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
16
Q
Pharmacotherapeutic Comparisons
A
- Most trials show diphenhydramine decreases the time to fall asleep and increases sleep quality
- Not as effective as Rx-benzos and shouldn’t be recommended for chronic insomniacs
- Only recommend diphenhydramine, there are many dosage forms available
17
Q
Special Populations - Insomnia
A
- Safety in pregnant isn’t established, use based on risk:benefit
- Doxylamine + Pyridoxine is approved for pregnant women for N/V
- Refer preggos for medical evaluation over recommending
- Diphen. recommended for BF (enters milk) especially if chronically used, okay if only in small doses after last feedings
- Behavior interventions and good sleep hygiene are first line for kids and teens
- Don’t use in kids <12 y.o. (paradoxical effects)
- Anticholinergic toxicity is more common in kids and may be more severe
- Don’t double up and use multiple diphen. products together
- Elderly: behavioral therapy and approved agents, refer to PCP since diphen. is on Beers List
18
Q
Complementary Therapies - Insomnia
A
- Melatonin, Valerian, and Kava are the most common
- Melatonin shown to have limited benefits, and MAY help in delayed sleep phase disorder
- Valerian - limited benefit but needs several days-weeks to see effect, so not for acute insomnia
- Slowly taper after extended use, causes benzo-like withdrawals within heart complications
- Kava causes severe hepatotoxicity, DON’T RECOMMEND
- Don’t recommend to patients unless done by PCP
- Acupuncture, tai chi, and light therapy may help, but not adequately evaluated
19
Q
Counseling - Insomnia
A
- Good sleep hygiene
- Non-Rx sleep aids if appropriate and review drug duration and dosing
- Also go over SE, interactions, and warnings
- Don’t take multiple products together, could increase the risk of adverse drug reactions
20
Q
Evaluation - Insomnia
A
- Decreased time to fall asleep
- Increased sleep quality
- Decreased daytime fatigue and drowsiness
- Seek medical evaluation if sleep hasn’t improved in 10 days
21
Q
Drowsiness & Fatigue
A
- Acute or chronic
- Increases risk of accidents and can effect mood and health
- Caffeine used commonly and its daily intake can lead to SE, withdrawal, and interactions
22
Q
Pathophysiology - D/F
A
- Commonly from inadequately sleep (duration and goal)
- Sleepiness is determined by homeostasis process and circadian process
- CNS depressants, dopamine agonists, antibiotics, and antihypertensives increases drowsiness
- Depression, cancer, hyperthyroidism, chronic pain, overexertion, diet, and exercise can also increase drowsiness
23
Q
D/F Clinical Presentation
A
- Yawning
- Eye rubbing
- Tendency to fall asleep
- Decreased ability to focus or concentrate
24
Q
D/F Treatment Goal
A
Identify and eliminate underlying cause to increase mental alertness and productivity.
25
D/F General Approach
- Self-treat with caffeine and non-Rx caffeine products
- Rule out any drug-induced cause of daytime D/F first
- Referral for chronic symptoms
26
D/F Nonpharmacologic
SLEEP HYGIENE
27
D/F Pharmacologic
- Caffeine - non-selective adenosine antagonists (A1 and A2a)
- Stops sleep promotion and increases alertness through secondary sources
- Only FDA- approved non-Rx stimulant
- Good products for 12 y.o. +, only for occasional use
28
Caffeine
- Low-moderate doses: increases arousal, decreases fatigue, elevates mood, increases HR & BP
- High doses: anxiety, nausea, jittery, nervousness
- Rapid and wide distribution within 30-75 minutes
- Withdrawal may occur with habitual drinkers
- Can increase aspirin absorption and decrease theophylline clearance (additive effects like increased HR)
- Quitting smokers should decrease caffeine intake by half
- CI: MAOIs, coronary heart disease, uncontrolled hypertension, preexisting arrhythmia
- Delays sleep onset, decreases deep sleep, and increases awakenings before bed
- Can't compensate for inadequate sleep
- Doesn't counteract all of alcohol's effects
- Inform them of the high amount of caffeine in weight loss products
29
Caffeine Withdrawal
- Headache
- Fatigue
- Decreased concentration
- Irritability
- Starts 12-24 hours after cessation, lasts 1-5 days)
30
Caffeine Special Populations
- Crosses placenta but moderate consumption is okay, <200 mg/day
- BF: only in low-moderate consumption
- None in < 12 y.o.
- Avoid in elderly due to exaggerated effects and sleep interference
31
D/F Complementary Therapies
- Ginseng: frequently used to increase physical and mental energy
- Study revealed contradictory evidence to this claim
- Cola nut, guarana, and yerbamate (diet supplements), and taurine/guarana (sport/energy drink products) have caffeine but not enough to likely cause therapeutic or adverse effects
32
D/F Assessment
- Consider medical/psych. problems, medication use, caffeine consumption, sleep patterns, and lifestyle
- Recommend sleep hygiene, lifestyle changes, and medical referral before caffeine
33
D/F Counseling
- Sleep hygiene
- Eliminate interfering sleep factors
- Review dosage and adverse effects if caffeine is indicated
- Excessive intake symptoms and withdrawal should also be counseled
34
D/F Evaluation
- Daytime altertness, increased productivity, peak performance regarding psychmotor tasks and cognitive function (like attention and concentration)
- Seek medical evaluation if drowsiness and fatigue persists after 7-10 days despite sleep hygiene and limited caffeine
35
Drugs Causing Insomnia
* Amphetamines (methylphenidate, modafinil, phentermine)
* Antidepressants (bupropion, fluoxetine, venlafaxine)
* Steroids (anabolic, prednisone, methylprednisolone)
* Beta-blockers (propranolol, metoprolol, pindolol)
* Decongestants (pseudoephedrine, phenylephrine)
* Diuretics (hydrochlorothiazide, furosemide)
* Thyroid agents (levothyroxine, liothyronine)
* Caffeine
* Alcohol
* Tobacco
36
Drug Withdrawal Causing Insomnia
* Amphetamines (methylphenidate, modafinil, phentermine)
* Antihistamines (diphenhydramine, doxylamine)
* Barbiturates (phenobarbital)
* Benzodiazepines (diazepam, clonazepam, alprazolam) • Opiates (oxycodone, hydrocodone, morphine)
* Tricyclic antidepressants (amitriptyline)
* Illicit drugs (cocaine, marijuana)
* Alcohol
37
Good Sleep Hygiene
- Go to bed and wake up at the same time
- Don't eat or drink right before bed
- Keep naps short and before 5 PM
- Exercise regularly
- Develop bedtime rituals
- Keep the bedroom a relaxing space, don't work in there
- Go to bed in a dark, quiet room that isn't too hot or cold
- Don't lie in bed awake
38
D/F Exclusions
* Chronic fatigue
* Medication-induced drowsiness
* Heart disease
* Anxiety disorders
* Age <12 years
* Pregnancy or breastfeeding
39
Insomnia Exclusions
* Chronic insomnia
* Frequent nocturnal awakenings or early morning awakening
* Sleep disturbance due to psychiatric or medical disorders
* Age <12 or ≥65 years
* Pregnancy
