Feb 23, 2024 Discussion: Sleep/Wake Disorders NURS 6630
A Sample Answer For the Assignment: Discussion: Sleep/Wake Disorders NURS 6630
For this discussion, the case of a young adult male patient with a history of insomnia has been used. The patient is 31 years old and presents with insomnia as the chief complaint. He reports that the lack of sleep has been getting worse over the past 6 months. According to him, sleeping problems have never created a great concern as he is used to them. However, it has been worse ever since the death of his fiancé, as he struggles to fall and stay asleep. This has greatly compromised his quality of life as his job performance has reduced. He also claims that due to poor sleep at night, he sometimes falls asleep at the workplace.
He confirms that he has been taking diphenhydramine to help him sleep in the past, but is unhappy with the way it makes him feel the next morning. His previous physician reports that the patient has a history of opiate abuse following his ankle fracture in a skiing accident that led to the use of hydrocodone/APAP (acetaminophen) for the management of pain. He has however not used analgesics for the past 4 years. The patient however confirms to be taking alcohol to help with his sleeping. Mental status examination results reveal that the patient current healthcare need is only insomnia.
Several patient factors affect their pharmacokinetic and pharmacodynamic processes hence must be considered when making decisions concerning which drug to prescribe to the patient. For this patient, some of such factors include his male gender, adult age, diagnosis of insomnia, previous use of diphenhydramine, substance use history of opiate abuse, and use of alcohol. The purpose of this paper is thus to consider the above patient factors and determine the most effective choice of drugs for the management of the patient’s insomnia, and necessary medication adjustments based on the treatment outcomes.
Decision Point One
Selected Decision and Rationale
Based on the patient-specific factors, the initial decision was to administer trazodone 50mg orally at bedtime. Despite trazodone being approved by the FDA for the management of depression, evidence demonstrates that its off-label use in the management of insomnia has surpassed its antidepressant indications (Bollu & Kaur, 2019). Trazodone mode of action is associated with the inhibition of serotonin reuptake, antagonizing serotonin, antagonizing alpha1 (α1) adrenergic receptors, and inhibitor of serotonin reuptake transporter (Levenson et al., 2015; Medalie & Cifu, 2017).
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It is effective for patients with diphenhydramine withdrawal (Krystal et al., 2019: Bollu & Kaur, 2019). The drug is also rapidly absorbed from the GI when administered orally with a short onset of action of between 1 to 2 hours, hence appropriate in helping the patient fall asleep easily (Sateia et al., 2017). Its half-life is also short promoting its safety profile as a result of reduced toxicity risks (Zhand & Milin, 2018).
It was not necessary to consider zolpidem as the medication can only be prescribed in case there is no other better option for the management of the patient’s insomnia, as the drug has increased risks of adverse events such as hallucination and amnesia (Krystal et al., 2019; Palagini et al., 2020).Hydroxyzine on the other hand could also not be selected given that it is an antihistamine just like diphenhydramine (Levenson et al., 2015). As such, it will lead to similar side effects to the ones that made the patient stop using the drug, to begin with (Sateia et al., 2017).
Expected Outcome
The patient’s insomnia should be getting better with the use of trazodone for the following four weeks. He should be able to easily fall asleep and stay asleep (Bollu & Kaur, 2019). Achievement of 50% remission of symptoms within the first four weeks, is demonstrated as a positive response to the medication (Levenson et al., 2015).
Ethical Considerations
When deciding on which medication to prescribe to the patient, the PMHNP must demonstrate a high level of critical thinking with the patient’s interest at hand (Krystal et al., 2019). Ethical guidelines recommend all healthcare professionals uphold the patient’s autonomy and promote their health while preventing harm (Sateia et al., 2017; Medalie & Cifu, 2017).
The patient is a male patient who is 31 years old and has insomnia. Since he lost his fiancé, the sleeplessness has been worse over the past six months. The patient claimed that although he hasn’t always been a “great sleeper,” he now has trouble going to sleep or staying asleep at night. The patient claims that his inability to sleep is now impairing his performance at work as a forklift operator at a chemical plant, where he is dozing off in the course of his duties. He usually takes diphenhydramine to fall asleep, but the morning after is unpleasant.
Review of the patient’s medical file reveals that he has a history of opiate usage dating back more than 4 years, when he was prescribed hydrocodone for an ankle fracture sustained in a skiing accident. Prior to going to bed, the patient has been consuming about 4 beers and using diphenhydramine to put him to sleep. The patient is awake, alert, and aware of place, time, people, and events. The patient denies experiencing auditory or visual hallucinations and is adequately dressed. He is future-focused, denies SI or HI, and has sound insight and judgment.
Decision one
The patient was first given 50 mg of trazodone PO at bedtime. Trazodone is a drug that belongs to the category of a serotonin reuptake inhibitor and antagonist. Trazodone is an off-label treatment for insomnia and has FDA approval as an antidepressant. For those with chronic alcohol use like the patient in question, trazodone is a secure pharmaceutical option. Alcohol consumption may not interact with hydroxyzine or zolpidem to provide an additional sedative effect.
Since the patient has been taking diphenhydramine as a supplement, hydroxyzine may not be as beneficial because it works on comparable receptors. Zolpidem may cause sleepwalking and other unusual sleep habits, which are undesirable side effects. The option with less negative effects was trazodone. Trazodone may be able to address two issues since the patient also sounds like he may be having difficulties adjusting to the death of his fiancé.
Alcohol and substance abuse can be a bad coping mechanism for depressive disorders, and depression and sleeplessness are frequently co-occurring disorders. As the other two do not have antidepressant characteristics and can cause further sedations when combined with alcohol, trazodone would be the better option. Zolpidem in combination with alcohol can lead to further respiratory depression and death (Jaffer et al., 2017).
Decision two
When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented. The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime.
An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Settimo et al., 2018).
When the patient comes back two weeks later, he says the drug works great but gives him a 15-minute erection when he wakes up. The patient additionally claims that this makes it challenging to prepare for work. He rejects auditory and visual hallucinations and is future oriented. The decision was made to reduce the dosage of trazodone to 25 mg once a day at bedtime.
An erection that lasts longer than four hours is known as priapism and is a side effect of the drug trazodone. Since the patient is still developing, lowering the dose may reduce that side effect and be a safer alternative than using the other two drugs (Schifano et al., 2022).
Decision three
The patient returns to the clinic two weeks after the trazodone dosage is reduced and notes that while the trazodone is good for promoting sleep, the 25mg dose is occasionally insufficient for a full night’s rest. He rejects auditory or visual hallucinations and is future oriented. The choices were to keep taking the medication, encourage good sleeping habits, or return in four weeks. Stop taking trazodone and replace it with remolten 8 mg at bedtime. Follow up in four weeks.
Discussion: Sleep/Wake Disorders NURS 6630
Trazodone should be stopped, and hydroxyzine 50 mg should be prescribed at bedtime, with a follow-up after 4 weeks. The decision was made to advocate good sleeping habits and then reevaluate in four weeks. Because the trazodone was effective and he had only sometimes complained of not being able to sleep through the night, it was decided to continue using it. If the medicine is changed, the patient may become irritated and less likely to follow instructions because it may be necessary to try several different medications and doses and run into options that don’t work (Krzystanek et al., 2020).
Because hydroxyzine has CNS depressive and sedative effects that may intensify with alcohol, causing dizziness and stumbling and a hangover effect the next morning, it is not a viable alternative to diphenhydramine. Ramelteon is a highly selective melatonin receptor agonist for MTI and MT2.This medicine may help with insomnia and enhance several aspects of sleep.
Alcohol and ramalteon both intensify each other’s effects. Ramelteon was not chosen due to the increased side effects of the drug and alcohol as well as the fact that trazodone is effective and only rarely causes interrupted sleep, making it unwise to start a new treatment (Uchiyama et al., 2019).
Conclusion
Insomnia can accompany depression or cause it, as well as result in poor work performance, anxiety, and substance abuse. The guy has been grieving the loss of his fiancé for six months and has trouble sleeping. Trazodone is an effective sedative antidepressant that affects serotonin neurotransmitters and can help with depression and sleep-related issues. The histamine class of drugs includes hydroxyzine, and the patient has been using diphenhydramine with minimal effects and lingering effects of lethargy the next day.
Since trazodone had some negative effects, reducing the dose could lessen them while maintaining the medication’s current level of effectiveness. Poor sleep hygiene can reduce most people’s capacity to sleep, making it a crucial factor to consider. Changing a patient’s drug regimen on a regular basis can result in noncompliance and frustration if the patient continues to experience unwanted side effects (Riemann et al., 2017).
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. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5842888/
Krzystanek, M., Krysta, K., & Pałasz, A. (2020). First generation antihistaminic drugs used in the treatment of insomnia–superstitions and evidence. Pharmacotherapy in Psychiatry and Neurology/Farmakoterapia w Psychiatrii i Neurologii, 36(1), 33- 40. Doi:10.33450/fpn.2020.04.003
Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., … & Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of Sleep Research, 26(6), 675-700. Doi: 10.1111/jsr.12594.
Schifano, N., Capogrosso, P., Boeri, L., Fallara, G., Cakir, O. O., Castiglione, F., … & Salonia, A. (2022). Medications mostly associated with priapism events: Assessment of the 2015–2020 Food and Drug Administration (FDA) pharmacovigilance database entries. International Journal of Impotence Research, 1-5. Doi: 10.1038/s41443-022- 00583-3
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. Doi: 10.1177/0269881117742101
Uchiyama, M., Sakamoto, S., & Miyata, K. (2019). Effect of ramelteon on insomnia severity: evaluation of patient characteristics affecting treatment response. Sleep and Biological Rhythms, 17(4), 379-388. https://link.springer.com/article/10.1007/s41105-019-00224-1
Pharmacologic Agents and Their Dosing
According to the case, the patient has been diagnosed with comorbid major depressive disorder alongside obstructive sleep apnea. However, the present section will only concern itself with the antidepressant therapy based on agents’ pharmacologic and pharmacokinetic properties. Therefore, the nurse practitioner will consider prescribing Citalopram at a starting dose of 10 mg/d, which will be increased to a maintenance dose of 20mg/d due to the patient’s age (Lavresky et al., 2015).
On the other hand, the nurse practitioner should also consider prescribing duloxetine at a starting dose of 30 mg/day that will be increased gradually to 60 mg/day (Stahl, 2014). These two agents are under consideration because of their shorter half-lives and ability to quickly reach maximum plasma concentration.
The former pharmacological agent (Citalopram) is a selective serotonin reuptake inhibitor while the latter (duloxetine) is a serotonin and norepinephrine selective inhibitor. Both inhibit the reuptake of neurotransmitter serotonin, making its level to be higher in the brain (Stahl, 2014).
However, duloxetine additionally prevents the reuptake of norepinephrine by the nerve cells, essentially ensuring that the brain has a higher level of neurotransmitters, thus improving mood. Therefore, based on the mechanism of action alone, duloxetine is more effective and will be used by the present nurse practitioner to manage the MDD symptomatology of the present patient.
Contraindications/Alterations of Using Duloxetine
According to available information concerning duloxetine pharmacokinetics and dosage, no study has been conducted to identify the effect of ethnicity on dosage and/or contraindication. However, using other closely-linked antidepressants, Lesser et al. (2010) discovered that no noticeable differences existed in dosages and contraindications in a study sample that consisted of African-Americans and Caucasians.
Perhaps the results of this study can be extrapolated to duloxetine and make us to tentatively conclude that ethnicity is not a factor regarding its dosage and contraindications.
Check-Point Data
Assuming that the follow-up data applies to the present drug, there are things that will need to be changed or introduced to the therapy. The results of the first follow-up visit indicate that while the MDD symptoms have received slight improvement, the patient is still symptomatic of OSA. Therefore, duloxetine will be titrated to 40mg/day while the patient will be given a hypnotic, most preferably Gabitril to manage the OSA symptoms.
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During the interim follow-up through four months, since the symptoms of MDD still exist, the duloxetine dosage will be increased to 60 mg/day as allowed by various studies. In addition, Gabitril will be replaced with Zaleplon 5 mg at night as the latter is a more effective hypnotic.
During the interim follow-up through nine months, duloxetine should be augmented with bupropion XL (Wellbutrin-XL) to increase the therapy’s anti-depressant effect. In addition, the dosage of Zaleplon should be increased towards the maximum dosage of 10mg/day for the elderly.
The interim follow-up through the ninth month will see duloxetine maintained at 60 mg/day, Zaleplon maintained at 10 mg/day as required while there will be an introduction of 300 mg of Gabapentin bi-daily to combat RLS. In addition, Modafinil will also be used 400 mg/d to manage the OSA symptoms. This is expected to provide a full remission of MDD symptoms while significantly managing OSA symptoms.
It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015).
Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors.
Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disordersAnalyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disordersEvaluate efficacy of treatment plans for clients presenting for sleep/wake therapyApply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disordersLearning ResourcesNote: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through this link provided.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 11, “Disorders of Sleep and Wakefulness and Their Treatment”Stahl, S. M. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
To access information on the following medications, click on The Prescriber’s Guide, 5th ed tab on the Stahl Online website and select the appropriate medication.
Review the following medications:
For insomnia
alprazolamamitriptylineamoxapineclomipramineclonazepamdesipraminediazepamdoxepinflunitrazepamflurazepamhydroxyzineimipraminelorazepamnortriptylineramelteontemazepamtrazodonetriazolamtrimipraminezaleplonzolpidem
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Davidson, J. (2016). Pharmacotherapy of post-traumatic stress disorder: Going beyond the guidelines. British Journal of Psychiatry, 2(6), e16-e18. doi:10.1192/bjpo.bp.116.003707. Retrieved from http://bjpo.rcpsych.org/content/2/6/e16
To prepare for this Discussion:
Note: By Day 1 of this week, your Instructor will have assigned you to one of the following case studies to review for this Discussion. To access the following case studies, click on the Case Studies tab on the Stahl Online website and select the appropriate volume and case number.
Case 1: Volume 2, Case #16: The woman who liked late-night TV
Case 2: Volume 2, Case #11: The figment of a man who looked upon the lady
Case 3: Volume 1, Case #5: The sleepy woman with anxiety
Review this week’s Learning Resources and reflect on the insights they provide.Go to the Stahl Online website and examine the case study you were assigned.Take the pretest for the case study.Review the patient intake documentation, psychiatric history, patient file, medication history, etc. As you progress through each section, formulate a list of questions that you might ask the patient if he or she were in your office.Based on the patient’s case history, consider other people in his or her life that you would need to speak to or get feedback from (i.e., family members, teachers, nursing home aides, etc.).Consider whether any additional physical exams or diagnostic testing may be necessary for the patient.Develop a differential diagnoses for the patient. Refer to the DSM-5 in this week’s Learning Resources for guidance.Review the patient’s past and current medications. Refer to Stahl’s Prescriber’s Guide and consider medications you might select for this patient.Review the posttest for the case study.Note: For this Discussion, you are required to complete your initial post before you will be able to view and respond to your colleagues’ postings. Begin by clicking on the “Post to Discussion Question” link and then select “Create Thread” to complete your initial post. Remember, once you click on Submit, you cannot delete or edit your own posts, and you cannot post anonymously. Please check your post carefully before clicking on Submit!
By Day 3
Post a response to the following:
Provide the case number in the subject line of the Discussion.List three questions you might ask the patient if he or she were in your office. Provide a rationale for why you might ask these questions.Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.Explain what physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.List three differential diagnoses for the patient. Identify the one that you think is most likely and explain why.List two pharmacologic agents and their dosing that would be appropriate for the patient’s sleep/wake therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.If your assigned case includes “check points” (i.e., follow-up data at week 4, 8, 12, etc.), indicate any therapeutic changes that you might make based on the data provided.Explain “lessons learned” from this case study, including how you might apply this case to your own practice when providing care to patients with similar clinical presentations.Read a selection of your colleagues’ responses.
By Day 6
Respond to at least two of your colleagues who were assigned to a different case than you. For example, if you were assigned to Case Study 1, respond to one colleague assigned to Case Study 2 and one colleague assigned to Case Study 3. Explain how you might apply knowledge gained from your colleagues’ case studies to you own practice in clinical settings.
Submission and Grading InformationGrading CriteriaTo access your rubric:
Week 7 Discussion Rubric
Post by Day 3 and Respond by Day 6To participate in this Discussion:
Week 7 Discussion
It is not uncommon to experience a night or two of disrupted sleep when there is something major going on in your life. However, sleep/wake disorders are much more than an occasional night of disrupted sleep. A recent report from the Centers for Disease Control and Prevention estimated that between 50 and 70 million American have problems with sleep/wake disorders (CDC, 2015).
Although the vast majority of Americans will visit their primary care provider for treatment of these disorders, many providers will refer patients for further evaluation. For this Discussion, you consider how you might assess and treat the individuals based on the provided client factors. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
Learning Objectives
Students will:
Assess client factors and history to develop personalized therapy plans for clients with sleep/wake disorders
Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring therapy for sleep/wake disorders
Evaluate efficacy of treatment plans for clients presenting for sleep/wake therapy
Apply knowledge of providing care to adult and geriatric clients presenting for sleep/wake disorders
Learning Resources
Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.
Required Readings
Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press. NURS 6630: Therapy for Clients With Pain and Sleep/Wake Disorders.
To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 11, “Disorders of Sleep and Wakefulness and Their Treatment”
Stahl, S. M. (2014b). The prescriber’s guide (5th e
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