DB Sleep

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Wilkes University *

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Apr 3, 2024

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1 Sleep/Wake, Somatic, and Eating Disorders Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, or both, despite having the opportunity to sleep (Stahl, 2023). People with insomnia often experience poor sleep quality, which can lead to daytime fatigue, irritability, difficulty concentrating, and impaired functioning. Insomnia has distinct patterns of sleep disruption that occur at different stages of the night and can be classified as initial, middle, and terminal. Initial Insomnia Initial insomnia, is also known as “sleep onset insomnia.” This refers to difficulty falling asleep at the beginning of the night. Individuals with initial insomnia may have trouble transitioning from wakefulness to sleep when they first go to bed. Patients with this type of sleep disturbance will benefit from medications with rapid onset of action and short half-lives to facilitate sleep initiation without causing residual sedation upon awakening. The appropriate medications for this condition are (Ambien) and triazolam (Halcion), which have relatively short half-lives and are effective for initiating sleep. Triazolam (Halicon) is a fast-acting benzodiazepine with a short duration of action. Ambien has a rapid onset of action and short- half-life (Moses, 2024). Middle Insomnia Middle insomnia involves waking up in the middle of the night and having difficulty returning to sleep. Middle insomnia is characterized by nocturnal awakenings. This interruption can disrupt the overall quality and duration of sleep. Taking into consideration of the nocturnal awakenings, I think the most appropriate medication for middle insomnia are Eszopiclone (Lunesta): Longer duration of action (about 6-8 hours) and sustained-release formulations available.

2 Extended-release formulations of zolpidem (Ambien CR): Provide continuous drug delivery throughout the night, helping to reduce middle-of-the-night awakenings. Terminal Insomnia Terminal insomnia, also known as early morning awakening, occurs when individuals wake up too early in the morning and are unable to fall back asleep. They may awaken much earlier than desired and find it challenging to return to sleep, resulting in shortened total sleep duration (Stahl, 2023). Individuals with terminal insomnia may benefit from medications with intermediate to long half-lives to promote sleep maintenance during the early morning hours. Therefore, if the patient is awakened, they can easily fall back asleep. The medication that is appropriate for this type of sleep disturbance is temazepam (Restoril) and extended-release formulations of zolpidem (Ambien CR) (Gabbard, 2014). Secondary Causes Given the patient's medical history, current medications, and substance use, several secondary causes of insomnia have been identified. Fluoxetine (Prozac), an antidepressant, can sometimes cause insomnia as a side effect. It is typically taken in the morning due to its potential to cause insomnia. Metoprolol succinate (Toprol XL), a beta-blocker may also contribute to sleep disturbances, although it is less likely to cause insomnia compared to other beta-blockers (Moses, 2024). While the patient reports consuming only 2 alcoholic drinks per night, alcohol can disrupt sleep patterns and lead to difficulty falling asleep and maintaining sleep, especially when consumed close to bedtime (Perlis & Gehrman, 2013). Major depressive disorder is associated with sleep disturbances, including difficulty falling asleep, frequent awakenings during the night, and early morning awakening. The patient's depressive disorder may contribute to his insomnia symptoms, particularly if they are not adequately managed. BPH can cause

3 nocturia (frequent urination at night), which can disrupt sleep and lead to difficulty returning to sleep after waking up to urinate. Treatment Plan I begin each treatment plan by addressing any gaps in understanding and empowering individuals to grasp their condition and medications better. KL is presently prescribed multiple medications for diverse purposes, each with its unique set of potential side effects. I will provide KL with education on sleep hygiene and elucidate the effects of alcohol on both the body and mind. As mentioned above, KL’s fluoxetine can contribute to insomnia. Therefore, I will adjust the timing of fluoxetine administration. Given KL's depressive disorder and the possibility of antidepressant-induced insomnia, I will review the timing of fluoxetine administration. Taking into account KL's medical background and medication regimen, I may contemplate the use of a short-acting sedative-hypnotic medication like zolpidem (Ambien) for temporary relief of insomnia symptoms. References Buysse, D. J. (2013). Insomnia. JAMA , 309 (7), 706. Retrieved March 2, 2024, from https://doi.org/10.1001/jama.2013.193 Gabbard, G. O. (2014). Gabbard's treatments of psychiatric disorders . American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9781585625048 Moses, S., MD. (2024, February 1). Insomnia . Family Practice Notebook. Retrieved February 29, 2024, from https://fpnotebook.com/ Perlis, M., & Gehrman, P. (2013). Types of insomnia. In Encyclopedia of sleep (pp. 199–202). Elsevier. https://doi.org/10.1016/b978-0-12-378610-4.00175-3

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4 Qaseem, A., Kansagara, D., Forciea, M., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the american college of physicians. Annals of Internal Medicine , 165 (2), 125. Retrieved March 2, 2024, from https://doi.org/10.7326/m15-2175 Stahl, S. M. (2023). Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (5th ed.). Response: Great post that provides a comprehensive overview of the different types of insomnia and the importance of considering the half-life of pharmacologic treatments in managing specific sleep disturbances. Your consideration of short-acting agents like zolpidem and ramelteon for initial insomnia, intermediate-acting drugs for middle insomnia, and longer-acting medications for terminal insomnia aligns with current guidelines (Buysse, 2020). This tailored approach not only addresses the specific challenges associated with each phase of insomnia but also minimizes the risk of residual sedation or morning hangover effects. The case of KL, a 79-year-old with a complex medical history, emphasizes the need for a judicious selection of pharmacologic treatments. The suggestion of ramelteon, a melatonin receptor agonist with a short half-life, appears to be a prudent choice, considering its minimal side effects and low potential for interactions (Buysse, 2020). However, ramelteon is usually indicated for the treatment of insomnia characterized by difficulty with the onset of sleep (Gabbard, 2014). In this case, I think KL statement of “I need something to help me sleep,” warrants further investigation of his specific difficulties with either initial, middle or terminal

5 insomnia. This will help us further prescribe the most appropriate and beneficial medication to assist with his sleeping issues. Moreover, your emphasis on non-pharmacologic interventions such as cognitive- behavioral therapy for insomnia (CBT-I) and lifestyle modifications aligns with a holistic and patient-centered approach to insomnia management (Qaseem et al., 2019). These interventions not only complement pharmacotherapy but also contribute to long-term improvements in sleep quality. In addition to non-pharmacological treatments, I think it’s key to also take into consideration the patient's medical history, current medications, and substance use. Further consideration of these factors will also help identify secondary causes of his insomnia. To dive deeper into the case study, even though this post required us to prescribe medication and as providers that’s usually our first step to treat problems. However, sometimes medication isn’t warranted and the issue (i.e. insomnia) could have likely been managed with the non- pharmacological interventions you noted and assessment of secondary causes. In KL’s case, I suggested adjusting the timing of fluoxetine dose. Also, addressed his alcohol use and history of major depression disorder as all contributing factors. Your recommendation of ramelteon due to it's low potential for dependence was a great assessment. In conclusion, your well-referenced and evidence-based response provides valuable insights into the nuanced approach to treating insomnia based on its specific manifestations and individual patient characteristics. References

6 Buysse, D. J. (2013). Insomnia. JAMA , 309 (7), 706. Retrieved March 2, 2024, from https://doi.org/10.1001/jama.2013.193 Gabbard, G. O. (2014). Gabbard's treatments of psychiatric disorders . American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9781585625048 Qaseem, A., Kansagara, D., Forciea, M., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the american college of physicians. Annals of Internal Medicine , 165 (2), 125. Retrieved March 2, 2024, from https://doi.org/10.7326/m15-2175

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