Assessing and Treating Patients with Sleep/Wake Disorders – Decision Tree

Sleep disorders are conditions that disturb normative sleep patterns. Insomnia, parasomnias, sleep-related movement disorders, and circadian rhythm sleep-wake disorders are some sleep disorders recognized by the International Classification of Sleep Disorders (ICSD). Regardless of the form, sleep disorders interfere with the mental, physical, social, and emotional functionalities of adults and children with the disorder. This paper details the assessment and treatment of patients with sleep disorders.

The assigned case is of a 31-year-old male with complaints of insomnia. He is having difficulties falling and maintaining sleep. The problem started six months ago after the loss of his lover and has since been progressing. His insomnia is affecting his ability to perform his professional duties. His past medication history revealed that he has been taking diphenhydramine to ease into sleep. He, however, does not like how he feels the morning after. The patient has a history of opiate abuse, a problem that began after being prescribed an acetaminophen/hydrocodone combination to manage pain following a skiing accident he was involved in. He has not recovered an opiate prescription for over four years.

The patient has been taking alcohol recently to induce sleep. He currently takes approximately four beers to fall asleep. The patient works as a forklift operator in a chemical company. He reports that he has fallen asleep while at work because of not getting sufficient sleep. A mental status examination revealed that the patient is alert and oriented to place time, and event. He denies experiencing any delusions and auditory or visual hallucinations. His judgment, insight, and affect are all intact. The case reveals that the patient has insomnia. He has a history of opiate abuse and is currently taking up to four beers to sleep. Factors in the case presented that may impact the decision-making process on the prescribed medications include the severity state of insomnia, history of opiate abuse, and heavy alcohol consumption for sleep induction.

Decision #1: Trazodone 50mg

The first decision point is to start the patient on trazodone 50mg. The patient has had a problem inducing sleep. As evident in the case study, he has to take at least four bottles of beer to fall asleep. Low-dose trazodone maintains effectiveness in the management of insomnia. It helps in inducing sedation and can be used as a sleep aid (Pelayo et al., 2023). The patient, in this case, can benefit from this medication.

The other available options were to initiate zolpidem 10mg and hydroxyzine 50mg. Zolpidem and hydroxyzine have been used for the management of insomnia. Zolpidem is an FDA-approved medication for the short-term management of insomnia. Its use in the case presented was not preferred because the patient is currently on alcohol and is highly unlikely to stop abruptly. Patients on alcohol taking zolpidem may sometimes experience visual and auditory hallucinations with agitation (Panin & Peana, 2019). This may not be favorable for the patient. The use of hydroxyzine was also not preferred since concomitant use of hydroxyzine and alcohol may potentiate CNS side effects, further affecting the patient’s functionalities.

The intervention selected aims to help the patient fall asleep. Trazodone maintains effectiveness as a sleeping aid. At 50mg once daily dose, trazodone produces marked sedation that may help patients with sleeping problems fall asleep (Pelayo et al., 2023). As evident in the case, the patient takes at least four bottles of beer to fall asleep. Notably, when deciding which medication to give to the patient, the ethical principles of beneficence and non-maleficence come into play. Beneficence requires the caregivers to work in the best interest of the patients, while non-maleficence requires them to do no harm. In this respect, the patient’s welfare is adequately taken care of as he is given medication that will alleviate his insomnia and thereby increase the quality of his life.

Decision #2: Trazodone 25mg

The second decision point is to halve the dose of trazodone to 25mg. This decision point was arrived at after the patient developed unpleasant side effects. As evident in the case, the patients returned to the clinic complaining of an erection lasting up to 15 minutes. Priapism, or persistent penile erection, is a common side effect of trazodone (Eisenach & Lynch, 2023). It is common when the medication is taken at higher doses and manifests as persistent penile erection. Reducing the dose of trazodone may successfully help in addressing the priapism (Eisenach & Lynch, 2023). The patient, in this case, can benefit from a dose reduction.

The alternative option was to discontinue trazodone and initiate suvorexant 10mg. Despite the effectiveness of suvorexant in managing insomnia, its initiation is not warranted as the patient already responds to trazodone. Another alternative option was to explain to the patient that the penile erection experienced is not priapism and that it would diminish after some time. This decision point is not favorable as it goes against the ethical provisions of beneficence. Beneficence requires that caregivers act in the best interest of their patients. Failing to address the patient’s concerns contravenes the ethical provisions requiring caregivers to do good to their patients (Cheraghi et al., 2023). Likewise, prolonged penile erection may be debilitating to the patients and should be addressed.

Halving the dose of trazodone sought to lower the toxicity profile of the medication. Besides, Eisenach and Lynch (2023) note that halving the dose of trazodone may successfully eliminate the majority of the side effects experienced upon initiating the medication. In this respect, halving the dose sought to address the penile erection that the patient complained of. The ethical consideration that impacted the decision point is beneficence. Per the principle of beneficence, patients’ welfare should be protected during their management. This means that whenever they present with complaints of side effects from a medication, it is in the caregivers’ and patients’ best interest to address the side effects without rubbing them off.

Decision #3: Continue with the Same Dose, Encourage Sleep Hygiene, and Follow-Up in Four Weeks

The third decision point is to continue the dose of trazodone and encourage sleep hygiene. Administering trazodone 25mg at bedtime maintains effectiveness in inducing sleep. At this dose, the toxicity profile is considerably lowered. In the case presented, the patient demonstrated a partial response to the trazodone at 25mg. While complaints concerning the dose not being enough to maintain sleep during the entire sleep period are apparent, this can be managed by optimizing the sleep environment and observing good sleep hygiene. Alanazi et al. (2023) note that good sleep hygiene helps in optimizing sleep quality and may go a long way in preventing and managing sleeping difficulties. The patient in the case can benefit from this intervention.

The alternative option was to advise the patient to halve the dose by splitting it in half and that the dose would be sufficient to minimize daytime drowsiness. While this option is partially correct, it falls short of adequately addressing the patient’s concerns. As evident in the case, the patient complained that the 25mg dose sometimes failed to give him a full night’s sleep. This means that halving the dose alone cannot guarantee the patient night-long sleep. Wang et al. (2020) note that low-dose trazodone may sometime fail to guarantee night-long sleep and should thus be augmented by non-pharmacological interventions such as maintaining sleep hygiene. The other alternative was to discontinue trazodone and initiate sonata 10mg. This option is not warranted as the patient has already started responding to the medication.

The selected option is targeted to enhance the sleep quality of the patients. It sought to address the complaints of a lack of night-long sleep. Trazodone, along with sleep hygiene maintenance, helps in sleep optimization (Krystal et al., 2019). These modalities can be used adjunctively for high-quality night sleep. An ethical consideration that may impact the treatment plan and the communication process with the patient is the principle of accountability. Accountability requires that caregivers demonstrate high standard practice and provide the best care to their patients. Using strategies that optimize their client’s outcomes is thus crucial. In this respect, patient education on good sleep hygiene, along with medication use, remains a best practice in managing the apparent sleep disorder.

Conclusion

The assigned case presents a 31-year-old male with insomnia. He has a history of opiate abuse and takes four bottles of alcohol to fall asleep. As a forklift operator, the insomnia considerably affects his ability to work effectively. Notably, insomnia is a common sleep disorder characterized by difficulty in initiating and maintaining sleep. Comprehensive management of insomnia utilizes pharmacological and non-pharmacological interventions. Non-pharmacological interventions such as maintaining good sleep hygiene, sleep restriction therapy, CBT for insomnia, and relaxation therapy maintain effectiveness in sleep optimization (Alanazi et al., 2023). Pharmacotherapy using benzodiazepines, non-benzodiazepine medications such as zolpidem and zaleplon, first-generation antihistamines such as hydroxyzine and diphenhydramine, orexin receptor antagonists such as suvorexant and others have been used to induce and maintain sleep in patients with insomnia (Krystal et al., 2019). The choice of medication used is often dependent on patient and disease factors. For severe cases, adjunctive pharmacotherapy and psychotherapies are superior to either agents used alone in managing insomnia.

The choice of pharmacotherapy is often dependent on the toxicity profile and the patient’s response. The modality selected must be that which is effective in helping the patients induce and maintain sleep and highly tolerable by the patients. Drug discontinuation and or substitution is preserved when the medication selected is unable to address the insomnia and when the side effects are intolerable to the patients (Krystal et al., 2019). Dose optimization may be observed when the patient responds to the medications but is unable to tolerate one or two side effects. As evident in the case, dose reduction was necessary to address the debilitating side effects. In addition, when prescribing sleep medication, ethical prescribing is necessitated. The ethical principles of non-maleficence, beneficence, justice, and autonomy guide the decision regarding which medication to prescribe. Caregivers, in this respect, should select a medication that will alleviate the patient’s suffering and is highly acceptable to the patient.

References

Alanazi, E. M., Alanazi, A. M., Albuhairy, A. H., & Alanazi, A. A. (2023). Sleep hygiene practices and its impact on mental health and functional performance among adults in Tabuk City: A cross-sectional study. Cureus. https://doi.org/10.7759/cureus.36221

Cheraghi, R., Valizadeh, L., Zamanzadeh, V., Hassankhani, H., & Jafarzadeh, A. (2023). Clarification of ethical principle of the beneficence in nursing care: An integrative review. BMC Nursing, 22(1). https://doi.org/10.1186/s12912-023-01246-4

Eisenach, C., & Lynch, S. (2023). Trazodone-induced priapism and increased recurrence risk with antipsychotics. American Journal of Psychiatry Residents’ Journal, 19(1), 16–19. https://doi.org/10.1176/appi.ajp-rj.2023.190105

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

Panin, F., & Peana, A. T. (2019). Sleep and the pharmacotherapy of alcohol use disorder: Unfortunate bedfellows. A systematic review with meta-analysis. Frontiers in Pharmacology, 10. https://doi.org/10.3389/fphar.2019.01164

Pelayo, R., Bertisch, S. M., Morin, C. M., Winkelman, J. W., Zee, P. C., & Krystal, A. D. (2023). Should trazodone be the first-line therapy for insomnia? A clinical suitability appraisal. Journal of Clinical Medicine, 12(8), 2933. https://doi.org/10.3390/jcm12082933

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

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Question

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.

Assessing and Treating Patients with Sleep Disorders – Decision Tree

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 recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Assessing and Treating Patients with Sleep/Wake Disorders – Decision Tree