Assessing and Treating Patients with Sleep/Wake Disorders

The case presented is of a 31-year-old male presenting with insomnia. His insomnia began six months ago after he lost his fiancee. The patient’s insomnia has been progressively worsening over the past six months. In addition, he reports that he has had a history of sleeping problems and often had difficulties maintaining sleep. Currently, he is having difficulties in both maintaining and falling asleep.

The patient reports that he has been using diphenhydramine to help with his sleep but does not like the morning-after feeling. He also says that he has recently been using alcohol to induce sleep. The patient’s social history reveals he works as a folk lift operator at a local chemical company. He notes that his insomnia affects his operability as he sometimes falls asleep on the job. His past medical history reveals opiate abuse. This began after breaking his ankle during a skiing accident and being prescribed a hydrocodone and acetaminophen combination to manage his pain.

The mental status exam revealed that he is alert and oriented to person, event, time, and place. The patient has dressed appropriately for the time of the year. The patient also makes good eye contact. The patient denies having auditory or visual hallucinations. His judgment, contact with reality, and insight are also still intact. He also denies having any suicidal ideation or tendencies. The patient is also orientated to the future.

The case study describes a patient who has a positive diagnosis of insomnia. Insomnia is a sleep disorder characterized by difficulties inducing and maintaining sleep. Individuals with this disorder often experience multiple night awakenings and fail to achieve restorative sleep (Kaur et al., 2022). Functional deficits are usually apparent in this disorder and are attributable to fatigue, irritability, and lack of concentration that accompanies the disorder.

Decision Point 1

The initial intervention for the patient is to administer trazodone 50mg every 24 hours at bedtime. Trazodone is a serotonin antagonist and reuptake inhibitor. This medication is used in the off-label management of insomnia and other sleep disorders. Research findings reveal that trazodone effectively improves sleep duration and sleep latency and promotes daytime wakefulness (Wang et al., 2020). The patient in the case may benefit from this medication.

The other two options provided are equally effective in the management of insomnia. Their use is, however, limited by their intolerable toxicity profile. Zolpidem has been associated with headaches, dizziness, and nasal stuffiness that may affect the patient’s operability during the day (Xiang et al., 2021). Hydroxyzine also causes headaches, dizziness, and xerostomia, which may also affect the patient’s functionality during work. Trazodone maintains higher efficacy in managing insomnia and has tolerable side effects. Additionally, the desired outcome of maintaining wakefulness during work hours is only effectively and optimally achieved with trazodone.

The choice of trazodone aims to enhance the patient’s sleep quality and optimize daytime operability. Trazodone maintains superiority in managing insomnia as it improves sleep latency and duration and promotes daytime wakefulness. These features are the most desired in the patient as he works as a machine operator and requires maximum alertness when executing his duties. When administering this medication, the patient should be educated on the anticipated side effects of the drug. He should also be advised to report these side effects. Before initiating therapy, informed consent should be obtained from the patient. Confidentiality between the patient and his caregiver is also important.

Decision Point 2

The decision is to decrease the dose of trazodone to 25mg daily at bedtime. The patient’s report on return to the clinic confirmed the effectiveness of trazodone in managing insomnia. The patient stated that the medication worked well except for the side effects. Trazodone maintains effectiveness in managing insomnia but may elicit unwanted effects when used at conventional doses in depression. These side effects include headaches, prolonged erections, and dizziness. A dose reduction from 50mg to 25 mg is necessitated in this patient because of complaints of prolonged erection reported by the patient. Trazodone dose reduction lessens its side effects while maintaining its effectiveness in managing insomnia. In the patient case presented, halving the dose may eliminate the side effects encountered with the initial dose.

Discontinuing trazodone is not warranted in this case. This is because the patient has started responding to the medications. The benefits of continuing with this regimen outweigh its withdrawal or stoppage. Suvorexant maintains effectiveness in the management of insomnia. Its use is not favorable because of its high cost. Priapism that is apparent with trazodone use may sometimes persist. Moreover, the patient reported that it disturbs his functionality and causes discomfort. It is thus inappropriate to advise the patient to continue the medication.

Halving the dose in the patient was aimed at offsetting the prolonged erection that the patient reported. Besides, Shah et al. (2021) say that trazodone dose reduction effectively eliminated the symptoms of priapism that are apparent when this medication is administered at higher doses. When treating the patient, he should be notified of the reason for the dose reduction. His presentations should be kept confidential by the caregiver. The caregiver should also be wary of his communication techniques to avoid giving the patient the impression of ridicule. This can be ensured by maintaining objectivity and employing appropriate gestures.

Decision Point 3

The third decision is to continue the dose of trazodone, encourage the patient to maintain good sleep hygiene, and return for review after four weeks. Upon return, the patient noted that the trazodone dose he has been using is effective. Upon returning to the clinic, the patient did not report any considerable side effects from the medication. This shows that the dose reduction intervention effectively eliminated the side effects earlier experienced while maintaining its effectiveness. Sticking to the medication regimen and observing good sleep hygiene may help the patient achieve good sleep throughout the night. Maintaining a good sleep environment and hygiene are contributory to good sleep. Drake et al. (2018) reinforce the significance of nonpharmacological intervention in managing insomnia and other sleep disorders. In the patient’s case above, maintaining sleep hygiene may augment the effects of his medications and ensure that he gets quality sleep. Switching to hydroxyzine or ramelteon is not necessary in this case. This is because of the proof of efficacy exhibited with trazodone use.

This intervention aims to improve the patient’s sleep behavior and maintain the gains from the medications. Optimal sleep hygiene, in combination with sleep pharmacotherapy, is superior to pharmacotherapy alone in optimizing sleep. The patient is encouraged to maintain proper hygiene as a complementary measure to the medications he has been using. The patient should be educated on the role of a sound sleep environment and sleep hygiene in managing insomnia. He should be told, in this regard, to improve his sleep environment and allocate sufficient time for sleep. When treating this patient, the provider should be informed that the use of sleeping prescription pills is warranted as it is per the ethical principle of non-maleficence that requires them not to harm.

Conclusion

The patient in the case study presented with insomnia. His social history revealed that he is a machine operator, and his insomnia negatively impacts his job. The treatment plan for the patient should consider his career and target enhancing his night sleep and daytime operability. Several medications are utilized in the management of insomnia. This medication maintains effectiveness in alleviating this disorder but has diverse side effects.

Trazodone is a serotonin antagonist and reuptake inhibitor that is approved for use in managing major depressive disorders. This medication has off-label use for insomnia. Trazodone, at conventional doses used in depression, effectively works against insomnia but produces considerable side effects. Its toxicity profile can be enhanced by halving the dose. As noted in the patient case presented, this medication maintains its anti-insomnia effects at half the dose with minimal side effects. It remains one of the most effective modalities of managing insomnia.

Medications used in managing insomnia include trazodone, ramelteon, hydroxyzine, suvorexant, and Zolpidem, among others. The choice of medication depends on its effectiveness, cost, and toxicity profile. The best medicine to be applied should have the most minor side effects, produce superior anti-insomnia effects, and be cost-effective. In this case, suveroxan use was limited by its high costs and the inadequacy of its cheaper generic substitutes. Hydroxyzine is equally effective against insomnia and has a better toxicity profile than ramelteon and Zolpidem. Its anticholinergic side effects may sometimes limit its use. In the patient’s case above, hydroxyzine may be a better option when trazodone fails. Maintaining good sleep hygiene and an optimal sleep environment underlines pharmacotherapy efforts to manage this disorder (Johnson et al., 2018). The patient should be advised to complement his medications by ensuring good sleep hygiene and an optimal sleep environment.

References

Drake, C., Kalmbach, D., Arnedt, J., Cheng, P., Tonnu, C., Cuamatzi-Castelan, A., & Fellman-Couture, C. (2018). Treating chronic insomnia in postmenopausal women: a randomized clinical trial comparing cognitive-behavioral therapy for insomnia, sleep restriction therapy, and sleep hygiene education. Sleep, 42(2). https://doi.org/10.1093/sleep/zsy217

Johnson, D., Billings, M., & Hale, L. (2018). Environmental Determinants of Insufficient Sleep and Sleep Disorders: Implications for Population Health. Current Epidemiology Reports, 5(2), 61-69. https://doi.org/10.1007/s40471-018-0139-y

Kaur, H., Spurling, B., & Bollu, P. (2022). Chronic Insomnia. Ncbi.nlm.nih.gov. Retrieved 23 September 2022, from https://www.ncbi.nlm.nih.gov/books/NBK526136/.

Martsenkovskyi, D., & Napryeyenko, O. (2019). 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

Shah, T., Deolanker, J., Luu, T., & Sadeghi-Nejad, H. (2021). Pretreatment screening and counseling on prolonged erections for patients prescribed trazodone. Investigative And Clinical Urology, 62(1), 85. https://doi.org/10.4111/icu.20200195

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. https://doi.org/10.3389/fpsyt.2020.00620

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in treating insomnia disorder for one month: a meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250-256. https://doi.org/10.1016/j.sleep.2021.09.005

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Question

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. Consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

Assessing and Treating Patients with Sleep-Wake Disorders

You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before making your decision, ensure that you have researched each option and considered the decision 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)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your suggestions 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 reasoning, it will not count toward the resource requirement. It would be best if you were utilizing the primary and secondary literature.