Chapter 4 - Insomnia Flashcards
What is insomnia?
Difficulty getting to sleep
Difficulty staying asleep
Early wakening
Impaired daytime functioning e.g. impaired concentration, fatigue, mood affected
What is the difference between short and long term insomnia
Short term - less than3 months
Long term - symptoms occurring in more than 3 nights a week for more than 3 months
List some lifestyle advice for insomnia
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
How is short term insomnia managed?
First, try lifestyle measures
Address triggers e.g. stress
If ineffective use a short term s-drug
Don’t prescribe routinely
How is long term insomnia managed?
Lifestyle advice
Address triggers
For severe exacerbations, a short course of hypnotics can be considered
What should be used for insomnia in the elderly?
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)
What are the main indications of benzodiazepines?
Short term use in anxiety and insomnia
What are the withdrawal symptoms associated with benzodiazepines?
Anxiety
Treat or
Rebound insomnia
Loss of appetite
How do you withdraw a benzodiazepine?
- Transfer the patient in a stepwise manner to the equivalent dose of diazepam
- 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
List some examples of
a) long action benzodiazepines
b) short acting benzodiazepines
a) diazepam, nitrazepam, flurazepam
b) lorazepam, temazepam
Is withdrawal a bigger issue with long or short acting benzodiazepines?
Short acting
Why should benzodiazepines and a-drugs be avoided in the elderly?
They may lead to confusion, falls and injury
Which z-drugs are used in insomnia?
Zopiclone
Zolpidem
Are zolpidem and zopiclone short or long acting?
Short acting
Which antihistamines can be brought OTC for insomnia?
Promethazine
Diphenhydramine
What limits the use of antihistamines in insomnia?
Their long duration of action
This can often lead to drowsiness the next day
They are also associated with antimuscarinic side effects
Should alcohol be used for sleep disorders?
No, they can worsen sleep disorders
Why shouldn’t opioids and temazepam be co-prescribed?
Risk of respiratory depression
Symptoms include SOB
What are the main side effects of temazepam?
Respiratory depression Sedation Paradoxical side effects Hypotension Withdrawal, tolerance, dependence
What classification is temazepam?
CD3
When should melatonin be taken?
Adults >55 - 1-2 hours before bedtime
Patients with learning difficulties - 30-60 minutes before bedtime
How long should melatonin be used in:
a) jet lag
b) insomnia in adults over 55
a) 5 days
b) 13 weeks
Should melatonin be taken with or without food?
Modified release - with food
Immediate release - empty stomach
What doses of zopiclone should be given in insomnia?
Adult - 7.5mg at bedtime
Elderly - 3.75-7.5mg at bedtime
How long should zopiclone or zolpidem be used for in insomnia?
Max 4 weeks
List some contraindications of z-drugs
Pregnancy
Psychotic illnesses
Obstructive sleep apnoea
Neuromuscular respiratory weakness
List some side effects of z-drugs
GI - nausea, vomiting, dry mouth
Neurological - confusion, dizziness, headache, respiratory depression
Psychiatric effects - depression, suicide ideation, aggression, delusions hallucinations, inappropriate behaviour
Dependance, tolerance, withdrawal
How long should patients leave between taking zolpidem and driving?
8 hours
What is narcolepsy?
A brain condition causing for people to suddenly fall asleep at inappropriate times
What treatment options are there for narcolepsy?
CNS stimulants - modafinil, methylphenidate, pitolisant
CNS depressant - sodium oxybate - this is not yet funded on the NHS
What classification is sodium oxybate?
CD2
Can modafinil be used in pregnancy?
No, it can cause congenital malformations
