Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
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Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult
Introduction
Individuals with insomnia face difficulty falling asleep, staying asleep, or getting enough restful slumber. Therefore, insomnia is a sleep disorder that must be addressed with the urgency it deserves. People with the illness often wake up early and fail to get back to sleep. Insomnia is often characterized by falling asleep initially, waking up during the night, and waking earlier than desired (Harvey & Buysse, 2018). These are some of the features defining insomnia. Other symptoms include not feeling well-rested after a night’s sleep, daytime fatigue or sleepiness, ongoing worries about sleep, and difficulty paying attention. The two common types of insomnia include primary insomnia, secondary insomnia. Primary insomnia means that the patient’s sleep problems are not linked to any other health condition or problem (Chokroverty, 2017). On the other hand, secondary insomnia means that the individual has trouble sleeping because of a health condition such as arthritis, cancer, pain, medications, and others.
The patient in the case study is a 31-year-old male who presents to the clinic with a chief complaint of insomnia. He stated that her insomnia has gotten worse progressively over the past 6 months. The patient stated that he has never enjoyed his sleep and it’s now difficult falling asleep and staying asleep at night. He reiterated further that this problem is affecting his ability to carry out daily activities as well as his occupation. During mental health status examination, the patient was alert and oriented to person, place, time, and event. The patient is well dressed and makes good eye contact. In that regard, the purpose of this paper is to discuss decisions that would be applied to improve the patient’s condition.
Decision Point One
The selected decision point one is Trazodone 50 mg PO at bedtime. This decision was selected because is widely used for the treatment of both depressive and sleep disorders. At low doses, trazodone helps patients get to sleep and stay asleep at night without feeling sleepy during the day or without causing the patient to build up a tolerance (Yi et al., 2018). It works like that mostly because of its short half-life of 3-6 hours. Another reason for selecting trazodone is its affordability compared to other sleep aids.
For one reason or the other, the other two options were not selected. For example, Zolpidem: 10 mg daily at bedtime was not selected because it is associated with many negative side effects. It should not be the first choice of therapy due to these side effects (Harvey & Buysse, 2018). Some of these side effects include daytime drowsiness, tiredness, loss of coordination, diarrhea, constipation, and memory loss. additionally, Hydroxyzine: 50 mg daily at bedtime was not selected because the medication is usually associated with anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia. These are the reasons why the two options were not selected.
In 2 weeks the patient is expected to experience improvement or reduction of all symptoms associated with insomnia. His insomnia is expected to improve. Other symptoms such as fatigue and dizziness were expected to disappear (Yi et al., 2018). The patient returned to the hospital in two weeks and reports that the medication works well on him. He states that his symptoms have improved, however, he complains of an unpleasant side effect of erection that lasts about 15 minutes after waking. The patient states that the side effect makes it difficult for him to get ready for work or even to have coffee with his girlfriend and daughter in the morning. He denies visual/auditory hallucination. Some of the ethical concerns include the principles of beneficence, non-maleficence, and justice (McDermott-Levy et al., 2018). The decisions made must be beneficial and harmless to the patient. The patient should be treated fairly.
Decision Point Two
The selected decision point two is to explain that an erection lasting 15 minutes is not considered priapism and should diminish over time, and continue with the current dose. Since the patient showed improvement with the current dose, it is important to continue with the dosage to make the improvements progressive (Yi et al., 2018). Additionally, explaining to the patient and educating him about morning erection will help remove his fear. The 15-minute erection in the morning will disappear by time. It is recommended to continue with the current dose when it indicates positive improvements.
Discontinuing trazodone and initiating therapy with suvorexant 10 mg daily at bedtime was not selected because there was no need to support such a regiment. There was no need to discontinue trazodone because it showed improvement of the symptoms (Yi et al., 2018). Additionally, Similarly, there was no need to decrease trazodone to 25 mg daily at bedtime because the initial dose was not associated with bad side effects. Erection that lasts 15 minutes in the morning is not a concern because it would disappear over time.
It was expected that the patient would return to the hospital in two weeks. The patient is expected to experience reduced symptoms of erections. He should have medication tolerance and should not develop any side effects (Harvey & Buysse, 2018). He should not experience any visual/auditory hallucinations and should be future-oriented. The expected results were similar to the actual ones. The patient returned to the clinic in two weeks. He reported diminished symptoms of erection. He also denied auditory/visual hallucinations. The patient states trazodone is effective at 50 mg dose but sometimes wakes up the following day with next-day drowsiness. Ethical issues include patient education, the principles of beneficence, non-maleficence, and justice (McDermott-Levy et al., 2018). All these issues are expected to improve the quality of care delivered.
Decision Point Three
In decision point three, the recommendation is to Continue the dose and explain to the patient he may split the 50 mg tablet in half to resolve the next-day drowsiness. Still, at this point, there was no need to discontinue trazodone due to its positive results (Yi et al., 2018). Half the tabled would resolve the next-day drowsiness.
Sonata was not a good option because it carries with it the risk of complex sleep behaviors. Sonata is associated with some serious side effects that would put the patient’s life in danger (Harvey & Buysse, 2018). On the other hand, the decision to discontinue trazodone and initiate therapy with hydroxyzine 50 mg at bedtime was not selected because, although, hydroxyzine is an antihistamine with strong sedative properties, it is associated with anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.
It is expected that in four weeks, the patient should return to the clinic. The patient will present massive improvement. More than 99% of the symptoms are expected to have resolved by the fourth week (Chokroverty, 2017). Insomnia as well as the next day’s drowsiness should be gone by week four. The 15-minute morning erection is expected to resolve. The patient’s sleep pattern should be normal. These results will be evaluated in four weeks. Ethical consideration includes a proper follow-up strategy. Patient education regarding medication adherence and healthy lifestyle. Others include beneficence and non-maleficence (McDermott-Levy et al., 2018). The regimen or any other decision should be beneficial and harmless to the patient.
Conclusion
Insomnia can be very detrimental to the patient if not properly addressed. Insomnia is a sleep disorder that makes it difficult for the patient to fall asleep, stay asleep, or get enough sleep. It is often characterized by falling asleep initially, waking up during the night, and waking earlier than desired. The two common types of insomnia include primary insomnia, secondary insomnia. Primary insomnia is not associated with any health or medical condition. Secondary insomnia is associated with a health condition. The patient in the case study was diagnosed with insomnia. The patient is a 31-year-old male who presents to the clinic with a chief complaint of insomnia.
To help improve his condition, three decisions or treatment options were identified. The selected decision point one is Trazodone 50 mg PO at bedtime. The selected decision point two is to explain that an erection lasting 15 minutes is not considered priapism and should diminish over time and to continue with the current dose. In decision point three the recommendation is to Continue the dose and explain to the patient he may split the 50 mg tablet in half to resolve the next-day drowsiness. Ethical considerations during the treatment include beneficence, non-maleficence, patient autonomy, and justice. All these ethical issues were observed during the treatment.
References
Chokroverty, S. (2017). Oxford textbook of sleep disorders. United Kingdom Oxford University Press.
Harvey, A. G., & Buysse, D. J. (2018). Treating sleep problems: A transdiagnostic approach. The Guilford Press.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing outlook, 66(5), 473-481. https://doi.org/10.1016/j.outlook.2018.06.013
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 medicine, 45, 25-32. https://doi.org/10.1016/j.sleep.2018.01.010