Assignment 2: 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.

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

To prepare for this Assignment:

• Review this week’s Learning Resources, including the Medication Resources indicated for this week.
• Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with sleep/wake disorders.

The Assignment: 5 pages

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.

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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder : The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Medication Resources (click to expand/reduce)

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.

• alprazolam
• amitriptyline
• amoxapine
• amphetamine
• desipramine
• diazepam
• doxepin
• eszopiclone
• flunitrazepam
• flurazepam
• hydroxyzine
•  imipramine
• lemborexant
• lorazepam
• melatonin
• methylphenedate
• modafinil
• armodafinil
• carnitine
• clomipramine
• clonazepam
• nortriptyline
• pitolisant
• ramelteon
• sodium oxybate
• solriamfetol
• SSRI’s
• temazepam
• trazodone
• triazolam
• trimipramine
• wellbutrin
• zaleplon
• zolpidem

BACKGROUND

This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

SUBJECTIVE

Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One

Select what you should do:

Zolpidem: 10 mg daily at bedtimeTrazodone: 50–100 mg daily at bedtimeHydroxyzine: 50 mg daily at bedtime

Decision Point One

Zolpidem: 10 mg daily at bedtime

RESULTS OF DECISION POINT ONE

• Patient returns to clinic in 2 weeks.
• Patient states the medication “knocked him out” but felt he slept well.
• His new girlfriend was concerned as he woke up in the middle of the night and cooked breakfast, yet the patient has no recollection of the occurrence.
• Patient states that the medication helps him sleep especially well when taken with a beer right before bedtime. Patient denies auditory/visual hallucinations and is future oriented.

Decision Point Two

Decrease zolpidem to 5 mg daily at bedtime

RESULTS OF DECISION POINT TWO

• Patient returns to clinic in 2 weeks.
• Patient states his episodes of “nighttime activity” has greatly decreased.
• His girlfriend told him that one time in the 2 weeks he got up and was getting ready to go for a drive.
• Patient denies auditory/visual hallucinations and is future oriented.
• Patient states that he likes the way the zolpidem helps him sleep and “is good with continuing to take it if most of the time I sleep through the night undisturbed.”

Decision Point Three

Select what you should do next:

Maintain dose. Patient to return in 4 weeks for follow up appointmentDiscontinue zolpidem 5 mg tablets. Initiate therapy with Intermezzo 5 mg sublingual tablet nightly at bedtime, as needed. Follow up in 4 weeksDiscontinue zolpidem. Initiate therapy with trazodone 50 mg nightly at bedtime. Instruct patient he may take up to 100 mg if 50 mg is ineffective. Follow up in 4 weeks

Decision Point One

Zolpidem: 10 mg daily at bedtime

RESULTS OF DECISION POINT ONE

• Patient returns to clinic in 2 weeks.
• Patient states the medication “knocked him out” but felt he slept well.
• His new girlfriend was concerned as he woke up in the middle of the night and cooked breakfast, yet the patient has no recollection of the occurrence.
• Patient states that the medication helps him sleep especially well when taken with a beer right before bedtime. Patient denies auditory/visual hallucinations and is future oriented.

Decision Point Two

Decrease zolpidem to 5 mg daily at bedtime

RESULTS OF DECISION POINT TWO

• Patient returns to clinic in 2 weeks.
• Patient states his episodes of “nighttime activity” has greatly decreased.
• His girlfriend told him that one time in the 2 weeks he got up and was getting ready to go for a drive.
• Patient denies auditory/visual hallucinations and is future oriented.
• Patient states that he likes the way the zolpidem helps him sleep and “is good with continuing to take it if most of the time I sleep through the night undisturbed.”

Decision Point Three

Maintain dose. Patient to return in 4 weeks for follow up appointment

Guidance to Student
Zolpidem is a medication that has a host of negative side effects. It should not be the first choice of therapy due to these side effects. Caution must be exercised if prescribing this medication to a patient. The patient should be instructed not to mix the medication with alcohol or any other medication unless first speaking with their provider.
In this case, the patient is experiencing complex sleep behavior. It is prudent as the patient’s healthcare provider to discontinue this medication and prescribe something different.
Trazodone is a selective serotonin reuptake inhibitor that is a much safer choice. In adults you will want to start with 50mg at bedtime and titrate up as needed.

USE 6 RESOURCES FROM SCHOOL RESOURCES