Insomnia Flashcards
What are 2 requirements for a diagnosis of insomnia?
- Adequate opportunity and circumstances for sleep
- Daytime impairment
Can a patient have a psychiatric disorder and insomnia at the same time?
Yes. Treating depression successfully will not necessarily improve the insomnia
What is the prevalence for chronic insomnia? Transient insomnia?
Chronic insomnia = 10%
Transient insomnia = 30%
What are the 4 components of CBT?
- Sleep restriction
- Stimulus control therapy
- Relaxation therapy
- Sleep hygiene
What is the minimum amount of time in bed for sleep restriction therapy?
5 hours
In sleep restriction therapy, what sleep efficiency should the patient obtain before lengthening the time in bed? How much time should be added?
At least 85% sleep efficiency
Increase TIB by 15 to 30 min
What is cognitive restructuring?
Changing faulty beliefs and attitudes that patient’s with insomnia have about sleep
What is an essential feature of idiopathic insomnia?
Onset of the insomnia in childhood or infancy
What is the MOA of suvorexant (abelsomra)? Is it addictive?
Orexin antagonist. It has the potential for addiction.
What do beta blockers, NSAIDS and corticosteroids have in common?
They can all cause insomnia
Which can cause insomnia: Alpha 1 or alpha 2 blockers?
Alpha 1 blockers (like prazosin) can cause insomnia
Alpha 2 blockers like yohimbine are not used much In humans
Which are associated with somnolence and fatigue: alpha 1 or alpha 2 agonists?
Alpha 2 agonists (like clonidine) are associated with somnolence and fatigue
What are the major neurotransmitters that regulate sleep?
- GABA
- Galanin
- Melatonin
- Adenosine
What receptors do benzodiazepines bind to?
They nonselectively bind to GABA A receptors
What receptors to non benzodiazepine BzRAs bind to?
Alpha 1 subunit on GABA A receptors
What pharmacologic effects are lost with non benzodiazepine BzRAs?
Anxiolysis and muscle relaxant effects
It still has antiseizure and amnesia effects
What does the MSLT show in patients with insomnia?
Usually normal. Several studies show longer mean MSLT, indicating hyperalertness
What effect do barbiturates have on REM sleep?
They are potent REM inhibitors
What is the main effect of benzodiazepines on sleep architecture?
They inhibit N3 sleep and to a lesser degree, REM sleep
What antidepressants are the most potent inhibitors of REM sleep?
MAOIs
- selegiline
- rasagiline
Zolpidem (Ambien) peak plasma level?
1/2 life?
- 5 hours
- 5 hours
Antipsychotics typically increase N3 sleep except for?
quetiapine
Mirtazepine helps with sleep because it blocks what receptors?
- Adrenergic (alpha 1, alpha 2)
- Sertoninergic (5HT2 and 5HT3)
- Histaminergic (H1)
Why is buspirone not sedating?
It is a partial serotonergic (5HT1A) agonist. It is an anxiolytic
What effects does caffeine have on sleep architecture?
Prolongs latency to sleep onset and decreases N3 sleep
What is the 1/2 life of caffeine?
3 to 5 hours
What effects does diphenhydramine have on sleep?
- Shortens sleep onset
- Does NOT increase TST
- Does NOT reduce nightime awakenings
When is chloral hydrate used and what effects does it have on sleep architecture
- Pediatric sleep aid
- Acts on barbiturate receptor sites at GABA A receptors
- 5 to 10 hr 1/2 life
- Shortens LTSO and improves sleep continuity
- No significant effect on N3 or REM
Doxepin is FDA approved to help with what areas of sleep?
Onset and maintenance insomnia, mostly maintenance
How long does it take for doxepin to achieve peak plasma level and what area of sleep does it help the most?
Peak plama in 1.5 to 4 hours after ingestion (15 hr 1/2 life)
It helps most with the last 1/3 of sleep
What MOA likely explains beta blockers affect on sleep?
They decrease melatonin release
What H2 receptor antagonist can decrease the clearance of benzo receptor agonists the most?
Cimetidine
Name 3 effects that NSAIDs have that impairs sleep
- Decreases melatonin release
- Decrease the synthesis of protaglandin D2
Prostaglandin (PG) D2 and adenosine are potent humoral sleep-inducing factors that accumulate in the brain during prolonged wakefulness. PGD2 is produced in the brain by lipocalin-type PGD synthase, which is localized mainly in the leptomeninges, choroid plexus and oligodendrocytes, and circulates in the cerebrospinal fluid as a sleep hormone.
- Impair the normal drop in body temperature
What is the prevalence of insomnia in persons older than 65 years?
35 to 50%
How many times per week should a patient have difficulty sleeping to meet a diagnosis of chronic insomnia?
At least 3 times per week
What is paradoxical insomnia?
Also called sleep state misperception. Pt reports severe insomnia without daytime symptoms or correlating PSG findings
What is adjustment insomnia?
Insomnia associated with an identifiable stressor lasting only a few days to several weeks but less than 3 months
What is the most common cause of nocturnal awakenings during pregnancy?
Nocturia
In sleep restriction therapy, what does the sleep efficiency need to be to allow an additional 15 minutes in bed for the next 7 days?
At least 85%
What will the EEG show during acute sleep deprivation?
- Decreased alpha activity with eye closure (if awake > 115 hours alpha can disappear entirely)
- In chronic sleep deprivation alpha activity might not change at all
- Increased theta and delta activity
What are the diagnostic criteria for irregular sleep-wake rhythm disorder?
- At least 3 irregular sleep-wake cycles (1 to 4 hrs sleep) over 24 hours
- 2 week sleep diary/actigraphy
What disorders commonly have irregular sleep-wake rhythm disorder?
- Dementia
- Developmental disorders
- Head injury
- Schizophrenia
What 2 OTC meds are FDA approved for treating insomnia?
- Diphenhydramine
- Doxylamine (Unisom)
