Assessing and Treating Patients with Sleep-Wake-Disorders

Maureen

3 years ago

Assessing and Treating Patients with Sleep-Wake-Disorders

Introduction

The patient described in the case study is a 31-year-old male whose presenting complaint is insomnia. The patient reports that the onset of the insomnia was 6 months before the current visitation and was attributable to the loss of his fiancée. The patient agrees to have altered sleep patterns, as evidenced by difficulty in falling asleep as well as in maintaining sleep. On the patient’s account, the insomnia is beginning to affect his daytime functionality with bouts of sleepiness and sleep during normal work time. Additionally, his workability as a forklift operator at a local company has been considerably affected by his disorder. Our assignment writing help is at affordable prices to students of all academic levels and academic disciplines.

The patient’s past medical history reveals previous abuse of opioids. This began upon being prescribed hydrocodone/acetaminophen for pain management when he broke his ankle in a skiing accident. He also reported using alcohol to help him with his sleep. On mental examination, the patient was found to be alert and exhibiting proper orientation to person, time, place, and event. He also makes good eye contact. He is also appropriately dressed for events and weather and denies any auditory or visual hallucinations. Additionally, he exhibits orientation to the future and denies any suicidal thoughts.

The patient described in the case study has a positive diagnosis of insomnia. Insomnia is a sleep disorder that is characterized by difficulty in falling asleep or staying asleep (Bjorvatn, Olufsen & Sørensen, 2019). Diagnosis is usually subjective, often depending on the individual’s account. People with insomnia often report multiple awakenings during their sleep and difficulty or considerable delays in falling asleep outside the usual. Insomnia also causes daytime fatigue, daytime loss of concentration, irritability, and anxiety in the short term(Hall, Kline & Nowakowski, 2016). In the long term, it may lead to multiple chronic pathologies. As evident in this patient, daytime fatigue and reduced workability are a consequence of his insomnia. Appropriate management of this patient will utilize pharmacological as well as non-pharmacological interventions. The goal is to alleviate insomnia to prevent other effects attributable to insomnia.

Decision Point One

The first intervention in this patient will be to initiate trazodone 50mg once daily at bedtime. Trazodone is an antidepressant under selective serotonin reuptake inhibitors. It has off-label utility in the management of insomnia. Use in insomnia is, however, at lower doses compared to doses for antidepressant use. Trazodone uses, however, often present with several adverse events. These events include anticholinergic effects of constipation, headaches, dizziness, and xerostomia, among others. These events are considerably pronounced at higher doses. As evident in the patient, the prolonged erection 15 minutes after waking was considerably unpleasant and was a point of concern for him (Sateia, Buysse, Krystal, Neubauer & Heald, 2017). This is an effect of high doses of trazodone utilized in this therapy.

The higher efficacy of trazodone, coupled with its tolerable toxicity profile, informed my decision to select it over other medications. Zolpidem and hydroxyzine also exhibit near equal efficacy as zolpidem in the management of insomnia. However, zolpidem exhibits side effects that may be intolerable to some patients. Zolpidem is a non-benzodiazepine drug belonging to the Z class of drugs. It is an FDA-approved drug for the treatment of insomnia. This drug maintains high efficacy in the treatment of insomnia but may be associated with several side effects, such as headache, dizziness, and stuffy nose, among others(Satheesh et al., 2020). These effects limit its use.

Likewise, hydroxyzine has been used for its off-label efficacy in insomnia. The drug has been linked with anticholinergic side effects that may be intolerable to some patients. Such adverse effects include xerostomia, xeropthalmia, headache, dizziness, and urinary retention (Hassinger, Bletnisky, Dudekula & El-Solh, 2020). These side effects may be debilitating to the patient and may sometimes warrant withdrawal. In the case with the patient case study, the patient reported dryness of the eyes and mouth, evidence of the anticholinergic effects of the drugs on the patient. The adverse event profile of hydroxyzine and zolpidem grants trazodone superiority over them and makes it the drug of choice.

The treatment plan with trazodone is aimed at alleviating insomnia and improving the quality of life of the patients. The patient should be educated on the expected side effects of the drugs. They should also be educated on the significance of reporting these side effects that they may experience with the drug. Withdrawal of the drug, dose reduction, or substitution of the drug should remain an option during the entire treatment process. Informed consent is often required before initiating these therapies. Confidentiality should also be maintained between the provider and the patient.

Decision Point Two

Trazodone maintains high efficacy in the management of insomnia. Its use at higher doses has, however, been linked to adverse events such as constipation, headaches, and dizziness. Prolonged erection and priapism have also been reported by some patients and often result from an alpha blockade effect of the drug. This is evident with the patient case presented in the case study as he complains of prolonged erections up to 15 minutes after waking up. This necessitated the choice of reducing the dose of trazodone to 25mg once daily at bedtime. Dose reductions in trazodone use have been implicated in significant reductions in the toxicity profile of this drug. In the case of this patient, the prolonged erections in the morning are expected to be alleviated with these reductions.

Discontinuation of trazodone and initiating suvorexant 10mg is not warranted in this patient’s case. This is because the patient has already begun responding to this drug, and the benefits are so far outweighing the disadvantages. Suvorexant maintains equivalent efficacy as zolpidem in the management of insomnia. Its use is however limited by its relatively higher costs and the absence of cheaper generics. Explaining to the patients that priapism is just a side effect and that it will diminish with time may as well not be warranted. This is because priapism attributable to high trazodone dosing may persist over and above the expected clinical period. The patients also find it disturbing. It, therefore, presents clinical unethicality not to treat this patient.

Dose reduction in this patient’s case was aimed at eliminating the side effects of priapism evident in this patient. Dose reduction could effectively manage the priapism presenting in this patient. The patient should be told the reason for this dose reduction. They should be made to understand the adverse effect they were experiencing is courtesy of the higher dose regimen of the drug trazodone. The communication language utilized should be respectful to the patient and should not ridicule their situation. Confidentiality is also key, and the patient’s problem should remain confidential between him and the provider.

Decision Point 3

The patient reported the effectiveness of trazodone 25mg in managing his insomnia. He, however, reports that the usual dose is sometimes not sufficient to help him sleep. The decision is to maintain the 25mg once daily bedtime dose of trazodone and return for a follow-up after 4 weeks. The patient will also be encouraged to maintain proper sleep hygiene.

The positive sleep results reported by the patient informed this selection. The patient achieved sleep at the 25mg dose. Additionally, no considerable adverse effects were reported as a consequence of using this drug. Switching therapy to ramelteon or hydroxyzine is, therefore, not warranted in this case. However, augmenting therapy with other non-pharmacological interventions may prove to be beneficial. Proper sleep hygiene is necessary for sleep conditioning and consequent attainment of good sleep. In this regard, the patient should assess their sleep environment to eliminate sleep distractors (Drake et al., 2018). They should also ensure that they avail enough time for their sleep. 8 hours is recommended for optimal sleep.

These interventions aim to optimize sleep in this patient as well as to create a perfect environment that promotes sleep. Optimal sleep is not only dependent on the nature of the person but also the environment of sleep. Whereas medications improve the person’s ability to achieve optimal sleep, these medications do not affect the sleep environment. Environmental enhancement sufficiently augments sleep and has been implicated in better sleep patterns and attainment of optimal sleep. The patient should, therefore, be educated on the importance of ensuring their sleep environment is free of sleep distractions and that they maintain their sleep routine and hygiene. The patient should be allowed to participate in their treatment plan as their feedback is necessary for informing clinical decisions.

Conclusions

Insomnia management utilizes a wide range of pharmacological agents. Such agents include zolpidem of the z class of pharmacological agents, hydroxyzine of the antihistamine class, and trazodone of the antidepressant class of pharmacological agents, among others. These drugs maintain efficacy in the management of insomnia. They, however, differ in their toxicity profiles. Their utility in the management of clinical insomnia is informed by their effectiveness in inducing and maintaining sleep, as well as their toxicity profile.

Zolpidem is an FDA-approved drug in the management of insomnia. It, however has been linked to several adverse events. Headache and dizziness are the most common side effects. However, anterograde amnesia, stuffy nose, and generalized body weakness have also been reported. Its use, therefore, requires precaution to prevent the occurrences of these adverse events that may be debilitating to some patients.

Trazodone is an antidepressant with off-label use in the management of insomnia. Trazodone produces equal efficacy in managing insomnia at lower doses. Its use at higher doses has, however, been implicated in several adverse events. Dizziness, headache, and vomiting are some of the implicated adverse events of this drug. The drug is, however, tolerable at pharmacological doses utilized in the management of insomnia. It is the drug of choice for most adults due to its bearable toxicity profile.

Another drug that is utilizable in case of intolerance to trazodone is hydroxyzine. This drug is equally efficacious but produces anticholinergic adverse events of xerostomia and xeropthalmia. Its use should be based on risk versus benefit analysis. Maintaining proper sleep hygiene and ensuring proper sleep environments have the benefits of promoting optimal sleep. Patients with insomnia should thus be encouraged to observe them as a way to augment drug use.

References

Bjorvatn, B., Olufsen, I., & Sørensen, M. (2019). The ICSD-3/DSM-5 diagnostic criteria for insomnia reinforce the association between insomnia, anxiety, and depression. Sleep Medicine, 64, S41. DOI: 10.1016/j.sleep.2019.11.114

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). DOI: 10.1093/sleep/zsy217

Hall, M., Kline, C., & Nowakowski, S. (2016). Insomnia and sleep apnea in midlife women: prevalence and consequences to health and functioning. F1000prime Reports, 7. doi: 10.12703/p7-63

Hassinger, A., Bletnisky, N., Dudekula, R., & El-Solh, A. (2020). Selecting a pharmacotherapy regimen for patients with chronic insomnia. Expert Opinion On Pharmacotherapy, 21(9), 1035-1043. DOI: 10.1080/14656566.2020.1743265

Sateia, M., Buysse, D., Krystal, A., Neubauer, D., & Heald, J. (2017). 0395 CLINICAL PRACTICE GUIDELINE FOR THE PHARMACOLOGIC TREATMENT OF CHRONIC INSOMNIA IN ADULTS: AN AMERICAN ACADEMY OF SLEEP MEDICINE CLINICAL PRACTICE GUIDELINE. Sleep, 40(suppl_1), A147-A147. DOI: 10.1093/sleepj/zsx050.394

Satheesh, G., Puthean, S., Sharma, A., Mishra, S., Jose, J., Kakkan, S., & Unnikrishnan, M. (2020). Effects of sedative-hypnotics on sleep quality among patients with insomnia: evidence from an observational, pre-post study in India. Health And Quality Of Life Outcomes, 18(1). DOI: 10.1186/s12955-020-01379-z

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Question

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/DT/week_11/index.html
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)

Assessing and Treating Patients with Sleep-Wake-Disorders

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)