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Clinical - Winter > 20 - Insomnia > Flashcards

20 - Insomnia Flashcards

1
Q

What are the 4 stages of NREM sleep?

A
  • Stage 1 = transition stage between wakefulness and sleep (on average 0.5-7 min)
  • Stage 2 = “light” sleep, intermediate sleep, largest percentage of total sleep time (50%)
  • Stage 3 and 4 = deep sleep (restorative sleep); largely affects sleep quality; aka delta sleep
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2
Q

What occurs during REM sleep?

A
  • Increased brain activity
  • Vivid dreams
  • Active inhibition of voluntary muscles
  • Rapid eye movement
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3
Q

How often does the sleep cycle occur during the night?

A
  • Lasts 1.5-2 h and repeats 4-5 times per night

- With each cycle, time in stage 2 and REM sleep will typically increase

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4
Q

What is sleep latency?

A

How long it takes to fall asleep

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5
Q

What is insomnia?

A
  • Difficulty falling asleep
  • Difficulty maintaining sleep
  • Not feeling rested despite sufficient time for sleep
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6
Q

What is insomnia associated w/?

A
  • Higher usage of healthcare services
  • Increased number of days in bed or w/ limited activity
  • Impaired job performance
  • More absenteeism
  • Higher risk of traffic and workplace accidents
  • Reduced QOL
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7
Q

What is included in the DSM-5 diagnostic criteria for insomnia?

A
  • Unsatisfactory sleep quantity or quality w/ difficulty falling asleep, staying asleep, or waking early and unable to fall back asleep
  • Dysfunction in social, occupational, educational, academic, behavioural, or any other areas of life
  • *Occurs 3 or more nights/week and for 3 or more months
  • Not related to another sleep-wake disorder
  • Not result of a substance, mental disorder, or medical condition
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8
Q

What is the pathophys of insomnia?

A

1) Cognitive model – stress induces worry, resulting in difficulty falling asleep; over time, causes worry due to lack of sleep and dysfunction that will occur
2) Hyperarousal from physiological factors – higher metabolic rate in px w/ insomnia vs others; higher levels of urinary and plasma cortisol, and adrenocorticotropic hormone in px w/ insomnia

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9
Q

What are some risk factors for insomnia?

A
  • Female
  • Elderly
  • Comorbid psychiatric or medical illness
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10
Q

What are the characterizations of insomnia?

A
  • Episodic = 1-2 month duration
  • Persistent = 3 or more month duration
  • Recurrent = 2 or more episodes per year
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11
Q

What are the types of insomnia?

A
  • Independent (cause is situational; stress, conflict, environment)
  • Comorbid w/ another mental disorder (ex: dementia, mood, anxiety or psychotic disorders, eating or substance-use disorders)
  • Comorbid w/ another medical condition (ex: CVD, pain, respiratory, GI, hormonal changes, infection)
  • Comorbid w/ another sleep disorder (ex: breathing-related sleep disorder, circadian rhythm disorders, parasomnias)
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12
Q

What are some drugs associated w/ insomnia?

A
  • Alcohol
  • Amphetamines or other stimulants
  • Antidepressants
  • Caffeine
  • Adrenergic agonists and antagonists
  • Corticosteroids
  • Hormones
  • Nicotine
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13
Q

How is insomnia assessed?

A
  • Assess sx (time asleep, early or frequent awakening, sleep latency, daytime impact?)
  • Investigate for potential underlying cause (illness or drug associated?)
  • Duration of sx
  • Assess sleep hygiene/stimulus control
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14
Q

What are red flags for insomnia?

A
  • Sx associated w/ shift work
  • OTC ineffective after 3 evenings or required longer than 7 consecutive days
  • Comorbid sleep disorders associated w/ insomnia (restless leg, breathing related sleep disorder, narcolepsy, parasomnias)
  • Drug induced where pharmacists are unable to change drug therapy
  • Comorbid w/ mental or medical conditions
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15
Q

What are the goals of therapy for insomnia?

A
  • Prevent sx associated w/ poor sleep
  • Promote sound and satisfying sleep
  • Resolve/relieve impact of underlying conditions
  • Prevent dependence on drug therapy
  • Reinstate normal sleep pattern w/o medication
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16
Q

What is the first line for insomnia?

A

Non-pharms, specifically cognitive behavioural therapy

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17
Q

What are some non-pharms for insomnia?

A
  • Stimulus control
  • Relaxation techniques
  • Cognitive-behavioural therapy (*first line for acute and chronic insomnia)
  • Sleep restriction
  • Paradoxical intention
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18
Q

What are some stimulus control recommendations for insomnia?

A
  • Only use bed for sleep or intimacy
  • Go to bed only when tired
  • Avoid trying to force sleep, if you don’t fall asleep in 20-30 mins, leave bed to perform a relaxing activity until drowsy
  • Avoid napping during the day
  • Have regular times to wake and sleep
  • Avoid blue spectrum light from tv, smart phones, tablets, etc.
19
Q

What is cognitive behavioural therapy?

A

Behavioural therapy (stimulus control or sleep hygiene or sleep restriction) w/ cognitive therapy (changing incorrect beliefs and attitudes about sleep)

20
Q

What are some sleep hygiene recommendations for insomnia?

A
  • Establish regular sleep/wake schedule
  • Exercise routinely 3-4 times weekly but not too close to scheduled bedtime
  • Avoid poor sleep conditions (noise, bedding, temp)
  • Do something relaxing and enjoyable at bedtime, have a pre-sleep routine
  • Avoid caffeine, nicotine, and alcohol 4-6 h before bedtime
  • Avoid heavy, spicy, or sugary foods 4-6 h before bedtime
21
Q

What are the general principles of drug use for insomnia?

A
  • Always use non-drug measures

- Use lowest possible dose for shortest possible time period

22
Q

What are some considerations when choosing an OTC product for insomnia? Duration of use? When to refer?

A
  • Consider CI and SE
  • Don’t use in elderly b/c of anticholinergic effects
  • Limit up to 4 times weekly; no more than 7 consecutive days
  • Refer is OTC tx needed for more than 7 consecutive nights and/or if ineffective after 3 evenings
23
Q

What are the general principles for Rx insomnia therapy?

A
  • Never exceed recommended dose
  • Supply should be limited to 1 week w/o refills to ensure adequate follow-up and evaluation
  • After two 7 day trials, if sleep performance and daytime functioning have not returned to normal – re-evaluate diagnosis and consider referral to sleep specialist
24
Q

Why is drug therapy for insomnia used cautiously?

A

Associated w/ cognitive impairment, increased risk of falls, work-place injuries, tolerance, dependence, withdrawal, and rebound effects

25
Q

What are the OTC and Rx options for insomnia?

A
  • OTC = 1st gen antihistamine (diphenhydramine) and natural products (melatonin, valerian)
  • Rx = antidepressants, BZDs, non BZD GABA agonists (zopiclone and zolpidem)
26
Q

When is diphenhydramine taken for insomnia? Onset? Side effects? CI?

A
  • Taken 30-60 mins before bedtime
  • Onset = 1-3 h
  • SE = morning drowsiness, dizziness, grogginess, impaired psychomotor and cognitive function; anticholinergic effects (dry mouth, dry eyes, urinary retention, tachycardia)
  • CI = enlarged prostate, cardiac disease, hyperthyroidism, glaucoma, dementia or cognitive impairment
27
Q

What is the recommended dosing of diphenhydramine for insomnia? When should the px be referred?

A
  • Intermittent dosing (no more than 4 nights/week) and not for longer than 7 consecutive days
  • Refer if using product longer than 1 week
28
Q

Does melatonin have evidence of benefit? What are some SE?

A
  • No evidence; less benefits than pharmacological agents

- SE = fatigue, headache, dizziness, irritability, abdominal cramps

29
Q

Can melatonin be used chronically?

A

Not recommended

30
Q

Is valerian recommended for insomnia? What are some SE?

A
  • Not recommended b/c minimal evidence of efficacy and reports of hepatotoxicity
  • SE = dizziness, nausea, headache, upset stomach, morning hangover
31
Q

What sx should be monitored when using OTC therapy for insomnia?

A
  • Sleep diary (sleep quantity and quality)
  • If ineffective after 3 nights, and tx still required, refer
  • Should see improvement in subjective sleep quality w/in 3 days
32
Q

Are antidepressants proven to help w/ insomnia? When should they be used?

A
  • Not well studied
  • Considered an option for those who shouldn’t take BZD or BZD-like drugs (ex: depression, pain, or risk of substance abuse)
33
Q

Which antidepressant is used for insomnia? What are some SE?

A
  • Trazodone

- SE = dizziness, sedation, hypotension, headache, priapism (painful or persistent erection of penis)

34
Q

When are tricyclic antidepressants used for insomnia? What are some SE?

A
  • Useful in p w/ comorbid conditions such as chronic pain, depression, diabetic neuropathy
  • SE = daytime sedation, anticholinergic effects, weight gain, cardiac arrhythmias, lowered seizure threshold
35
Q

What is the effect of BZDs for insomnia?

A
  • Reduce latency to sleep onset
  • Increase total sleep time
  • Increase stage 2 sleep
  • Decrease delta sleep
36
Q

What are SE of BZDs?

A
  • Daytime sedation
  • Tolerance
  • Withdrawal
  • Falls
  • Dizziness
  • *SE are dose dependent and vary according to PK profile; shorter half life and lower dose = less chance of SE
37
Q

Why are BZDs the ideal medication for insomnia? Which BZDs can be used

A
  • Fast onset
  • Duration of action (reasonable t1/2)
  • No active metabolites
  • Can use lorazepam, oxazepam, temazepam, and triazolam
38
Q

What are some benefits to zopiclone over BZDs?

A
  • Less effect on sleep structure
  • Less effect on daytime performance
  • Less dependence or abuse
  • No tolerance issues
39
Q

What is the MOA of zopiclone?

A

Acts selectively at BZD receptor (GABA) and has no anxiolytic, anticonvulsant or muscle relaxant properties

40
Q

What are some counselling tips w/ zopiclone and zolpidem?

A
  • Risk of impairment the following day, even if feel fully awake
  • Allow at least 12 h for zopiclone (8 h for zolpidem) between dose and performing any duties requiring mental alertness
  • Alcohol use and rebound insomnia
  • Don’t exceed 7-10 days of consecutive use
41
Q

How should sedatives/hypnotics be discontinued?

A
  • Should be tapered to prevent rebound

- Usually lasts 2-6 weeks, but may take several months

42
Q

What should be monitored when px is using Rx therapy for insomnia?

A
  • Sleep diary (sleep quantity and quality)
  • Expect to see improvement in 2-3 days
  • Px should be evaluated after 1 week (determine efficacy, adverse effects and adherence)
43
Q

What is sleep apnea? What are some sx?

A
  • Cessation of airflow lasting at least 10 seconds

- Sx of obstructive sleep apnea = heavy snoring, awakened by gasping, daytime drowsiness

Clinical - Winter (24 decks)

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