Assessing And Treating Patients With Sleep/Wake Disorders

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.

Paper For Above instruction

In this case study, a 31-year-old male presents with a six-month history of worsening insomnia, which significantly impacts his daily functioning and quality of life. The patient’s past medical history is notable for opioid abuse following a skiing accident and prescription for hydrocodone/acetaminophen, which he has not used in four years. Currently, he reports using alcohol to aid sleep and has previously used diphenhydramine, which he discontinued due to undesirable morning effects. The mental status exam indicates alertness, orientation, and no evidence of hallucinations or psychosis, but ongoing insomnia and recent substance use raise concerns about his sleep health and potential addiction risk.

This patient's insomnia appears to have been precipitated by emotional distress following the loss of his fiancée, compounded by maladaptive coping strategies such as alcohol use. His history of opioid abuse warrants caution in prescribing medications that may have abuse potential or adverse interactions with alcohol. Furthermore, his current substance use pattern and history highlight the importance of selecting a safe, effective pharmacologic approach aimed at improving sleep without exacerbating his vulnerability to addiction or side effects. Factors influencing pharmacologic decision-making include his age, prior substance use history, current use of alcohol, and the potential for medication interactions affecting metabolism and efficacy (Kolla et al., 2022).)

Decision Point One: Prescribing Trazodone 50 mg

The initial decision involves prescribing trazodone 50 mg at bedtime, a common choice for insomnia management in adults owing to its sedative properties and relatively favorable side effect profile. Trazodone, a serotonin antagonist and reuptake inhibitor, can promote sleep without significant dependence risk (Staner, 2021). However, a notable side effect—an prolonged erection or priapism—must be addressed. The patient reports experiencing a 15-minute erection post-waking, which although not classified as priapism, warrants monitoring and patient education regarding warning signs, since priapism is a medical emergency (Salonia et al., 2022). Given his history of substance use and current alcohol consumption, monitoring for sedative interactions and potential side effects is essential. Trazodone's metabolism involves hepatic cytochrome P450 enzymes, notably CYP3A4, which can be affected by alcohol and other medications (Kumar et al., 2020). The decision to initiate trazodone should include patient counseling about side effects, adherence, and the importance of follow-up.

Decision Point Two: Continuing at 50 mg and Managing Side Effects

At the two-week follow-up, the patient reports that the medication remains effective in improving sleep but experiences next-day drowsiness. The previous side effect related to priapism has diminished, and he has been reassured about the transient nature of the erection, which is not immediately concerning but requires ongoing vigilance. The continued efficacy suggests that trazodone is appropriate; however, managing residual drowsiness is important to maintain safety and adherence, especially given his occupation as a forklift operator. Trazodone's sedative effects can be dose-dependent (Staner, 2021). The clinician might consider splitting the 50 mg dose, administering 25 mg at bedtime, to mitigate next-day drowsiness and sustain therapeutic efficacy. This strategy aligns with current evidence favoring dose minimization to reduce adverse effects while preserving benefits (Kolla et al., 2022). Patient education about gradual dose adjustment and close follow-up are essential components of care (Kumar et al., 2020).

Decision Point Three: Dose Adjustment and Patient Education

Given the residual somnolence, the clinician recommends halving the dose and instructs the patient on splitting the tablet. This approach aims to optimize sleep quality while minimizing next-day impairment. The patient agrees to follow this plan, and a follow-up is scheduled in four weeks to reassess sleep patterns, side effects, and any signs of adverse reactions. It is crucial to continue patient education regarding the risk of alcohol interactions, as alcohol can potentiate sedation and may interfere with medication metabolism, increasing the risk of adverse effects (Kollins et al., 2020). Additionally, considering the patient’s history of substance use disorder, ongoing counseling and possible referral to addiction services should be discussed to support sustained recovery and prevent relapse (Sinha, 2022). Alternative non-pharmacological strategies, like cognitive-behavioral therapy for insomnia (CBT-I), should also be incorporated into the comprehensive treatment plan.

Throughout this process, monitoring for adverse effects, assessing sleep quality, and evaluating functional outcomes will guide future adjustments. The choice of trazodone, given its efficacy and low dependence potential, combined with dose modifications and patient education, provides a balanced approach tailored to this patient’s unique clinical circumstances. Ensuring safety, efficacy, and addressing underlying emotional distress are paramount to achieving optimal treatment outcomes.

References

• Kolla, B. P., Joy, A., & Morgan, C. (2022). Pharmacodynamics and pharmacokinetics of trazodone in the management of sleep disorders. Sleep Medicine Reviews, 61, 101595.
• Kumar, S., Bhat, S., & Nair, N. (2020). Trazodone: Pharmacology, clinical uses, and adverse effects. International Journal of Pharmacology, 16(1), 31-36.
• Kollins, S. H., McClernon, F. J., & Arnold, L. E. (2020). Alcohol use and medications for sleep: Risks and considerations. Addictive Behaviors Reports, 12, 100286.
• Salo, A. R., & Salonia, A. (2022). Priapism and its management: A review. Urology Journal, 19(4), 278-283.
• Sinha, R. (2022). Recovery from addiction: The essential role of ongoing care and support. Addiction, 117(3), 515-518.
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