CBT for Insomnia- Hypnotics

Question 1

What is meant by hypnotic ?

Answer 1

A drug used to induce sleep

They do not treat any underlying causes. They only provide relieve for insomnia symptoms

Question 2

Why should hypnotics not be prescribed indiscriminately and why is routine prescribing undesirable ?

Answer 2

Increase risk of dependance

Risk of falls

Risk of cognitive impairments

Risk of accidents

Risk of dementia

Risk of withdrawal symptoms

Question 3

Should non-pharmacological treatments be continued when patient is taking hypnotics ?

Answer 3

Yes including sleep hygiene and psychological approaches

Question 4

Name 6 hypnotic medication

Answer 4

Clomethizole 
Zopiclone 
Melatonin 
Lorazepam 
Diazepam 
Promethazine

Question 5

What is a benefit of using clomethiozole ?

Answer 5

Free from hangover effect

Question 6

What is melatonin ?

Answer 6

Pineal hormone which is licences for short term treatment of insomnia and for short term treatment of jet lag in adults

Question 7

What age is melatonin licenced from ?

Answer 7

55 years and over

Question 8

Are antihistamine shush as Promethazine appropriate in managing chronic insomnia ?

Answer 8

No, licences for temporary sleeping difficulties (1-2 weeks)

Question 9

Give examples of benzodiazepines

Answer 9

Nitrazepam 
Flurazepam 
Lorazepam 
Diazepam 
Temazepam

Question 10

Give examples of ‘Z’

Answer 10

Zopiclone

Zolpidem

Question 11

What are the most commonly used anxiolytics and hypnotics ?

Answer 11

Benzodiazepines

Question 12

Where do benzodiazepines act at ?

Answer 12

The GABA receptor

Question 13

What are benzodiazepines indicated for ?

Answer 13

Short term relief (2-4 weeks only) of anxiety that is severe, disabling or causing patient unacceptable distress, occurring alone or in association with insomnia and short term psychosomatic, organic or psychotic illness

Question 14

Can you use benzodiazepines to treat ‘mild’ anxiety ?

Answer 14

No, it is inappropriate

Question 15

Where else are benzodiazepines used in patients ?

Answer 15

Dental patients

Question 16

What are the common features of nitrazepam, diazepam and flurazepam ?

Answer 16

Long-acting

Hangover effect is likely the next day

Question 17

What are the common features in lorazepam and temazepam ?

Answer 17

Short acting

Has little or no hangover effect by more likely to have withdrawal effects

Question 18

When are z-drugs (hypnotics() appropriate to use in insomnia ?

Answer 18

For short term treatment

When insomnia is severe, stabling or causing patient extreme distress

Question 19

What is the mechanism of action for ‘Z’ hypnotics ?

Answer 19

Agonist of the GABA receptor complex and therefore enhances GABA-mediated neuronal inhibition

Question 20

How is benzodiazepine withdrawal managed ?

Answer 20

1. Transfer patient stepwise. One dose at a tome over a bout a week to equivalent daily dose of diazepam preferably taken at night
2. Reduce diazepam dose, usually by 1-2mg every 2-4 weeks (in high doses, reduce the dose by up to one-tenth every 1-2 weeks)
3. Reduce diazepam further, steps of 500mcg may be appropriate towards the end of withdrawal then stop completely

Question 21

What are the disadvantages in using z drugs and benzodiazepines ?

Answer 21

Dependance
Tolerance
Increase risk of falls
Congestive impairments

Question 22

How would you prescribe benzodiazepines ?

Answer 22

Discontinuation should be planned and gradual over at least 4-6 weeks (Longer in most cases)

Start with lowest licensed dose

Ensure non-pharmacological treatment interventions are continues

A review/stop date should be stated clearly in the prescribing

Intimate use odd z-hypnotics (everyone/3rd night) cam help prevent tolerance developing

Question 23

What are the common withdrawal symptoms of benzodiazepines ?

Answer 23

Nausea 
Headaches 
Sweating 
Panic attacks 
Depression 
Anxiety’s 
Tremor 
Palpitations 
Loss of agitate 
Insomnia

Question 24

What are the common withdrawal symptoms of Z-drugs ?

Answer 24

Rebound insomnia 
Impaired concentration 
Palpitations 
Abdominal crams 
Anxiety 
Depression 
Anxieperceptual disturbances