Assessing and Treating Patients With Sleep/Wake Disorders
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. CORE SKILL: sleep complaints are usually a SYMPTOM, not a disease. The first analytic move is to ask what is driving the insomnia rather than reaching for a hypnotic.
CLASSIFY FIRST. Insomnia disorder (difficulty with sleep initiation or maintenance ≥3 nights/week for ≥3 months with daytime consequences) vs. hypersomnolence vs. NARCOLEPSY (Type 1 with cataplexy, associated with hypocretin/orexin deficiency; Type 2 without) vs. circadian rhythm disorders (delayed sleep phase, shift work) vs. OSA vs. parasomnias vs. restless legs syndrome. THE ONE YOU MUST NOT MISS IS OBSTRUCTIVE SLEEP APNEA — sedating a patient with untreated OSA can worsen hypoxemia. Screen (STOP-BANG) before prescribing anything sedating.
SLEEP ARCHITECTURE: NREM stages N1–N3 (N3 = slow-wave, restorative, front-loaded in the night) and REM (dreaming, muscle atonia, back-loaded). This matters pharmacologically: benzodiazepines SUPPRESS slow-wave sleep and REM, so the patient may sleep longer without sleeping better — that’s the mechanism behind “I slept 8 hours and feel unrefreshed.”
PHARMACOLOGY BY MECHANISM (know these classes, not just names):
— BZD receptor agonists / “Z-drugs”: zolpidem, eszopiclone, zaleplon. Positive allosteric modulation at GABA-A. Risks: complex sleep behaviors (FDA BOXED WARNING for sleep-driving/sleep-eating), next-day impairment, tolerance, falls in the elderly. Zolpidem dosing is LOWER IN WOMEN (slower clearance).
— Benzodiazepines (temazepam): generally avoid for chronic insomnia; dependence, tolerance, Beers Criteria caution in older adults.
— OREXIN RECEPTOR ANTAGONISTS: suvorexant, lemborexant, daridorexant — block wake-promoting orexin. Newer, less dependence liability.
— MELATONIN RECEPTOR AGONIST: ramelteon (MT1/MT2) — no dependence, useful in delayed sleep phase and in patients with substance-use history.
— SEDATING ANTIDEPRESSANTS: trazodone (widely used off-label; watch priapism, orthostasis), doxepin (low-dose, H1 antagonism, FDA-approved for sleep maintenance), mirtazapine.
— AVOID in older adults: diphenhydramine and other anticholinergics (confusion, falls, urinary retention; anticholinergic burden is linked to dementia risk).
THE EVIDENCE-BASED PUNCHLINE THE RUBRIC WANTS: CBT-I (cognitive behavioral therapy for insomnia) is FIRST-LINE for chronic insomnia per the American College of Physicians — not medication. Its components: stimulus control, sleep restriction, sleep hygiene, cognitive restructuring, relaxation. Any decision tree that jumps straight to a hypnotic without addressing CBT-I, comorbid depression/anxiety, substances (caffeine, alcohol — which fragments sleep in the second half of the night), and OSA will lose points.
LIFESPAN/ETHICS: dose adjustment for the elderly (start low, go slow), pregnancy considerations, and the deprescribing conversation.
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