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Unit 8 Medications for Sleep Disorders —2 Peer Response 600w. due 10-25-23

Please read and respond to at least two of your peers' initial postings. You may want to consider the following questions in your responses to your peers:

• Compare and contrast your initial posting with those of your peers.

• How are they similar or how are they different?

• What information can you add that would help support the responses of your peers?

• Ask your peers a question for clarification about their post.

• What most interests you about their responses?

Please be sure to validate your opinions and ideas with citations and references in APA format.

Ingrid A.

· There are multiple sleep disorders such as insomnia, sleep apnea, restless leg syndrome, hypersomnia, circadian rhythm disorders, and parasomnia which I think is “sleepwalking” or at least very similar to sleepwalking (Sleep Disorders, 2020).

Screening tools to diagnose sleep disorders can be just as gathering information from the patient, like history and physical. There are other screening tools such as actigraphy which is something like a watch the patient must wear and this tracks the movements the patient makes when sleeping and being awake (How is actigraphy used to evaluate sleep?, 2022)

Adding more we also have polysomnography also known as the “sleep study”, and this particular test records brain waves, oxygen level as well as heart rate (Polysomnography (Sleep Study) 2023). Epic (electronic health record) has something called the stop-bang questionnaire and it basically asks questions about snoring, blood pressure, and the size of the neck. There is also something called the Athens Insomnia Scale and Epworth Sleepiness Scale (Sleep disorders: Clinical tools, 2023).

Z-drugs such as zolpidem, zopiclone, and zaleplon are innovative hypnotics that aid with sleep, reduce sleep latency, and improve quality. These drugs are prescription dispensed only and they work by slowing the activity in the brain (Commissioner, 2023).

Benzodiazepines are medications such as lorazepam, diazepam, temazepam, alprazolam, and clonazepam among others that can have potential side effects such as respiratory depression, drowsiness, impaired judgment, nausea and vomiting, confusion, addiction, and even respiratory distress (Brandt & Leong, 2017).

References:

Brandt, J., & Leong, C. (2017). Benzodiazepines – statpearls – NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470159/

Commissioner, O. of the. (2023). Taking z-drugs for insomnia? know the risks. U.S. Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/taking-z-drugs-insomnia-know-risks

How is actigraphy used to evaluate sleep?. Sleep Foundation. (2022, May 10). https://www.sleepfoundation.org/sleep-studies/actigraphy

Mayo Foundation for Medical Education and Research. (2023, February 17). Polysomnography (Sleep Study). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/polysomnography/about/pac-20394877#:~:text=Polysomnography%2C%20known%20as%20a%20sleep,measures%20eye%20and%20leg%20movements.

Sleep disorders: Clinical tools. CAMH. (2023). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/sleep-disorders/sleep-disorders—clinical-tools

U.S. National Library of Medicine. (2020, January 3). Sleep disorders. MedlinePlus. https://medlineplus.gov/sleepdisorders.html

Mojgan A

Week 8, Medications for Sleep Disorders

What screening tools can be used to affirm your initial diagnosis that a patient may meet the diagnostic criteria for a sleep disorder?

        There are different tools for assessing sleep disorders. Among various rating scales, the Pittsburgh Sleep Quality Index (PSQI) was specifically designed to evaluate overall sleep quality and is among the recommended questionnaires for examining global sleep patterns and symptoms related to insomnia (Zitser et al., 2022). It is a self-report questioner and will assess the sleep quality over one month. Another useful scale is the Epworth Sleepiness Scale (ESS), which is a questionnaire designed to assess daytime sleepiness. A higher score on the ESS suggests the need for further evaluation for possible sleep disorders (Clinical application of headache impact test (HIT)-6 and Epworth Sleepiness Scale, 2023).

        According to the literature, the gold standard for monitoring sleep and breathing is polysomnography (PSG). PSG observes various physiological factors during sleep, including brain activity, eye movement, heart rate, and muscle activity. It involves the use of special bands around the chest and abdomen, as well as sensors for temperature and airflow in the nose. PSG also utilizes a device to measure airflow and sensors for air pressure in the airway. However, it's important to note that these methods can be invasive and time-consuming to set up and understand (Naik et al., 2023). Home sleep apnea testing (HSAT) is a simplified version of PSG that can be conducted at home and offers several potential benefits compared to traditional PSG, such as increased accessibility, quicker treatment initiation, and cost savings (Johns et al., 2022).

Describe the pharmacological actions of non-z sleep medications?

       Non-benzodiazepine (non-Z) sleep medications, such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata), function by enhancing the activity of the neurotransmitter known as gamma-aminobutyric acid (GABA) in the central nervous system. GABA is an inhibitory neurotransmitter that promotes relaxation and facilitates sleep. One key distinction between benzodiazepine medications and non-Z medications is their selectivity in targeting GABA receptors (Stahl, 2021).

       Benzodiazepines act on various GABA receptor subunits (including alpha 1, alpha 2, alpha 3 and alpha 5 receptors) nonselectively. Benzodiazepines acting on alpha2 and alpha3 receptor subtypes have effects that reduce anxiety, promote muscle relaxation, and enhance the effects of alcohol. On the other hand, the alpha5 subtype, found in the hippocampus, may be implicated in cognitive processes. As a result, benzodiazepines are employed for the treatment of sleep disorders, seizure disorders, and anxiety disorders due to their broader spectrum of activity (Stahl, 2021).

        In contrast, non-Z medications selectively target alpha 1 receptors, which are primarily associated with the sleep process. Therefore, non-Z medications are specifically designed to induce and improve sleep without affecting the full spectrum of GABA receptors. Another distinction to note is that benzodiazepines typically have longer half-lives, which means they remain in the body for a more extended period compared to non-Z medications. This difference in half-life can have implications for factors such as prolong sedation and potential for dependence or withdrawal when using these medications. Non- Z medications are usually used for short amount of time and do not cause dependence or withdrawal symptoms (Stahl, 2021).

What problems can occur when benzodiazepines are used to help with sleep?

        Benzodiazepines are potent medications known for their effectiveness, but they come with a range of significant concerns and potential problems. They have sedative properties, leading to drowsiness and increased sleepiness in patients. Additionally, benzodiazepines exhibit a prolonged half-life, resulting in an extended duration of action within the body, which can impact a patient's overall quality of life. These medications have been associated with several adverse effects (Stahl, 2021).

        Benzodiazepines can impair cognitive function, memory, and coordination, potentially leading to accidents and reduced overall performance. A major concern with benzodiazepines is the development of tolerance. Over time, patients may require higher doses to achieve the same therapeutic effect. This can lead to physical and psychological dependence, as patients become addicted to the sedative properties of the medication (Stahl, 2021).

        Abruptly discontinuing benzodiazepines can result in unpleasant withdrawal symptoms, which can be challenging for patients. One study by Ritvo et al. (2023) revealed that over 40% of the respondents reported experiencing 17 or more symptoms persisting for at least one year after discontinuing their use of benzodiazepines. Common side effects associated with benzodiazepines include dizziness, drowsiness, and coordination problems, which can be especially problematic for individuals who need to remain alert and functional. It's essential to be mindful of potential drug interactions, as benzodiazepines can interact with other medications, potentially affecting their effectiveness or causing unexpected side effects (Stahl, 2021)

        Given these concerns, it is advisable to use benzodiazepines cautiously and only for short durations. When discontinuing their use, a slow tapering approach is often recommended to minimize the risk of withdrawal symptoms. This ensures that the benefits of these medications are balanced against the potential risks and adverse effects they may cause.

References

Clinical application of headache impact test (HIT)-6 and Epworth Sleepiness Scale (ESS) for sleep apnea headache. (2023). 
Sleep Science and Practice, 7, 1-9. 
https://doi.org/10.1186/s41606-023-00084-2Links to an external site.

Johns, J. D., Armin, M., Alexandra, W., Jeffrey, K. H., Mikula, S. K., & Hoa, M. (2022). Reliability of home sleep apnea testing for diagnosing obstructive sleep apnea in patients with spontaneous cerebrospinal fluid leaks. 
Cureus, 14(10)

https://doi.org/10.7759/cureus.29854

Naik, G. R., Breen, P. P., Jayarathna, T., Tong, B. K., Eckert, D. J., & Gargiulo, G. D. (2023). Morphic sensors for respiratory parameters estimation: Validation against overnight polysomnography.
 Biosensors, 13(7), 703. 
https://doi.org/10.3390/bios13070703Links to an external site.

Ritvo, A. D., Foster, D. E., Huff, C., Reid Finlayson, ,A.J., Silvernail, B., & Martin, P. R. (2023). Long-term consequences of benzodiazepine-induced neurological dysfunction: A survey.
 PLoS One, 18(6) https://doi.org/10.1371/journal.pone.0285584

Stahl, S. M. (2021). 
Stahl’s essential psychopharmacology: Neuroscientific basis and practical application (5th ed.).

Zitser, J., Allen, I. E., Falgàs, N., Le, M. M., Neylan, T. C., Kramer, J. H., & Walsh, C. M. (2022). Pittsburgh Sleep Quality Index (PSQI) responses are modulated by total sleep time and wake after sleep onset in healthy older adults.
 PLoS one, 17 (6) https://doi.org/10.1371/journal.pone.0270095

 Reply

Initial Post

Foundational Neuroscience

The term foundational neuroscience refers to a three-course series that explores the structure and function of the nervous system – from the inner workings of a single nerve cell to the staggering complexity of the brain and the social interactions it enables (Harvard Edu. 2020)

According to studies, cases of mental and psychiatric conditions have been on the increase. As a result of this crisis, there is a need for quality psychiatric health care that encompasses appropriate knowledge by health practitioners of dealing with these issues (Harvard Edu. 2020). This involves a deep understanding of the pathophysiology of psychiatric disorders and understanding the impact of certain drugs on a specific disorder. It has been advocated those psychiatric patients be referred to as clients as it is more favorable for mental health. This discussion will address the agonist and antagonistic agents, g- g-couple proteins and ion-gated channels, and the role of epigenetics in psychopharmacology.

The agonist-to-antagonist spectrum of action of psychopharmacologic agents.

 Also known as the agonist spectrum, describes the range of effects that can be exerted by psychopharmacological agents. For example, it describes how some medications/drugs can stimulate receptors in the brain just like natural neurotransmitters and how other drugs can block/prevent this action (Stahl, 2013). For example, benzodiazepines (Valium) increase/mimic the GABA neurotransmitter (agonist) and Flumazenil decreases/blocks this neurotransmitter (antagonist).  The agonist-to-antagonist spectrum psychopharmacologic agents work at the sites of neurotransmission and conduct their effects based on a spectrum of agonist-to-antagonist (Stahl, 2013). The spectrum ranges from true agonist to inverse agonist. Some examples of effects between the two ends are partial agonist, silent antagonist, and partial inverse agonist.

Agonist

Agonist is a chemical substance that binds to and activates certain receptors on cells. Agonistic drugs are drugs that modify or change the state of receptors to trigger a biological response. Oxycodone, morphine, heroin, fentanyl, methadone, and endorphins are all examples of opioid receptors (Stahl, 2013). According to Stahl (2013), a full agonist allows the receptor to fully open the ion channel which allows the downstream signal transduction to occur maximally. An agonist is any drug that activates specific brain receptors, thereby causing the full effects of the drug to take place

Partial Agonist

A partial agonist is any drug that acts as an agonist, but the degree of receptor activation is reduced. The receptor has a resting state. When a partial agonist is in contact with the receptor in a resting state, the ion channel will partially open, allowing some downstream signal transduction (Stahl, 2013).

Antagonist

Antagonistic drugs refrain or stop minimizing any biological response by blocking any presenting receptors (Camprodon et al., 2016). The antagonist will return the receptor to a resting state (Stahl, 2013). Constitutive activity still occurs in the presence of an antagonist, which is the minor ion flow despite being in a resting state (Stahl, 2013). When a drug is classified as an antagonist, it means that it blocks the receptors, so they are not able to bind to the agonist. In the realm of opioids, an example of an agonist is Heroin, the antagonist is Naloxone, while the the partial agonist is Buprenorphine. To illustrate this example, Heroin is an addictive agonistic substance. In the case of heroin overdose, Naloxone, an antagonist can be used to reverse the binding and block receptors from binding with free-floating Heroin. The pharmacological treatment for heroin addiction often includes the partial agonist, Buprenorphine. Buprenorphine allows partial binding to opioid receptors, thus reducing withdrawal symptoms and curving drug cravings (Camprodon et al., 2016).

Inverse Antagonist

Inverse agonists are the last type on the spectrum. Inverse agonists cause receptor changes, leading to the closing of the ion channels and eventual inactivation if not reversed (Stahl, 2013).

G Couple Proteins and ion-gated channels

G couple proteins and ion-gated channels are both major membrane receptors. The binding of a signaling molecule to a G-coupled protein receptor results in G protein activation, which in turn triggers the production of any number of second messengers, leading to G-coupled proteins helping to regulate a person’s immune system, growth, taste, smell, behavior, and mood (Rosenbaum et.al, 2009). Gated ion channels are proteins that open to allow ions such as Na+, K+, Ca2+or Cl- to pass through the cell membrane in response to a ligand such as a neurotransmitter (Stahl, 2013).

Comparison between G-couple protein and ion-gated channel and their actions

 The ion-gated channels, commonly known as, ligand-gated channels consolidate rapid postsynaptic responses while G-proteins consolidate slow postsynaptic responses (Camprodon et al., 2016). In terms of structure, the ion-gated channels are pores that open and close at the ligand binding while G-proteins include a single polypeptide. The G-protein receptors interact with proteins while ion channels regulate the flow of ions. G Couple Proteins and Ion-Gated Channels. Neurotransmission occurs not only electrically such as with ion-gated channels but also occurs chemically at receptors. G-protein linked receptors have seven transmembranes that each have a receptor to bind a neurotransmitter (Stahl, 2013). The first messenger is an extracellular neurotransmitter, and it passes the message to the second messenger system (Stahl, 2013). When the first messenger binds to the receptor, it changes the shape allowing the binding of the G protein, which then changes confirmation to allow binding with an enzyme (Stahl, 2013). Once bound, cyclic adenosine monophosphate is synthesized leading to the second messenger continuing neurotransmission to other messengers (Stahl, 2013).

Explain how the role of epigenetics may contribute to pharmacologic action.

Epigenetics not only has a role in the development of psychiatric and mental health disorders, but it can also affect the way medications work for each person. DeSocio (2016) describes synaptogenesis as the development of new neuronal connections that occur more rapidly during childhood but continue through adulthood as well. When stress hormones are present at high levels, there is a decrease in synaptogenesis (DeSocio, 2016).  Epigenetics can be defined in many ways, but the basis is that gene function can be altered without changing the DNA and RNA code. This functional change in the gene can also be inherited (Camprodon & Roffman, 2016, p. 64). As a result, epigenetics can determine how a medication works and what illnesses an individual may develop. If a medication works on a specific gene, but that gene has an altered function, the drug’s efficacy may change. For example, individuals with altered dopamine formation and receptor binding may have an affinity toward drug addiction or a degree of natural tolerance (Saad et al., 2019, p. 1534). For non-addictive substances, this logic holds as to why some medications work for one person, but not another individual.

Explain how this information may impact the way you prescribe medications to patients. Include a specific example of a situation or case with a patient in which the psychiatric mental health nurse practitioner must be aware of the medication’s action.

The above concepts of foundational neuroscience analyses will have an impact on how and what a psychiatric mental health nurse practitioner will prescribe to all clients. The knowledge learned will enable the provider to determine exactly which medication will help each client the most for their illness whether it be short-term or long-term. The PMHNP will be made more aware of the effectiveness of all medications used and their action for the client’s individual needs. Examples of the effects and actions are used to treat clients with anxiety and insomnia such as benzodiazepines which have an immediate effect on clients. Benzodiazepines can act as a full agonist on a positive allosteric modulator (PAM) by exhibiting an anxiolytic, hypnotic, anticonvulsant, amnestic, and muscle relaxant action (Stahl, 2013). Benefit-risk assessments must be considered by all providers when prescribing specific drugs to certain groups of clients. Extra care should be considered for clients, such as pregnant women, children, and the elderly because of their vulnerable states (Alshammari, 2016). An advanced psychiatric mental health nurse practitioner must be able to match the client’s symptoms with the correct medication to sometimes control their difficult symptoms (Laureate Education, 2016).

References

Alshammari, T. M. (2016). Drug safety: The concept, inception, and its importance in patients’ health. Saudi Pharmaceutical Journal, 24 (4), 405-412. doi: 10.1016/j.jsps.2014.04.008

Camprodon, J. A., & Roffman, J. L. (2016). Psychiatric neuroscience: Incorporating pathophysiology into clinical case formulation. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 1-19). Elsevier.

DeSocio, J. E. (2015). Epigenetics: An Emerging Framework for Advanced Practice Psychiatric Nursing. Perspectives in Psychiatric care/Volume 52, Issue 3/.201-207. https://doi.org/10.1111/ppc.12118Links to an external site.

Harvard University (2020). Fundamentals of Neuroscience: Electrical Properties of the Neuron. Retrieved September 4, 2023, from https://www.edx.org>lrstn>harva…

Laureate Education (Producer). (2016i). Introduction to psychopharmacology [Video file]. Retrieved from https://class.waldenu.eduLinks to an external site.

Rosenbaum, M. J., Clemmensen, L. S., Bredt, D. S. et al. Targeting receptor complexes: a new dimension in drug discovery. Nat Rev Drug Discov 19, 884-901 (2020). https://doi.org/10.1038/s41573-020-0086-4

Saad, M. H., Rumschlag. M., Guerra, M. H., Savonen, C. L., Jaster, A. M., Olson, P. D., Alazizi, A., Luca, F., Pique-Regi, R., Schmidt, C. J., & Bannon, M, J. (2019). Differentially expressed gene networks, biomarkers, long noncoding RNAs, and shared responses with cocaine identified in the midbrains of human opioid abusers. Scientific Reports, 9, pp. 1534. Retrieved from https://www.nature.com/articles/s41598-018-38209-8

Stahl, S. M. (2013). Stahl’s Essential Psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

According to Yoder-Wise (2022) mentoring is an important leadership function; The Robert Wood Johnson Nurse executive fellows program identify five main “competencies for leaders and mentors” Those five competencies are Interpersonal and communication effectiveness, risk-taking and creativity, self-knowledge, inspiring and leading change, and strategic vision.

Create an annotated bibliography (Refer to APA 7th ed, pgs. 307, 308), analyze this article, (LINK BELOW) and summarize (critique) it and post your analysis. Must use 2 citations. Please use link and article that has been uploaded for citations

ALSO answer questions 

How can one develop these competencies?  Can they be learned? Are all leaders mentors? Do you choose your mentor? or Does your mentor choose you? Examine your leadership and mentoring strengths and identify a mentor who can help you in your career journey? How can you differentiate between mentoring and leading?

Here is link to article:

 https://0633rykay-mp03-y-https-journals-lww-com.prx-keiser.lirn.net/naqjournal/fulltext/2023/04000/developing_and_evaluating_the_effectiveness_of_a.9.aspx