KL is a 79 yo man requesting assistance for ‘something to help with sleep’. His past medical history is significant for coronary artery disease and s/p CABG, hyperlipidemia, hypertension, major depressive disorder, and benign prostatic hypertrophy. He is taking the following medications: Aspirin 81 mg daily, Lisinopril 20 mg daily, Metoprolol succinate 100 mg daily, Simvastatin 20 mg daily, fluoxetine 40 mg hs, and doxazosin 4 mg hs. He admits to drinking 2 alcoholic drinks/night and denies smoking. Include in your discussion:
The differences in initial, middle, and terminal insomnia and how would you best choose pharmacologic treatment for each one of these based on the half-lives of each hypnotic?
Identify any secondary causes for insomnia.
What treatment plan do you recommend for KL’s insomnia? (Be specific with your recommendations-which hypnotic and why)
Post your initial response by Wednesday – minimum of 150 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section
Insomnia comes in three stages; the first is initial or predorminational, whereby the onset of sleep is delayed, and the individual cannot get to sleep early enough. On the other hand, middle insomnia whereby an individual experiences broken, choppy and lacunary sleep. The last is terminal or postdormitional insomnia, where the individual wakes up very early and is unable to fall asleep again.
Initial insomnia – This type of insomnia is treated using hypnotic agents such as Zolpidem ER, Zaleplon, and Zolpidem sublingual (5, 10mg). On the other hand, Ramalteon is also considered useful in treating this type of insomnia. However, the use of Zolpidem can be incorporated, but it has a short half-life of 1.5 to 2.4 hours (Sabbag, 2015).
Middle insomnia – treatment includes the use of Flurazepam, Estazolam, and Zolpidem sublingual (Men 3.5mg and Women 1.75mg). However, in middle insomnia, Estazolam has the shortest half-life among the above medication.
Terminal insomnia – this condition comes with depression, and the recommended treatment includes Flurazepam, Quazepam, and Estazolam. However, the administration of these drugs is classified into a half-life, sex, and patient age (Sabbag, 2015). On the other hand, psychiatric disorders are associated with insomnia, and this special attention should be taken before the administration of these drugs.
Secondary Causes of Insomnia
However, it is essential to note that there are secondary cause of insomnia. These range from mental health issues, cold medication, depression, or hyperthyroidism, which affects an individual’s sleep. However, a patient can be advised to check on their sleeping schedule and at the same time stay active during the day to keep the body fit (Stahl, 2021). On the other hand, checking on their medication can positively impact the treatment of insomnia. In cases of persistence, medication can be used in line with the stage of insomnia.
Recommendation for KL’s Insomnia
In the case of Mr. KL, the best recommendation is cognitive behavioral therapy for insomnia. The approach will help Mr. KL to control negative thoughts and actions that keep him awake. On the other hand, it is evident that he is currently taking Fluoxetine at night, and the medication includes SSRI, which has the potential to cause insomnia (Qaseem et al., 2016). Therefore, the best appropriate is to implement a change in the antidepressants prescribed and eliminate the use of alcohol before bedtime. In summary, I would recommend CBT-I first-line treatment for insomnia which combines holistic approaches such as healthy sleep habits and treatment of other relevant comorbidities, and finally, change of Fluoxetine medication. I would recommend Eszopiclone to manage his condition instead of Fluoxetine which he was using earlier.
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., Denberg, T. D., & Clinical Guidelines Committee of the American College of Physicians*. (2016). Management of chronic insomnia disorder in adults: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 165(2), 125-133.
Sabbag, S. (2015). Gabbard’s Treatments of Psychiatric Disorders, Glen O. Gabbard, MD (Ed)(2014) Arlington VA: American Psychiatric Publishing, Incorporated.
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. Cambridge university press.