Assessing and Treating Patients with Sleep or Wake Disorders
Assessing and Treating Patients with Sleep or Wake Disorders
Assessing and Treating Patients with Sleep or Wake Disorders
Assessing and Treating Patients with Sleep or Wake Disorders
Introduction to the Case
The case presented is about a 31-year-old male with a chief complaint of insomnia. The patient reports worsening his insomnia over the last six months. The patient has a history of using diphenhydramine but stopped using it because of how it made him feel the morning after. He also reports a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap for pain management. Additionally, the patient has been using alcohol to help him fall asleep. The sudden loss of his fiancé appears to trigger his insomnia, impacting his ability to perform his job as a forklift operator at a local chemical company. The patient’s mental status exam reveals that he is alert and oriented to person, place, time, and event. Judgment, insight, and reality contact are intact. The patient denies suicidal or homicidal ideation and is future-oriented.
Several factors should be considered when prescribing medication for this patient with insomnia. The patient’s history of abusing opiates indicates that caution should be taken when prescribing potentially addictive medications. The patient’s record on alcohol use to help him sleep should also be considered to prevent the adverse effects of drug reactions to alcohol. The patient’s occupation should also be considered, as some drugs cause drowsiness and impaired coordination. Furthermore, the patient’s recent loss of his fiancé indicates the need to address the underlying psychological factors contributing to his insomnia. Psychological interventions such as cognitive-behavioral therapy or counseling can be beneficial in addressing these factors.
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Decision #1 – Trazodone 50 mg at Bedtime
Trazodone 50 mg PO at bedtime was selected as the medication of choice for the patient with insomnia. Trazodone is a serotonin antagonist and reuptake inhibitor (SARI) that has been used off-label for the treatment of insomnia due to its efficacy in improving sleep quality and quantity, with a low risk of abuse and dependence (Mazza et al., 2022). Moreover, trazodone has been shown to be effective in treating insomnia in patients with depression, making it a suitable option for a patient experiencing insomnia after losing his fiancé. The starting dose of trazodone is typically 25-50 mg, taken one hour before bedtime, which can be increased to a maximum dose of 150-200 mg per day.
On the other hand, Zolpidem 10 mg daily at bedtime and Hydroxyzine 50 mg daily at bedtime were not selected for the patient with insomnia. Zolpidem has been associated with adverse effects such as next-day somnolence, impaired cognitive function, and a higher risk of dependence and withdrawal, making it a less favorable option than Trazodone (Edinoff et al., 2021). Hydroxyzine, an antihistamine, is sometimes used off-label for insomnia treatment, but limited evidence supports its efficacy for this indication, and it may cause next-day sedation and cognitive impairment (Burgazli et al., 2023). Therefore, trazodone was chosen as the optimal medication for the patient’s insomnia.
Ethical considerations are important in the treatment of patients with insomnia. It is essential to obtain informed consent from the patient and inform them about the medication’s potential side effects, particularly those related to sexual dysfunction. It is also vital to address any underlying psychological issues contributing to the patient’s insomnia, such as grief related to losing his fiancé, and to provide appropriate counseling and support.
Decision #2 – Decrease Trazodone to 25 mg
For several reasons, I selected decreasing trazodone to 25 mg daily at bedtime as the best option for this patient’s insomnia. Trazodone is commonly used off-label as a sleep aid due to its sedating effects, and the patient reported that it has been effective for his insomnia. However, trazodone can also cause priapism, a prolonged erection that can be painful and requires medical intervention, especially in males (Mazza et al., 2022). The risk of priapism increases with higher doses of trazodone. Decreasing the dose to 25 mg daily at bedtime can decrease the risk of this side effect while still providing effective treatment for insomnia.
I did not select the other two options in the exercise because they are not the best for this patient’s situation. The first option was to explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, while continuing with the current dose will only worsen the side effects of trazodone. The second option involves discontinuing trazodone and initiating therapy with suvorexant, a nonbenzodiazepine hypnotic that inhibits orexin receptors in the brain. While suvorexant can be effective for treating insomnia, it is contraindicated in patients with a history of substance abuse or dependence, which the patient in this case has. Suvorexant can also cause significant side effects, such as somnolence, dizziness, and impaired driving ability, which can be dangerous for a forklift operator (Vermeeren et al., 2019). Therefore, it is not the best choice for this patient.
Decreasing the trazodone dose to 25 mg daily at bedtime was to reduce the risk of priapism while still providing effective treatment for insomnia. Evidence supports the use of trazodone for the treatment of insomnia, with studies showing improved sleep onset latency, total sleep time, and sleep quality in patients with insomnia. Lower doses of trazodone (25-50 mg) have also been shown to be effective for treating insomnia, with fewer side effects than higher doses (Mazza et al., 2022). Therefore, decreasing the trazodone dose to 25 mg daily at bedtime can effectively treat insomnia while minimizing the risk of side effects.
Ethical considerations can impact the treatment plan and communication with patients. In this case, the patient has a history of substance abuse, which raises concerns about the potential for addiction or abuse of sleep aids. It is essential to discuss the risks and benefits of treatment options with the patient and to monitor the patient closely for signs of abuse or dependence (Haddad & Geiger, 2022). It is also essential to consider the patient’s occupation as a forklift operator, which requires alertness and attention to safety. Sedating medications like trazodone or suvorexant can impair driving ability and increase the risk of accidents.
Decision Point #3 – Continue the Current Dose of Trazodone
I selected the decision to continue the dose of trazodone, encourage sleep hygiene, and follow up in 4 weeks because of several reasons. Firstly, trazodone is a commonly prescribed medication for insomnia. It has improved sleep quality and duration in patients with insomnia, including those with comorbid depression and anxiety (Mazza et al., 2022). The patient, in this case, has a history of opiate abuse, which raises concerns about the potential for addiction to other sedative medications. Trazodone is not a controlled substance and has a lower risk of abuse and dependence than other sedatives, such as benzodiazepines or barbiturates. Additionally, trazodone has a low potential for drug-drug interactions, which is vital given the patient’s history of opiate use.
Encouraging sleep hygiene is also an essential aspect of managing insomnia. Research has shown that non-pharmacological interventions, such as cognitive-behavioral therapy for insomnia (CBT-I) and sleep hygiene education, effectively improve sleep quality and duration in patients with insomnia (Rossman, 2019). In this case, the patient is using alcohol to help him fall asleep, which is a maladaptive coping mechanism that can exacerbate insomnia symptoms over time. Providing education on sleep hygiene, such as avoiding alcohol before bedtime, establishing a regular sleep schedule, and creating a comfortable sleep environment, can help improve the patient’s sleep habits and overall sleep quality.
I should have selected the other two options in the exercise for several reasons. Ramelteon is a melatonin receptor agonist that has been shown to improve sleep latency in patients with insomnia; however, it is not as effective as trazodone in improving sleep quality and duration (Hyung & Kwang, 2022). On the other hand, hydroxyzine is an antihistamine with sedative effects and is sometimes used off-label for treating insomnia. However, there is limited evidence to support the use of hydroxyzine for insomnia, and it may cause anticholinergic side effects such as dry mouth, constipation, and cognitive impairment. By making this decision, I aim to achieve improved sleep quality and duration for the patient, which can lead to better overall health and well-being. The patient should be fully informed about the risks and benefits of trazodone and encouraged to ask questions and express any concerns.
Summary and Conclusion
The best treatment option for this patient’s insomnia is to continue the dose of trazodone, encourage sleep hygiene, and follow up in 4 weeks. Trazodone is a commonly prescribed medication for insomnia due to its low risk of abuse and dependence and its efficacy in improving sleep quality and duration in patients with insomnia. Encouraging sleep hygiene is another critical aspect of managing insomnia, as maladaptive sleep habits, such as using alcohol to help fall asleep, can exacerbate insomnia symptoms over time (Hyung & Kwang, 2022). Sleep hygiene education, such as avoiding alcohol before bedtime, establishing a regular sleep schedule, and creating a comfortable sleep environment, can help improve the patient’s sleep habits and overall sleep quality. Ramelteon and hydroxyzine are not the best treatment options for this patient due to their limited efficacy and potential for side effects. Furthermore, the patient has a history of substance abuse, which raises concerns about the potential for addiction or abuse of sleep aids. Therefore, continuing the trazodone dose, encouraging sleep hygiene, and following up in 4 weeks is the best treatment option for this patient’s insomnia.
References
Burgazli, C. R., Rana, K. B., Brown, J. N., & Tillman, F. (2023). Efficacy and safety of hydroxyzine for sleep in adults: Systematic review. Human Psychopharmacology: Clinical and Experimental, 38(2). https://doi.org/10.1002/hup.2864
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). https://doi.org/10.52965/001c.24927
Haddad, L. M., & Geiger, R. A. (2022, August 22). Nursing ethical considerations. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526054/
Hyung K., & Kwang Y. (2022). Melatonin and melatonergic drugs in sleep disorders. Translational & Clinical Pharmacology, 30(4), 163–163. https://doi.org/10.12793/tcp.2022.30.e21
Mazza, M., Emanuele Caroppo, Giuseppe Carlo Marano, Kotzalidis, G. D., Avallone, C., Camardese, G., Janiri, D., Moccia, L., Simonetti, A., Janiri, L., & Sani, G. (2022). Trazodone prolonged-release monotherapy in cannabis dependent patients during lockdown due to COVID-19 pandemic: A case series. International Journal of Environmental Research and Public Health, 19(12), 7397–7397. https://doi.org/10.3390/ijerph19127397
Rossman, J. (2019). Cognitive-Behavioral therapy for insomnia: An effective and underutilized treatment for insomnia. American Journal of Lifestyle Medicine, 13(6), 544–547. https://doi.org/10.1177/1559827619867677
Vermeeren, A., Sun, H., Vuurman, E. F. P. M., Jongen, S., Van Leeuwen, C. J., Van Oers, A. C. M., Palcza, J., Li, X., Laethem, T., Heirman, I., Bautmans, A., Troyer, M. D., Wrishko, R., & McCrea, J. (2019). On-the-Road driving performance the morning after bedtime use of suvorexant 20 and 40 mg: A study in non-elderly healthy volunteers. Sleep, 38(11), 1803–1813. https://doi.org/10.5665/sleep.5168
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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 (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.
scenario
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
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
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
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.
