Assessing and Treating Patients With Sleep/Wake Disorders

Decision Tree for the Treatment of Insomnia

This case is of a thirty-one-year-old male who presents to the office because of insomnia. This insomnia has progressively worsened over the past six months. The problem is having difficulties in falling asleep or maintaining sleep. This problem started around six months ago after his fiance’s death. The patient works as a forklift operator. He complains that this problem affects his work because he has fallen asleep at his job several times. He notes that he has previously used Diphenhydramine but dislikes it due to the morning-after hangover effects. The patient has a history of opioid abuse, which began after breaking his leg and using opioids for the pain. He claims that he has not used opioids for close to four years. The patient drinks alcohol to help him fall asleep. The mental status evaluation indicated a goal-oriented and well-groomed patient.

When treating this patient, the nurse practitioner must consider patient-specific factors that influence drug pharmacokinetics. He must also consider the current medical conditions and past medical history when managing this patient. In addition to this, the clinician must consider the patient’s occupation status and not prescribe drugs that can negatively affect the patient’s productivity. Finally, the clinician must know the history of medications the patient has been using to help in prescribing medications with no drug interactions. This essay will discuss the decision tree in managing a 31-year-old male with a complaint of insomnia. It will further discuss the interventions selected based on patient-specific factors. Each decision will be backed by evidence-based literature. Finally, this paper will highlight the legal and ethical considerations which will impact this decision tree.

Decision Point One

The first decision was to start the patient on Trazodone 50mg every day at bedtime. Trazodone is a serotonin antagonist and reuptake inhibitor. It exerts its therapeutic action by blocking the H1 histaminergic, alpha-one adrenergic receptors, and 5HT2A serotonergic receptors, resulting in hypnotic activity (Jaffer et al., 2017). Trazodone 50mg is sufficient to induce sleep without resulting in the morning after hangover effects or daytime drowsiness. This is attributed to the short half-life of Trazodone (Jaffer et al., 2017). This drug is suitable for this patient since he cannot maintain or induce sleep. This patient is also a forklift operator, and Trazodone does not have side effects of daytime drowsiness.

The patient was not initiated on Zolpidem since this medication is ineffective in managing long-term insomnia. The client has been suffering from insomnia for more than six months now. Compared to Trazodone, Zolpidem has severe adverse effects, such as nocturnal eating disorders, which will make the drug intolerable to the patient (Ho et al., 2020). In addition, the patient was not started on Hydroxyzine due to its strong anthistaminergic and anticholinergic effects, such as xerostomia and xeropthalmia (Kim et al., 2020). This patient complained of daytime drowsiness while taking Diphenhydramine. Hydroxyzine belongs to the same pharmacological class as Hydroxyzine, and hence, this medication should not be given this medication. This patient also operates a forklift, and it would be harmful to prescribe a drug that can result in daytime drowsiness.

By initiating the patient on Trazodone, the clinician hoped that the patient would induce and maintain overnight sleep (Jaffer et al., 2017). The clinician further hoped that this medication would be well tolerated by the patient with minimal adverse effects. This would improve the patient’s quality of life. This would further improve the patient’s compliance with the treatment plan.

Decision Point Two

The patient returned to the office two weeks later, noting that the medication was effective but caused priapism lasting for an estimated fifteen minutes. The patient further narrated that this priapism made it hard for him to prepare for work and have breakfast with his family in the morning. He denies any visual or auditory hallucinations. The decision made was to advise the patient that priapism is a common side effect of Trazodone. The same dose of the drug was thus maintained.

This decision was made since the patient is responding well to the medication and can induce and maintain sleep. Priapism is a common side effect associated with using Trazodone (Scherzer et al., 2019). This medication should not be terminated since the side effect progressively wears off during the treatment. The clinician did not discontinue Trazodone and initiated the client on Suvorexant 10mg. This is because the client is inducing and maintaining sleep with Trazodone, and the side effect of priapism gradually wears off with time. The adverse side effects of Suvexorant include daytime drowsiness, which can negatively impact the patient’s time productivity (Kawabe et al., 2017). This patient is a forklift operator; hence, daytime drowsiness would be dangerous for him. The dosage of Trazodone was not reduced to 25mg since this is a suboptimal dose, and the patient may not be able to maintain overnight sleep (Jaffer et al., 2017).

By maintaining the patient on Trazodone, the nurse practitioner hoped to help the patient induce and maintain sleep. The clinician also hoped that the priapism would gradually resolve. The clinician hoped that regardless of the priapism, the patient would still be compliant with the treatment.

Decision Point Three

The patient returns to the clinic two weeks later, noting he no longer has the priapism. The patient denies any auditory or visual hallucinations. The client notes that he can induce and maintain sleep, with the only drowsiness being daytime drowsiness. The clinician decided to ask the patient to split the 50mg Trazodone tablet into half and only take one half. This decision was made since the patient is experiencing excess daytime drowsiness, and reducing the dose to 25mg will help lower the daytime drowsiness (Jaffer et al., 2017).

The clinician initiated the patient on Sonata 10mg since this medication has a life-threatening sleep disorder as a side effect. This side effect leads to patients driving their cars, participating in sexual activities, cook meals but will not remember doing these things in the morning (Harbourt et al., 2020). The clinician did not initiate the patient on Hydroxyzine due to its strong anticholinergic and antihistaminergic adverse effects on xerostomia and xeropthalmia (Kim et al., 2020). This patient had drowsiness with Diphenhydramine and Trazodone. It is thus not wise to initiate the patient on a medication that will affect patient compliance and quality of life.

By asking the patient to divide the tablet into two, the clinician hoped to reduce the excessive daytime drowsiness. By reducing the dosage, the clinician hoped that the patient will still be able to induce and maintain sleep.

Ethical Considerations

In any medical decision-making process, ethical principles must be applied. The essential ethical principles that should be utilized include beneficence, veracity, non-maleficence, and autonomy (Haddad & Geiger, 2020). The patient should be part of the treatment process, and accurate information regarding dosage and side effects should be provided to enable him to make an informed decision. All the decisions made during the decision tree should be for the benefit of the patient. The drugs prescribed should have optimum therapeutic effects with minimum side effects. This is in accordance with beneficence and non-maleficence principles (Haddad & Geiger, 2020)

Conclusion

The patient in the case study presents with a complaint of insomnia. The decision was to initiate the patient on Trazodone 50mg. When the patient returned to the clinic two weeks later, the drug was effective in helping him induce and maintain sleep, but he was experiencing priapism, which embarrassed him. The clinician then advised the patient that priapism was a common side effect of Trazodone, and it will disappear gradually. When the patient returned two weeks later, his priapism had disappeared, but he was experiencing excessive daytime drowsiness. The patient was then advised to divide the tablet into half and only take one half.

The clinician utilized drug factors and patient factors throughout the decision tree. The clinician explained to the patient and gave him all information to enable the patient to make an informed decision. Ethical principles guided the decision tree, which ensured that the autonomy of the patient was preserved. This exercise has been of great importance to me. I have learned of the benefits of evidence-based practice in clinical practice. I will use this to become a better nurse practitioner in the future.

References

Haddad, L. M., & Geiger, R. A. (2020, February 18). Nursing ethical considerations – StatPearls – NCBI bookshelf. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK526054/

Harbourt, K., Nevo, O. N., Zhang, R., Chan, V., & Croteau, D. (2020). Association of eszopiclone, zaleplon, or Zolpidem with complex sleep behaviors resulting in serious injuries, including death. Pharmacoepidemiology and drug safety, 29(6), 684-691.

Ho, T., Jimenez, A., Sanchez, I., Seeger, C., & Joseph, M. (2020). Sleep-Related Eating Disorder Associated with Zolpidem: Cases Compiled From a Literature Review. Sleep Medicine: X, 100019.

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., … & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(7-8), 24.

Kawabe, K., Horiuchi, F., Ochi, M., Nishimoto, K., Ueno, S. I., & Oka, Y. (2017). Suvorexant for the Treatment of Insomnia in Adolescents. Journal of child and adolescent psychopharmacology, 27(9), 792-795.

Kim, G., Lee, J., Kim, H., & Nam, S. (2020). The Effectiveness and Side Effects of Conscious Sedation using Chloral Hydrate, Hydroxyzine, and Nitrous Oxide. THE JOURNAL OF THE KOREAN ACADEMY OF PEDIATRIC DENTISTRY, 47(2), 109-119.

Scherzer, N. D., Reddy, A. G., Le, T. V., Chernobylsky, D., & Hellstrom, W. J. (2019). Unintended consequences: a review of pharmacologically-induced priapism. Sexual medicine reviews, 7(2), 283-292.

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