Insomnia Case Study
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.
Decision Point One-Trazodone 50mg po at bedtime.
Trazodone po at bedtime
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 an erection lasting 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
Decrease trazodone to 25 mg daily at bedtime
RESULTS OF DECISION POINT TWO
• Patient returns to clinic in 2 weeks
• Patient states trazodone is very effective for sleep
• Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night
• Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three
Continue dose. Encourage sleep hygiene. Follow up in 4 weeks
Feedback to Student
Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.
ASSIGNMENT QUESTIONS. 5 pages please see below;
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 (Zolpidem: 10 mg daily at bedtime, Hydroxyzine 50mg daily at bedtime), 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 (Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose, Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime) 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 (Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks, Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks), 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.
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Introduction to the case:
This case study is about a 31-year-old male patient who has been experiencing insomnia for the past 6 months. The patient’s insomnia began approximately 6 months ago after the sudden loss of his fiancé. He states that he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The patient’s insomnia is affecting his ability to perform his job as a forklift operator at a local chemical company. He has a history of opiate abuse, which began after he broke his ankle in a skiing accident, and he has been using alcohol to help him fall asleep, approximately four beers prior to bed.
Decision #1:
The decision selected was to prescribe Trazodone 50mg po at bedtime. This decision was selected because Trazodone is a sedative-hypnotic medication that is effective in treating insomnia. It works by increasing the levels of serotonin, a neurotransmitter that regulates mood and sleep, in the brain. Trazodone is considered a first-line treatment for insomnia and is safe and effective when used at low doses (American Academy of Sleep Medicine, 2017).
The other two options, Zolpidem and Hydroxyzine, were not selected because they both have potential negative side effects. Zolpidem is a non-benzodiazepine hypnotic medication that is effective in treating insomnia, but it has a risk of dependence and withdrawal symptoms (American Academy of Sleep Medicine, 2017). Hydroxyzine is an antihistamine medication that can cause drowsiness and is effective in treating insomnia, but it has a risk of causing dry mouth and dry eyes (American Academy of Sleep Medicine, 2017).
The goal of this decision was to improve the patient’s sleep quality and reduce the negative impact of insomnia on his job performance. By prescribing Trazodone, the patient’s insomnia symptoms should improve, and he should be able to perform his job better.
Ethical considerations that may impact the treatment plan and communication with patients include the patient’s history of opiate abuse and the use of alcohol to help him fall asleep. Before prescribing Trazodone, the patient’s history of substance abuse should be assessed, and a risk-benefit analysis should be performed. The patient should be counseled about the potential for addiction and the importance of avoiding alcohol while taking the medication.
Decision #2:
The decision selected was to decrease the dose of Trazodone from 50mg to 25mg daily at bedtime. This decision was selected because the patient reported an unpleasant side effect of an erection lasting approximately 15 minutes after waking. By decreasing the dose, the patient’s symptoms should improve and the unpleasant side effect should be reduced.
The other two options, switching therapy and continuing the current dose, were not selected because switching therapy would not be prudent at this point since the patient is already showing a partial response from Trazodone. Continuing the current dose without addressing the side effect could lead to non-compliance and poor treatment outcomes.
The goal of this decision was to improve the patient’s sleep quality and reduce the negative impact of insomnia on his job performance while minimizing the unpleasant side effect. By decreasing the dose of Trazodone, the patient should be able to sleep better and perform his job better without experiencing the unpleasant side effect.
Ethical considerations that may impact the treatment plan and communication with patients include the patient’s privacy and autonomy. The patient should be informed about the potential side effect and the option to decrease the dose of Trazodone. The patient should be able to make an informed decision about his treatment plan, and his privacy and autonomy should be respected.
