Changes in DSM-5 Sleep-Wake Disorders

Sleep disorders are conditions that result in changes in an individual’s pattern of sleep (Mayo Clinic, 2020). Not surprisingly, a sleep disorder can affect an individual’s overall health, safety, and quality of life. Psychiatric nurse practitioners can treat sleep disorders with psychopharmacologic treatments, however, many of these drugs can have negative effects on other aspects of a patient’s health and well-being. Additionally, while psychopharmacologic treatments may be able to address issues with sleep, they can also exert potential challenges with waking patterns. Thus, it is important for the psychiatric nurse practitioner to carefully evaluate the best psychopharmacologic treatments for patients that present with sleep/wake disorders.Changes in DSM-5 Sleep-Wake Disorders

To prepare for this Assignment:

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders.

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The Assignment: 5 pages

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.

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

 Decision Tree:   Insomnia case

I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest.  The course page suggests writing 1 page per decision – my opinion is that it will be very difficult to justify your treatment decisions and provide scientific evidence in 1 page (especially for decision #1). I do not need you to tell me about the patient or the treatment options available to you – I am very familiar with the cases.  Your introductory page should be an overview of the disease state you are treating along with a purpose statement for the assignment.  Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data).

Introduction to the case (1 page)

Briefly explain and summarize the disease state you are treating 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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!

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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!Changes in DSM-5 Sleep-Wake Disorders

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)

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. Again, provide STRONG scientific evidence.  Clinical studies or treatment guidelines are a good place to start!

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.

After writing up your rationale at each decision point, I would ask yourself the following questions:

Have I provided clinical data from a meta-analysis, case report or clinical trial to support the drug I picked being safe, efficacious and the best choice for this patient?

Have I provided clinical data, etc. to support a clear rationale as to why the other treatment options are NOT optimal?

Is the focus of my discussion on mechanism of action and receptors/neurotransmitters that the drug acts on? If the answer is YES, you should consider doing additional research to address the above two questions

Also include how ethical considerations might impact your treatment plan and communication with clients.

 The rubric, as I interpret it, suggests 5 references cited with every assignment for full credit on this portion (20 points).  References used for your introductory paragraph, ethical considerations or conclusion do not count towards the 5 references required.  As a general rule of thumb, I would encourage you to reference AT LEAST two sources (not including the textbook) for each decision point – this will result in 6 references total for your clinical decision making.Changes in DSM-5 Sleep-Wake Disorders

Assessing And Treating Patients With Insomnia

Insomnia is the repetitive difficulty in falling asleep, maintaining sleep continuity, or poor sleep quality despite the adequate opportunity to sleep hence causing daytime dysfunction (Riemann, et al, 2020). It is the commonest sleep disorder in the United States of America affecting almost a third of the total population. Almost 5 million patients visit the hospital due to sleep disturbances. It is more prevalent in women and older adults. According to the international classification of sleep disorders, insomnia is classified into chronic insomnia disorder, short-term insomnia, and other insomnia. Chronic-term insomnia is a disorder whose symptoms have been present for at least three months. It can affect the quality of life, academic performance, increase the risk of motor vehicle accidents, and decreased productivity of work. Short-term insomnia has been present within 3 months while other insomnia disorder presents with difficulty in initiating sleep that does not meet the criteria of short-term or long-term insomnia disorder.

Insomnia is a risk factor for chronic illnesses such as diabetes, obesity, cardiovascular diseases, and chronic pain syndrome. Treatment modes of insomnia are pharmacological and non-pharmacological. Pharmacological treatment modalities are drugs that act on the GABA-A receptors, drugs acting on the melatonin receptors, drugs acting as Histamine-1 receptor antagonists, and drugs acting as orexin receptor antagonists. Drugs acting on the GABA-A receptors such as benzodiazepines exert sedative, hypnotic, and anxiolytic, and muscle-relaxing effects. This paper discusses the assessment and treatment of patients a 31-year-old male who has had progressive insomnia for 6 months after a sudden loss of his fiancée. The author describes the pharmacological treatment for a patient with insomnia supporting with clinical evidence and includes the ethical considerations.

Decision One

Decision Selected

Zolpidem 10mg daily at bedtime

Reasons For Selecting This Decision

Zolpidem is an FDA approved drug used in the management of insomnia in patients experiencing difficulties in falling asleep. It is administered orally in form of tablets, absorbed in the gastrointestinal system, and has a short half-life (Zhang, et al, 2020). In the GUT it is converted into an active metabolite and excreted through the kidneys. It is a non-benzodiazepine drug that works on the GAMA-A receptor agonist that causes increased inhibitory effects of GABA-A leading to sedation. This drug has been known to improve sleep latency, duration, and reduces awakening episodes. It works well in the treatment of chronic insomnia and muscle relaxation.

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Trazodone is still an option for managing insomnia because it is a selective serotonin inhibitor that has sedative effects as well as relieving anxiety. It is approved by the FDA as an effective drug in the management of the major depressive disorder (Jaffer, et al, 2017). It has adverse effects such as somnolence, fatigue, and dizziness after sedation. Therefore, this drug is not appropriate for this patient because he complains of similar symptoms after taking diphenhydramine and is not FDA-approved to treat insomnia. Hydroxyzine is a first-generation antihistamine that has sedative side effects hence it is used as a mild sleeping aid. Mostly, it is used in the management of itchiness, tension, anxiety, and nausea (Mortier, et al, 2017). Its adverse effects are confusion, blurring of vision, and dizziness. This drug is not appropriate for this patient since it is not FDA-approved to treat insomnia and it has unpleasant adverse effects on the patient.

The Expected Outcome

After administration of zolpidem 10mg at bedtime, the expected outcome is; ability to fall asleep and remain asleep throughout the night, improve his performance at work, stop depending on alcohol to fall asleep, and feel refreshed after waking up in the morning. This is because zolpidem works as the GADA-A receptor inhibitor which leads to sedation and improved sleep latency.

Comparison Of The Expected Outcome And The Actual Outcome

After two weeks of treatment, the patient reports that the medication knocked him out but he slept well. His new girlfriend was concerned since he woke up in the middle of the night to cook breakfast yet he has no recollection of such an occurrence. He reports that the medication helped him sleep properly especially when taken with beer before bedtime. He denies visual and auditory hallucinations and is future-oriented. The actual outcome was the opposite of the expected results.Changes in DSM-5 Sleep-Wake Disorders

Decision Two

Decision Selected

Discontinue zolpidem and initiate the patient with eszopiclone 1mg daily at bedtime.

Reasons For Selecting This Decision

Eszopiclone is a hypnotic agent approved by the FDA in the management of transient and chronic insomnia. It is effective and efficient in initiating and maintaining sleep. Comparing to zolpidem, it has lower risks of abuse and independence. Also, it has more selectivity in the subunits of GABA-A receptors (Mylonas, et al, 2020). Through research, has shown improvement in the ability to fall asleep, remain asleep, and reduced the occurrence of nocturnal awakening. Its adverse effects are uncommon and mild. They are headache, nausea, and unpleasant taste. The patient is instructed not to mix this medication with alcohol or any other medications.

This drug is appropriate for this patient because of the uncommon adverse effects, it is well-tolerated, it has a low risk for abuse, and it is effective in treating insomnia. Reducing the dose of zolpidem from 5mg to 10mg would worsen the patient’s symptoms; increase the episodes of nocturnal awakening and reduce his ability to fall asleep at night. Changing his therapy from zolpidem to trazodone would worsen his morning-after sickness due to the adverse effects associated with trazodone.

Expected Outcome

After initiating the medicine, the expected outcome was to improve the ability to fall asleep, stay asleep the whole night, and reduce nocturnal awakening. The care provider expected that the patient would not depend on alcohol to fall asleep. He is also expected to improve his memory.

Comparison Between The Expected Outcomes And The Actual Outcome

The patient returned to the clinic after two weeks and reported that eszopiclone helped him sleep well. He reports that the drug makes him feel good from the time he takes it to the point he passes out. He denies auditory and visual hallucinations.

Decision Three

Decision Selected

Continue with the dose and instruct the patient to take medication 30 minutes before bed. Follow up with the patient in four weeks.

Reasons For Selecting This Decision

The reason for instructing the patient to take the drug 30 minutes before bedtime unlike the 2 hours before bedtime is to reduce the “feel good” moments. Also, the drug is fast-acting hence the patient will fall asleep earlier (Mylonas, et al, 2020). Changing the drug to hydroxyzine would not be effective on this patient because it causes mild sedation and is FDA- approved to treat anxiety. Trazodone cannot be prescribed for this patient because it causes unpleasant adverse effects.Changes in DSM-5 Sleep-Wake Disorders

Expected Adverse Effects

The care practitioner expected the patient to have improved the ability to fall asleep and stay asleep the whole night. He is expected to have improved his performance at work.

Ethical Consideration

Ethics are moral values that guide the practices of care providers. Ethical principles used in making decision one, two, and three are beneficence, autonomy, informed consent, privacy and confidentiality, and non-maleficence (Ohnishi, et al, 2019). Assuring the patient of privacy and confidentiality creates rapport and prevents social stigma. Before drug administration, the nurse should obtain a fully informed consent. The care provider should protect the patient from harmful drug adverse effects. The nurse should also consider the patient’s needs and preferences before initiating treatment.

Conclusion

Insomnia is the repetitive difficulty in falling asleep, maintaining sleep continuity, or poor sleep quality despite the adequate opportunity to sleep hence causing daytime dysfunction. It is treated by pharmacological and non-pharmacological modalities. Pharmacological treatment modalities are involves the use of drugs that act on the GABA-A receptors, drugs acting on the melatonin receptors, drugs acting as Histamine-1 receptor antagonists, and drugs acting as an orexin receptor antagonist. Drugs acting on the GABA-A receptors such as benzodiazepines exert sedative, hypnotic, and anxiolytic, and muscle-relaxing effects. Zolpidem is an FDA-approved drug used in the management of insomnia in patients experiencing difficulties in falling asleep, unlike trazodone and Hydroxyzine. Both trazodone and hydroxyzine have sedative effects but are not approved to treat insomnia. They also have an unpleasant adverse effect on the patient. Eszopiclone is a hypnotic agent approved by the FDA in the management of transient and chronic insomnia. Through research, it has been known to be more efficient and effective than Zolpidem due to its selectivity at the GABA-A receptors.

references

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., … & Ishak, W. W. (2017). Trazodone for insomnia: a systematic review. Innovations in clinical neuroscience, 14(7-8), 24.

Mortier, C. P., Frapsauce, A., Rucheton, A., Boivin, P. N., & Aubin, F. (2017). CP-234 Is hydroxyzine–pentobarbital association efficient in pediatric sedation?.

Mylonas, D., Baran, B., Demanuele, C., Cox, R., Vuper, T. C., Seicol, B. J., … & Manoach, D. S. (2020). The effects of eszopiclone on sleep spindles and memory consolidation in schizophrenia: a randomized clinical trial. Neuropsychopharmacology, 45(13), 2189-2197.

Ohnishi, K., Kitaoka, K., Nakahara, J., Välimäki, M., Kontio, R., & Anttila, M. (2019). Impact of moral sensitivity on moral distress among psychiatric nurses. Nursing Ethics, 26(5), 1473-1483.

Riemann, D., Krone, L. B., Wulff, K., & Nissen, C. (2020). Sleep, insomnia, and depression. Neuropsychopharmacology, 45(1), 74-89.

Zhang, J., Yetton, B., Whitehurst, L. N., Naji, M., & Mednick, S. C. (2020). The effect of zolpidem on memory consolidation over a night of sleep. Sleep, 43(11), zsaa084.Changes in DSM-5 Sleep-Wake Disorders