Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample

Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample

Insomnia is a common psychiatric illness occurring in the general population. According to Rios et al. (2019), about 33% of the adult population reported dissatisfaction with their sleep; one symptom was insomnia. Furthermore, between 6 and 10 percent of persons aged 18 years and above met the stricter and standardized criteria of diagnosis for insomnia based on the International Classification of Sleep Disorders (ICSD) or the Diagnostic and Statistical Manual of Mental Disorders –the fifth edition (DSM—5)(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample). Over time insomnia can lead to severe functional impairments at the individual’s workplace, home, or community and is closely associated with decreased quality of life, issues of memory and attention, mood disturbance, and lowered ability to execute one’s daily routine activities. Mental healthcare experts also posit that insomnia is a significant risk factor for the onset of other mental disorders like substance abuse, depression, and anxiety. The selected case study is a 31-year-old male who works as a forklift operator whose insomnia has gotten progressively worse following the sudden loss of his fiancé six months ago. The initial approach to treatment generally includes a behavioral intervention and a necessary medication intervention where the choice of the most appropriate drug is premised on symptom pattern, the treatment goal, cost, existing comorbidities, if any, and past responses to treatment (Lie et al., 2015). Other guiding factors in the decision-making process for the suitable treatment option are concurrent medication interaction, availability of other treatments, potential adverse effects, and patient preferences. Subsequently, this paper outlines a 3-point decision-making tree on an appropriate treatment course for a patient diagnosed with insomnia.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Decision Point #1(DP# 1)-Available Treatment Options, Treatment Selected, and Rationale of This Choice

At the first decision point(DP#1), the treatment options available are to start Zolpidem 10mg PO at bedtime daily, start Trazodone 50mg PO at bedtime daily, or start hydroxyzine 50mg PO at bedtime daily. The selected medication was to initiate Zolpidem 10mg PO at bedtime. According to Randall et al. (2012), placebo-controlled trials indicate no signs of withdrawal, tolerance rebound insomnia, or next morning residual effects if administered at recommended therapeutic doses. In clinical practice, six months of zolpidem treatment have been determined to be efficacious and safe. Lie et al. (2015) aver that in prescribing medications for insomnia, the recommended sequence of medication trials is to administer short- or intermediate-acting benzodiazepine receptor agonists (BzRAs) or melatonin agonists ramelteon. If the initial agent is found ineffective, the prescriber should go for the alternative short- or intermediate-acting BzRAs before sedating antidepressant-like trazodone or doxepin, then try a combination therapy of a BzRA with a sedating antidepressant. Other sedating agents like atypical antipsychotics or anti-epilepsy medications should be administered as a last resort.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Why the other Two Options Were Not Selected

The option of starting Trazodone 50 mg PO daily at bedtime was not selected because, in clinical trials based on 50mg doses of trazodone, the findings have led to clinicians being recommended not to use trazodone as a treatment for sleep onset or sleep maintenance insomnia in adults because the harms outweigh benefits (Smith et al., 2016). This is based on the summary of clinical practice recommendations and GRADE components of decision-making, with the quality of evidence regarded as moderate. Smith et al. (2016) note that hydroxyzine should start at 25 mg at bedtime. Despite being a common prescription for insomnia, the researchers acknowledge that little data supports its efficacy or safety for this indication. While it is true that both Zolpidem and hydroxyzine pamoate (Vistaril) are sedatives, the latter is an antihistamine with anticholinergic and sedative properties used to treat anxiety and tension and therefore alleviate insomnia. However, anxiety does not appear to be an underlying cause; hence, it is not considered the best option.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Treatment Goals and Ethical Considerations at DP#1

The short-term treatment goals for insomnia at DP#1 are to alleviate the sleep and waking symptoms, improve daytime function, and reduce the patient’s distress. Since sleep medicine is still an emerging field, psychiatric services providers need to revisit core ethical principles and use them to guide the treatment and management of insomnia. As Peters (2014) notes, the fundamental principles of no maleficence, autonomy, truthfulness, justice, and beneficence must be the basis of all healthcare providers to guide their actions. On the ethical principle of the potential for beneficence, I would communicate with the patient about the possibility of effective life-saving treatment and lower the long-term risk of significant health effects that could be detrimental to the patient. For example, a vital role of the prescribing physician in sleep medicine is to administer treatments that mitigate the risk of adverse consequences. The interaction between insomnia and other medical or psychiatric comorbidities is established. These include anxiety, depression, and suicidality, where careful inquiry leads to their recognition, and treatment would take place concomitantly.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Results of DP#1

The results of DP#1 are that the patient returns to the clinic after 14 days and reports the zolpidem 10mg at bedtime knocked him out, although he felt he slept well. His new girlfriend was concerned the medication could be responsible for his amnesia as he woke up in the middle of the night prepared breakfast yet had no recollection of the occurrence in the morning. The patient further denies audio/visual hallucinations and stakes taking the medication with a beer at bedtime helps him sleep soundly. He also is future-oriented.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Decision Point 2(DP#2) Available Treatment Options, Choice Selected, and Rationale for Its Selection

At the second decision point (DP#2), the treatment options available are to decrease the Zolpidem from 10mg to 5 mg daily at bedtime, discontinue Zolpidem, and initiate eszopiclone 1mg daily, discontinue Zolpidem and initiate therapy with trazodone 50-100mg at bedtime. I chose to discontinue Zolpidem and initiate eszopiclone 1mg at bedtime. According to Rosner et al. (2018), benzodiazepine hypnotics are effective for short-term treatment of insomnia but have several downsides, among them the risk of rebound insomnia, withdrawal symptoms, dependence, and are responsible for traffic and machine operation accidents. Eszopiclone has a longer half- lifetime than Zolpidem and is bound to be more helpful in treating sleep maintenance insomnia. Eszopiclone has FDA approval for both short- and long-term treatment of sleep onset and sleeps insomnia in adults (Rosner et al., 2018).(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Additionally, a six-month double-blind placebo-controlled parallel-group study with about 800 patients indicated that eszopiclone effectively treated insomnia within sleep latency, total sleep time, and wake time after sleep onset (Rosner et al., 2018). The drug also benefits from not being as habit-forming as some sleep medicines, but caution should be taken to discontinue it by lowering the dosage in phase as sudden discontinuation can cause withdrawal syndrome (Rosner et al., 2018). The patient should also be advised to stop taking the medication with beer at bedtime.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Why the Other Two Options Were Not Selected

A study of subjects aged between 24 and 64 years who reported nocturnal awakenings before 3: 00 am determined that a dose of Zolpidem 5mg at bedtime was ineffective in men (Catro et al. 2019). The protocol comprised five onsite visits. The first visit entailed screening; the second was for randomization and was scheduled the morning following after polysomnography (PSG), while the third, fourth, and fifth were follow-up visits. Performance was measured using the psychomotor vigilance test (PVT), and the legible participants received active doses of Zolpidem as sublingual 5mg or 10 mg tablets. The findings determined a 5mg dose not to be effective in men. Neubauer et al. (2021) report that in one study with more than 350,000 patients treated with insomnia medication, the risk of suicide attempt was 61% greater with trazodone at high doses than with Zolpidem. Hence, discontinuation of Zolpidem and starting trazodone 50-100mg is ruled out. Additionally, higher doses of trazodone would be required for this patient since depression could be an underlying cause after losing his fiancé six months ago. Higher doses would translate to more side effects.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Treatment Goals at DP#2 and Ethical Considerations

Since the treatment goals at DP#1 were to improve sleep quality and quantity, and improvement of insomnia related daytime impairments, the treatment goals at DP#2 focused on specific outcome measures like a reduction of wake time after sleep onset (WASO), decreased number of awakenings, and increased sleep time, improved sleep-related to psychological distress and a decrease in amnesia (Schutte-Robin et al., 2008). Advising the patient to stop taking beer close to bedtime was meant to increase sleep time and alleviate amnesia symptoms. Gabe et al. (2016) opine that sleep medicines have the potential for dependence and other adverse effects like increased mortality risks. At DP#2, the ethical issue to consider is to use the medication that would act in a manner that has the least harm beyond the expected and inevitable consequences of the disease process. The researchers mentioned above report that in their study, the subjects depicted themselves and their connection to hypnotics from the six repertoires of a deserving patient, the responsible user, the compliant patient, the addict, the sinful user, and the noble or virtuous non–user (Gabe et al., 2016). I would engage the patient on these and how to understand their need to use sleep medication and the non-pharmacological options available to him.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Results of DP#2

After two weeks, the patient returns to the clinic and reports that the eszopiclone helps with sleep. He further reports that it takes him about two hours before he sleeps, which makes him feel good, and he also continues to report negative audio-visual hallucinations and remains future-oriented. Subsequently, the majority of the sleep parameters from sleep latency (SL), wake time after sleep onset (WASO), number of awakenings (NWAK), total sleep time), and depth and quality of sleep have improved. The quality of life assessed using the Insomnia Severity Index had improved from 20 (indicative of moderate insomnia to 13 (meaning subthreshold insomnia but still below the target score of 0-7), indicating the absence of insomnia (Dieperink et al., 2020).(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Decision Point 3 (DP#3) Available Options, Choice Selected, and the Rationale for Taking This Option

The three treatment options available were maintaining the current medication and dose and retaining the current medication, eszopiclone. Option 2 is to discontinue the dose and start hydroxyzine with a follow-up in four weeks, while Option 3 is to discontinue the dose and start therapy with trazodone 50 mg nightly at bedtime. The patient is advised to take up to 100 mg if 50 mg is ineffective. Option 1 is selected, and the dosage may increase from 1mg to a maximum of 3mg at bedtime combined with behavioral intervention. Clinical studies in younger adults aged 44 years determined that eszopiclone can be administered for 6 to 12 months with no problems (McCrae et al., 2007). This option is selected because it has demonstrated its efficacy and safety in the short-term treatment of primary insomnia, although it was in older adults aged 64 and 91 years (McCrae et al., 2007). As a schedule IV drug under the controlled substances Act, eszopiclone is accepted for medical treatment within the US and has a low potential for abuse than other drugs in Schedule III (McCrae et al., 2007).(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Additionally, in trials on non-elderly adults, a sample diagnosed with chronic primary insomnia established that a dose of 3mg of eszopiclone led to significant improvement in SL, TST, NWAK, WASO, and quality of sleep compared to a placebo (McCrae et al., 2007). The researchers also noted that non-pharmacological interventions like cognitive behavioral therapy offer an attractive treatment either as an alternative or adjuvant to eszopiclone (McCrae et al., 2007). These and several other factors dictated my choice for option two.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Why the Other Two Options Were Not Selected

A study comparing the efficacy of hydroxyzine, a placebo, and prazosin, sleep quality, and the degree of other psychiatric symptoms were assessed at baseline and at the end of eight weeks (Ahmadpanah et al., 2014). Most importantly, the key findings of this study were that hydroxyzine was found to be less effective than prazosin. As such, it was not considered the best option to initiate. In another study making indirect comparisons of the effectiveness of treatments for insomnia, two of which were eszopiclone and trazodone, it was determined that SOL and WASO in minutes, eszopiclone had -16.7 and -25.8 respectively compared to those of trazodone at -12.2 for SOL and no effect on WASO (Ramakrishnan 2007). These findings demonstrate that in comparative terms, trazodone is less effacious in treating insomnia when compared to eszopiclone, hence why it was not considered the best option.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Treatment Goals and Ethical Consideration sat DP#3

At DP#3, the treatment goals are to achieve no insomnia, as indicated by a score of 0 to 7 on the ISI, and to prevent relapse on a long-term basis. Suffice it to say, owing to the high relapse rate of insomnia, and there is a need for clinical reassessment to occur every few weeks monthly until insomnia appears stable or resolved, then every six months. Due to the high risk of side effects, eszopiclone was not chosen as a first-choice treatment. The patient is also advised not to mix the medication with alcohol. Schutte-Robin (2008) further opines that the provider has an ethical and moral responsibility to consider combined therapies, behavioral therapies, and revaluation for occult comorbid disorders if monotherapy or a combination of treatments has proven ineffective.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

Conclusion

The goal for the medication using Zolpidem 10 mg at bedtime was primarily to alleviate sleep and waking symptoms, improve daytime function, and reduce the distress caused by insomnia in general. At the end of the treatment course, the expected outcome was to stabilize insomnia by determining the minimum effective and maintenance dose required to contain the patient’s symptoms and resolve them. Most importantly, it was necessary to improve the patient’s quality of life and prevent a relapse of insomnia after its resolution on a long-term basis.  (Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)   

Zolpidem 10 mg is considered the first-line medication for insomnia. However, it was discontinued because it was recommended as a short-term treatment drug for a treatment course of fewer than four weeks. Chung et al. (2013) determined that patients receiving Zolpidem treatment had a higher risk (1.96 times) for injury occurrence than a matched population of comparison patients. Briefly speaking, Zolpidem has several side effects: drowsiness, reduced mental alertness, extended reaction time, and coordination problems (Chung et al., 2013). As a provider, I had to take extra care and discontinue this prescription because it was reported that the patient would get out of bed in the middle of the night and even prepare breakfast, yet have no recollection of these events in the morning.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

At the same time, eszopiclone medication was settled for because, regardless of age, it appeared safe and improved sleep variables in insomnia patients whether they had other psychiatric disorders (Uchimura et al., 2012). Summary statistics capturing sleep parameters like SL, TST, and WASO demonstrated improved results. As captured in the self-report sleep diary, its efficacy found that 88% of the elderly patients and 83% of the non-elderly reported improvement in both SL and TST at Week 4 compared to the baseline.(Insomnia Decision Making Case Study-A Comprehensive Nursing Paper Sample)

References

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