Treatment of Insomnia Assignment

The client in the case study presented with complaints about insomnia that has progressively become worse over the last six months. The client reported difficulties in falling asleep and remaining asleep. Insomnia became worse after the unexpected loss of his fiancé, about 6 months ago. The problem has affected his ability to work as a forklift operator. The client has utilized diphenhydramine to improve sleep but reports unwanted side effects. He has a history of opiate abuse (hydrocodone/apap (acetaminophen). According to the DSM-5 diagnostic criteria, insomnia is characterized by symptoms such as difficulties in falling asleep, difficulty in maintaining sleep, frequent awakenings, and difficulties returning to sleep after waking up. The sleep disturbance should be present for a minimum of three months and significantly affects the functionality of an individual for instance the ability to work or study (Zheng et al., 2018). The client manifests the majority of these symptoms as he reported difficulties initiating sleep and inability to remain asleep; this has significantly affected his ability to work. It is important to take into account risk factors for insomnia for this client. For example, the loss of his fiancé could be the traumatic event that triggered insomnia for this client because high-stress levels and distress due to traumatic life events can cause insomnia (Huang et al., 2021). It is also important to consider the client’s history of opiate abuse and the current use of diphenhydramine to treat the sleep problem. Accordingly, this paper will discuss the treatment choices, treatment goals, and treatment outcomes for this client. The treatment decisions will be based on the client’s symptoms and past medication history.

Decision Point One

The chosen treatment decision was for the patient to begin Trazodone: 50–100 mg daily at bedtime. Trazodone is approved by the FDA to treat depression and is also commonly prescribed to treat insomnia (Jaffer et al., 2017). Trazodone works by blocking the reuptake of serotonin and stimulates antagonism on α1-adrenergic and histamine H1 receptors. At low doses (25-100 mg), this produces a hypnotic effect hence inducing and maintaining sleep without causing drowsiness during the daytime because the medication has a short half-life (Jaffer et al., 2017). The client does not have a history of depression before the loss of his fiancé and thus his insomnia may be related to bereavement-related grief. Trazodone is a serotonergic hypnotic and hence it does not cause dependence and withdrawal symptoms after discontinuation. The reason why zolpidem was not selected is because it is a sedative-hypnotic and thus can cause dependence and addiction and upon withdrawal can cause serious withdrawal symptoms (Lähteenmäki et al., 2019). Therefore, zolpidem is a second-line treatment choice for insomnia. The reason why hydroxyzine was not selected is due to its numerous side effects such as dizziness, dry mouth, drowsiness, fatigue, blurred vision, headache, confusion, and urinary retention (Stahl, 2016).

By selecting trazodone 50-100 mg for this client, the treatment goal was for the insomnia symptoms to improve as indicated by the client being able to fall asleep and maintain sleep. This is due to the efficacy of trazodone in inducing and maintaining sleep (Jaffer et al., 2017). It was also expected that the client would not experience daytime drowsiness because trazodone has a short half-life and at small doses (50-100 mg) the medication induces and maintains sleep at night without causing drowsiness at daytime (Jaffer et al., 2017).

The treatment outcome was that the patient was able to sleep well as he reported that the medication was working well. However, he reported that the medication was giving him a prolonged penis erection about 15 minutes after waking up; this was making him uncomfortable. Priapism and prolonged erections are some of the side effects of trazodone treatment (Shah et al., 2021).

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Decision Point Two

The selected decision is to reduce trazodone to 25 mg. The rationale for selecting this decision is because the medication was effective in inducing and maintaining sleep for the client and hence the medication should be maintained. However, since the client reported the side effect of having a prolonged erection, the trazodone dose needs to be reduced to prevent the side effects. Evidence indicates that lower doses of trazodone are effective and have lesser side effects since the medication is short-acting (Wang et al., 2020). The reason why the decision to continue with the same trazodone dose and explain to the client that priapism is a side effect of the medication was not chosen is because he seems very concerned about the side effect and this can affect his treatment adherence. The reason why the decision to discontinue trazodone and start suvorexant 10 mg was not chosen is because apart from priapism, trazodone is proving to be effective in treating insomnia. Additionally, suvorexant is a sedative that has addictive effects and other numerous side effects (Ishibashi et al., 2020).

By reducing the Trazadone dose to 25 mg, it was hoped that the client would continue responding to the medication but the priapism would diminish. This is because low doses of trazodone (even 25 mg) are able to induce sleep without causing unwanted side effects (Jaffer et al., 2017).

As expected, the client reported that the medication was effective for sleep and he no longer reported priapism. This is because the reduced dose effectively induced sleep but did not cause any side effects (Jaffer et al., 2017). However, he reported that at times the trazodone 25 mg was not very effective in helping him sleep throughout the night.

Decision Point Three

The third decision was to continue the dose and encourage sleep hygiene. The rationale for this treatment decision is because the trazodone 25 mg is effective in treating insomnia symptoms without causing side effects for this client. However, the client reported that at times the trazodone 25 mg was not effective in maintaining sleep throughout the night. As a result, it is important to encourage sleep hygiene. Sleep hygiene includes the environmental, behavioral, and cognitive modifications used to improve sleep (Nikles et al., 2020). Therefore, the client will be informed about the necessary modifications to make to improve the quality of sleep. The reason why decisions to discontinue trazodone and stat ramelteon or hydroxyzine medications is that there is no clinical reason to discontinue trazodone. The maximum effective dose of the first-line medication should be evaluated before changing the medication (Stahl, 2016).

By selecting to continue with trazodone 25 mg and encourage sleep hygiene, it was expected that the client would continue responding to the treatment through the ability to initiate sleep and adequately maintain sleep throughout the night.

During the treatment of this client, informed consent was sought from the client by providing all information about the medications to allow him to make informed treatment decisions. The autonomy of the client was also respected as was not influenced or forced to receive any treatment (Varkey, 2021). Confidentiality and privacy of his health information were maintained.

Conclusion

The diagnosis for this client is insomnia as manifested by difficulties in initiating or maintaining sleep. The first treatment choice for the client was thus to start trazodone 50–100 mg. Trazodone is effective in improving insomnia symptoms and has minimal side effects when compared to other available treatment options. The client reported significant symptom improvement but reported prolonged erection, a side effect of trazodone. As a result, the second decision was to lower the trazodone dose to 25 mg. This is because lower doses of medications are associated with minimal side effects. With the second decision, it was expected that the medication would be effective in treating insomnia and the client would no longer experience prolonged erection. As expected, the side effect of prolonged erection in the morning diminished and the medication was effective in treating insomnia. However, he reported that at times the 25 mg dose was not effective to maintain sleep the whole night. Therefore, the third decision was for the client to continue with trazodone 25 mg and encourage sleep hygiene. The ethical principles applied during his treatment included autonomy, informed consent, and confidentiality.

References

Huang, Y., Xu, J., Zheng, S., Xu, S., Wang, Y., Du, J., … & Su, T. (2021). The risk factors for insomnia and sleep-disordered breathing in military communities: A meta-analysis. PloS one, 16(5), e0250779.

Ishibashi, Y., Nishitani, R., Shimura, A., Takeuchi, A., Touko, M., Kato, T., Chiba, S., Ashidate, K., Ishiwata, N., Ichijo, T., & Sasabe, M. (2020). Non-GABA sleep medications, suvorexant as risk factors for falls: Case-control and case-crossover study. PloS one, 15(9), e0238723. https://doi.org/10.1371/journal.pone.0238723

Jaffer, K. Y., Chang, T., Vanle, B., Dang, J., Steiner, A. J., Loera, N., Abdelmesseh, M., Danovitch, I., & Ishak, W. W. (2017). Trazodone for Insomnia: A Systematic Review. Innovations in clinical neuroscience, 14(7-8), 24–34.

Lähteenmäki, R., Neuvonen, P. J., Puustinen, J., Vahlberg, T., Partinen, M., Räihä, I., & Kivelä, S. L. (2019). Withdrawal from long‐term use of zopiclone, zolpidem, and temazepam may improve perceived sleep and quality of life in older adults with primary insomnia. Basic & clinical pharmacology & toxicology, 124(3), 330-340.

Nikles, J., Mitchell, G. K., de Miranda Araújo, R., Harris, T., Heussler, H. S., Punja, S., … & Senior, H. E. J. (2020). A systematic review of the effectiveness of sleep hygiene in children with ADHD. Psychology, health & medicine, 25(4), 497-518.

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.

Stahl M., S., (2016). Stahl’s essential psychopharmacology. Fourth edition. Cambridge University Press.

Varkey, B. (2021). Principles of clinical ethics and their application to practice. Medical Principles and Practice, 30(1), 17-28.

Wang, J., Liu, S., Zhao, C., Han, H., Chen, X., Tao, J., & Lu, Z. (2020). Effects of Trazodone on Sleep Quality and Cognitive Function in Arteriosclerotic Cerebral Small Vessel Disease Comorbid with Chronic Insomnia. Frontiers in psychiatry, 11, 620. https://doi.org/10.3389/fpsyt.2020.00620

Zheng, W., Luo, X. N., Li, H. Y., Ke, X. Y., Dai, Q., Zhang, C. J., … & Ning, Y. P. (2018). Prevalence of insomnia symptoms and their associated factors in patients treated in outpatient clinics of four general hospitals in Guangzhou, China. BMC psychiatry, 18(1), 1-7.

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https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/DT/week_11/index.html

first option trazodone

decision 2 decrease trazodone to 25mg

continue dose and encourage sleep hygiene. Follow up in 4 weeks

I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest. The course page suggests writing 1 page per decision – my opinion is that it will be very difficult to justify your treatment decisions and provide scientific evidence in 1 page (especially for decision #1). I do not need you to tell me about the patient or the treatment options available to you – I am very familiar with the cases. Your introductory page should be an overview of the disease state you are treating along with a purpose statement for the assignment. Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option – why is it the best option, using clinically relevant data from primary literature (clinical trials, treatment guidelines) and patient specific data AND why you did not choose the other options (with clinically relevant data from primary literature and patient specific data).

Introduction to the case (1 page)

Briefly explain and summarize the disease state you are treating this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

At each decision point stop to complete the following:

Decision #1 (1.5+ pages)

Which decision did you select?

Why did you select this decision? Support your response with strong scientific evidence discussing efficacy, safety, tolerability and patient outcomes from primary literature (not information from Micromedex, Epocrates or UpToDate) and references. Why did you NOT select the other treatment options available? Again, provide STRONG scientific evidence from the primary literature. Clinical studies or treatment guidelines are a good place to start!

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

What ethical considerations impacted your treatment plan and communication plan with the patient?

Decision #2 (1+ pages)

Which decision did you select?

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

What ethical considerations impacted your treatment plan and communication plan with the patient?

Decision #3 (1+ pages)

Which decision did you select?

What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.

What ethical considerations impacted your treatment plan and communication plan with the patient?

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. You should provide new data here – not a repeat of the data you used previously in the paper.
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