Insomnia 1.3

Question 1

What is insomnia?

Answer 1

• The inability to initiate or maintain sleep, or lack of refreshing sleep
• Associated with daytime symptoms
• Fatigue, sleepiness, inattention, mood disturbance and impaired performance

Question 2

What is insomnia most often caused by?

Answer 2

• an insomnia disorder
  
  • adjustment sleep disorder
    
    • acute emotional stressors
  • psychophysiologic insomnia
    
    • insomnia that persists beyond resolution of precipitating factors
• inadequate sleep hygiene
  
  • Caffeine/stimulant medication in afternoon/evening
  • Exercise or other stimulating activity (eg Netflix!) in the evening
  • Irregular sleep wake schedule
• psychiatri disorder
  
  • depression, anxiety, substance use disorder
• medical disorder
  
  • pulmonary, musculoskeletal, chronic pain

Question 3

What are the adverse outcomes of insomnia?

Answer 3

• Decreased quality of life
  
  • Fatigue, anxiety, depression, sick days, medical issues
• Subjective decrease in cognitive function and performance
• Self medication
• Association with suicide
• Increased cardiovascular risk

Question 4

What are the risk factors & co morbidities of insomnia?

Answer 4

• Complex relationship with other medical and psychological disorders
  
  • No longer necessarily primary or secondary (usually some overlap)
• Primary insomnia
• Secondary insomnia
  
  • Associated with other disorders
  • Eg depression, pain, substance use disorder
• Insomnia can also be a part of some other disorders such as sleep apnoea and episodic movement disorders (eg restless legs syndrome)
• Successful treatment of insomnia requires management of both the insomnia itself and any underlying conditions

Question 5

What are some individual factors associated with an increased risk of insomnia?

Answer 5

• Older age
• Female gender (esp peri- and post-menopausal)  Previous episode of insomnia
• Family history
• “light sleeper”

Question 6

What are the 3 main components of diagnosing insomnia?

Answer 6

• Persistent sleep difficulty
• Adequate sleep opportunity
• Associated daytime dysfunction

Question 7

What are the types of insomnia?

Answer 7

• Short-term
  
  • Days to weeks (usually <1 mth, definitely <3months)
  • In response to an identifiable stressor
• Chronic
  
  • Sx >3x/week for >3 months

Question 8

What is the goal of treating insomnia?

Answer 8

• Aim to improve sleep quality and quantity, and relieve insomnia-related daytime impairment

Question 9

How do we treat/ manage insomnia?

Answer 9

• Stepwise approach
  
  • Management of underlying problems
  • Good sleep practices
  • Psychological and behavioural interventions
  • Pharmacological treatment

Question 10

How do we manage underlying problems?

Answer 10

• Address the underlying condition and you may assist the insomnia
  
  • Eg nocturnal pain – optimise analgesia
  • GORD – treat with PPI
  • Co-morbid depression – SSRI
  • Excess caffeine – reduce consumption and change time consumed
  • Nocturia – take diuretic earlier in day
  • Sleep disturbance due to intrinsic sleep disorders require specific treatment (eg OSA and RLS)

Question 11

What are good sleep practices?

Answer 11

• sleep- wake activity regulation
  
  • go to bed at the same time each day
  • arise at a regular time
  • avoid lying in bed for long periods of time worrying about sleeping
  • avoid oversleeping
  • avoid napping (if necessary, limit to afternoon ‘powernap’ of 10 to 15 mins)

Question 12

What are some other good sleep practices?

Answer 12

• sleep setting & influences
  
  • seek exposure to bright light after waking
  • avoid heavy means within 3 hours of bedtime
  • undertake regular daily exercise but avoid vigorous exercise 3 hrs b4 bedtime
  • ensure a quiet, dark room for sleeping- remove TV, music player, laptop, mobile phone
  • avoid having pets & highly illuminated digital clocks in the bedrooom
  • use a suitable mattress & pillow for comfort & support
  • reserve bedroom for sleep & intimacy
  • avoid caffeine after midday
  • reduce excessive alcohol intake
  • avoid tobacco esp in evening
  • avoid illicit drugs

Question 13

Other good sleep practices?

Answer 13

• sleep-promoting adjuvants
  
  • have a light snack or a warm milk drink before bed
  • have a warm bath before bed
  • ensure a comfortable temperature for sleep & maximal darkness

Question 14

What are some psychological & behavioural interventions for treatment of insomnia? What are these used for?

Answer 14

• relaxation therapies
• cognitive therapy
• stimulus control
• sleep restriction
• most effective treatments for CHRONIC insomnia
• also effective in the treatment of insomnia

Question 15

What do relaxation therapies involve?

Answer 15

• Hypnosis, meditation, deep breathing, progressive muscle relaxation
  
  • Reduce physiological hyperarousal
  • Useful for people who have trouble relaxing/winding down
  • Practice during the day, before bed and during the night if needed
  • Often several weeks of practice are required to improve sleep
    
    • Eg Smiling mind, Headspace, Happy Habit apps

Question 16

What does cognitive therapy involve?

Answer 16

• People with insomnia often have dysfunction beliefs and unrealistic expectations about sleep  Vicious cycle of worry about sleep
  
  • Reassure them that most people with insomnia get more sleep than they perceive
  • Cognitive therapy targets these maladaptive beliefs about insomnia

Question 17

What is stimulus control?

Answer 17

• Useful for people who have trouble sleeping because they associate the bedroom with frustration, worry and poor sleep
• Limit time spent in bed awake.
• Learn to associate the bedroom only with sleep
  
  • Go to bed only when sleepy and get out of bed if awake/worrying for >15 minutes
  • Return to bed when sleepy and leave again if remain awake

Question 18

What is sleep restriction?

Answer 18

• Suitable for people who have difficulty staying asleep due to poor sleep drive
  
  • a person with insomnia feels they sleep only 4 hours per night, despite generally being in bed from 10pm till 8am
  • tell patient to start restricting their sleep to ONLY 4 hours a night as this is the length of time they think they are sleeping
  • they must comply with sleep schedule until they are regularly sleeping throughout the 4 hours & they feel increasingly sleepy, wanting to go to bed earlier
  • once this target is reached, they can increase the time in bed by 30mins until they are sleeping through & craving sleep at an earlier time
  • again the reward of an extra 30min sleep will occur when the person is sleeping through their allocated time

Question 19

What pharmacological treatment can be used to treat insomnia?

Answer 19

• hypnotic drug
  
  • benzo–> temazepam
  • zolpidem
  • zoplicone
• melatonin
  
  • for short term management
  • & chronic insomnia when hypnotic drug not effective

Question 20

How does a Dr decide when to prescribe a hypnotic drug or melatonin?

Answer 20

• The cause of insomnia
• The level of distress caused by the lack of sleep
• The degree of impairment from the daytime sequelae of insomnia
• Likely benefits balanced against the possible harms of treatment

Question 21

What are the treatment considerations with hypnotics?

• temazepam
• zolpidem
• zoplicone

Answer 21

• Explain potential problems of hypnotics
  
  • Impaired daytime alertness
  • Tolerance and dependence with long-term use
  • Falls risk
  • Sleep may not be “refreshing”
  • Watch for contraindications (eg OSA)
• If treatment prescribed
  
  • Shortest possible timeframe (preferably dosed intermittently and for <2weeks)
  • Intermittent tx for long-standing treatment resistant insomnia may be considered
  • A definite duration of use agreed with the patient at the outset
  • Limit quantity prescribed
• Rebound insomnia
  
  • Broken sleep with vivid dreams may occur when hypnotics ceased
  • May take days-weeks for sleep patterns to be re-established
  • May be misinterpreted as needing more medication

Question 22

What are some considerations for temazepam as hypnotic for insomnia?

Answer 22

• Preferred option for insomnia (per eTG)
• Rapid onset and short t 1⁄2
• May still cause daytime drowsiness the next day
  
  • Avoid benzodiazepines with longer t 1⁄2
• May be used short term in the management of insomnia
  
  • Eg when starting on an SSRI
• Benzodiazepines can cause cognitive dysfunction with long-term use which may not be fully reversible
• Elderly patients are at increased risk of over-sedation, ataxia, falls, memory impairment and respiratory depression
  
  • Use lowest dose for shortest possible time  Avoid longer acting agent
  • avoid longer acting agents

Question 23

What are some considerations for zolpidem & zoplicone?

Answer 23

• Compared to benzodiazepines
  
  • Similar hypnotic properties
  • Minimal anxiolytic, muscle relaxant and anti-epileptic properties
  • Less morning sedation and less disruptive effect on sleep patterns?
  • Dependence, tolerance, withdrawal and misuse can still occur
• Black box warning - Zolpidem (and possibly all hypnotics)
  
  • zolpidem may be associated with potentialy dangerous complex sleep related behaviours which may include sleep walking, sleep driving & other bizarre behaviours
  • NOT to be taken w alcohol
  • limit use to 4 weeks under close supervision

Question 24

What is the issue with long term hypnotic use? What needs to be done?

Answer 24

• Patient may have unwittingly become dependant
• Discuss and trial a cessation of long-term hypnotic where possible
  
  • Regular contact between patient and Dr
  • Tailored dose reduction
  • Non-pharmacological treatments
  • Lots of support and encouragement

Question 25

When can we continue long term use of hypnotics?

• temazepam
• zolpidem
• zoplicone

Answer 25

When:

• Detailed history shows no adverse effects
• Patient is aware they may be dependent
• Reduction program has been unsuccessful or is against patients wishes

Question 26

What are some other options for treatment of insomnia?

Answer 26

• melatonin
• suvorexant
• TCAs, sedating antihistamines, chloral hydrate, antopsychotics, mirtazepine
• valerian

Question 27

Discuss melation as insomnia treatment….

Answer 27

• indication
  
  • Short-term monotherapy in primary insomnia with poor sleep quality
  • Trials only included those >55yrs
  • No data in hepatic impairment
• Dose
  
  • 2mg CR 1-2 hours before bed for up to 13 weeks
  • also available in liquid form
• practice points
  
  • Limited evidence it may improve sleep quality
  • May be effective in delayed sleep phase syndrome
  • People with severe neurological, neurosurgical or psychiatric diseases, or taking drugs that affect the CNS were excluded from clinical trials
  • There do not appear to be any dependence or withdrawal effects, or rebound insomnia
  • Used for children/adolescents with sleep disorders in neurodevelopmental disorders

Question 28

Explain suvorexant as insomnia treatment?

Answer 28

• orexin receptor antagonist
• new medication
• Indication
  
  • treatment of chronic insomnia
    
    • people with neurological or psychological issues exculded from trials
• dose
  
  • Adult <65 years – 20mg at night, 30 minutes before bed
  • Adult >65 years – 15mg at night, 30 minutes before bed
    • Best on empty stomach for faster effect

Question 29

What are some ADV of suvorexant?

Answer 29

• Common – somnolence, headache
• Infrequent – abnormal dreams, sleep paralysis, hallucinations in sleep
• Rare – sleepwalking, suicidal ideation

Question 30

What are some practice points with suvorexant?

Answer 30

• Avoid in combination with CYP3A4 inhibitors or inducers
• Only take if intending to get a full nights rest (at least 7 hours)
• May be drowsy the following day (don’t drive for at least 9 hours)
• Assess response to treatment after 7–10 days; reassess after 3 months
• May be useful for sleep-maintenance insomnia
• Uncertain benefit for sleep-onset insomnia
• Unclear whether rebound insomnia, dependence or withdrawal effects occur
• Head-to-head studies are required to assess its relative efficacy compared to other drugs used to treat insomnia

Question 31

How do we manage insomnia for older people?

Answer 31

• good sleep practices
• non pharmacological management
• hypnotics only started in hospital or in residential care facilities when non pharmacological approaches are unavailable or not practical
• Highest rates of benzodiazepine use is in the elderly
  • Elderly are the most at risk of harm from adverse effects
  • Falls, cognitive impairment, incontinence, confusion, dependence
• dementia patients
  
  • Often have marked sleep fragmentation
    
    • Dozing during day
    • Sundowning (agitated, wandering and wakeful early evening/night)
    • Non-pharmacological interventions recommended

Question 32

What is an example of circadan rhythm disorder?

Answer 32

• jet lag
• commonly affects travellers who cross several time zones
  
  • body clock out of sync with local time
    
    • worsens depending on how many time zones crossd
    • wose in an eastlery direction

Question 33

What is the treatment for jetlag/ circadian rhythym disorders?

Answer 33

• Adjust to new time zone as quickly as possible
  
  • Exercise and early morning light
• Melatonin – taken at target bedtime at destination decreases jet lag
• Short-acting hypnotic on flight and for 3 consecutive nights at bedtime
  
  • Increased DVT risk if taken on plane
  • May be additive sedation if used with melatonin