Assignment 2: Assessing and Treating Patients with Sleep/Wake Disorders
Cynthia Ogom
Doctor of Nursing Philosophy, Walden University
NURS 6630: Psychopharmalogical Approaches to Treat Psychopathology
Dr. Reome
July 25th, 2022
Assignment 2: Assessing and Treating Patients With Sleep/Wake Disorders
Insomnia is the most prevalent sleep disorder affecting a substantive amount of the population. It is characterized by the inability to initiate, and maintain sleep or simply a poor sleep quality. Insomnia affects 10-15% of the population (Kaur et al., 2020). Insomnia can be graded based on the duration and the frequency of symptoms. This week’s case study focuses on a 31-year-old male who presented with a chief complaint of insomnia which has progressively gotten worse over the past six months. The symptomatology includes difficulty in falling asleep and staying asleep at night. The problem began after the loss of his fiancé. The problem affects his work. He has used diphenhydramine in the past to sleep but stopped due to the side effect of marked morning drowsiness. He has a history of opiate abuse which started with the prescription medication hydrocodone when he broke his ankle. He has not had any other prescription for the opiate for four years. The patient currently uses alcohol to help him fall asleep. The Mental Status Exam is normal. He denies any auditory or visual hallucinations. His judgment and insight are intact. The patient denies any suicidal ideations and is future-oriented. There are no features of depression or any other mental or physical illness.
The symptomatology of increased sleep latency, difficulty maintaining sleep, and daytime symptoms confirm the diagnosis of insomnia. The co-morbidities like alcohol use disorder, history of opiate abuse, previous pharmacotherapy for insomnia using diphenhydramine, and the maladaptive disorder of alcohol abuse to induce sleep will all greatly influence medication decisions. The selected drug must confer low toxicity, high efficacy for reduction of sleep latency and maintaining sleep, tolerability to minimize drug non-compliance, and minimal side effects especially drowsiness that may affect the subsequent day’s work. Cognitive Behavioral Therapy in conjunction with drug therapy is highly efficacious in insomnia management. The treatment is aimed at providing the best-indicated medication to the patient to provide remission of symptomatology. The treatment also aims at preventing the development of complications like depression, diabetes, and other cardiovascular diseases. Standard individualized care is indicated for a full recovery. The purpose of this paper is to describe the decision points taken to treat this patient regarding medication choice, the expectation with each decision, and ethical considerations
Decision 1
Trazodone 50mg at bedtime.
Reason for Selection
For this particular case, trazodone is the drug for use in the management. From Randomized Clinical Trials on Trazodone use in the treatment of Insomnia, it was highly efficacious in maintaining sleep by reducing the number of awakenings during sleep, it remarkably improved the quality of sleep, and was well tolerated by a majority of patients in short-term treatment (Wichniak et al., 2021). In primary Insomnia, a combination of CBT and Trazodone was found to have the highest efficacy in reducing sleep latency. Trazodone has a half-life of 12 hours with a peak plasma concentration of four hours. When trazodone is taken 1-2 hours before bedtime, it can reduce sleep latency. Trazodone reduces the risk of relapse in alcohol-dependent patients. Hypnotics like Zolpidem reduce the quality and depth of sleep and has a higher risk of drug dependence. As a result, Zolpidem is not effective in the treatment of patients with poor quality sleep insomnia (Wichniak et al., 2021). Zolpidem is also associated with adverse effects such as anterograde amnesia and an increased risk of falls. Concerning Hydroxyzine, it is only indicated for the treatment of accidental insomnia (Krysta, 2020). It is also associated with marked sedation and increased morning drowsiness. The use of hydroxyzine in the management of insomnia is highly unpopular due to hyperacute tolerance and increased daytime somnolence (Albrecht et al., 2019). There is no further literature that justifies its use.
Expectations
From the treatment with Trazodone, there is an expected reduction in sleep latency, increased duration of sleep, reduced number of awakenings during sleep, and a general increase in sleep quality. As the patient is currently dependent on alcohol for sleep, trazodone will work to reduce the relapse. There is also an expected clearing of the depressive symptoms that are set in.
Ethical Considerations
Ethical considerations of beneficence, justice, non-maleficence, and confidentiality go a long way in the management of the patient. These are achieved through explaining the illness to the patient. Psychosocial therapy like CBT requires the help of family members. Through this, the patient needs to understand there is a need for breach in confidentiality (Barber, 2017). Providing the patient with the best pharmacotherapy for the illness based on research and current studies. The need to employ a clinical innovation poses an ethical risk as these are auxiliary to the main course of treatment and have not been adequately researched though they possess an advantage such as sleep restriction therapy in insomnia. Proper communication between the caregiver and the patient provides an enabling environment for the treatment of both somatic and psychological disorders.
Decision 2
Explain to the patient that an erection lasting fifteen minutes is not considered priapism and should diminish over time and the patient to continue with the current dosage of Trazodone.
Reason for Selection
Priapism affects less than 1% of low-dose trazodone users (Shah et al., 2021). Priapism is a prolonged painful erection ideally lasting more than four hours. The 15-minute early morning erection does not qualify as priapism. It vital to watch out for these adverse effects among others to ensure early management. Suvorexant is rejected as it is associated with an increased number of awakenings and abnormal dreams. These greatly impair the quality and duration of sleep (Xue et al., 2022). The dual orexin receptor agonists have not been adequately compared to trazodone. Suvorexant has a higher efficacy in associated motor insomnia (Janto et al., 2018). Trazodone brought a huge improvement in the patient and there would not be any need to change the medication. Reducing the dosage of trazodone to 25mg at bedtime was rejected as the unpleasant side effect could not be attributed to trazodone. Moreover decreasing the dose just after a short course may lead to rebound insomnia (Jaffer et al., 2017). This makes this decision unsuitable.
Expectations
The expectations are that the prolonged erection will abate over time and the action of trazodone of reducing sleep latency and maintaining sleep will continue due to the low tolerance of the body to these effects. The patient should tolerate the drug with minimal side effects as only the low doses are used.
Ethical considerations
Constant continuous counseling on adherence is prime. Counseling the patient on the features of side effects such as priapism and hallucinations and the need for an immediate clinic visit when any of the adverse effects occur (Barber, 2017). Continue the perfect doctor-patient relationship to allow for ease of communication of the patient’s concerns
Decision 3
Continue dose. Explain to the patient that he may split the 50mg in half
Reason for selection
One of the main side effects of trazodone is morning drowsiness. This is due to its long half-life which is 12 hours. To reduce the symptoms, a reduction in the dosage is employed. The effective dose for insomnia ranges from 25mg to 200mg per day. A titration of the dosage to the lowest effective dose confers a reduction in the side effects (Jaffer et al., 2017). Monitoring and follow-up are important in appropriately managing any other side effects. Sonata is suitable for induction of sleep. It reduces sleep latency. It has a short half-life, and this leads to an increased number of awakenings in its use from randomized clinical trials. This makes it poor at the maintenance of sleep. The use of Hydroxyzine an H1 receptor antagonist is widely shunned due to its hyperacute tolerance and increased daytime somnolence. The use of hydroxyzine is likely to worsen morning drowsiness (Albrecht et al., 2019). Sedation is the main feature of this drug. Discontinuation of trazodone needs to be in a step-wise fashion, not abrupt.
Expectations
With a reduction in the dosage of trazodone, there is an expected reduction in the side effect of morning drowsiness. The reduced dose is still expected to be effective in the management of insomnia. With this duration of treatment, it is expected that the features of insomnia would have mostly abated and treatment could be done by other mechanisms like sleep deprivation and following a fixed timetable.
Ethical Considerations
At this point of management, a professional and cordial relationship between the doctor and the patient is still essential. Proper communication between the doctor and the patient on the reduction of dosage must be discussed (Barber, 2017). There is a need to stick to a single therapy for better outcomes.
Conclusion
Insomnia is one of the most common sleep disorders affecting people of all races and ages. It is a major predisposing factor to many diseases including Alcohol use disorder, diabetes, and hypertension among others. This case study provides a perfect example of a 31-year-old male with a six-month history of initiation and maintenance of sleep. The precipitating factor was the loss of his fiancé. He has currently tipped into alcohol use disorder. Zolpidem reduces the quality and depth of sleep and has a higher risk of drug dependence. As a result, Zolpidem is not effective in the treatment of patients with poor quality sleep insomnia (Wichniak et al., 2021). Hydroxyzine is also rejected as it is only indicated for the treatment of accidental insomnia (Krysta, 2020). The use of hydroxyzine in the management of insomnia is highly unpopular due to hyperacute tolerance, marked morning drowsiness, and increased daytime somnolence (Albrecht et al., 2019). There is no further literature that justifies its use. Randomized Clinical Trials show Trazodone use in the treatment of Insomnia as highly efficacious in maintaining sleep by reducing the number of awakenings during sleep, it remarkably improved the quality of sleep and was well tolerated by a majority of patients in short-term treatment (Wichniak et al., 2021). In primary Insomnia, a combination of CBT and Trazodone was found to have the highest efficacy in reducing sleep latency. Trazodone also reduces the risk of relapse in alcohol-dependent patients. In the management of different disorders, the importance of monotherapy is stressed. This prevents unnecessary changes in regimen and encourages adherence. In the management of insomnia, drug choice is based on the pharmacokinetics, pharmacodynamics of the drug, and the individual patient characteristics which may include the type of insomnia an individual has. All these help determine the right regimen. Ethical consideration at all steps of the treatment is based on the patient-caregiver interaction, informed consent, adherence to treatment, and provision of the best form of treatment to benefit the patient.
References
Albrecht, J. S., Wickwire, E. M., Vadlamani, A., Scharf, S. M., & Tom, S. E. (2019). Trends in Insomnia Diagnosis and Treatment Among Medicare Beneficiaries, 2006–2013. The American Journal of Geriatric Psychiatry, 27(3), 301–309. https://doi.org/10.1016/j.jagp.2018.10.017
Barber, L. K. (2017). Ethical considerations for sleep intervention in organizational psychology research. Stress and Health, 33(5), 691–698. https://doi.org/10.1002/smi.2745
Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in Clinical Neuroscience, 14(7-8), 24–34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/
Janto, K., Prichard, J. R., & Pusalavidyasagar, S. (2018). An Update on Dual Orexin Receptor Antagonists and Their Potential Role in Insomnia Therapeutics. Journal of Clinical Sleep Medicine, 14(08), 1399–1408. https://doi.org/10.5664/jcsm.7282
Kaur, H., Spurling, B. C., & Bollu, P. C. (2020). Chronic Insomnia. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK526136/
Krzystanek, M., Krysta, K., & Pałasz, A. (2020). First generation antihistaminic drugs used in the treatment of insomnia – superstitions and evidence. Pharmacotherapy in Psychiatry and Neurology/Farmakoterapia w Psychiatrii i Neurologii, 36(1), 33-40.
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
Silberman, M., Stormont, G., & Hu, E. W. (2022). Priapism. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK459178/#:~:text=Introduction-
Wichniak, A., Wierzbicka, A., & Jarema, M. (2021). Treatment of insomnia – effect of trazodone and hypnotics on sleep. Psychiatria Polska, 55(4), 743–755. https://doi.org/10.12740/pp/125650
Xue, T., Wu, X., Chen, S., Yang, Y., Yan, Z., Song, Z., Zhang, W., Zhang, J., Chen, Z., & Wang, Z. (2022). The efficacy and safety of dual orexin receptor antagonists in primary insomnia: A systematic review and network meta-analysis. Sleep Medicine Reviews, 61, 101573. https://doi.org/10.1016/j.smrv.2021.101573
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