20 - Insomnia Flashcards
What are the 4 stages of NREM sleep?
- 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
What occurs during REM sleep?
- Increased brain activity
- Vivid dreams
- Active inhibition of voluntary muscles
- Rapid eye movement
How often does the sleep cycle occur during the night?
- 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
What is sleep latency?
How long it takes to fall asleep
What is insomnia?
- Difficulty falling asleep
- Difficulty maintaining sleep
- Not feeling rested despite sufficient time for sleep
What is insomnia associated w/?
- 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
What is included in the DSM-5 diagnostic criteria for insomnia?
- 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
What is the pathophys of insomnia?
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
What are some risk factors for insomnia?
- Female
- Elderly
- Comorbid psychiatric or medical illness
What are the characterizations of insomnia?
- Episodic = 1-2 month duration
- Persistent = 3 or more month duration
- Recurrent = 2 or more episodes per year
What are the types of insomnia?
- 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)
What are some drugs associated w/ insomnia?
- Alcohol
- Amphetamines or other stimulants
- Antidepressants
- Caffeine
- Adrenergic agonists and antagonists
- Corticosteroids
- Hormones
- Nicotine
How is insomnia assessed?
- 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
What are red flags for insomnia?
- 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
What are the goals of therapy for insomnia?
- 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
What is the first line for insomnia?
Non-pharms, specifically cognitive behavioural therapy
What are some non-pharms for insomnia?
- Stimulus control
- Relaxation techniques
- Cognitive-behavioural therapy (*first line for acute and chronic insomnia)
- Sleep restriction
- Paradoxical intention
What are some stimulus control recommendations for insomnia?
- 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.
What is cognitive behavioural therapy?
Behavioural therapy (stimulus control or sleep hygiene or sleep restriction) w/ cognitive therapy (changing incorrect beliefs and attitudes about sleep)
What are some sleep hygiene recommendations for insomnia?
- 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
What are the general principles of drug use for insomnia?
- Always use non-drug measures
- Use lowest possible dose for shortest possible time period
What are some considerations when choosing an OTC product for insomnia? Duration of use? When to refer?
- 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
What are the general principles for Rx insomnia therapy?
- 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
Why is drug therapy for insomnia used cautiously?
Associated w/ cognitive impairment, increased risk of falls, work-place injuries, tolerance, dependence, withdrawal, and rebound effects
What are the OTC and Rx options for insomnia?
- OTC = 1st gen antihistamine (diphenhydramine) and natural products (melatonin, valerian)
- Rx = antidepressants, BZDs, non BZD GABA agonists (zopiclone and zolpidem)
When is diphenhydramine taken for insomnia? Onset? Side effects? CI?
- 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
What is the recommended dosing of diphenhydramine for insomnia? When should the px be referred?
- Intermittent dosing (no more than 4 nights/week) and not for longer than 7 consecutive days
- Refer if using product longer than 1 week
Does melatonin have evidence of benefit? What are some SE?
- No evidence; less benefits than pharmacological agents
- SE = fatigue, headache, dizziness, irritability, abdominal cramps
Can melatonin be used chronically?
Not recommended
Is valerian recommended for insomnia? What are some SE?
- Not recommended b/c minimal evidence of efficacy and reports of hepatotoxicity
- SE = dizziness, nausea, headache, upset stomach, morning hangover
What sx should be monitored when using OTC therapy for insomnia?
- 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
Are antidepressants proven to help w/ insomnia? When should they be used?
- 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)
Which antidepressant is used for insomnia? What are some SE?
- Trazodone
- SE = dizziness, sedation, hypotension, headache, priapism (painful or persistent erection of penis)
When are tricyclic antidepressants used for insomnia? What are some SE?
- 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
What is the effect of BZDs for insomnia?
- Reduce latency to sleep onset
- Increase total sleep time
- Increase stage 2 sleep
- Decrease delta sleep
What are SE of BZDs?
- 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
Why are BZDs the ideal medication for insomnia? Which BZDs can be used
- Fast onset
- Duration of action (reasonable t1/2)
- No active metabolites
- Can use lorazepam, oxazepam, temazepam, and triazolam
What are some benefits to zopiclone over BZDs?
- Less effect on sleep structure
- Less effect on daytime performance
- Less dependence or abuse
- No tolerance issues
What is the MOA of zopiclone?
Acts selectively at BZD receptor (GABA) and has no anxiolytic, anticonvulsant or muscle relaxant properties
What are some counselling tips w/ zopiclone and zolpidem?
- 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
How should sedatives/hypnotics be discontinued?
- Should be tapered to prevent rebound
- Usually lasts 2-6 weeks, but may take several months
What should be monitored when px is using Rx therapy for insomnia?
- 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)
What is sleep apnea? What are some sx?
- Cessation of airflow lasting at least 10 seconds
- Sx of obstructive sleep apnea = heavy snoring, awakened by gasping, daytime drowsiness
