Insomnia Flashcards
Facts about sleep
Sleep is vital
Part of circadian rhythm – many functions including growth, rest & recovery.
Pattern varies throughout life
Adults need 4 to 9 hours sleep
Deprivation leads to –ve effect on mood, motivation, alertness, memory & physical function.
Lab rats die after 14 days of no sleep!!
Normal adult sleep pattern in one night
Level of sleep is not the same Goes via several stages of sleep REM- Shallowest stage of sleep, they are most aware and the brain is functional waking in between cycle They do not spend more time at REM sleep
Define Insomnia
A condition of unsatisfactory quantity and/or quality of
sleep which persists for a considerable period of time,
including difficulty falling asleep, difficulty in staying
asleep, or early final wakening.
Insomnia is a common
symptom of many mental and physical conditions. True or false?
True
How Insomnia is described
Can be indicated if an individual reports two or more of the following: Take more than 30 mins to go to sleep Difficulty maintaining sleep Disturbed sleep - >3 x per week Daytime functioning impaired Short but healthy sleep vs. insomnia
State the two types of Insomnia
- Primary Insomnia
2. Secondary Insomnia
What type of insomnia comes from an unknown origin or arises from sleep environment?
Primary Insomnia
Define secondary Insomnia
Insomnia that arises due to an underlying psychological or physical condition
List and briefly explain the classification of insomnia due to duration of symptoms
- Transient Insomnia- Lasts 2-3 days
- Short-term- Lasts longer than three days, but
<3 weeks - Long-term (chronic) -Lasts longer than three
weeks
A high level of cortisol production during the day and at night time could result in lack of sleep. True/false.
True
What is the common reason for the excessive production of cortisol
One common reason for the excessive production of cortisol is tumor in the pituitary gland
Production of high levels of steroids hormones leads to what type of insomnia?
Secondary Insomnia
Most of the P medicines are licensed for short term and transient insomnia. True/false
True
Epidemiology of Insomnia
About 10-38% of all people have sleep problems in any given year
In a UK study, 30-48% of people reported insomnia symptoms and 8-18% sleep dissatisfaction, only 6% met the criteria for a diagnosis of insomnia
Prevalence seems to be greater in women, older people, and those who are socioeconomically disadvantaged
Insomnia typically develops at times of increased life stress
Primary Insomnia mainly caused by;
- A poor sleep environment e.g. light, noise, heat
- Behaviour that makes sleep difficult e.g.
Physical / intellectual arousal - Varying sleep routine – mismatch between
attempts to sleep and circadian rhythm e.g. Jet-
lag and shift
State the ‘5 P’s’ approach to causes of secondary Insomnia
1.Physical- CV disease; COPD/asthma; pain
2.Physiological- Late heavy meals, high in fat or
protein or both
3.Psychological- Stress; tension; grief;
ASPS/DSPS
4. Psychiatric- Mood and/or anxiety disorders
5. Pharmacological- Alcohol; medicines; illicit
recreational drugs
What is ASPS?
Advanced Sleep Phase Syndrome- The patient becomes really tired much earlier in the day than you would expect, they feel like its late at sort of tea time. Their 24 hour is shorter in ASPS
Whats DSPS?
Delayed Sleep Phase Syndrome- 24hour longer in
DSPS
This is where the patient does not keep to 24-hour pace circadian rhythm
Effect of Alcohol on the sleep cycle
Alcohol prevents deep sleep (REM) REM cycle from happening, it does not provide a refreshing sleep although it helps people to sleepalcohol-fuelled sleep is marked less refreshing than the non-alcohol fuelled sleep
List POMs which can cause insomnia
Anticonvulsants (Phenytoin, Lamotrigine) Beta-blockers (Atenolol, Propranolol) SSRIs (Fluoxetine, Sertraline) Antiparkinson drugs (Levodopa) Decongestants (Pseudoephedrine) Corticosteroids (Prednisolone, Dexamethasone) Levothyroxine
List Information needed for diagnosis of Insomnia
Detailed questioning required
Sleep diary
Patient records sleep diary over 2 weeks
Includes:
quantity of sleep, awakenings during night,
quality of sleep,
activity during the day, caffeine, nicotine
this helps to establish a pattern
List the relevant information needed for the diagnosis of Insomnia
pattern of sleep
daily routine
underlying medical condition
Recent travel
When to refer a patient suffering from Insomnia
Children under 12 Longer than 3 weeks No known cause Previous undiagnosed medical conditions Symptoms of anxiety/depression Other sleep disorders Sleep apnoea Narcolepsy Hypersomnia
List the available treatment options for Insomnia
Sleep hygiene OTC Medication: Diphenhydramine Promethazine Herbal products POM Medication
Sleep hygiene measures includes;
Sleep hygiene – developing a routine
Reducing caffeine, nicotine; address alcohol intake
Increasing exercise
Bathing before bedtime
Avoiding Carbohydrate intake before bed
Facts about Diphenhydramine as a treatment option for Insomnia
A large body of evidence
Consistently superior to placebo in terms of induction of sleep, using 50mg ON
50mg is as effective as 60mg sodium pentobarbital.
No increase in effectiveness over 50mg
ADRs – antimuscarinic, additive sedation
Do not use in: glaucoma, prostatic enlargement
TREATMENT OF CHOICE
Diphenhydramine is contraindicated in what kind of condition?
Do not use in glaucoma, prostatic enlargement
What is the brand name of Diphenhydramine?
Nytol
State the dosage of Diphenhydramine 50mg tablets
Adult dose - Over 16; 1 tablet taken 20 mins before bed
Is Diphenhydramine recommended for under 16years old?
Children (under 16) not recommended
State the dosage of 25mg Diphenhydramine tablet.
Diphenhydramine 25mg tablets
(Adult dose - Over 16) - 2 tablets taken 20 mins before bed
Children (under 16) - not recommended
Facts about Promethazine
Widely accepted but only 1 trial found
Adam and Oswald (1986) – 12 healthy volunteers, placebo or 20 or 40mg Promethazine
Both doses increased length of sleep and reduced sleep disturbances cf placebo
Not clear if statistically significant.
Same ADRs / CI as Diphenhydramine
What is the brand name of Promethazine?
Sominex
What is dosage for 20mg Promethazine tablet?
Promethazine 20mg tablets Adult dose (over 16) – One tablet at bedtime Child dose (under 16) – not recommended
List the herbal products available for the treatment of insomnia
Valeriana officinalis Hops (NOT beer though!!!) Wild lettuce – powdered extract Passionflower –leaves, flowers & fruit Lemon balm - leaves Lavender - flowers Jamaica dogwood – root bark
Facts about Valerian
Many trials, not all easy to compare so meta-analysis is difficult
Most show subjective improvement in patients perception of insomnia
Often patients state that their insomnia is ‘much improved’
Not much hard evidence
One trial shows similar effects to low-dose Oxazepam.
.
List the ADRs of Valerian
Hepatotoxicity and impairment
State the dosage of Valerian used for the treatment of Insomnia
Blend of Valerian, Hops, and Passionflower
2 tablets one hour before bedtime
Facts about Hypnotics
Prescribers must weigh up risk vs. benefit Rx only in short-term cases 1 or 2 doses may suffice in these cases BNF – Limit course to 2-4 weeks max Intermittent ( every 3 nights) dosing Tolerance develops within 14 days!!
Facts about Benzodiazepines
Act on GABA by binding to benzodiazepine receptors, boosting inhibitory action of GABA.
CSM warning to only use when insomnia is severe, disabling and causing stress
Do change sleep ‘type’
reducing REM sleep – associated with dreaming.
Seems to reduce quality
when should Benzodiazepines be used in the treatment of Insomnia according to CSM?
CSM warning to only use when insomnia is severe, disabling, and causing stress
List examples of short-acting benzodiazepines?
Temazepam, Lorazepam
List examples of Long-acting Benzodiazepines
Nitrazepam
State the dosage of Temazepam
Temazepam: 10-40 mg ON
What is the dose of Temazepam in elderly patients?
10mg for elderly (20mg exceptionally
Temazepam. is recommended in children. True/false?
True
What kind of effect is seen in patients on Short-acting Benzodiazepines?
little hangover effect
Benzodiazepine is a CD schedule …..
3
List the ADRs of Benzodiazepines
Drowsiness, light-headedness, Confusion, ataxia, amnesia, dependence
Facts about Z- drugs?
Zopiclone, Zolpidem, Zalepon
Non-benzodiazepines, but act on GABA
Short duration of action
ADRS – Similar to Benzodiazepines PLUS tremors, libido changes
Perceived by Psychiatrists to cause less dependence than Benzodiazepines (Pharm J 11/5/2002)
More expensive than Benzodiazepines
Facts about Hypnotic withdrawal programme
Transfer to equivalent diazepam dose
Reduce dose every 2/52, in 2-2.5 mg stages
Stop for a while if symptoms start
Reduce in smaller steps if needed near end of process
Stop completely
Timescale: 4 weeks to 1 year !
