Discussion: Assessing and Treating Patients with Sleep/Wake Disorders – Solved

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Solution

Assessing and Treating Patients with Sleep/Wake Disorders

Introduction to the Case

The case is of a 31-year-old male presenting a complaint of insomnia. He reports that insomnia had progressively gotten worse in the last six months following the demise of his fiancé, before which he used to have a good sleep. Sleep disorders are conditions that cause changes in a person’s sleep patterns (Mayo Clinic, 2020). The lack of sleep is affecting the client’s job function as a forklift operator. The client has used diphenhydramine but does not like how it makes him feel. He has fallen asleep on the job due to a lack of sleep. The patient claims that he has never slept well since he has difficulty falling and staying asleep at night.

The client’s medical record indicates he has a history of opiate abuse. He had broken his ankle after a skiing accident and was prescribed hydrocodone for acute pain management. Hydrocodone is a synthetic opioid, and once the body becomes dependent on hydrocodone to feel normal, it becomes addictive (Addiction Centre, 2019). However, he has not been on an opiate analgesic prescription in 4years. The client reveals that he has been using alcohol to help him sleep.

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A medical examination reveals that the patient is alert and oriented to person, place, time, and event. He has dressed well and makes good eye contact. The client denies any auditory or visual hallucination. Besides, his judgment, insight, and sense of reality are intact. He also denies any suicidal or homicidal thoughts. The client demonstrates signs of future orientation.

Decision One

I selected Trazodone 50–100 mg daily at bedtime. Trazodone is a selective serotonin reuptake inhibitor (SSRI) with low side effects. Therefore, it is widely recommended and used to manage insomnia, and it is approved by the USA Food and Drug Administration. (Morin et al., 2020). Trazodone acts by preventing the serotonin receptor from being reabsorbed by neurons once released into the central nervous system (Lie et al., 2015; Pagel et al., 2018). This can also remedy the alcohol dependence of the patient.  I believe that the client’s condition is not just insomnia or difficulty in sleeping. Since he lost his fiancé’, the patient might also be experiencing depression and anxiety (Pagel et al., 2018). Therefore, the prescription will treat both insomnia and depression.

Hydroxyzine was no selected because it is an opioid that has a sedative effect. However, some people have anticholinergic side effects the morning after (Smith et al., 2016). Hydroxyzine is a short-acting drug, and the patient may have to take it several times a day. This might lead to a lack of compliance as the patient had already admitted to its inefficiency. Zolpidem was not chosen because it is a sedative and may only work for insomnia but not depression, which is the inducer of the patient’s insomnia (Pagel et al., 2018). Zolpidem is also associated with rebound insomnia and withdrawal effects (Huang et al., 2011).

The prescription was made with the expectation that the client will adhere to and tolerated the medication. According to Morin et al. (2020), Trazodone is well tolerated and efficacious for sleep maintenance, quality, and daytime functioning. In this sense, it was expected that the client would have increased and undisturbed sleeping hours and improved work function.

The ethical principle of informed consent directed this prescription. As a medical practitioner, it is crucial to disclose any information, guiding the patient in decision-making and subsequent contribution to their health care intervention (Sorrell, 2017). Before administering this prescription, the patient should be informed of the potential adverse effects, including nausea, vomiting, diarrhea, lethargy, dizziness, fatigue, loss of vision, or priapism. This way, the practitioner-patient relationship is enhanced.

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Decision Two

I chose to have the client continue the dose and explain that priapism is a harmless side effect of Trazodone and will diminish with time. The decision to continue medication was because the client was already tolerating the medication significantly save for 15-minute priapism. On rare occasions, Trazodone causes priapism and increased libido (Jaffer et al., 2017).  Though priapism is a common side effect of Trazodone, it affects a client’s perception of drugs, affecting his time to ready for work. Discussing with the client about his condition would be appropriate in making them adhere to the prescription, knowing that there is no immediate effect on his health. Besides, Trazadone is also used for the treatment of depression (Pagel et al., 2018). It can aid in the improvement of your mood, appetite, and energy levels, as well as the reduction of anxiety and insomnia. Trazodone is a sedating antidepressant that modulates serotonin (5-HTA) receptors.

The decision to decrease medication was not selected since there were no significant side effects or lack of response to drugs from the client. Stopping Trazodone is associated with withdrawal symptoms, including anxiety, agitation, or difficulty falling asleep (Yi et al., 2018). Equally, stopping the medication and starting suvorexant dosage was not chosen because the client responded well to medication. Suvorexant has been shown to have serious side effects of morning-after dizziness and drowsiness, affecting daily activities (Herring et al., 2016). Besides, suvorexant can cause palpitations, psychomotor hyperactivity, and anxiety. This would reduce the drug’s efficacy.

The expected outcome was a further decrease in dizziness, drowsiness, priapism, and sleep inability. Besides, it is likely that the client will report a positive attitude towards the medication and would not be sleeping at work. The client is also expected to experience no adverse side effects with diminished priapism.

These decisions were based on the ethical principle of veracity. A practitioner should continue to provide comprehensive and objective information concerning medical intervention and a patient’s condition to understand the clinical situation (Sorrell, 2017). Through careful communication, the practitioner will gain the client’s trust and respect, crucial for the clinical relationship.

Decision Three

I chose to have the client continue the dose and explain that he may split the 50 mg tablet in half. However, the patient is experiencing prolonged somnolence. It will be wise to reduce the trazodone dosage by half and re-evaluate after four weeks (Pagel et al., 2018). The decrease in dosage was crucial in decreasing the morning-after drowsiness (Camargos et al., 2014). The decision to continue medication was because the client reported diminished priapism and has tolerated the drug well. Besides, the client reported no auditory or visual hallucinations and demonstrated signs of future orientation. Similarly, the client had a positive attitude towards the medication, with minor effects of drowsiness.

I did not choose to prescribe sonata because of the associated behavioral risks and is largely recommended for sleep onset and not maintenance (Ebbens & Verster, 2010). In contrast, I did not select Hydroxyzine since it is an antihistamine with strong sedative properties (Smith et al., 2016). Besides, Hydroxyzine is associated with Xerostomia and Xerophthalmia, which are morning-after anticholinergic adverse effects. Since the client is a forklift worker, this medication can affect his function leading to fatal workplace accidents.

The expectation from the prescription was a full recovery from insomnia. Trazodone is the preferred remedy in cases where insomnia is a feature and outcome of a depressive episode (Jaffer et al., 2017). It was expected that the client would have an appropriate night’s sleep with no priapism and experience of morning-after drowsiness. According to Jaffer et al. (2017), drowsiness is a significant side effect of Trazodone dose-dependence due to the sedative nature and can be reduced with a lower dosage.

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Assessing and Treating Patients with Sleep/Wake Disorders
Assessing and Treating Patients with Sleep/Wake Disorders

The significant communication and ethical consideration, in this case, is informed consent. Only if the patient has enough facts to make a rational decision will the patient’s right to self-decision be properly exercised (Haddad & Geiger, 2018). Following sound medical practice, the practitioner has an ethical duty to help the patient decide from among the treatment options (Haddad & Geiger, 2018). Another significant ethical consideration is non-maleficence, which requires that practitioners avoid causing harm to their patients (Haddad & Geiger, 2018). In this case, the practitioner should inform the client of the benefits and side effects of the ideal and other relevant medication. Communication is crucial in creating rapport with the client and ultimate drug adherence and effective decision making.

Conclusion

The first prescription was trazodone 50–100 mg daily at bedtime. Trazodone has few side effects and is one of the most often used sleep aids (Pagel et al., 2018). Once serotonin has been released into the CNS, Trazodone prevents neurons from reabsorbing it. Trazodone functions by aiding with the maintenance of serotonin hormone regulation in the brain. The second decision was for the client to continue the same prescription and dosage. The decision to continue medication was because the client was already tolerating the medication significantly. Besides, there was no significant side effect save of priapism, to which the client was advised that priapism as a side effect of his medication, Trazodone diminishes over time.  

The last decision was to continue medication and to split the tablet in half. The decision was made considering the client’s positive response to medication and limited side effects. The need to break the tablet into two ways to reduce the dosage and its morning-after side effect of drowsiness affected client work activities.  As a result, the patient was able to sleep and work as desired. Consequently, the ethical and communication considerations for this case included informed consent and non-maleficence. Every practitioner must inform a patient regarding his condition, available medical interventions, benefits, and side effects to achieve a person cantered care. Communicating with a patient creates a good rapport, commitment to medical intervention, and satisfaction. Equally, practitioners are obliged to practice safely and effectively. In sum, the decisions made in this case had a significant health outcome for the patient.

References

Addiction Centre. (2019). What Is Hydrocodone Addiction? Available at: https://www.addictioncenter.com/opiates/hydrocodone-addiction/ [Accessed 26 March 2021]

Camargos, E. F., Louzada, L. L., Quintas, J. L., Naves, J. O., Louzada, F. M., & Nóbrega, O. T. (2014). Trazodone improves sleep parameters in Alzheimer’s disease patients: a randomized, double-blind, and placebo-controlled study. The American Journal of Geriatric Psychiatry22(12), 1565-1574. https://doi.org/10.1016/j.jagp.2013.12.174

Ebbens, M. M., & Verster, J. C. (2010). Clinical evaluation of zaleplon in the treatment of insomnia. Nature and science of sleep2, 115. https://doi.10.2147/nss.s6853

Haddad, L. M., & Geiger, R. A. (2018). Nursing ethical considerations. https://www.ncbi.nlm.nih.gov/books/NBK526054/

Herring, W. J., Connor, K. M., Ivgy-May, N., Snyder, E., Liu, K., Snavely, D. B., … & Michelson, D. (2016). Suvorexant in patients with insomnia: results from two 3-month randomized controlled clinical trials. Biological psychiatry79(2), 136-148. https://doi.10.1016/j.biopsych.2014.10.003

Huang, Y. S., Hsu, S. C., Liu, S. I., & Chen, C. K. (2011). A double-blind, randomized, comparative study evaluates the efficacy and safety of zaleplon versus zolpidem in shortening sleep latency in primary insomnia. Chang Gung Med J34(1), 50-6.

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 neuroscience14(7-8), 24.

Lie, J. D., Tu, K. N., Shen, D. D., & Wong, B. M. (2015). Pharmacological treatment of insomnia. Pharmacy and Therapeutics40(11), 759. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4634348/

Mayo Clinic. (2020). Sleep disorders. https://www.mayoclinic.org/diseases-conditions/sleep-disorders/symptoms-causes/syc-20354018

Pagel, J. F., Pandi-Perumal, S. R., & Monti, J. M. (2018). Treating insomnia with medications. Sleep Science and Practice2(1), 1-12.

Smith, E., Narang, P., Enja, M., & Lippmann, S. (2016). Pharmacotherapy for insomnia in primary care. The primary care companion for CNS disorders18(2). 10.4088/PCC.16br01930

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 medicine45, 25-32. https://doi.org/10.1016/j.sleep.2018.01.010

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