55. Insomnia

Question 1

Describe : Insomnia (4)

Answer 1

• 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

Question 2

Describe acute insomnia (2)

Answer 2

• <3 months duration
• Often sudden onset and associated with stress or disrupted sleep schedule

Question 3

Describe chronic insomnia (2)

Answer 3

> 3 months for > nights/week, impairs daytime function

Question 4

Name DDX categories of insomnia (3)

Answer 4

• Psychiatric
• Medical
• Sleep disorders

Question 5

Name DDX PSYCHIATRIC insomnia (4)

Answer 5

• Depression**
• Anxiety**
• Substance use (especially EtOH, caffeine, nicotine, stimulants)
• Post-traumatic stress disorder

Question 6

Name DDX MEDICAL insomnia (3)

Answer 6

• Hyperthyroidism
• Diabetes
• Medication (CNS stimulants/depressants, bronchodilators, antidepressants, beta antagonists, glucocorticoids)

Question 7

Name DDX SLEEP DISORDERS insomnia (5)

Answer 7

• Hypersomnolence disorder
• Narcolepsy
• Circadian rhythm sleep-wake disorders
• Restless legs syndrome
• Obstructive Sleep Apnea**

Question 8

Name DDX : Circadian rhythm sleep-wake disorders (3)

Answer 8

• 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

Question 9

Name Non-REM Sleep Arousal Disorders (2)

Answer 9

• Sleep terrors
• Sleep walking

Question 10

Describe history : Insomnia ()

Answer 10

• 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

Question 11

Describe investigations : Insomnia

Answer 11

• 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)

Question 13

What is the GOAL of tx of insomnia ?

Answer 13

Goal is improved continuity and quality of sleep (not 8 hours of sleep)

Question 14

Describe Non-Pharmacological Summary tx of insomnia (4)

Answer 14

• 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

Question 15

Describe Sleep Hygiene tips for insomnia (7)

Answer 15

• 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

Question 16

Does alcohol help insomnia ?

Answer 16

Alcohol helps with sleep initiation but impairs sleep maintenance

Question 17

Describe Stimulus control tips for insomnia (3)

Answer 17

• 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

Question 18

Describe : Sleep Consolidation (Restriction therapy)

Answer 18

• 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

Question 19

Describe : Relaxation therapy (2)

Answer 19

• Stress management
• Relaxation techniques (breathing, light exercise, stretching, yoga)

Question 20

Describe : CBT-I (Cognitive Behavioural Therapy for Insomnia) (4)

Answer 20

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

Question 21

Generally pharmacotherapy of insomnia has high risks what? (3)

Answer 21

• Fatigue
• Cognitive effects (memory impairment)
• Fall, motor vehicle accident, fracture, mortality

Question 22

Consider pharmacotherapy for insomnia when ?

Answer 22

only when disordered sleep has a severe impact on function, and only with a clear indication

Question 23

Ideally prescribe pharmaco tx for insomnia for how long ?

Answer 23

Ideally prescribe at lowest effective dose for short-term <7 days

Question 24

Long-term use may be considered for insomnia when ?

Answer 24

• 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

Question 25

Name prefered agents for insomnia (3)

Answer 25

• Histamine receptor antagonists (Doxepin)
• Benzodiazepine receptor agonists (Z-drugs or Benzodiazepines)
• Variable evidence for natural sources (and variable quality control if OTC)

Question 26

Describe : Doxepin (4)

Answer 26

• Doxepin 6mg PO qHS
• Doxepin 10mg (generic) may be cheaper
• Minimal side effects and minimal risk of tolerance
• Preferred in elderly

Question 27

Name : Benzodiazepine receptor agonists (Z-drugs or Benzodiazepines) (3)

Answer 27

• Zopiclone
• Zolpidem
• Temazepam

Question 28

Describe dose : Zopiclone

Answer 28

Zopiclone 3.75-7mg PO qHS

Question 29

Describe : Zopiclone (3)

Answer 29

• Short half-life
• Side effect: Metallic taste, daytime sleepiness
• Risk of tolerance/dependence

Question 30

Describe dose : Zolpidem

Answer 30

5-10 mg SL qHS

Question 31

Describe : Zolpidem (2)

Answer 31

• Caution in elderly
• Risk of tolerance/dependence

Question 32

Describe dose : Temazepam (1)

Answer 32

15-30mg PO qHS

Question 33

Describe : Temazepam (3)

Answer 33

• Intermediate half-life (higher risk of daytime sleepiness)
• Avoid in elderly
• Risk of tolerance/dependence

Question 34

Name natural sources for insomnia (3)

Answer 34

• Melatonin 0.3-5mg (consider 0.1-0.5mg physiologic doses)
• L’Tryptophan 500mg-2000mg
• Valerian 400-900mg

Question 35

Describe : Melatonin

Answer 35

• 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

Question 36

Name other agents for insomnia

Answer 36

(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

Question 37

Describe what to cover in first visit (4)

Answer 37

• Assess and treat comorbidity
• Sleep hygiene and behavioural interventions/CBT
• Consider sleep diary
• Consider investigation/pharmacotherapy based on patient

Question 38

Describe what to cover in FU visit

Answer 38

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