Unit 13 Assignment – Insomnia Case Study
Unit 13 Assignment – Insomnia Case Study: Emmanuel, a Hispanic-black male, age 21-year-old and a pharmacy student, came to the local pharmacy last week with a seven-day prescription for…
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Unit 13 Assignment – Insomnia Case Study
Paper details
Emmanuel, a Hispanic-black male, age 21-year-old and a pharmacy student, came to the local pharmacy last week with a seven-day prescription for diazepam 10mg tablets, one to be taken at night. The drug was prescribed to him by his primary care provider because around five weeks ago Emmanuel started suffering from insomnia.
In fact, although he is typically supposed to wake up at 7:00 am to attend his lectures, at 4:00 am he is already fully awake. He does not find it difficult to fall asleep, nor does he wake up too frequently during the night. During the day, he feels very tired, anxious, and tearful. It is now three days since the pharmacist dispensed his prescription and Emmanuel has returned to the pharmacist because he claims he is still not able to sleep properly.
Write a short case formulation paper 3-5 pages, based on the case above, and answer the following:
- Definition and diagnostic criteria of insomnia.
- What are the risk factors for the development of insomnia? Does Emmanuel have any of the risk factors for developing insomnia?
- What group of drugs does diazepam belong to? What are the main pharmacokinetic differences between the components of this class of drugs?
- What is the mechanism of action of diazepam in the treatment of insomnia?
- What are the side effects of diazepam?
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- What alternative medications could you as a PMHNP provider seeing Emmanuel for follow-up provider versus diazepam?
- What specific environmental changes can be made so the patient can improve sleep?
- Describe your treatment plan, include the following:
- Pharmacological tx
- Non-pharmacological to
- Patient Education
- Referral to other providers
- Follow-up
- Conclusion
- References (minimum of 3 in APA format)
Solution
Insomnia Case Study
Insomnia refers to the condition where an individual reports having difficulties with sleep. 10% to 30% of the population are affected by insomnia which translates to $92.5 to $107.5 billion annually for healthcare costs (Hertenstein et al., 2019). There are three main categories of insomnia: short-term, chronic, and other types. Van Someren (2021) adds that insomnia describes the presence of polysomnographic evidence of disturbed sleep, including long sleep latency, prolonged wakefulness during the sleep period, frequent nocturnal awakenings, or frequent transient arousals. To receive an insomnia diagnosis, patients have to experience at least one of these problems.
Additionally, patients must experience at least one of the following daytime impairments after a night of disturbed sleep. These symptoms include fatigue or malaise, excessive daytime sleepiness, high risk of accidents or errors, hyperactivity, aggression, impaired performance, difficulty concentrating and remembering, decreased motivation and energy, and concerns about disturbed sleep (Van Someren, 2021). Nonetheless, these symptoms should be present at least three times a week.
While insomnia may be a primary condition, several risk factors are associated with the condition. First, insomnia may develop at any age, but the problem tends to increase as an individual becomes older. Second, insomnia tends to be more common in women than men. Specifically, hormonal changes during pregnancy contribute significantly to sleeping problems.
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Third, a family history of insomnia risks the development of sleeping problems to the subsequent generations, where a person can be a light or heavy sleeper. Forth, the bedroom environment affects one is sleeping patterns. In this regard, an environment with extremely high or cold temperatures, noisy or much light, may cause insomnia (Van Someren, 2021). Fifth, people who work during early morning or late night shifts are prone to having sleeping problems. Nonetheless, stress, breathing difficulties, poor sleeping routines, and lifestyle can contribute to sleep loss. In this regard, Emmanuel does not have any risk factors for insomnia.
Diazepam is classified under benzodiazepines and works by calming abnormal brain overactivity. Diazepam and midazolam are the most common benzodiazepines. While benzodiazepines work by enhancing the inhibitor effects by binding to a specific receptor, they have differences in their pharmacokinetic properties and metabolism.
For example, diazepam is eliminated from the body at a relatively slow rate, oxazepam, triazolam, and temazepam are metabolized more rapidly. Nonetheless, diazepam, prazepam, fosazepam, and clorazepate have a long-acting metabolite N-desmethyldiazepam compared to other benzodiazepines (Neubauer et al., 2018). These pharmacokinetic differences are clinically essential as they determine the duration of the drug effect.
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Diazepam exerts sedatives, anxiolytic, muscle-relaxant anticonvulsant, and amnestic effects (Van Someren, 2021). In addition, it enhances the actions of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA) at its receptor. GABA is a neurotransmitter that acts as a natural nerve-calming agent as it balances the nerve activity in the brain, relaxing muscles, reducing anxiety, and inducing sleep. In this regard, increasing the GABA activity in the brain, diazepam increases these calming effects, addressing insomnia. The side effects of this medication include drowsiness, blurred vision, confusion, apathy, dizziness, muscle weakness, ataxia, lightheadedness, and dysarthria (Hertenstein et al., 2019).
As a PMHNP, I would recommend estazolam as an alternative to diazepam. The medication is also a benzodiazepine that helps one fall and stays asleep. However, it can lead to dependence. Neubauer et al. (2018) highlight that 15% to 40% of patients who took estazolam long-term report severe withdrawal symptoms upon cessation. Additionally, some patients reported having rebound insomnia and increased anxiety.
Therefore, it should be used for a short term, between seven and ten days. I would recommend 1mg to be taken orally at bedtime for one week. Additionally, the patient needs to create a more suitable environment to help him sleep appropriately. In this regard, Emmanuel should use comfortable bedding, keep electronics away from the bedroom, eliminate lighting, block distracting noise and adjust the temperature to the most suitable one for sleep.
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Treatment Plan
The treatment goal is to reduce sleeping problems, distress and improve daytime function. Therefore, my treatment plan aims to achieve these goals.
Pharmacological intervention
Provide estazolam, 1 mg, to be taken orally at bedtime for seven days.
Non-pharmacological interventions
Stimulus control therapy- The patient can avoid behaviors that affect sleep, such as watching, eating, and doing school-related work from the bedroom. Additionally, this intervention includes regulating the sleep-wake schedules to ensure the patient sleeps enough to enhance productivity. Research shows that stimulus control therapy is efficient in improving sleep problems, with 55% improvement at post-treatment (Hertenstein et al., 2019)
Sleep restriction therapy- This intervention involves decreasing the amount of time the patient spends in bed trying to find an opportunity for sleep. In addition, the patient should avoid daytime napping to allow the patient to sleep well at night. World Sleep Society (2021) highlights that waking up during sleeping decreased by 54% following treatment.
Relaxation therapy- This intervention includes progressive muscle relaxation to reduce somatic arousal and attention focusing techniques such as meditation and imagery training to reduce cognitive arousal.
Sleep hygiene- The patient should set appropriate sleep goals to enhance its quality and duration.
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Education
- Educate the patient on appropriate sleep habits and attitudes that promote sleep.
- Educate the patient on sleep hygiene.
- Educate the patient on the medication’s side effects, including dry mouth, weakness, dizziness, grogginess, aggression, and constipation.
- Educate the patient on the need to adhere to treatment in improving symptoms.
- Educate the patient on the need to create a suitable environment for sleeping.
- Referral to other Providers
- Refer the patient to a psychologist to help in therapy.
Follow Up
The patient should return to the clinic if the medication does not work or when side effects become unbearable.
Conclusion
Insomnia has adverse effects on sleep quality and overall productivity. Therefore, Emmanuel needs a change in medication to help him sleep appropriately and reduce his daytime symptoms. Estazolam will help him fall and stay asleep, making him more productive during the day. However, the medication should not be used for the long term as it leads to increased anxiety and relapse of insomnia. Nonetheless, other interventions, including therapy, may help to improve the symptoms.
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References
- Hertenstein, E., Feige, B., Gmeiner, T., Kienzler, C., Spiegelhalder, K., Johann, A., Jansson-Fröjmark, M., Palagini, L., Rücker, G., Riemann, D., & Baglioni, C. (2019). Insomnia as a predictor of mental disorders: A systematic review and meta-analysis. Sleep Medicine Reviews, 43, 96-105. https://doi.org/10.1016/j.smrv.2018.10.006
- Neubauer, D. N., Pandi-Perumal, S. R., Spence, D. W., Buttoo, K., & Monti, J. M. (2018). Pharmacotherapy of insomnia. Journal of Central Nervous System Disease, 10, 117957351877067. https://doi.org/10.1177/1179573518770672
- Van Someren, E. J. (2021). Brain mechanisms of insomnia: New perspectives on causes and consequences. Physiological Reviews, 101(3), 995-1046. https://doi.org/10.1152/physrev.00046.2019
- World Sleep Society. (March 19, 2021). Environmental sleep factors. World Sleep Day March 19, 2021. https://worldsleepday.org/environmental-sleep-factors
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