BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.
MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.
Decision Point One
Trazodone: 50–100 mg daily at bedtime
RESULTS OF DECISION POINT ONE
- Patient returns to clinic in 2 weeks
- Patient states medication works well but gives him an unpleasant side effect of a prolonged erection of the penis, approximately 15 minutes after waking
- Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
- Patient denies auditory/visual hallucinations and is future oriented
Decision Point Two
Explain that priapism is a side effect of trazodone that should diminish over time. Continue dose
RESULTS OF DECISION POINT TWO
- Patient returns to clinic in 2 weeks
- Patient states priapism has diminished over time
- Patient denies auditory/visual hallucinations and is future oriented
- Patient states trazodone is effective at 50 mg dose but sometimes wakes up following day with next-day drowsiness
- Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Continue dose. Explain to patient he may split the 50 mg tablet in half. The decreased dose should minimize next-day drowsiness. Follow up in 4 weeks
Guidance to Student
Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.
The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks.
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.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/
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.
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.
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).
- 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.
Solution:
Introduction to the Case
Insomnia is recognized as a sleep movement disorder that is characterized by difficulty in falling asleep, difficulty in maintaining regular and quality sleep, disruption of sleep, significant anxiety, in a duration of 3 to 4 or more months. Based on the DSM-IV criteria, the provider can only rule out insomnia only when it is independent of other conditions such as sleep apnea, narcolepsy, substance abuse, or drug indication (Olufsen, Sørensen, & Bjorvatn,2020). Usually, psychiatrists often find it hard to diagnose the disease as it is always associated with anxiety or depression. Upon the establishment of insomnia, drug therapy is often recommended to reduce the symptoms and achieve remission (Rios et al., 2019).
The current case study involves a 31 old male patient who reports having difficulty initiating sleep and remaining asleep as well. While the patient had always reported having a challenge in falling asleep, the condition became worse when he lost her fiancé about 6 months ago. The problem does not just end at home. The patient reports falling asleep at work during the day. His medical history indicates that he was once an addict to opiates when he accidentally broke his knee. Also, the patient admits that he has been taking alcohol frequently before bed to help him fall asleep. Previously, the client has tried several drugs to aid his sleep but ended up suffering from their side effects. The patient denies any visual or auditory hallucinations. He also denies suicidal or homicidal ideation. Further, the mental exam indicates that he is alert and oriented. He has dressed appropriately and is in place, time and event.
Decision #1
I decided to begin with the Trazodone 50 mg before bedtime. I decided to start with this drug due to its efficacy in treating insomnia and regulating the symptoms related to depression. The drug has high efficacy and reduced the potential for abuse (Jaffer et al., 2017). Trazodone is suitable in case some comorbidities such as depression are present. Although the patient was not diagnosed with depression, his recent loss of his loved one may increase his level of anxiety which would, in turn, lead to depression (Oh, Kim, Na, Cho, & Chu, 2019). Indeed, some of the sleep disturbances were attributed to the death of his fiancé. Trazodone is one of the most commonly available off-label drugs for insomnia.
I did not choose the other options including Zolpidem and Hydroxyzine. Zolpidem is very notorious for adverse drug events. Patients using this drug reported dose-dependent sedation and increased risk of psychomotor impairments (Wong et al., 2017). These effects can be fatal as they interfere with normal physiological functioning and thus affecting the patient’s quality of life. Further, Zolpidem has extended risks of abuse along with aggravating the sleep movement conditions and thus becoming less desirable for patients who were once dependent on other drugs such as opiate (Wong et al., 2017). Hydroxyzine was undesirable due to its sedative elements. According toDirani, Nasreddine, Melhem, Arabi, and Beydoun (2017), the sedative effects lead to heightened drowsiness and sleepiness during the day. This may interfere with the patient’s daytime work.
I expected to see Trazodone does reduce the patient’s inability to achieve quality sleep and help him to fall asleep and maintain steady sleep throughout. Also, I would love to see the patient report reduced daytime sleepiness and thus ensure good concentration during the workplace. Jaffer et al. (2017)suggest that Trazodone enhances sleep quality by blocking chemicals that interact with serotonin and the brain neurotransmitters such as alpha1 adrenergic receptors, 5-HT2A, as well as H1 histamine receptors. This is the main reason the drug works best in aiding sleep.
Regarding the ethical considerations, it is important to ensure that the selected treatment is of help to the patient without creating any harm. It was, therefore, necessary to evaluate the…..Please click the icon below to purchase full answer at only $15