Assessing and Treating Patients with Sleep-Wake Disorder

In this case study, we are presented with a 31-year-old male patient with a chief complaint of worsening insomnia. Over the past six months, the patient has experienced difficulties falling asleep and staying asleep at night. As a forklift operator at a local chemical company, his sleep problems negatively affect his job performance and daily functioning. The patient had previously used diphenhydramine to address his sleep issues but discontinued it due to undesirable side effects.

Several patient-specific factors come into play when considering medication options for this individual. Firstly, his history of opiate abuse is essential, as it may impact his response to certain medications and raise concerns about potential substance interactions. While the patient hasn’t used opiate analgesics for the past four years, there may still be considerations regarding his previous substance use (Wheeler, 2020). Secondly, the patient’s dislike for the morning-after effects of diphenhydramine, a sleep aid he used in the past, indicates a preference for alternative medications with fewer undesirable side effects (Wheeler, 2020). The patient’s use of alcohol to help him fall asleep is another significant factor. Alcohol consumption can interact with sleep medications and affect their efficacy and safety. Therefore, medication choices must account for this aspect of the patient’s sleep hygiene (Sateia et al., 2017). Moreover, the patient’s occupation as a forklift operator emphasizes the importance of selecting a sleep medication that doesn’t impair his alertness or job performance during the day.

The mental status exam indicates that the patient is alert, oriented, and mentally stable, with no signs of hallucinations or suicidal ideation. These findings suggest that the patient’s insomnia is likely a reaction to his recent loss rather than a symptom of an underlying mental health disorder (American Psychiatric Association, 2013). However, his emotional state should still be considered when prescribing medications, as the treatment plan needs to be sensitive to his grief and overall psychological well-being.

Given these patient-specific factors, the decision-making process for prescribing medication for this patient should prioritize safety, efficacy, and compatibility with his medical history and emotional state. It is essential to consider medications with a proven track record in managing insomnia while minimizing potential side effects and interactions with alcohol or substances. Close monitoring and patient education will also play a vital role in ensuring the best possible treatment outcome and addressing any concerns or adverse effects that may arise during treatment.

Decision #1

I decided to prescribe Trazodone 50 mg PO at bedtime for the patient’s insomnia.

Reasoning

I chose Trazodone as the initial medication for the patient’s insomnia based on its well-established efficacy in treating sleep disturbances, which aligns with the patient’s primary complaint. Trazodone is a serotonin antagonist and reuptake inhibitor with sedative properties, commonly prescribed for sleep disorders due to its ability to improve sleep latency and maintenance (Sateia et al., 2017). Moreover, it effectively managed sleep disturbances in patients with a history of substance abuse, which is relevant to our patients with a history of opiate abuse (Wheeler, 2020).

Reasons for Not Selecting Other Options

Zolpidem (Ambien)

While Zolpidem is effective for short-term insomnia, it is associated with a higher risk of tolerance, dependence, and rebound insomnia, which may not be ideal for a patient with a history of substance abuse (Winkleman, 2015). Additionally, Zolpidem may have interactions with alcohol, which the patient is currently using to help with sleep.

Hydroxyzine

Although Hydroxyzine has sedative properties and is sometimes used off-label for insomnia, it is primarily an antihistamine with potential anticholinergic side effects. Given the patient’s report of not liking the side effects of diphenhydramine, a similar antihistamine, Hydroxyzine, might not be the best choice (Winkleman, 2015).

Expected Outcome

With Trazodone, my goal was to improve the patient’s sleep quality, reduce the time it takes to fall asleep, and minimize nighttime awakenings. The patient’s daytime functioning, job performance, and overall quality of life should improve by achieving better sleep (Sateia et al., 2017).

Ethical Considerations

Given the patient’s history of opiate abuse, there is a need for cautious prescribing to minimize the risk of medication misuse. Close monitoring for any signs of dependence or adverse effects is necessary. Moreover, open communication with the patient to discuss Trazodone’s benefits and potential risks is essential (American Psychiatric Association, 2013). The patient should be educated about the medication’s potential side effects, including the possibility of priapism, to ensure informed consent and address any concerns he may have.

Decision #2

Selected Decision

To explain to the patient that an erection lasting 15 minutes is not considered a priapism and should diminish over time and to continue with the current Trazodone dose of 50 mg at bedtime.

Reasoning

The patient’s report of an erection lasting approximately 15 minutes after waking up is likely a side effect of Trazodone, known as priapism. However, it is essential to reassure the patient that this particular duration of erection is not considered a medical emergency and should diminish over time as his body adjusts to the medication (Levenson et al., 2015). Providing clear information and alleviating concerns may make the patient more comfortable continuing the treatment.

The patient reported that Trazodone at the current dose of 50 mg improves his sleep. Given the effectiveness of the medication in managing his insomnia, it is reasonable to continue the treatment and manage the side effects with proper patient education (Sateia et al., 2017). The patient’s concern about next-day drowsiness can be addressed separately, as it is a common side effect of Trazodone. By managing the dose, this side effect can be minimized without compromising the effectiveness of the medication (Levenson et al., 2015).

Reasons for Not Selecting Other Options

Discontinuing Trazodone and Initiating Suvorexant

This may not be the best option because the patient has already experienced improvements in sleep with Trazodone. Additionally, introducing a new medication may come with its side effects and potential interactions with the patient’s medical history (Levenson et al., 2015).

Decreasing Trazodone to 25 mg

While decreasing the dose of Trazodone may reduce the side effects of next-day drowsiness, it might also compromise the efficacy of the medication in managing the patient’s insomnia. The patient has reported a good response to the current dose, so reducing it might not be the most appropriate action (Levenson et al., 2015).

Expected Outcome

The patient will likely experience a reduction in the duration and frequency of priapism as his body adjusts to Trazodone. By providing reassurance and proper patient education, the patient should feel more at ease continuing the medication and managing any potential side effects (Winkleman, 2015).

Ethical Considerations:

It is crucial to provide the patient with clear and honest information about the side effects while reassuring him that it should diminish over time. The patient’s consent and autonomy should be respected, and any concerns or questions about the medication or side effects should be addressed with empathy and understanding (American Psychiatric Association, 2013). Open communication with the patient is essential in building trust and ensuring the treatment plan aligns with the patient’s values and goals.

Decision #3

Selected Decision

To continue with the current Trazodone dose of 50 mg, but 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.

The Reasoning for Decision #3

The patient has reported that the current dose of Trazodone (50 mg) effectively improves his sleep quality. However, he also experiences next-day drowsiness, which can negatively impact his job performance as a forklift operator. By reducing the dose to 25 mg, the patient may experience reduced next-day drowsiness while still benefiting from the sleep-enhancing effects of Trazodone (Winkleman, 2015).

The patient has already responded positively to Trazodone at the current dose. Introducing a new medication, such as Sonata or Hydroxyzine, may come with additional side effects and risks, which might not be necessary given that the patient’s insomnia is effectively managed with Trazodone (Levenson et al., 2015). By offering the option to split the 50 mg tablet in half, the patient may feel more in control of his treatment and more willing to adhere to the prescribed regimen. This empowerment can improve treatment adherence and overall patient satisfaction (Winkleman, 2015).

Reasons for Not Selecting Other Options

Discontinuing Trazodone, which the patient has found effective, in favour of initiating a new medication like Sonata or Hydroxyzine may not be necessary at this point. These alternatives come with their own set of side effects and may not guarantee better outcomes compared to adjusting the Trazodone dose (Levenson et al., 2015).

Expected Outcome

By reducing the Trazodone dose to 25 mg and instructing the patient to split the 50 mg tablet, the patient should experience a decrease in next-day drowsiness while maintaining the benefits of improved sleep quality. The patient’s overall sleep pattern and daytime functioning should improve, positively impacting his job performance and quality of life (Levenson et al., 2015).

Ethical Considerations

Healthcare providers must ensure informed consent and provide the patient with clear explanations of the potential benefits and risks of the lower dose. The patient’s autonomy and preference should be respected, and any concerns or questions about the dosage change should be addressed empathetically (American Psychiatric Association, 2013).

Conclusion

In conclusion, for the treatment of insomnia in the 31-year-old male patient, I recommended a patient-specific approach, taking into account his medical history, medication preferences, and reported side effects. The initial choice was Trazodone 50 mg PO at bedtime. This decision was supported by clinical evidence showing Trazodone’s efficacy in improving sleep latency and maintenance. Considering the patient’s history of opiate abuse and aversion to diphenhydramine’s side effects, Trazodone was a suitable option (Wheeler, 2020).

For decision two, I opted to explain that priapism lasting 15 minutes is not an emergency and should diminish over time and to continue with the current Trazodone dose. This decision balanced patient comfort and medication effectiveness. Introducing new medications was avoided to maintain treatment continuity. The third selected action was to continue with the current Trazodone dose but split the 50 mg tablet in half to minimize next-day drowsiness. Lower Trazodone doses have shown efficacy in improving sleep while reducing side effects (Sateia et al., 2017). This approach aimed to achieve a balance between medication effectiveness and tolerability.

Throughout the decision-making process, ethical considerations played a vital role. The patient’s autonomy and informed consent were prioritized, and patient education was emphasized to foster shared decision-making. Open communication with the patient built trust and allowed him to actively participate in his treatment plan. (American Psychiatric Association, 2013). By implementing these recommendations, the patient’s insomnia should improve, leading to enhanced job performance and overall well-being. Regular follow-ups will ensure treatment efficacy and address any new concerns.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

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(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444.

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