Ch. 46 - Insomnia, Fatigue Flashcards
1
Q
Insomnia
A
- 3rd most common complaint after headache and common cold
- Diverse etiologies and can become a disorder
- Trouble falling or staying asleep, waking too early and can’t fall back asleep, or don’t feel refreshed after sleeping
- Preferably should see a sleep specialist
- 64% experience sleep problems and people use alcohol, non-Rx sleep aids, and Rx hypnotics to help
- 3-21% of men and 7-29% of women >65 y.o. use hypnotics, 5% use non-Rx sleep aids
- Also higher instances of sleep apnea and restless leg syndrome at this age which correlates to a higher risk of CV caused death
2
Q
Sleep Stages
A
- Transitional sleep - patient in process of falling asleep, EEF resembles waking state
- Stage 2 - 50% of sleep time in this stage, light sleep
- Stage 3/4 - Deep sleep or delta waves (slow frequency)
- REM - neither light or deep sleep, high frequency waves
**Time to first REM sleep - REM latency, ~70-90 minutes, first REM lasts ~5-7 minutes, as sleep progresses REM becomes longer and deep sleep becomes shorter
3
Q
Insomnia Categories
A
- Transient - self-limiting, < 1 week
- Short term - lasts 1-3 weeks (book), < 3 months (lecture)
- Chronic - lasts > 3 weeks to years (book) or > 3 months for at least 3 days per week (lecture) and leads to medical problems, psychological disorders, and substance abuse
- Each stage can progress to the next
4
Q
Primary Insomnia
A
Sleep difficulty for at least 1 month that effects functioning but isn’t related to another disorder.
5
Q
Secondary Insomnia
A
Caused by an underlying disorder; general medical or psychological disorder, that needs to be identified and managed for improvement.
6
Q
Insomnia Pathophysiology
A
- Older adults need the same amount of sleep but their total sleep duration shortens, number of awakenings increases, and they speed less time in Stage 4 and REM sleep
- Shift workers often complain of sleep disturbances
- Caffeine, late night workouts, late night meals, or other disturbances (light, noise, environment) can cause difficulty sleeping
- Chronic insomnia - common in those with pain syndromes. Can also be related to medication use, sleep-wake schedules, and primary sleep disorders
- CHRONIC INSOMNIACS NEED A MEDICAL REFERRAL
- Antidepressants, antihypertensives, and sympathomimetic agents all commonly cause insomnia
7
Q
Insomnia Clinical Presentation
A
- Difficulty falling asleep, frequent waking, early morning waking and inability to fall back asleep, disturbed sleep quality, and troublesome dreams
- If they have these issues for 4 or more weeks, refer to a medical specialist
- Fatigue, drowsiness, decreased concentration, and impaired memory in daily life are also side effects
- Increased accidents and increased morbidity/mortality rates are also associated with insomnia
8
Q
Insomnia Treatment Goals
A
- Improve patient’s presenting symptoms
- Improve their quality of life
- Improve their functioning
9
Q
Insomnia General Treatment Approach
A
- Transient/short-term insomnia - good sleep hygiene with or without a non-Rx sleep aid
- Chronic insomnia - medical referral
10
Q
Insomnia Nonpharmacologic
A
- Sleep hygiene
- Try before drug therapy on its own
- Try one or two measures of sleep hygiene at a time
11
Q
Insomnia Pharmacologic
A
-Diphenhydramine is the only FDA-approved sleep aid for self-treatment
12
Q
Antihistamines
A
- Diphenhydramine and doxylamine - ethanolamine antihistamines
- Block H1 and muscarinic receptors
- Few studies show doxylamine’s safety and efficacy
- Both are well absorbed, have similar Cmax
- Half life of diphenhydramine - 2.4-9.3 hours, max at 3-6 hours
- Half life of doxylamine - 10 hours
13
Q
Diphenhydramine
A
- Primary indication is insomnia
- Poor efficacy for chronic insomniacs due to tolerance
- Use lowest effective dose and take “off” night to decrease tolerance development
- Max of 7-10 consecutive nights, seek medical evaluation if needing to use it more consistently
- Additive sedation effects if used with anticholinergic or sedative medications
- Inhibits CYP2D6 and decreases the clearance and metabolism of several drugs (codeine, venlafaxine, propranolol for example)
- Adverse SE: Anticholinergic primarily like dry mouth, constipation, blurred vision, urinary retention
- CI: prostatic hyperplasia, closed-angle glaucoma, CV disease, and dementia
- Don’t drink alcohol, operate machinery, drive, or cook
- Paradoxical effects in kids, elderly, and those with organic, mental disorders
- Combinations available with systemic analgesics, but they are not proven to help insomniacs with pain
- Those with psychoses are more likely to abuse this
14
Q
CNS Anticholinergic Toxicity
A
- Anticholinergic toxicity - excessive dosing or drug interactions leading to CNS anticholinergic toxicity
- Causes anxiety, pupil dilation, delirious, excited, hallucinations, flushed skin, hot/dry mucous membranes, increased body temperature, tachycardia
- Severe cases: coma, seizures, and death
15
Q
Ethanol
A
- Commonly used with chronic insomniacs
- Hazardous drinking behavior
- At low and high doses, initially helps with sleep but at high doses the second half of sleep is disturbed
- Tolerance develops quickly and causes users to increase their intake
- Often lessens the user’s total sleep
- Rebound/worsened insomnia can occur after withdrawal as well
- Some non-Rx combination products have ethanol in it like NyQuil liquid, but its safety/efficacy is debated
- Their multiple ingredient increases the risk of adverse SE and interactions
