NURS 6630 Case Study Pharmacologic Approaches to Treatment of Insomnia in Younger Adult
NURS 6630 Case Study Pharmacologic Approaches to Treatment of Insomnia in Younger Adult
NURS 6630 Case Study Pharmacologic Approaches to Treatment of Insomnia in Younger Adult
Assessing and Treating Patients With Sleep/Wake Disorders
Sleep disorders comprise of a wide spectrum of diseases affecting an individual’s sleep wake cycle, which interferes with the patient’s driving, work, and social activities. Studies show that despite sleep disorders being very common, they are usually under-diagnosed with associated serious consequences (Riemann et al., 2017). However, with early diagnosis, individuals tend to benefit greatly from the available treatment options. The most common sleep/wake disorder is insomnia. Studies show that approximately 30 to 40% of adults display some level of insomnia in any given year, while approximately 10 to 15% of the cases indicating chronic or severe insomnia or both (Krystal, Prather, & Ashbrook, 2019). This paper illustrates the pharmacological management of an adult patient diagnosed with insomnia, and the legal and ethical issues encountered in choosing the best therapeutic agent for the management of the patient’s symptoms.
The 31-year-old male patient in the provided case study presented to the clinic with a chief complaint of insomnia, which has gotten worse over the past six months. The patient claims that his sleeping has not been good all along, but currently he is having problems falling and staying asleep. It got worse about 6 months ago after losing his fiance. The insomnia is affecting her work performance, which requires a high level of alertness. The patient has used diphenhydramine before but hates the way it makes him feel in the morning. The patient even reports that he once fell asleep at work as a result of a lack of sleep the night before. His past medical history reveals that the patient has a history of opiate abuse, which started when he broke his ankle and was prescribed hydrocodone/APAP (acetaminophen) for management of his pain. He however denies taking the drug in the past four years. He confirms drinking about 4 beers every day before going to sleep. Denies visual or auditory hallucination, or potential harm to self or others.
Decision #1
Trazodone: 50–100 mg daily at bedtime
Reasons Behind the Decision
Initiating the patient on 50mg trazodone is the best treatment choice for this patient. Trazodone is a phenylpiperazine antidepressant, FDA approved for the management of the major depressive disorder in adults. Studies however report great effectiveness in the use of this drug, for the management of insomnia among adults (Riemann et al., 2017). Trazodone work by relatively inhibiting the reuptake of serotonin at the receptor site, with minimal affinity for dopamine or norepinephrine reuptake (Krystal, Prather, & Ashbrook, 2019). Trazodone is rapidly absorbed, with a peak plasma concentration attained within 1 to 2 hours after the oral dose. It is highly protein-bound with a relatively short half-life, of approximately 5 to 9 hours. The drug also displays minimal side effects, unlike diphenhydramine, while reducing the symptoms of opiate withdrawal, making it the best choice for the patient.
Zolpidem is a hypnotic also utilized in the management of insomnia (Chigome, Nhira, & Meyer, 2018). The drug is however associated with numerous side effects such as amnesia, hallucinations, depression, confusion, and agitation among others (Riemann et al., 2017). It is thus not the best first choice for the patient.
Hydroxyzine on the other hand is an antihistamine, just like diphenhydramine, which is also used for the management of insomnia (Krystal, Prather, & Ashbrook, 2019). The drug will however lead to the side effects that made the patient stop using diphenhydramine (Abad, & Guilleminault, 2018).
NURS 6630 Case Study Pharmacologic Approaches to Treatment of Insomnia in Younger Adult
Insomnia
31-year-old Male
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
Select what you should do:
Zolpidem: 10 mg daily at bedtime
Trazodone: 50–100 mg daily at bedtime
Hydroxyzine: 50 mg daily at bedtime
Decision Point One
Zolpidem: 10 mg daily at bedtime
RESULTS OF DECISION POINT ONE
- Patient returns to clinic in 2 weeks.
- Patient states the medication “knocked him out” but felt he slept well.
- His new girlfriend was concerned as he woke up in the middle of the night and cooked breakfast, yet the patient has no recollection of the occurrence.
- Patient states that the medication helps him sleep especially well when taken with a beer right before bedtime. Patient denies auditory/visual hallucinations and is future oriented.
Decision Point Two
Decrease zolpidem to 5 mg daily at bedtime
RESULTS OF DECISION POINT TWO
- Patient returns to clinic in 2 weeks.
- Patient states his episodes of “nighttime activity” has greatly decreased.
- His girlfriend told him that one time in the 2 weeks he got up and was getting ready to go for a drive.
- Patient denies auditory/visual hallucinations and is future oriented.
- Patient states that he likes the way the zolpidem helps him sleep and “is good with continuing to take it if most of the time I sleep through the night undisturbed.”
Decision Point Three
Maintain dose. Patient to return in 4 weeks for follow up appointment
Guidance to Student
Zolpidem is a medication that has a host of negative side effects. It should not be the first choice of therapy due to these side effects. Caution must be exercised if prescribing this medication to a patient. The patient should be instructed not to mix the medication with alcohol or any other medication unless first speaking with their provider.
In this case, the patient is experiencing complex sleep behavior. It is prudent as the patient’s healthcare provider to discontinue this medication and prescribe something different.
Trazodone is a selective serotonin reuptake inhibitor that is a much safer choice. In adults you will want to start with 50mg at bedtime and titrate up as needed.
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
Discontinue trazodone. Initiate therapy with sonata 10 mg nightly at bedtime. 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.
Decision Point One
Hydroxyzine: 50 mg daily at bedtime
RESULTS OF DECISION POINT ONE
- Patient returns to clinic in 2 weeks
- Patient states medication helps with sleep but leaves a similar next-day feeling to what the patient experienced with diphenhydramine
- Patient also states his mouth and eyes are extremely dry in the morning
- Patient denies auditory/visual hallucinations and is future oriented
Decision Point Two
Discontinue hydroxyzine. Initiate therapy with temazepam 15 mg daily at bedtime
RESULTS OF DECISION POINT TWO
- Patient returns to clinic in 2 weeks
- Patient states temazepam really helps with sleep and makes him feel great when he washes it down with a beer
- Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Guidance to Student
The mixture of alcohol and benzodiazepines is one that can result in respiratory depression and death. It would be prudent to discontinue any benzodiazepines your patient is on if you are aware, or even have a suspicion, that the patient consumes alcohol. The mixture of hypnotics and alcohol can also cause respiratory depression and death. Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. Alcohol counseling should also be discussed with the patient to rule out any issues.
Learning Resources
Required Readings (click to expand/reduce)
Medication Resources (click to expand/reduce)
Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.
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Required Media (click to expand/reduce)
Assignment 2: Assessing and Treating Patients With 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.
Reference: Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018
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.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.