowered to 25 mg because a higher dose is more reasonable because it is associated with better outcomes than low doses (Zheng et al., 2022).

What I Was Hoping To Achieve By Making This Decision

The practitioner hoped that continuing the dose and explaining to the patient about trazodone-associated priapism would promote medication adherence and continuously improve sleep quality (Krystal et al., 2019). Earl et al. (2020) explain that clinicians should be aware that trazodone can cause a rare but potentially serious adverse effect of priapism that may need urgent care.

How Ethical Considerations May Impact the Treatment Plan

The principles of nonmaleficence and informed consent may impact treatment and communication with this patient. The provider upheld nonmaleficence by assessing Trazodone’s side effects and addressing them. Informed consent as to the risk of priapism with trazodone is essential.

Decision Point Three

Continue the dose and explain to the patient that he may split the 50 mg tablet in half. Follow up in 4 weeks.

Why I Selected This Decision

Splitting the Trazodone dose by half was selected to lower the severity of the reported drowsiness. Trazodone is linked with dose-dependent daytime somnolence, and reducing the dose is recommended to alleviate the side effect (Madari et al., 2021). A follow-up after four weeks is important to examine if the side effect has abated and assess improvement in insomnia (Zheng et al., 2022).

Why I Did Not Select the Other Two Options Provided

It was not ideal to change therapy to Sonata because it is also associated with side effects of dizziness and somnolence, as well as strange and dangerous sleep-related behaviors (Madari et al., 2021). Hydroxyzine was not also a good choice due to its strong sedative properties that cause side effects of drowsiness, daytime sedation, and involuntary motor activity (Krystal et al., 2019).

What I Was Hoping To Achieve By Making This Decision

            The practitioner hoped that reducing the Trazodone dose would lower the patient’s reported drowsiness but still improve sleep quality and lower nighttime awakenings (Earl et al., 2020). Low Trazodone doses are linked with decreased side effects (Madari et al., 2021).

How Ethical Considerations May Impact the Treatment Plan

            The practitioner must uphold nonmaleficence by taking measures that will reduce patient safety risks. In this case, the dose was reduced to alleviate the dose-dependent side effects. The principle of confidentiality may impact communication. The practitioner cannot share the patient’s information without seeking consent.

Conclusion

The patient complained of insomnia, trouble falling asleep, and nighttime awakening. Factors impacting treatment decisions include his previous treatment response, insomnia pattern, and history of opiate abuse. The first treatment decision was to initiate the patient on Trazodone 50 mg. It is widely used off-label to treat insomnia. It improves insomnia symptoms by reducing the frequency of awakenings and aiding in initiating sleep (Zheng et al., 2022). Zolpidem and Hydroxyzine were not selected because of their side effects like abuse potential, complex sleep behaviors, and drowsiness (Krystal et al., 2019)

The patient reported improved sleep with Trazodone. However, he complained of an erection that lasted 15 minutes. The provider reassured the patient about this side effect by explaining that an erection lasting 15 minutes is not considered a priapism. The Trazodone dose was maintained since the patient demonstrated a positive response. Patient education on the side effect of erection and priapism is important for patients initiated on Trazodone (Krystal et al., 2019). The patient’s priapism abated with time, but he came after four weeks with complaints of next-day drowsiness. This was attributed to dose-dependent sedation that occurs with Trazodone. As a result, the provider informed the patient to divide the Trazodone tablet to alleviate the side effect while improving sleep quality (Earl et al., 2020).

 

 

References

Earl, D. C., & Van Tyle, K. M. (2020). New pharmacologic agents for insomnia and hypersomnia. Current Opinion in Pulmonary Medicine, 26(6), 629–633. doi:10.1097/mcp.0000000000000722

Hassinger, A. B., Bletnisky, N., Dudekula, R., & El-Solh, A. A. (2020). Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert opinion on pharmacotherapy, 21(9), 1035–1043. https://doi.org/10.1080/14656566.2020.1743265

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry: official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674

Madari, S., Golebiowski, R., Mansukhani, M. P., & Kolla, B. P. (2021). Pharmacological Management of Insomnia. Neurotherapeutics: the journal of the American Society for Experimental NeuroTherapeutics, 18(1), 44–52. https://doi.org/10.1007/s13311-021-01010-z

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

Zheng, Y., Lv, T., Wu, J., & Lyu, Y. (2022). Trazodone changed the polysomnographic sleep architecture in insomnia disorder: A systematic review and meta-analysis. Scientific Reports, 12(1), 14453. https://doi.org/10.1038/s41598-022-18776-7

 

 

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Important information on Writing a Discussion Question

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• Follow APA-7th edition
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• Student paper example
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• The Writing Center is a great resource