Assessing and Treating Patients With Sleep/Wake Disorders

Introduction

The client in the provided case study presented with insomnia complaints. The client reported that the condition had worsened for the last 6 months after he suddenly lost his fiancé. He reported that insomnia has impacted his ability to work. he sometimes falls asleep while at work. He has used diphenhydramine but he reports it has some bad effects afterward. The client has a history of opiate abuse but had not used opiate in the last 4 years. He further reports that he has been drinking alcohol to assist him to fall asleep. The MSE indicates that he is alert and well oriented. He is well-groomed and maintains good eye contact throughout the interview. His judgment, reality, and insight are intact. He denies any suicidal thoughts. Insomnia is characterized by symptoms such as difficulty initiating sleep, difficulty maintaining sleep, and inability to return to sleep after awakening. The sleep difficulty should have been there for a minimum of 3 months and should significantly impact aspects such as education, work, social life, and other areas of functioning (Vargas et al., 2020). The client has all these symptoms and hence his symptoms meet the DSM-5 criteria of insomnia. Therefore, the purpose of this paper is to discuss the available treatment choices and select the most suitable medication for the patient. The appropriate ethical principles will be used to guide each treatment decision.

Decision Point One

The available treatment choices are zolpidem 10 mg; trazodone 50-100 mg; and hydroxyzine 50 mg. Zolpidem is a sedative (benzodiazepine receptor agonist (BzRA) that is used to treat insomnia. The medication works by increasing GABA activity which is a body chemical that causes sleepiness (Vargas et al., 2020). Therefore, increasing the activity of GABA helps a person fall asleep. Trazodone is an off-label medication for the treatment of insomnia, but it is approved by the FDA to treat depression (Jaffer et al., 2017). On the other hand, hydroxyzine is an antihistamine that is an off-label medication in the treatment of insomnia, but it is FDA approved to treat anxiety (Patel et al., 2018). Trazodone was selected for this patient as it is an SSRI that is associated with minimal effects, when compared to zolpidem and hydroxyzine medications, which are associated with many serious side effects, including negative side effects for zolpidem.

The targeted treatment outcome with Trazodone is that that the symptoms of insomnia for this patient will improve as manifested by the ability to initiate and maintain sleep. This is due to the medication’s efficacy in the treatment of insomnia (Jaffer et al., 2020). It is also expected that the patient will tolerate Trazodone, without any side effects because the medication is well tolerated.

As expected, after two weeks the client reported that the medication was working well. However, he reported that he was experiencing a prolonged erection, which was making him uncomfortable. A change in sexual interest/ability is one of the side effects of trazodone (Ilgın et al., 2018).

Beneficence and non-maleficence guided the selection of trazodone because the medication is likely to bring the best care outcomes for the client, and also the medication is associated with minimal side effects when compared to other available treatment choices. Informed consent was obtained from the client before initiating the treatment (Anderson & Anderson, 2018).

Decision Point Two

The available treatment choices in decision point two include continuing with the same trazodone dose but explain to the patient that priapism is a common side effect with trazodone but the side effect reduces over time; discontinue trazodone and start suvorexant 10 mg; and reduce trazodone to 25 mg daily. Sharma & Sharma (2019) explain that priapism is a very serious side effect associated with trazodone. Suvorexant is an orexin receptor antagonist that is used in the treatment of insomnia. Suvorexant works by hindering the action of substance within the brain associated with wakefulness (Tampi et al., 2018). The third choice involved reducing the dose of trazodone from 50 mg to 25 mg. The decision to have the patient continue with the same trazodone dose but explain to the patient that priapism is a common side effect with trazodone but the side effect reduces over time was selected because the client is responding well, and the side effect fades with time (Sharma & Sharma et al., 2019). There is no clinical reason to change to suvorexant since he is already responding to trazodone. Reducing the dose of trazodone was not chosen, as this would reduce the efficacy of the medication.

The treatment goal for this decision is that he would continue manifesting a good response to trazodone, but priapism would diminish over time. This is due to the medication’s efficacy in the treatment of insomnia, and also the patient is likely to tolerate the administered dose with time and thus stop experiencing priapism (Sharma & Sharma et al., 2019).

As expected, he continued responding to trazodone 50 mg, and the priapism reduced over time. However, the client reported some drowsiness after waking up the next day. Drowsiness is also a common side effect with trazodone (Settimo & Taylor, 2018).

Beneficence and non-maleficence guided the selection of the client continuing trazodone and being educated about the potential of the priapism diminishing over time. This is because the medication is likely to bring the best care outcomes for the client, and also the medication is associated with minimal side effects when compared to other available treatment choices (Anderson & Anderson, 2018).

Decision Point Three

The available treatment choices include discontinuing trazodone and start sonata 10 mg; discontinue trazodone and start hydroxyzine 50 mg; or continue trazodone and explain to the client he can spilt the tablet into a half to reduce the dose and hence reduce the drowsiness. Sonata is a pyrazolopyrimidine and a sedative-hypnotic utilized in the treatment of insomnia. Hydroxyzine is an antihistamine that is an off-label medication in the treatment of insomnia, but it is FDA approved to treat anxiety (Patel et al., 2018).  The treatment decision to have the patient continue dose and explain to the client he can spilt the tablet into a half to reduce dose was chosen because there is no clinical reason to change the medication as it is effective and while sonata is associated with various side effects, hydroxyzine has very strong sedative effects. Therefore, reducing the dose would help to eliminate the drowsiness that the client is experience. He is responding well to trazodone, apart from the reported drowsiness. This is due to the efficacy of trazodone in the treatment of insomnia (Wang et al., 2020).

The treatment goal with the chosen decision is that the symptoms of insomnia would remiss completely and also the client would stop experiencing drowsiness after waking up. This is because the reduced dose would lead to reduced side effects such as drowsiness, and at the same time ensure that the symptoms of insomnia continue reducing.

Beneficence and non-maleficence guided the selection of the client continuing with trazodone and explain to that he can spilt the tablet into a half to reduce the dose and hence reduce the drowsiness This is because he is responding well to trazodone and splitting the dose will reduce the potential side effects. Therefore, this is the decision likely to bring the best treatment outcomes for this patient (Anderson & Anderson, 2018).

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Conclusion

The diagnosis for the client is insomnia. Trazodone was selected for this patient as it is an SSRI that is effective in the treatment of insomnia. Trazodone has few side effects when compared to zolpidem and hydroxyzine medications, which are associated with many serious side effects, including negative side effects for zolpidem. The client responded to trazodone as he reported that he was no longer having a sleeping problem. However, he reported that he was experiencing a prolonged erection, which was making him uncomfortable. This is a serious side effect of trazodone. Therefore, the second decision was to continue with trazodone and explain to the client that priapism would clear over time. As expected, the client responded well to trazodone and also reported that priapism had diminished. However, he reported that he was experiencing strong drowsiness after waking up. Therefore, the third decision included continuing with trazodone but advise the client to split the dose in half in order to reduce the dose and hence reduce side effects such as drowsiness. With the decision, it is expected that the patient would eventually achieve full symptom remission, and stop experiencing drowsiness. During the treatment of this patient, informed consent was obtained to ensure he made informed treatment decisions. Moreover, beneficence and non-maleficence guided all the decisions to ensure the medications selected had the greatest benefits, minimal risks, and best treatment outcomes for the patient were achieved.

References

Anderson, M., & Anderson, S. L. (2018). GenEth: A general ethical dilemma analyzer. Paladyn, Journal of Behavioral Robotics, 9(1), 337-357.

Ilgın, S., Aydoğan-Kılıç, G., Baysal, M., Kılıç, V., Ardıç, M., Uçarcan, Ş., & Atlı, Ö. (2018). Toxic effects of trazodone on the male reproductive system via disrupting hypothalamic-pituitary-testicular axis and inducing testicular oxidative stress. Oxidative medicine and cellular longevity, 2018.

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.

Patel, D. R., Feucht, C., Brown, K., & Ramsay, J. (2018). Pharmacological treatment of anxiety disorders in children and adolescents: a review for practitioners. Translational Pediatrics, 7(1), 23–35. https://doi.org/10.21037/tp.2017.08.05

Settimo, L., & Taylor, D. (2018). Evaluating the dose-dependent mechanism of action of trazodone by estimation of occupancies for different brain neurotransmitter targets. Journal of Psychopharmacology, 32(1), 96-104.

Sharma, V., & Sharma, A. (2019). Polypharmacy Leading to Priapism in HIV Patients with Schizoaffective Disorder: A CYP450 Cascade. Case reports in psychiatry, 2019, 4562065. https://doi.org/10.1155/2019/4562065

Tampi, R. R., Manikkara, G., Balachandran, S., Taparia, P., Hrisko, S., Srinivasan, S., & Tampi, D. J. (2018). Suvorexant for insomnia in older adults: a perspective review. Drugs in Context, 7, 212517. https://doi.org/10.7573/dic.212517

Vargas, I., Nguyen, A. M., Muench, A., Bastien, C. H., Ellis, J. G., & Perlis, M. L. (2020). Acute and Chronic Insomnia: What Has Time and/or Hyperarousal Got to Do with It? Brain sciences, 10(2), 71. https://doi.org/10.3390/brainsci10020071

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.

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Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. 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.

Introduction to the case

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

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

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

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

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.
Please include introduction (different from the case introduction) purpose statement, and conclusion
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