Assessing and Diagnosing Clients with Sleep Disorders

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) 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). Assessing and Diagnosing Clients with Sleep Disorders. 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) 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. Assessing and Diagnosing Clients with Sleep Disorders

Introduction

Insomnia affects approximately one-third of the general population in the US with higher rates among individuals who are separated or divorced, females, and older people (Jaffer et al., 2017). Individuals diagnosed with insomnia may also have higher risks of anxiety, depression, chronic insomnia, substance abuse, depression, motor vehicle accidents, and suicide. It is primarily characterized by a chronic dissatisfaction with the quality and quantity of sleep and possesses major public health challenges associated with impaired QoL, functioning, physical and psychiatric morbidity, and accidents. Despite this evidence, insomnia is still under-diagnosed, under-recognized, and under-treated. As such, it is important that in clinical practice, PMHNPs have adequate knowledge to recognize, diagnose and manage insomnia to provide patients with an adequate opportunity for sleep and improved QoL. Assessing and Diagnosing Clients with Sleep Disorders

There are numerous strategies to manage insomnia. To begin treatment, it is important to describe and differentiate insomnia from other co-morbid psychiatric disorders. Evidence-based proven non-pharmacologic strategies include cognitive, stimulus control, and relaxation therapy followed by paradoxical intention, sleep restriction, and education on sleep hygiene. For the most promising pharmacotherapeutics agents, non-benzodiazepine hypnotics are recommended as the first line of management followed by amitriptyline, benzodiazepines, and antihistamines. In this paper, the author discusses the pharmacological management of a 31-year-old male who presented with a complaint of insomnia. The patient-specific factors that impact pharmacological decision-making at each point include; therapeutic outcomes, duration, frequency, and severity of side effects.

Case Overview

This case study involves a 31-year-old male who presented with a complaint of insomnia that has progressively worsened in the last six months. The patient acknowledged not being a great sleeper but over time, had had difficulties staying and falling asleep at night. The problem started six months before the presentation after suddenly losing his fiancé. Insomnia affected his ability to perform his job as a forklift operator. Past medications include diphenhydramine whose effects he disliked the following morning. He reported previous episodes of falling asleep on the job due to lack of sleep from the previous night. Assessing and Diagnosing Clients with Sleep Disorders

The patient has a history of opiate abuse ((apap (acetaminophen/) hydrocodone) that started after sustaining an ankle injury in a skiing accident. However, in the past 4 years, he has not received a prescription for an opiate analgesic. Recently, the patient states that he has been taking four beers to fall asleep. Mental Status Exam (MSE) revealed an alert and oriented patient to time, place, event, and person. He maintains good eye contact and has dressed appropriately with the season.  He denies auditory and visual hallucinations and his insight; judgment and reality contact is intact.  He also denies homicidal/suicidal ideation and is future-oriented.

Decision I

Decision Selected

Trazodone 50-100 mg daily at bedtime

Reason for Selecting This Decision

Trazodone is a selective-serotonin reuptake inhibitor (SSRI) and was approved by the FDA   to manage MDD (major depressive disorder). However, it also has other non-FDA/off-label uses such as inducing sedation in patients with sleep disorders, particularly patients without concurrent depression due to its sedative anti-depressive properties and the ability to act safely, quickly, and efficiently with very minimal adverse reactions. According to Jaffer et al (2017), benzodiazepine receptor agonists such as Zolpidem are the most common FDA-approved pharmacological agents to manage insomnia. However, trazodone remains the most widely prescribed pharmacological agent for insomnia in the US despite its approval for MDD by the FDA.Assessing and Diagnosing Clients with Sleep Disorders

Zolpidem 10mg daily at bedtime could be an alternative option since it is approved by the FDA to manage short-term insomnia in patients with difficulties initiating sleep. Zolpidem improves the quality and quantity of sleep by improving measures such as the duration of sleep, latency, and decreases night-time awakenings. However, it has numerous side effects that can easily result in non-adherence and subsequent treatment failure (Bouchette, Akhondi & Quick, 2020).  The most significant effect is complex sleep behaviors such as sleep eating, sleep-driving, and sleepwalking. During the daytime, it easily impairs memory, cognition, and motor performance. Apart from individual consequences, zolpidem can result in legal implications due to the dangers and harms linked to zolpidem-associated complex sleep behaviors. Therefore, it wouldn’t be the first therapy of choice for this patient. Similarly, hydroxyzine 50 mg daily at bedtime could be an alternative but it is an antihistamine with very strong sedative properties (Smith et al., 2016).  To add on, it has the anticholinergic effects of xerophthalmia and xerostomia the following morning that most patients usually complain of that can result in no-compliance.

Expected Outcome

By prescribing Trazodone 50-100 mg daily at bedtime, the author expected that the patient will have improved daytime functioning, decreased individual and work-related stress, and improved quality and quantity of sleep. Trazodone is an SSRI that acts by inhibiting the reuptake of serotonin and blocking alpha-1-adrenergic and histamine receptors. It also antagonizes serotonin 5-HT1a, 5-HT1c, and 5-HT2 receptors to prevent the uptake of serotonin resulting in a sedative effect (Generali & Cada, 2015). Assessing and Diagnosing Clients with Sleep Disorders

Ethical Considerations

The author prescribed Trazodone 50-100 mg daily at bedtime off-label meaning that this drug is not FDA approved for insomnia. Besides, the patient has a history of abuse (opiate). Therefore, the major ethical considerations with prescribing trazodone, in this case, are that of autonomy, beneficence, and non-maleficence (Williams, 2017).  The PMHNP must educate the patient about all the alternative medications to prescribe in this case and let him make an informed decision (Bollu & Kaur, 2019). When prescribing, the PMHNP must ensure that the dosage prescribed is adequate to meet the desired therapeutic doses. However, if the patient will require higher doses, the PMHNP should ensure that it does not result in any harm such as addiction.

Decision 2

Decision Selected

Decrease Trazodone to 25mg daily at bedtime

Reason for Selecting This Decision

After two weeks, the client returned to the clinic with reports that trazodone gave him unpleasant side effects. The most significant side effect was that of the prolonged erection of the penis that lasts approximately 15 minutes after waking up. Based on the patient’s reports, this side effect made it difficult for him to get ready for work especially going downstairs to have coffee with his daughter and girlfriend in the morning. However, he denied visual/auditory hallucinations but was future-oriented. Kamalika (2015) explains that trazodone can result in priapism in the following mechanisms; the effect of blocking alpha-adrenergic, stimulating central 5HT-_1b receptors, inhibiting 5HT-_1b, and 5HT-_2a. Generali & Cada (2015) emphasize that although trazodone is effective at a dosage of 50-100mg for both primary and secondary insomnia, clinicians should consider decreasing the dosage by half when patients experience significant side effects.  This includes trazodone-induced priapism, the prolonged blurred vision among others. Assessing and Diagnosing Clients with Sleep Disorders

The option to discontinue trazodone due to the side effect of priapism and initiating therapy with suvorexant 10mg daily at bedtime is not the best alternative since suvorexant is associated with excessive somnolence (Kripke, 2015). Considering that the patient works during the day this side effect will be a key concern as it can affect his work performance and routine ADL (Activities of Daily Life) such as driving to work. Similarly, continuing the initial dose after explaining to the patient that priapism is a side effect of trazodone may worsen or prolong the side effect of priapism. In clinical practice, Kamalika (2015) recommends that, in the off-label management of patients with trazodone who present with priapism as a side effect, clinicians should decrease the initial dosage of trazodone to prevent severe adverse effects and permanent serious dysfunction.Assessing and Diagnosing Clients with Sleep Disorders

Expected Outcome

The author expected that by decreasing the dosage of trazodone to 25mg daily at bedtime, the patient will have decreased episodes and duration of priapism, improved insomnia-associated daytime impairment, and improved sleep quantity and quality. Kamalika (2015) explains that the side effect of trazodone-induced priapism is associated with its antagonism at α-adrenergic receptors and is dose-dependent. He further explains that decreasing the dosage of trazodone reduces the frequency, duration, and severity of trazodone-induced priapism.

Ethical Considerations

Since trazodone is associated with incidences of drug-induced priapism as a side effect, when using it off-label as in this case, the PMHNP must consider the ethical considerations of non-maleficence, beneficence, and privacy. This requires that the PMHNP must weigh the side effects and gains of trazodone against other options before collectively deciding on the best course of action (Kamalika, 2015). Besides, the patient might be embarrassed to discuss the sexual side effects of the drug presenting a barrier to care. To address this barrier, the PMHNP must educate the patient on the sexual side effects of trazodone.Assessing and Diagnosing Clients with Sleep Disorders

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Decision 3

Decision Selected

Continue dose, encourage sleep hygiene and follow up in 4 weeks

Reason for Selecting This Decision

The patient returned to the clinic after two weeks with reports that the trazodone was very effective for sleep. However, he was concerned that the 25mg dosage was not adequate to help him sleep throughout the night. However, he denied auditory and visual hallucinations. The patient’s presentation showed that he had a partial response from trazodone, thus, it would be inappropriate to switch therapy. Bollu & Kaur (2019) emphasize that, among patients being managed for insomnia who fail to show the desired therapeutic response within   4-6 weeks after the initiation of treatment, clinicians should assess, educate and encourage them on sleep hygiene. Therefore, the PMHNP would start by using sleep hygiene scales and awareness scales to assess the patient’s sleep hygiene. If the outcomes demonstrate that the patient does not have good sleep hygiene, the PMHNP should continue to encourage and educate about sleep hygiene. Sleep hygiene education involves education on lifestyle modification to avoid dinners late at night limiting naps during the day, taking caffeine alcohol, or smoking in the evening (Chung et al., 2018). Sleep hygiene education should further emphasize the need to adopt healthy diets, maintaining regular sleep/wake schedules, and exercise regime.Assessing and Diagnosing Clients with Sleep Disorders

Initiating therapy with ramelteon 8mg nightly at bedtime and following up in 4 weeks after discontinuing trazodone is not a good alternative since this patient already demonstrated some partial response from trazodone. Although approved for insomnia by the FDA, the American Academy of Sleep Medicine (AASM) recommends that clinicians should use ramelteon for sleep-onset insomnia (Sateia et al., 2017). Similarly, initiating therapy with hydroxyzine 50mg nightly at bedtime and following up in 4 weeks after discontinuing trazodone is not a good option since hydroxyzine is associated with the side effects of xerophthalmia and xerostomia which are similar to that of diphenhydramine that the patient initially disliked.

Expected Outcome

The PMHNP expects that educating the patient on sleep hygiene, will increase his awareness and knowledge on good sleep hygiene, and inform his decision making on good sleep habits. Chung et al (2018) recommend good sleep hygiene for all patients with sleep disorders since it helps to address some of the aggravating factors that perpetuate insomnia over time such as night-time alcohol and caffeine intake, excessive night-time worrying, among others. With good sleep hygiene and adherence to the prescribed drug, the PMHNP expects that the patient will have decreased sleep and wake symptoms, and improved daytime functioning.Assessing and Diagnosing Clients with Sleep Disorders

Ethical Considerations

The most important ethical consideration in sleep education which is best provided through CBT (cognitive behavior therapy) is that of distributive justice with regards to costs versus delivery of CBT services which can be costly. However, it will be important to address the issue of costs by encouraging the use of online and telehealth resources for good sleep hygiene.

Conclusion

The effective management of insomnia requires a prompt and appropriate diagnosis, pharmacological management, and sleep hygiene. The patient who presented with insomnia in this case study was managed with trazodone, an SSRI with sedative effects, and given sleep hygiene education. The expected outcomes of management are that the patient will

The major ethical considerations in management are that of privacy, autonomy, beneficence, and non-maleficence.Assessing and Diagnosing Clients with Sleep Disorders

References

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.

Kamalika R. (2015). Priapism: A Rare but Serious Side Effect of Trazodone. The American Journal of Psychiatry Residents’ Journal, 15. Retrieved from https://ajp.psychiatryonline.org/pb/assets/raw/journals/residents-journal/2015/July_2015.pdf

Generali, J. A., & Cada, D. J. (2015). Trazodone: Insomnia (Adults). Hospital pharmacy, 50(5), 367–369. https://doi.org/10.1310/hpj5005-367

Chung, K. F., Lee, C. T., Yeung, W. F., Chan, M. S., Chung, E. W. Y., & Lin, W. L. (2018). Sleep hygiene education as a treatment of insomnia: a systematic review and meta-analysis. Family practice, 35(4), 365-375.

Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri medicine, 116(1), 68–75.

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307-349.Assessing and Diagnosing Clients with Sleep Disorders

Williams, S. (2017). Improved sleep quality and quantity through sleep hygiene education in adults.

Bouchette D., Akhondi H., & Quick J. (2020). Zolpidem. StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK442008/

Smith, E., Narang, P., Enja, M., & Lippmann, S. (2016). Pharmacotherapy for Insomnia in Primary Care. The primary care companion for CNS disorders, 18(2), 10.4088/PCC.16br01930. https://doi.org/10.4088/PCC.16br01930

Kripke, D. F. (2015). Is suvorexant a better choice than alternative hypnotics?. F1000Research, 4. Assessing and Diagnosing Clients with Sleep Disorders