Chapter 4 - Insomnia

Question 1

What is insomnia?

Answer 1

Difficulty getting to sleep
Difficulty staying asleep
Early wakening
Impaired daytime functioning e.g. impaired concentration, fatigue, mood affected

Question 2

What is the difference between short and long term insomnia

Answer 2

Short term - less than3 months

Long term - symptoms occurring in more than 3 nights a week for more than 3 months

Question 3

List some lifestyle advice for insomnia

Answer 3

Make sure that the bed is comfortable
Only use the bedroom for sleeping
Avoid blue light displays for 2 hours before bedtime
Don’t clockwatch (may help to remove clocks)
Avoid eating a large meal or drinking alcoholic for 2 hours before bed
Avoid caffeine after midday
Avoid exceeding within 4 hours before bed
Do exercise earlier in the day
Go to bed and wake up at the same time each day
Don’t nap in the day
Try not to go to bed too early

Question 4

How is short term insomnia managed?

Answer 4

First, try lifestyle measures
Address triggers e.g. stress

If ineffective use a short term s-drug
Don’t prescribe routinely

Question 5

How is long term insomnia managed?

Answer 5

Lifestyle advice
Address triggers

For severe exacerbations, a short course of hypnotics can be considered

Question 6

What should be used for insomnia in the elderly?

Answer 6

Melatonin (over 55 years)

Initial duration over 3 weeks
If there is a response to treatment can do up to 10 weeks

Risks include falls and fractures (same with all hypnotics)

Question 7

What are the main indications of benzodiazepines?

Answer 7

Short term use in anxiety and insomnia

Question 8

What are the withdrawal symptoms associated with benzodiazepines?

Answer 8

Anxiety
Treat or
Rebound insomnia
Loss of appetite

Question 9

How do you withdraw a benzodiazepine?

Answer 9

1. Transfer the patient in a stepwise manner to the equivalent dose of diazepam
2. Reduce the dose of diazepam gradually by 1-2mg every 2-4 weeks
   It may be necessary to reduce the dose by 500mcg near the end

Question 10

List some examples of

a) long action benzodiazepines
b) short acting benzodiazepines

Answer 10

a) diazepam, nitrazepam, flurazepam

b) lorazepam, temazepam

Question 11

Is withdrawal a bigger issue with long or short acting benzodiazepines?

Answer 11

Short acting

Question 12

Why should benzodiazepines and a-drugs be avoided in the elderly?

Answer 12

They may lead to confusion, falls and injury

Question 13

Which z-drugs are used in insomnia?

Answer 13

Zopiclone

Zolpidem

Question 14

Are zolpidem and zopiclone short or long acting?

Answer 14

Short acting

Question 15

Which antihistamines can be brought OTC for insomnia?

Answer 15

Promethazine

Diphenhydramine

Question 16

What limits the use of antihistamines in insomnia?

Answer 16

Their long duration of action
This can often lead to drowsiness the next day

They are also associated with antimuscarinic side effects

Question 17

Should alcohol be used for sleep disorders?

Answer 17

No, they can worsen sleep disorders

Question 18

Why shouldn’t opioids and temazepam be co-prescribed?

Answer 18

Risk of respiratory depression

Symptoms include SOB

Question 19

What are the main side effects of temazepam?

Answer 19

Respiratory depression
Sedation 
Paradoxical side effects 
Hypotension 
Withdrawal, tolerance, dependence

Question 20

What classification is temazepam?

Answer 20

CD3

Question 21

When should melatonin be taken?

Answer 21

Adults >55 - 1-2 hours before bedtime

Patients with learning difficulties - 30-60 minutes before bedtime

Question 22

How long should melatonin be used in:

a) jet lag
b) insomnia in adults over 55

Answer 22

a) 5 days

b) 13 weeks

Question 23

Should melatonin be taken with or without food?

Answer 23

Modified release - with food

Immediate release - empty stomach

Question 24

What doses of zopiclone should be given in insomnia?

Answer 24

Adult - 7.5mg at bedtime

Elderly - 3.75-7.5mg at bedtime

Question 25

How long should zopiclone or zolpidem be used for in insomnia?

Answer 25

Max 4 weeks

Question 26

List some contraindications of z-drugs

Answer 26

Pregnancy
Psychotic illnesses
Obstructive sleep apnoea
Neuromuscular respiratory weakness

Question 27

List some side effects of z-drugs

Answer 27

GI - nausea, vomiting, dry mouth
Neurological - confusion, dizziness, headache, respiratory depression
Psychiatric effects - depression, suicide ideation, aggression, delusions hallucinations, inappropriate behaviour
Dependance, tolerance, withdrawal

Question 28

How long should patients leave between taking zolpidem and driving?

Answer 28

8 hours

Question 29

What is narcolepsy?

Answer 29

A brain condition causing for people to suddenly fall asleep at inappropriate times

Question 30

What treatment options are there for narcolepsy?

Answer 30

CNS stimulants - modafinil, methylphenidate, pitolisant

CNS depressant - sodium oxybate - this is not yet funded on the NHS

Question 31

What classification is sodium oxybate?

Answer 31

CD2

Question 32

Can modafinil be used in pregnancy?

Answer 32

No, it can cause congenital malformations