Sleep disorders are conditions that result in changes in an individual’s

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:
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
 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
 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
 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 #3
 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.
Conclusion
 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.

Case Study – 31 y.o. male with insomnia31
ld Male

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 bedtime — SOME REASONS NOT TO USE THIS MEDICATION –Zolpidem
is a medication that has a host of negative side effects (Such as — 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.) 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.
Trazodone: 50–100 mg daily at bedtime ****** CHOOSE THIS OPTION ******
Hydroxyzine: 50 mg daily at bedtime — SOME REASONS NOT TO USE THIS MEDICATION —
Patient states medication helps with sleep but leaves a similar next-day feeling to what the patient
experienced with diphenhydramine
 Patient also states his mouth and eyes are extremely dry in the morning
 Patient denies auditory/visual hallucinations and is future oriented
Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of
anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.

RESULTS OF DECISION POINT ONE
 Patient returns to clinic in 2 weeks
 Patient states medication works well but gives him an unpleasant side effect of a prolonged
erection of the penis, approximately 15 minutes after waking
 Patient states this makes it difficult to get ready for work or go downstairs and have coffee
with his girlfriend and daughter in the morning
 Patient denies auditory/visual hallucinations and is future oriented
 Decision Point Two

 Select what you should do next:


 Explain that priapism is a side effect of trazodone that
should diminish over time. Continue dose ****** CHOOSE
THIS OPTION ******

 Discontinue trazodone. Initiate therapy with suvorexant
10 mg daily at bedtime SOME REASONS NOT TO USE THIS
MEDICATION — Patient states suvorexant works well for sleep
but leaves him with an awful next-day feeling, and “it’s very
difficult to get out of bed.” Next day drowsiness is a common
side effect of suvorexant. This would be a major concern as it
can affect the patient's ability to perform daily activities such
as driving or going to work.

 Decrease trazodone to 25 mg daily at bedtime


Results of Decision Point Two

Patient returns to clinic in 2 weeks
Patient states priapism has diminished over time
Patient denies auditory/visual hallucinations and is future oriented
Patient states trazodone is effective at 50 mg dose but sometimes wakes up
following day with next-day drowsiness
Patient denies auditory/visual hallucinations and is future oriented

Decision Point Three
Select what you should do next:

Discontinue trazodone. Initiate therapy with sonata 10 mg nightly at bedtime. Follow up in 4 weeks
SOME REASONS NOT TO USE THIS MEDICATION (Sonata) — Trazodone is a selective serotonin
reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it
carries with it the risk of complex sleep behaviors. — ****** PLEASE DISCUSS WHAT KIND OF COMPLES
SLEEP BEHAVIORS ARE ASSOCIATED WITH SONATA ******
Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg at bedtime. Follow up in 4
weeks

Continue dose. Explain to patient he may split the 50 mg tablet in half. The decreased dose
should minimize next-day drowsiness. Follow up in 4 weeks ****** CHOOSE THIS OPTION
******
Guidance to Student USE THIS IN EXPLANATION!! Trazodone is a selective serotonin reuptake
inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with
it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties.
However, many patients complain of anticholinergic adverse effects the following morning, such as
Xerostomia and Xerophthalmia.
The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of
trazodone by 50% and reassess in 4 weeks

Learning Resources

Required Readings (click to expand/reduce) MUST USE THESE RESOURCES
IN ASSIGNMENT!!!

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)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved
drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm
Note: To access the following medications, use the Drugs@FDA resource. Type
the name of each medication in the keyword search bar. Select the hyperlink
related to the medication name you searched. Review the supplements provided
and select the package label resource file associated with the medication you
searched. If a label is not available, you may need to conduct a general search
outside of this resource provided. Be sure to review the label information for each
medication 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