Assessing and Treating Patients with Sleep/Wake Disorders 

Assessing and Treating Patients with Sleep/Wake Disorders 

Assessing and Treating Patients with Sleep/Wake Disorders 

Sleep/wake disorders are characterized by problems with the timing, quality, and amount of sleep, causing daytime distress and impairment in functioning (Smith et al., 2018). They can occur along with other mental disorders like anxiety and depression or medical conditions. There are various sleep disorders, with insomnia being the most common. This paper aims to discuss the treatment of a patient with insomnia.

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Introduction to the Case

The patient is a 31-year-old man with complaints of insomnia which has worsened in the past half a year. Although he is normally not a great sleeper, he reports having trouble initiating and maintaining sleep. He started having insomnia after the death of his fiancé six months ago. The sleeping problem adversely impacts his occupational functioning as he frequently gets sleepy at work due to a lack of adequate sleep at night. The patient was previously taking diphenhydramine to enable him to sleep, but he had morning drowsiness. In addition, he once had opiate abuse after being prescribed hydrocodone/apap for acute pain following an ankle fracture when skiing. However, he has not taken an opiate analgesic prescription for four years. He states that he has been taking four beers before bed to bed to enable him to fall asleep.

The patient has no hallucinations or suicidal/homicidal ideations. His insight, judgment, and reality contact are intact. Factors that influence treatment choices for patients with insomnia include age, current medical and psychiatric disorders, previous medication trials, history of substance abuse, and the client’s treatment preferences (Krystal et al., 2019). Thus, the PMHNP should consider the client’s opiate abuse history, previous diphenhydramine therapy, and treatment preferences when planning the patient’s treatment.

Decision #1

Trazodone: 50–100 mg daily QHS.

Why the Decision was Selected

Trazodone is a nontricyclic antidepressant used off-label to manage insomnia. It is among the most commonly prescribed drugs for inducing sleep due to its side effect of drowsiness that aids in maintaining sleep (Pagel et al., 2018). Zheng et al. (2022) found that Trazodone can enhance sleep by modifying the sleep architecture in insomnia. However, it should be cautiously administered because of the potential adverse events.

Why the Other Options Were Not Selected

Although Zolpidem decreases sleep latency and improves sleep maintenance, it was not selected owing to its related abuse potential, psychomotor impairment, and complex sleep behaviors (Krystal et al., 2019). Hydroxyzine was not chosen because it is an antihistamine with strong sedative properties that cause drowsiness and is thus not a first-line drug in managing primary insomnia (Pagel et al., 2018).

What I was Hoping to Achieve

The practitioner hoped that Trazodone would aid the patient in falling asleep and reducing nighttime awakening resulting in increased quality and duration of sleep. Pagel et al. (2018) found that Trazodone can increase total sleep time and reduce latency to the onset of persistent sleep. Trazodone plays a crucial role in improving the internal structure of sleep, such as reducing non-rapid eye movement stage 1 and frequency of awakenings and increasing non-rapid eye movement stage 3 (Zheng et al., 2022).

How Ethical Considerations May Impact the Treatment Plan and Communication

Ethical factors of beneficence and autonomy may affect the treatment plan and communication with the patient, respectively. For example, beneficence impacted treatment since the clinician had to select a drug associated with the best outcomes and least harm to patients with insomnia. Autonomy affects communication since the clinician has to seek consent from the client to implement the treatment.

Decision #2

Inform the patient that priapism is a Trazodone side effect that will diminish over time and continue the dose.

Why the Decision was Selected

The client reported that he experienced a prolonged penis erection roughly 15 minutes after waking up, which was associated with Trazodone. Shah et al. (2021) explain that the primary side effects of Trazodone include sedation, headache, dizziness, orthostatic hypotension, dry mouth, blurred vision, and priapism.

Why the Other Options Were Not Selected

The decision to stop Trazodone and start Suvorexant was not selected since Trazodone has a positive impact in alleviating insomnia with no major side effects. Suvorexant causes daytime sedation and is associated with abuse potential, making it a less ideal therapy for this client (Krystal et al., 2019). In addition, reducing Trazodone to 25 mg was not the best choice since it has a short half-life. Thus a lower dose of Trazodone may be ineffective in helping the patient maintain sleep and avoid nighttime awakening (Zheng et al., 2022).  

What I was Hoping to Achieve

The PMHNP hoped that enlightening the client about the priapism associated with Trazodone would promote treatment adherence, thus promoting improved quality of sleep and daytime functioning. Shah et al. (2021) explain that priapism often occurs within the first 28 days of initiation of therapy, particularly in patients taking a dose of <150 mg/day.

How Ethical Considerations May Impact the Treatment Plan and Communication

Nonmaleficence and confidentiality can affect the patient’s therapy and communication by ensuring the safety of the medication, and that information is kept confidential. For instance, nonmaleficence influenced the PMHNP to assess the side effects of the available treatment options to ensure no harm to the patient. The PMHNP also had to assure the client that his health information would not be shared without his consent.

Decision #3

Continue Trazodone and explain he can split the 50 mg tablet in half. Follow up in 4 weeks.

Why the Decision was Selected

This decision was selected because Trazodone 50 mg was associated with drowsiness. Thus, dividing the dose by half to 25 mg would help reduce the drowsiness, and the patient should be reassessed within four weeks (Zheng et al., 2022). A lower dose of Trazodone is equally effective in enhancing sleep maintenance without drowsiness because of its short half-life (Krystal et al., 2019).

Why the Other Options Were Not Selected

Stopping Trazodone and starting Sonata was not the best option because the latter is associated with psychomotor impairment, dose‐dependent sedation, and abuse potential (Krystal et al., 2019). Hydroxyzine was not an ideal treatment choice because it is an antihistamine whose anticholinergic effects, like sedation, drowsiness, and dry mouth, cause intolerance (Pagel et al., 2018). 

What I was Hoping to Achieve

The PMHNP was hoping that reducing Trazodone by half would reduce the associated drowsiness while improving the quality and duration of sleep and reducing daytime awakening. Trazodone side effects are usually dose-dependent. Therefore, the PMHNP hoped reducing the dose would reduce the dose-dependent sedation (Krystal et al., 2019).

How Ethical Considerations May Impact the Treatment Plan and Communication

The PMHNP has an ethical obligation to promote the best health outcomes without causing harm to the client, which upholds beneficence. For example, the PMHNP instructed the patient to half the Trazodone dose to promote better health outcomes while minimizing side effects like sedation. Communication may be impacted by respect for the patient’s autonomy. For instance, the PMHNP had to respect the patient by involving him in decision-making regarding his treatment.

Conclusion

            The patient in the case scenario has insomnia based on trouble falling asleep and frequent nighttime awakenings. His history of opiate abuse, previous diphenhydramine therapy, and treatment preferences may influence treatment decisions. The client was started on Trazodone 50 mg because it enhances sleep by modifying the sleep architecture in insomnia (Zheng et al., 2022). In decision one, Zolpidem was not selected because it is associated with abuse potential, psychomotor impairment, and complex sleep behaviors. Besides, Hydroxyzine was not ideal because it has strong sedative properties that cause drowsiness and is not recommended as first-line therapy for insomnia.

The patient expressed concerns about experiencing priapism with Trazodone. The PMHNP informed the client that priapism is a known side effect of Trazodone, which would abate over time (Shah et al., 2021). Suvorexant was not selected at this point because it is associated with daytime sedation and abuse potential. Furthermore, lowering the trazodone dose would reduce its efficacy due to its short half-life.

            The patient reported that he experienced drowsiness attributed to Trazodone, which is a known side effect. The PMHNP advised the patient to divide the dose in half since drowsiness is usually dose-dependent. Thus, reducing the dose would minimize the associated drowsiness. Sonata was not selected because of its associated psychomotor impairment, dose‐dependent sedation, and abuse potential (Krystal et al., 2019). Hydroxyzine was not a good choice because its anticholinergic effects, like sedation, drowsiness, and dry mouth, cause intolerance. 

References

Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World psychiatry: official journal of the World Psychiatric Association (WPA), 18(3), 337–352. https://doi.org/10.1002/wps.20674

 Pagel, J. F., Pandi-Perumal, S. R., & Monti, J. M. (2018). Treating insomnia with medications. Sleep Science and Practice, 2(1), 1-12. https://doi.org/10.1186/s41606-018-0025-z

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

Smith, M. T., McCrae, C. S., Cheung, J., Martin, J. L., Harrod, C. G., Heald, J. L., & Carden, K. A. (2018). Use of actigraphy for the evaluation of sleep disorders and circadian rhythm sleep-wake disorders: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 14(7), 1231-1237. https://doi.org/10.5664/jcsm.7230

Zheng, Y., Lv, T., Wu, J., & Lyu, Y. (2022). Trazodone changed the polysomnographic sleep architecture in insomnia disorder: a systematic review and meta-analysis. Scientific Reports, 12(1), 14453. https://doi.org/10.1038/s41598-022-18776-7

BUY A CUSTOM- PAPER HERE ON; Assessing and Treating Patients with Sleep/Wake Disorders 

The Assignment: 5 pages
Examine Case Study (REFER TO FILE “CASE STUDY”). You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

* At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

OUTLINE
– Introduction to the case (1 page) // REFER TO FILE “CASE STUDY”
–> 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) // REFER TO FILE “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) // REFER TO FILE “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) // REFER TO FILE “Decision #3 (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.

– Conclusion (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.