Insomnia Flashcards
Aetiology, pathophysiology and diagnosis
Insomnia - difficulty sleeping, maintaining sleeping, early wakening, or non restorative sleep. affects day time functioning = Causes daytime symptoms.
- Sleep disturbance without day time impairment isn’t insomnia
Short term insomnia - symptoms <3 months
Chronic insomnia - 3times/ week for >3 months
Primary insomnia - cause unknown
Secondary insomnia - due to co morbid condition
Symptoms:
- Daytime = Poor concentration, mood disturbance, fatigue.
Sleep regulation and its importance
2 parts of sleep. REM and NREM
NREM = stage N1 - N3 (ds)
REM = last stage 20% of sleep cycle
NREM- easily awakened at sleep get deeper sleep the cycle progresses, BP drops, HR drops, Breathing rate drops, Body temp drops, eyes move slowly, tissue grows and repairs. (stage 1 and 2)
stage 3 (DS) delta waves produced by brain, energy restored, hormones released, brain becomes active
REM- rapid eye movements begins, muscles are paralysed, irregular HR and breathing.
Assessment
Take history and ask about:
- Symptoms
- Duration and frequency of symptoms
- Sleep schedule
- Sleep environment
- Triggers (stress, work shift, jet lag)
- Behaviour during sleep (snoring, apnoea, restless, sleep walking)
- Past medical history
- Impact of insomnia
- Meds and substances (caffeine, alcohol, nicotine, illicit drugs)
Investigation can do sleep diary
Complications
Issues with memory, attention, learning (cognitive issues)
decreased quality of life - poor work performance etc
psycho issues - depression anxiety, substance misuse.
Increase risk of CVD and T2DM
Increase mortality
Treatments
Short term insomnia:
- consider referral
- Address possible causes insomnia
- Offer sleep advise
- Advise don’t drive if sleepy
IF ABOVE FAILS, day time impairment is severe causing significant distress, and insomnia is likely to resolve soon:
- Consider short course (3-7 days) of a non-benzo hypnotic medication (z-drug).
- Hypnotics not for older, P, or BF
If not likely to resolve soon:
- Offer CBT-I 1st line any age
- Adjunctive short term hypnotic (a z-drug or MR melatonin if >55 )
- NO OTC
HYPNOTIC prescribed:
- Lowest effective dose for shortest time NOT >2 WEEKS preferably <1 week
- NO FURTHER PRESCRIPTION
- 1st hypnotic fail dont try another
Long term insomnia:
- CBT-I 1st line any age
- AVOID pharmacological therapy BUT: Severe symptoms or acute exacerbation - short course hypnotic drug (<1week) can be given as temporary adjunct OR
>55 persistent insomnia can use MR Melatonin:
- Melatonin recommended initially 3 weeks no response then 10 weeks.
CBT-I FAIL = daridorexant BUT:
- Short as possible treatment
- Asses within 3 months of starting and not stopped if insomnia hasn’t responded adequately
- Address triggers or possible causes (comorbidities(anxiety))
- Sleep hygiene advise
- DONT DRIVE IF SLEEPY
DRUGS:
Benzodiazepines (diazepam) - severe disabling extreme distress insomnia OR insomnia in anxiety
NON benzo hypnotics/sedatives (clomethiazole) elderly severe - short term use only
Barbiturates Severe short term - need to be already taking this b4 .
Z hypnotics (Zolpidem tartrate, zopiclone) - short term
Melatonin - short term or elderly or Patient with learning disabilities/ behaviour issues (specialist only). Can be used in kids under specialist
Follow up/Refer
ALL insomnia:
- Arrange regular follow up eg 2-4 weeks
Long term :
- Can refer to sleep clinic or neurology if another sleep disorder shown OR doubt in diagnosis or no good response to treatment.
