NUR 676 Module 5 Case Study Example

Case Study: Managing Chronic Insomnia in a 67-Year-Old With Cognitive Behavioral Therapy Rather Than Hypnotics

[Student Name]

Southern New Hampshire University

NUR 676: Primary Care for Mental Health

Module Five Case Study

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Case Study: Managing Chronic Insomnia in a 67-Year-Old With Cognitive Behavioral Therapy Rather Than Hypnotics

Few complaints are more frequent in primary care than poor sleep, especially among older adults, and the request for a sleeping pill is familiar to every clinician. Hypnotics work quickly, which makes them tempting, but in older adults they bring risks of falls, fractures, confusion and car crashes, and they do not address why the person cannot sleep. Helen is a 67-year-old retired teacher seen at a composite community clinic who asked for zolpidem after a year of poor sleep. The case walks through how she was evaluated and treated. It argues that confirming insomnia disorder while ruling out other sleep and medical problems, then offering cognitive behavioral therapy for insomnia as first-line treatment, provides lasting benefit without the harms of hypnotics.

Presentation

Helen reports that for about a year she has taken more than an hour to fall asleep most nights and wakes at 2 or 3 a.m., lying awake for an hour or more. She goes to bed at 9 p.m. because she is bored and tired, stays in bed until 8 a.m. hoping to catch up and naps for an hour most afternoons. She worries in bed about not sleeping and feels tired, irritable and forgetful during the day. Her sleep problems began after her husband's hospitalization, but continued after he recovered. Her caffeine comes from two morning coffees, and most evenings end with a glass of wine. She takes amlodipine and a daily calcium supplement and sometimes uses diphenhydramine from the pharmacy, which leaves her groggy. Her sister takes zolpidem nightly.

Her husband reports that she does not snore loudly or stop breathing during sleep. She does not have an urge to move her legs in the evening. Examination is unremarkable, with a body mass index of 24 and a normal neck circumference. PHQ-9 score 6 and GAD-7 score 5, both reflecting mostly sleep-related items. A two-week sleep diary shows an average of 9.5 hours in bed and 5.5 hours asleep.

Assessment

Chronic insomnia disorder: difficulty initiating and maintaining sleep at least three nights a week for more than three months, with daytime impairment, despite adequate opportunity for sleep. Her sleep efficiency, time asleep divided by time in bed, is about 58%. Obstructive sleep apnea is unlikely given no snoring or witnessed apneas and a normal body habitus, though it will be reconsidered if symptoms change. Restless legs syndrome is absent. Depression and anxiety scores are low and driven by sleep items. Contributing factors include long time in bed, daytime napping, evening wine, which fragments sleep, worry about sleep and use of diphenhydramine, which is anticholinergic and can impair memory. The original stressor has passed, but perpetuating habits have kept insomnia going, a pattern typical of chronic insomnia.

The Case for CBT-I First

Qaseem et al. (2016), writing the American College of Physicians guideline, advised that every adult with chronic insomnia disorder be offered CBT-I before anything else, and that the decision to add medication be made jointly with the patient when CBT-I alone is unsuccessful, weighing benefits, harms and costs. CBT-I combines stimulus control, meaning using the bed only for sleep and getting up when unable to sleep; sleep restriction, limiting time in bed to match actual sleep time and gradually extending it; cognitive therapy for unhelpful beliefs about sleep; relaxation; and sleep hygiene education.

Trauer et al. (2015) conducted a meta-analysis of randomized trials of CBT-I for chronic insomnia and found clinically meaningful improvements in how long it took to fall asleep, time spent awake after falling asleep and sleep efficiency, with benefits that appeared to be maintained at later follow-up. These gains are comparable to or larger than those seen with hypnotic medications, without their side effects, and persist after treatment ends.

Why Not a Hypnotic

The latest Beers Criteria tell clinicians to steer adults 65 and older away from benzodiazepines and from Z-drugs such as zolpidem, since these raise the odds of confusion, delirium, falls, broken bones and car accidents while adding only a little sleep (American Geriatrics Society Beers Criteria Update Expert Panel, 2023). Older sedating antihistamines like diphenhydramine are on the same list because their anticholinergic effects can cloud thinking and slow the bowel. Helen was told that her sister's prescription carries these risks and that her own diphenhydramine use may be contributing to her forgetfulness.

Plan

Helen agreed to try CBT-I. Because the nearest in-person provider has a long wait, she enrolled in a digital CBT-I program with weekly check-ins by the clinic's behavioral health clinician. Based on her diary, her initial time in bed was set at six hours, from midnight to 6 a.m., with no naps, to consolidate sleep; it will be increased by fifteen minutes each week when her sleep efficiency exceeds 85%. She will get out of bed if unable to sleep within about twenty minutes and return when sleepy. She will stop diphenhydramine, move her wine to dinner time or stop it and keep coffee to the morning. She was warned that daytime sleepiness may increase during the first two weeks of sleep restriction and advised not to drive when drowsy. Follow-up in two weeks to review her diary, then monthly. If insomnia persists after an adequate trial, options will be revisited with her.

Anticipating Barriers

CBT-I works only if the patient sticks with it, and sleep restriction is the hardest part. Helen worried that limiting her time in bed would leave her exhausted and that she would give up. She was told that the first two weeks are the most difficult, that the sleepiness usually improves as sleep consolidates and that the window will widen each week as her sleep efficiency rises. She chose a quiet activity to do if she got up at night, reading in a dim chair in the living room rather than using her phone, and her husband agreed to help her avoid afternoon naps by planning a daily walk together. The behavioral health clinician will review her diary each week by phone and adjust the window, which gives her support at the moments when many patients abandon treatment. If digital CBT-I proves difficult, a few in-person sessions can be arranged.

Conclusion

Helen asked for a sleeping pill, but her insomnia was sustained by habits that a pill would not change and her age made hypnotics risky. Confirming chronic insomnia disorder, ruling out apnea and other causes, offering CBT-I as the guideline recommends and explaining the risks the Beers Criteria identify gave her a treatment with lasting benefit and fewer harms.

References

American Geriatrics Society Beers Criteria Update Expert Panel. (2023). American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 71(7), 2052-2081. https://doi.org/10.1111/jgs.18372

Qaseem, A., Kansagara, D., Forciea, M. A., 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), 125-133. https://doi.org/10.7326/M15-2175

Trauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M. W., & Cunnington, D. (2015). Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis. Annals of Internal Medicine, 163(3), 191-204. https://doi.org/10.7326/M14-2841