55. Insomnia Flashcards
1
Q
Chez les patients qui consultent pour des problèmes de sommeil, obtenez une anamnèse détaillée afin de distinguer l’insomnie des autres troubles psychiatriques ou troubles reliés au sommeil.
Nommez des examples. (5)
A
- apnée du sommeil
- trouble du sommeil non-REM
- syndrome des jambes sans repos
- somnambulisme
- parler pendant le sommeil
2
Q
Lorsque vous évaluez les problèmes de sommeil, il faut obtenir quoi comme informations ?
A
- Obtenez, si possible ou approprié, la version du partenaire de lit ou des parents
- évaluez la prise de médicaments (sur ordonnance et en vente libre, drogues récréatives), de caféine et d’alcool
3
Q
Nommez des conseils sur l’hygiène du sommeil (5)
A
- limitations de caféine
- siestes
- temps devant un écran
- suivre un horaire régulier de sommeil
- activités dans la chambre à coucher limitées au sommeil et aux activités sexuelles
4
Q
Quoi faire lorsqu’on prescrit des somnifères ?
A
- Informez le patient sur les risques liés au médicament et parlez-lui de l’effet limité dans le temps
- Utilisez les hypnotiques judicieusement (p. ex., prescrivez-les seulement si l’insomnie entraîne d’importantes conséquences sur l’autonomie fonctionnelle, ne les prescrivez pas sans indication claire).
- Négociez avec le patient un plan de réduction de la dose visant l’arrêt du médicament
5
Q
Lorsqu’un patient sous somnifères depuis longtemps se présente pour renouveler son ordonnance, quoi faire?
A
réévaluez, informez et discutez de sevrage ou d’autres options de traitement.
6
Q
Describe : Insomnia (4)
A
- Difficulty initiating sleep, maintaining sleep or non-restorative/non-refreshing sleep
- causing clinically significant distress or impairments in function
- Acute vs chronic
- Both acute and chronic can be subdivided into initial (sleep-onset), middle (sleep-maintenance) or late (sleep-offset) insomnia
7
Q
Describe acute insomnia (2)
A
- <3 months duration
- Often sudden onset and associated with stress or disrupted sleep schedule
8
Q
Describe chronic insomnia (2)
A
> 3 months for > nights/week, impairs daytime function
9
Q
Name DDX categories of insomnia (3)
A
- Psychiatric
- Medical
- Sleep disorders
10
Q
Name DDX PSYCHIATRIC insomnia (4)
A
- Depression**
- Anxiety**
- Substance use (especially EtOH, caffeine, nicotine, stimulants)
- Post-traumatic stress disorder
11
Q
Name DDX MEDICAL insomnia (3)
A
- Hyperthyroidism
- Diabetes
- Medication (CNS stimulants/depressants, bronchodilators, antidepressants, beta antagonists, glucocorticoids)
12
Q
Name DDX SLEEP DISORDERS insomnia (5)
A
- Hypersomnolence disorder
- Narcolepsy
- Circadian rhythm sleep-wake disorders
- Restless legs syndrome
- Obstructive Sleep Apnea**
13
Q
Name DDX : Circadian rhythm sleep-wake disorders (3)
A
- Delayed sleep-wake phase disorder (sleep normally if go to bed later and wake up later) -> Common in adolescents
- Advanced sleep-wake phase disorder (sleep normally if go to bed earlier and wake up earlier)
- Non-REM Sleep Arousal Disorders
14
Q
Name Non-REM Sleep Arousal Disorders (2)
A
- Sleep terrors
- Sleep walking
15
Q
Describe history : Insomnia ()
A
- Sleep habits
(1) Sleep latency (time to fall asleep), sleep efficacy (sleeping vs. time in bed), duration, disturbance
(2) Activities (exercise, exposure to light/screens) - Stressors : Depression/anxiety screening
- Impact on life/function
- Alcohol
- Drugs
- Medications (including over-the-counter, herbal)
- Caffeine
- Collateral from bed-partner or household members
16
Q
Describe investigations : Insomnia
A
- Sleep clinic if suspect OSA or limb movement (or does not respond to treatment), or
(1) Nocturnal polysomnography for sleep apnea or periodic limb movements of sleep - Consider TSH, fasting glucose
- Consider Ferritin, Mg, renal function, B12 (restless leg syndrome)
17
Q
A
18
Q
What is the GOAL of tx of insomnia ?
A
Goal is improved continuity and quality of sleep (not 8 hours of sleep)
19
Q
Describe Non-Pharmacological Summary tx of insomnia (4)
A
- Discuss sleep hygiene, determine patient’s commitment to improve sleep
- Sleep diary
- Strict and constant routine of going to bed and getting up
- Strengthen appropriate thoughts about sleep
(1) Sleep needs to be allowed to occur, which can be very difficult for people trying desperately to enter that state
(2) Consider stimulus control, and relaxation therapy (meditation)
(3) Sleep restriction, avoid day-time napping
20
Q
Describe Sleep Hygiene tips for insomnia (7)
A
- No caffeine/alcohol within 6h of bedtime.
- No nicotine (including replacement) close to bedtime
- No excessive liquids or heavy evening meal before bedtime
- Moderate physical activity, avoid heavy exercise within 3h of bedtime
- Minimize noise and light
- Temperature (avoid too warm)
- Avoid watching/checking clock
21
Q
Does alcohol help insomnia ?
A
Alcohol helps with sleep initiation but impairs sleep maintenance
22
Q
Describe Stimulus control tips for insomnia (3)
A
- Re-associate bed/bedroom with sleep
- Go to different room if sleep onset >15 minutes
- Wake-up at same time each day despite how little sleep
23
Q
Describe : Sleep Consolidation (Restriction therapy)
A
- Sleep prescription to improve sleep efficacy (minimize bed time)
- Avoid napping
- Prescribe minimum sleep time (eg. 7h) + 30 minutes bedtime
(1) Monitor by sleep logs
(2) Once sleeping for >90% of time in bed for two weeks consecutively, and slowly increase bed time
24
Q
Describe : Relaxation therapy (2)
A
- Stress management
- Relaxation techniques (breathing, light exercise, stretching, yoga)
25
Describe : CBT-I (Cognitive Behavioural Therapy for Insomnia) (4)
Address inappropriate beliefs and attitudes that perpetuate insomnia
* Unrealistic sleep expectations (eg. must have 9h of sleep)
* Misconceptions about causes of insomnia (eg. chemical imbalance)
* Amplifying consequences (eg. cannot function after sleeping poorly)
* Performance anxiety, loss of control
26
Generally pharmacotherapy of insomnia has high risks what? (3)
* Fatigue
* Cognitive effects (memory impairment)
* Fall, motor vehicle accident, fracture, mortality
27
Consider pharmacotherapy for insomnia when ?
only when disordered sleep has a severe impact on function, and only with a clear indication
28
Ideally prescribe pharmaco tx for insomnia for how long ?
Ideally prescribe at lowest effective dose for short-term <7 days
29
Long-term use may be considered for insomnia when ?
* in severe insomnia resistant to CBT-I, but must be regularly re-assessed at each visit
* Consider discussing reduction and cessation plan, and alternative therapies for patients on chronic pharmacotherapy for insomnia
* Beware risk of rebound insomnia when deprescribing
30
Name prefered agents for insomnia (3)
* Histamine receptor antagonists (Doxepin)
* Benzodiazepine receptor agonists (Z-drugs or Benzodiazepines)
* Variable evidence for natural sources (and variable quality control if OTC)
31
Describe : Doxepin (4)
* Doxepin 6mg PO qHS
* Doxepin 10mg (generic) may be cheaper
* Minimal side effects and minimal risk of tolerance
* Preferred in elderly
31
Describe dose : Zolpidem
5-10 mg SL qHS
32
Name : Benzodiazepine receptor agonists (Z-drugs or Benzodiazepines) (3)
* Zopiclone
* Zolpidem
* Temazepam
32
Describe : Zolpidem (2)
* Caution in elderly
* Risk of tolerance/dependence
33
Describe dose : Zopiclone
Zopiclone 3.75-7mg PO qHS
33
Describe dose : Temazepam (1)
15-30mg PO qHS
34
Describe : Zopiclone (3)
* Short half-life
* Side effect: Metallic taste, daytime sleepiness
* Risk of tolerance/dependence
34
Describe : Temazepam (3)
* Intermediate half-life (higher risk of daytime sleepiness)
* Avoid in elderly
* Risk of tolerance/dependence
35
Name natural sources for insomnia (3)
* Melatonin 0.3-5mg (consider 0.1-0.5mg physiologic doses)
* L'Tryptophan 500mg-2000mg
* Valerian 400-900mg
36
Describe : Melatonin
* Dose : 0.3-5mg (consider 0.1-0.5mg physiologic doses)
* Preferred in pediatric population, especially if comorbid ADHD or ASD
* Often first-line as high safety profile, low price, and ease of availability
37
Name other agents for insomnia
(generally not recommended unless also treating comorbidity):
* Antidepressants: e.g., mirtazapine, amitriptyline, nortriptyline
* Antipsychotics: e.g., quetiapine, (Seroquel), methotrimeprazine (Nozinan)
* Muscle relaxants: e.g., cyclobenzaprine
38
Describe what to cover in first visit (4)
* Assess and treat comorbidity
* Sleep hygiene and behavioural interventions/CBT
* Consider sleep diary
* Consider investigation/pharmacotherapy based on patient
39
Describe what to cover in FU visit
F/U 2-4 weeks
* Evaluate sleep efficiency, daytime symptoms
* Reinforce behavioural interventions/CBT
* Review pharmacotherapy
F/U 3 months
* If limited progress, referral to sleep medicine program or psychologist
40
