Assessing and Treating Patients with Sleep/Wake Disorders
Introduction
The case study involves a 31-year old male with insomnia and has begotten progressively over the last six months. According to the patient, he has never been a greater sleeper, but now he has challenges sleeping (Walden University, 2021). The sleeping problems started after the loss of the fiancé. The symptoms are detrimental to daily activities and work. She is using diphenhydramine as a sleep aid, but the drug triggers an unwanted feeling. He falls asleep at work. The patient has a history of opiate abuse. He uses alcohol to make him fall asleep, approximately four beers before bed (Walden University, 2021).
The first decision is to start Trazodone 50 mg to 100 mg daily at bedtime. The medication is the best among the options available since it has fewer side effects (Vgontzas et al., 2020). The second decision is to continue with the drug since the patient reports the drug is effective in helping him sleep. The only precaution is to reduce Trazodone 25 mg to lower the risk of priapism (Vgontzas et al., 2020). The third decision is to continue with Trazodone 25 mg since it is helping reduce insomnia. Ethical considerations promote professionalism in the healthcare practice. The practice should adhere to the ethical requirements, including informed consent, beneficence, maleficence, confidentiality, integrity, and trust.
Decision One
The first decision is to prescribe Trazodone 50 mg to 100 mg daily at bedtime. The prescription decision should accompany the assessment of the patient’s alcohol use. Alcohol use can affect the drug’s adherence and recovery (Vgontzas et al., 2020). Although the drug is in the off-label category, it is the best choice compared to other options. Trazodone is better in treating insomnia since it generates quality results, unlike benzodiazepines (Vgontzas et al., 2020).
I did not select Zolpidem 10 mg at bedtime since the drug has adverse side effects that are risky for the patient and his work. For instance, Zolpidem causes daytime drowsiness, lightheadedness, loss of coordination, tiredness, and weakness (Oggianu et al., 2020). The side effects would affect the patient at the workplace, such as increasing the risk of causing an accident (Oggianu et al., 2020). If the patient realizes the drug is unfriendly, there is a risk of non-adherence. Another reason for not selecting Zolpidem is that the drug is habit-forming, leading to addiction (Caraci et al., 2020). The drug should be used for few weeks since patients may experience trouble sleeping without it. Treatment of sleep or wake disorders may take 8 to 12 weeks, increasing the risk of addiction (Caraci et al., 2020). The patient is already struggling with alcohol which he uses to help him sleep.
I ruled out Hydroxyzine 50 mg daily at bedtime since the drug has side effects related to diphenhydramine. Hydroxyzine makes a person groggy, tired, and sleepy the following day (Albrecht et al., 2019). The medication is not the best for the treatment of insomnia due to high non-adherence rates. The client can stop taking the drug if he realizes that it makes him sleepy and unable to perform his job as a forklift operator.
The expected outcome upon prescribing the medication is to improve the patient’s quality of sleep with minimal side effects. For example, it will be essential to eliminate grogginess as a side effect (Albrecht et al., 2019). The side effect can affect the patient’s job and lead to non-adherence. Another expectation is to avoid the risk of habit-forming medication due to his current alcohol addiction (Albrecht et al., 2019). Addiction can complicate his condition and affect his health.
Decision Two
When the patient reports back to the clinic after two weeks, he explains that the medication is working well to reduce insomnia. He complains that despite the efficacy of the drug, it makes him experience priapism. The prolonged erection makes it challenging to go downstairs to have breakfast with his girlfriend and daughter or get ready for work. Priapism can last up to 15 minutes. The patient denies visual and auditory hallucinations and is future-oriented.
The second decision is to educate the patient that priapism is a side effect of Trazodone and continue with the dose. The dose is helping the patient to generate quality results despite the side effect. It will be essential to reduce the dosage to lower the risk of priapism. I will prescribe Trazodone 25mg daily at bedtime. The potent medication has a half-life of three to nine hours (Vgontzas et al., 2020). The purpose of reducing the dosage is to ensure there is a minimal amount of drug circulating in the blood upon waking up (Vgontzas et al., 2020). Another reason for continuing with the drug is that the evidence-based practice shows that the side effects wear off approximately after four weeks. Trazodone 25mg PO QHS is a standard prescription for patients taking SSRI, which generates insomnia as a significant side effect (Vgontzas et al., 2020). Studies indicate that Trazodone 25mg is effective in reducing insomnia (Oggianu et al., 2020).
I ruled Suvorexant 10mg since the drug can cause side effects such as drowsiness, affecting the client at the workplace (Kuriyama & Tabata, 2017). Another reason is that suvorexant is a controlled substance, according to the U.S. Drug Enforcement Administration (DEA) (Kuriyama & Tabata, 2017). My treatment objective is to avoid prescribing controlled substances unless the decision is necessary and no alternatives are available. Changing a drug in the middle of the treatment of sleep or wake disorders can affect the recovery process (Kuriyama & Tabata, 2017).
The expected outcome is that the patient’s side effects will reduce significantly. Another expected goal is to sustain compliance with the drug. Reducing the dose will lower the risk of priapism and promote adherence (Kuriyama & Tabata, 2017).
Decision Three
The patient comes back to the clinic after two weeks. He reports the medication is effective in helping him sleep. His only complaint is that the dosage is not enough to keep him asleep throughout the night. He denies visual and auditory hallucinations and is future-oriented.
The third decision is to continue with the drug since it is working to reduce insomnia. I would encourage the client to practice sleep hygiene to address the issue of sleeping throughout the night (Morin et al., 2020). I will follow up with the patient in the next clinic after four weeks for further evaluation. It is essential to ask about activities that may undermine his sleep, such as noise, pets, or girlfriend.
It is not prudent to switch the drug since the patient is already responding to the drug and experiencing significant improvement in his sleep. A sleep hygiene assessment will be essential before the next clinic (Morin et al., 2020). If the outcome shows the patient is not practicing sleep hygiene, it would be good to encourage him to change and continue with the medication. If the patient is already practicing sleep hygiene, it would be prudent to switch to hydroxyzine (Morin et al., 2020). Despite the side effects of Xerostomia and Xerophthalmia, hydroxyzine is safe compared to ramelteon (Matheson & Hainer, 2017).
Hydroxyzine pamoate is ruled out since it is not a primary drug for treating insomnia (Matheson & Hainer, 2017). Ramelteon is ruled out since it is a melatonin agonist. The medication is effective in helping people sleep and not to keep them sleep throughout the night (Matheson & Hainer, 2017). If other options are not effective, ramelteon would be a better medication since it has a low risk of abuse and is not listed by U.S. Drug Enforcement Administration (DEA) (Matheson & Hainer, 2017).
The expected outcome is to reduce the side effects, promote quality sleep, optimize sleep atmosphere, and maintain adherence to the drug.
Ethical Considerations
Informed consent is a vital ethical consideration for the adult patient. It involves explaining to the patient the diagnosis and appropriate medication. The patient has the autonomy to decline treatment (Lyles et al., 2017). Beneficence and maleficence are crucial considerations to ensure the patient’s best interest while reducing the risk of harm. For example, reducing the dosage is vital to lower the risk of priapism (Lyles et al., 2017). Honesty and integrity are ethical considerations to enhance trust and communication. Confidentiality of the patient information according to the HIPPA laws is vital to avoid exposing the information to unauthorized parties (Lyles et al., 2017).
Conclusion
Treatment of sleep and wake disorders involves a series of decisions. Treatment decisions in the current case study involve balancing between drug efficacy and side effects. Trazodone is an effective medication, but a high dose causes priapism. Reducing the dosage is vital to avoid priapism while promoting adherence. I will observe various ethical considerations, including informed consent, beneficence, maleficence, confidentiality, integrity, and trust. Treatment of the patient is successful since the drug reduces insomnia.
References
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Morin, C. M., Edinger, J. D., Beaulieu-Bonneau, S., Ivers, H., Krystal, A. D., Guay, B., … & Busby, M. (2020). Effectiveness of sequential psychological and medication therapies for insomnia disorder: a randomized clinical trial. Jama Psychiatry, 77(11), 1107-1115.
Oggianu, L., Ke, A. B., Chetty, M., Picollo, R., Petrucci, V., Calisti, F., … & Tongiani, S. (2020). Estimation of an Appropriate Dose of Trazodone for Pediatric Insomnia and the Potential for a Trazodone–Atomoxetine Interaction. CPT: Pharmacometrics & Systems Pharmacology, 9(2), 77-86.
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 the insomnia with short sleep duration phenotype: a preliminary study. Journal of Clinical Sleep Medicine, 16(12), 2009-2019.
Walden University (2021). Insomnia 31-year old male. Retrieved April 20, 2021, from https://mym.cdn.laureate-medica.com/2dett4d/WaldenNURS/6630/DT/week_11/index.html
