Insomnia 31 year old Male

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.(Treatment of Insomnia Essay Example)

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.

https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_11/index.html

Treatment of Insomnia Essay Example-solution

Sleep-related disorders affect many people. Affected individuals complain of sleep dissatisfaction and deprivation in terms of time, quality, and amount of sleep, which causes impairment of core features of sleep-related disorders and daytime distress (American Psychiatric Association [APA], 2013). Furthermore, individuals with sleep disorders experience depression, anxiety, and cognitive changes that necessitate definitive diagnosis, treatment planning, and management. Sleep-wake disorders can sometimes present prodromal expressions of other mental health conditions, and this could give early intervention to prevent such conditions from going full-blown.(Treatment of Insomnia Essay Example)

When diagnosing sleep-wake symptoms as a PMHNP, it is critical to adopt a multidimensional approach, i.e., consider the possibility of other underlying neurological medical conditions. According to the American Psychological Association, healthcare personnel should not use coexisting medical/neurological conditions as an exception but rather as a rule that guides interventions (APA, 2013). The reasoning herein is that sleep disturbances are clinical indications of underlying neurological and medical illnesses. Usually, neurological and medical conditions coexist with other mental illnesses, with depression common. Sleep-wake disorders disturb sleep and are worsened by sleep.(Treatment of Insomnia Essay Example)

Various studies have associated sleep deprivation with changes in work performance, individual moods, immune function, and cognitive ability. The underlying mechanism involves the disruption of body circulation, which affects an individual’s emotional and cognitive abilities (Peng et al., 2020). For instance, sleep deprivation impairs response inhibition, i.e., the ability of the body to suppress negative emotions reduces visual acuity and memory function, including alertness, attention, and instant memory (Ning et al., 2014; Cote et al., 2014). Altogether, these impacts impair an individual’s social and work-related activities.(Treatment of Insomnia Essay Example)

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The presented care involves a 31-year-old male presenting insomnia with subjective and objective information justifying the complaints. The patient reports worsening insomnia over the last six months despite not being typically concerned with his sleeping routine. The patient’s condition followed the death of her fiancé and has continued to affect his work performance. He reports taking diphenhydramine with a negative side effect. The patient reports opiate when he broke his ankle and had used hydrocodone to manage the pain.(Treatment of Insomnia Essay Example)

Moreover, the patient uses alcohol to aid in sleeping. Otherwise, the patient’s mental examination showed that he is oriented × 4, makes good eye contact, is dressed appropriately, and has intact judgment and insight. Moreover, the patient has no homicide or suicide ideation and is future-oriented. The mental examination reveals no coexisting clinical factor that would affect decision-making.(Treatment of Insomnia Essay Example)

Decision Point One

Considering the patient’s presenting condition, i.e., no coexisting clinical condition, the best treatment decision is to start the Trazodone 50mg PO at bedtime. At this point, the treatment aim is to help the patient achieve significant sleep time. However, the patient’s consent to the medication would be critical, considering his previous experience with diphenhydramine. Trazodone act by reducing the number of arousal neurotransmitters, including histamine, dopamine, and serotonin (Shin & Saadabadi, 2017). At low dosage has a sedative effect that induces sleep through 5-HT-2A, alpha-1-adrenergic, and H1 receptor antagonism.(Treatment of Insomnia Essay Example)

Vgontzas et al.’s (2020) randomized control and open-label trials compared cognitive behavioral therapy and Trazodone, with the latter improving sleep. The study found that Trazodone significantly impacts objective sleep duration and minimizes distress associated with the hypothalamic-pituitary-adrenal (HPA) axis activation. In addition, Trazodone is well tolerated and effective in maintaining sleep, increasing sleep quality, and decreasing awakenings (Yi et al., 2018). These findings suggested that Trazodone effectively mitigates short-sleep duration, associated with increased risks of increased physiological hyperarousal as indicated by the HPA axis. The ethical consideration at this point is informed consent. Patients have the right to accept or refuse treatment, and their opinion is included in decision-making (Trachsel & Holtforth, 2019). As a PMHNP, the client should be informed about his condition, and the treatment considerations as this would equally enhance the PMHNP-patient relationship improves patient satisfaction, and contributes to positive health outcomes.(Treatment of Insomnia Essay Example)

Zolpidem 10 mg and Hydroxyzine 50 mg daily at bedtime were not selected in this case. Although Zolpidem is an effective and safe pharmacological intervention for insomnia, it is recommended as a short-time remedy (Xiang, Cai, Hong, & Pan, 2021). However, Zolpidem affects the sleep structure, affective the slow-wave sleep crucial for memory consolidation. Furthermore, Zolpidem is associated with various adverse events, including vertigo, fatigue, headache, nausea, and nasopharyngitis. Zolpidem is associated with side effects similar to those of diphenhydramine taken and crated poorly by the patient (Beaulieu-Bonneau et al., 2017). Other adverse events such as upper abdominal pain, upper respiratory infection, somnolence, and myalgia are also common among individuals under Zolpidem medication for insomnia. The adverse events were not ideal at this stage, considering the possibility of nonadherence to medication.(Treatment of Insomnia Essay Example)

Hydroxyzine is not selected due to its anticholinergic effects. Although Hydroxyzine can help alleviate mood and anxiety symptoms, it is an antagonist selective for H1 receptors with less affinity for acetylcholine receptors (Smith, Narang, Enja, & Lippmann, 2016). The nature of Hydroxyzine actions results in the blockade of H1-receptors having minimal anticholinergic effects. Moreover, there is limited study on Hydroxyzine tolerance, and a fed data support its dosage, efficacy, and safety when used for insomnia. Lastly, there is a critical concern on Hydroxyzine’s impact on electrocardiographic QTc interval prolongation and cardiac risk factors.(Treatment of Insomnia Essay Example)

Decision Point Two

The best decision is to explain to the patient that an erection lasting 15 minutes is not considered priapism and should diminish over time. Therefore, the patient should continue with the current dose. At this point, consideration is paid to the patient’s response to medication and potential patient factors limiting adherence. Other than the prolonged erection, the patient is responding well to medication. The patient reports no auditory/visual hallucinations, is future-oriented and sleeps well. According to Korade et al. (2021), priapism is rare, with a lower incidence of one in every 1000 and one in every 10000 in the general population. Shah, Deolanker, Luu, & Sadeghi-Nejad (2021) argue that psychotropic-induced priapism results from the antagonistic interaction between alpha one and adrenergic actions of psychotropic medication inhibiting the detumescence erection phase.(Treatment of Insomnia Essay Example)

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Usually, the erection phase is prolonged 2.4 times by Trazodone when sleeping (during rapid eye movement). However, in this case, a 15-minute erection is not considered priapism, which can last hours. Therefore, it is crucial to educate the patient about priapism and normal erection and counsel them before and during the medication (Shah et al., 2021). Education and counseling will inform them about the possible side effects of medication and side effects that require clinical attention. Besides, educating the patient on the proposed treatment fosters communication and nurse-patient relationship, improving their satisfaction and comfortability.(Treatment of Insomnia Essay Example)

Discontinuing trazodone and initiative suvorexant therapy is not ideal at this point. Although Suvorexant is recommended for the treatment of insomnia (Rhyne & Anderson, 2015), the patient is responding and tolerating the current medication. In this case, there is no need to change the medication. Suvorexant acts by blocking the action of natural substances that causes wakefulness. Rhyne & Anderson (2015) argue there is a limited head-to-head comparison of suvorexant with other pharmacological sleep agents and lacks a real-world and long-term evidence base.(Treatment of Insomnia Essay Example)

Furthermore, decreasing trazodone dosage to 25 mg is not ideal at this phase of treatment. This decision is based on the patient’s positive response and tolerance to the current medication. At this point, there is no indication or reason to reduce the dosage. Reducing dosage is permitted when there is a high level of drug intolerance and the patient is presenting adverse drug events. Moreover, 25 mg of Trazodone is considered an underdose and could result in a minimal reduction in patient symptoms (Karode et al., 2021). As a PMHNP, it is crucial to make decisions that do not harm the patient (nonmaleficence), which justifies reducing the current dosage to minimize drowsiness.(Treatment of Insomnia Essay Example)

Decision Point Three

The ideal decision at this point is to continue the current dose. Besides, it is an ideal phase to explain to the patient to split the tablet, which would decrease the side effects. The decision is supported by the patient’s tolerance and positive response to the medication. The patient reports diminished priapism and no auditory/visual hallucinations. The only concern at this stage is the patient’s drowsiness. As a PMHNP, there is a need to make decisions that do not pose a risk to the patient (Nonmaleficence) and produces positive health outcomes (Beneficence) (Beck, Kim, & Dunn, 2021). In this case, reducing the tablet would reduce the dosage and consequently the next-day drowsiness.(Treatment of Insomnia Essay Example)

It is not ideal to discontinue Trazodone at this point and initiate sonata therapy. Other than the excellent tolerance and response to the current medication, there is no indication to discontinue the current prescription. Sonata is a sedative and acts by binding type 1 benzodiazepine on gamma to the chloride-ion channel complex (Bhandari & Sapra, 2021). Significantly, Sonata does not have anticonvulsant erect as do other benzodiazepines, which contributes to high side effects. Besides, Sonata benefits from sleep induction only and no maintenance due to its short half-life. Discontinuing Trazodone and initiating Hydroxyzine was also not ideal, considering the anticholinergic adverse effects associated with Hydroxyzine. Hydroxyzine has not been adequately studied and its efficacy compared to other pharmacological agents is limited.(Treatment of Insomnia Essay Example)

Conclusion

The patient’s subjective symptoms define insomnia, a sleep-wake disorder associated with sleep deprivation (APA, 2013). The first decision is to start the patient on Trabzon. Treatment aimed to help the patient catch and maintain sleep. Trabzon improves sleep duration and minimizes distress associated with activating the hypothalamic-pituitary-adrenal (HPA) axis (Vgontzas et al., 2020). Trazodone is well tolerated and effective in maintaining sleep, increasing sleep quality, and decreasing awakenings (Yi et al., 2018). in the second visit, the decision was to explain to the patient that an erection lasting 15 minutes is not considered priapism and should diminish over time. The aim is to show the patient care for his concerns. Priapism is very rare, with a lower incidence of one in every 1000 and one in every 10000 in the general population. Psychotropic-induced priapism results from the antagonistic interaction between alpha-one and adrenergic actions of psychotropic medication, inhibiting the detumescence erection phase (Shah et al., 2021). In the third visit, the decision is to reduce the dosage by splitting the tablet. Treatment aims to decrease the side effects. Furthermore, as a PMHNP, there is a need to make decisions that do not pose a risk to the patient (Nonmaleficence) and produces positive health outcomes (Beneficence) (Beck, Kim, & Dunn, 2021). In this case, reducing the tablet would reduce the dosage and consequently the next-day drowsiness.(Treatment of Insomnia Essay Example)

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Treatment of Insomnia Essay Example

 

References

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American Psychiatric Publishing

Beaulieu-Bonneau, S., Ivers, H., Guay, B., & Morin, C. M. (2017). Long-term maintenance of therapeutic gains associated with cognitive-behavioral therapy for insomnia delivered alone or combined with Zolpidem. Sleep, 40(3). https://doi.org/10.1093/sleep/zsx002

Beck, N. S., Kim, D. S., & Dunn, L. B. (2021). Ethical Issues in Psychopharmacology. Focus, 19(1), 53-58. https://doi.org/10.1176/appi.focus.20200043

Bhandari, P., & Sapra, A. (2021). Zaleplon. https://www.ncbi.nlm.nih.gov/books/NBK551571/

Korade, Z., Allen, L. B., Anderson, A., Tallman, K. A., Genaro-Mattos, T. C., Porter, N. A., & Mirnics, K. (2021). Trazodone affects on developing brain. Translational Psychiatry, 11(1). https://doi.org/10.1038/s41398-021-01217-w

Ma, N., Dinges, D. F., Basner, M., & Rao, H. (2015). How acute total sleep loss affects the attending brain: a meta-analysis of neuroimaging studies. Sleep, 38(2), 233-240. https://doi.org/10.3389/fnins.2020.00469

Peng, Z., Dai, C., Ba, Y., Zhang, L., Shao, Y., & Tian, J. (2020). Effect of sleep deprivation on the working memory-related N2-P3 components of the event-related potential waveform. Frontiers in Neuroscience, 14, 469. https://doi.org/10.3389/fnins.2020.00469

Rhyne, D. N., & Anderson, S. L. (2015). Suvorexant in insomnia: efficacy, safety, and place in therapy. Therapeutic Advances in Drug Safety, 6(5), 189-195. https://doi.org/10.1177%2F2042098615595359

Shah, T., Deolanker, J., Luu, T., & Sadeghi-Nejad, H. (2021). Pretreatment screening and counseling on prolonged erections for patients prescribed Trazodone. Investigative and Clinical Urology, 62(1), 85. https://dx.doi.org/10.4111%2Ficu.20200195

Shin, J. J., & Saadabadi, A. (2017). Trazodone. https://www.ncbi.nlm.nih.gov/books/NBK470560/

Smith, E., Narang, P., Enja, M., & Lippmann, S. (2016). Pharmacotherapy for insomnia in primary care. The Primary Care Companion for CNS Disorders, 18(2), 27101. https://dx.doi.org/10.4088%2FPCC.16br01930

Trachsel, M., & grosse Holtforth, M. (2019). How to strengthen patients’ meaning response by an ethical, informed consent in psychotherapy. Frontiers in Psychology10, 1747. https://doi.org/10.3389/fpsyg.2019.01747

Vgontzas, A. N., Puzino, K., Fernandez-Mendoza, J., Krishnamurthy, V. B., Basta, M., & Bixler, E. O. (2020). Effects of Trazodone versus cognitive-behavioral therapy in insomnia with short sleep duration phenotype: a preliminary study. Journal of Clinical Sleep Medicine, 16(12), 2009-2019. https://doi.org/10.5664/jcsm.8740

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in the treatment of insomnia disorder for one month: a meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250-256. https://doi.org/10.1016/j.sleep.2021.09.005

Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., … & Zhou, X. Y. (2018). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Medicine, 45, 25-32. https://doi.org/10.1016/j.sleep.2018.01.010

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