Insomnia Flashcards
What is SL (sleep latency)
time to get to sleep following bedtime
What is WASO (Wake after sleep onset)?
sum of wake times from sleep onset to final awakaning
What is TIB
time from bedtime to getting out of bed
What is TST?
total sleep time = TIB-SL-WASO
What is sleep efficiency percent?
SE= TST/TIB x 100
What stage of sleep does most sleep occur?
stage 2
What sleep stage is it hardest to wake up from?
stage 3
What stage of sleep do we dream?
stage 4 or REM sleep
Generally How many times does does sleep cycle through?
4-5 cycles
WHat are some wake promoting neurotransmitters?
Glutamate, Acetylocholine, dopamine, Nor E, 5Ht, his
What is some sleep promoting neurotransmitters?
GABA, Melatonin, glycine, adenosine
What structure promotes wakefulness?
RAS
What are some major things to be diagnosed insomnia for DSM 5?
difficulty initiating sleep or maintaining or non restorative,
and impairment of daytime= cognitive, tired, mood
at least 3 x per week for at least 3 months
hard even though opportunity to sleep
What is the definition of insomnia?
SL of > 30 min, efficiency of < 85%, less than 6 hours of total sleep for > 3 days a week for 3 months
When is it acute insomnia?
1 month
What is sub chronic insomnia?
1-3 months
What is persistent insomnia?
> 3 months
What is primary insomnia?
no causation
What is secondary insomnia?
caused by medical condition or s/e
What would hyperthyroidism cause for sleep?
insomnia
What is some other conditions other than insomnia that it could be?
obstructive sleep apnoea
restless leg syndrome
narcolepsy- sleep in daytime
circadian rythym syndrome- sleep at wrong time
parasomnia
What can stimulate narcolepsy sleeping during day?
laughing
What is parasomnia?
unpleasant experiences with sleep that stops you from sleeping
What test can we use to see if it is sleep apnoea?
STOP-BANG
What is the general insomnia assessment?
Epworth sleepiness scale
SLEEP DIARY
Insomnia severity scale
For AIS what is mild moderate and sever insomnia score?
mild= 6-9
mod= 10-15
severe= 16-24
Which gender struggles more with sleep?
females
How does age relate to sleep?
older= worse sleep
What percentage of people meet criteria for insomnia?
6-10%
How does old make sleep worse?
delayed onset, less REM, wake up more
Why would women have worse sleep?
lots of hormonal changes
What comorbidities is very common with insomnia?
depression anxiety, congestive heart failure
What are some risk factors for poor sleep?
stress, age, female, Comorbidities, shift work, lower status
What meds could make sleep hard?
diuretic= pee
statin= muscle pain
prednisone, levodopa, stims, venlafaxine, fluvoxamine
Les than how many hours increases risk of obesity?
<5 hours
Why can lack of sleep cause obesity?
lower leptin levels
What is our primary goal of therapy for insomnia?
increase sleep quality, lower daytime impairments
What are some general secondary goals of therapy?
Sl <30 min
WASO <30 min
lower awakening
>6 total hours
What is the best way to treat insomnia?
treat underlying cause first/ psychological
How does CBT help?
lower SL and WASO
and lower severity NOT TST
What component of CBT is the most important?
sleep restriction
What are some good sleep hygiene?
don’t stay too long in bed, schedule, exercise, get out of bed if can’t sleep, comfortable, no stims, dark, no screens
What are the components of CBT?
cognitive=misconceptions
stim control=only go to bed sleepy, don’t do none sleep things in bed
sleep restriction
sleep hygiene
relaxation
How do you plan sleep restriction?
set wake time
set a bedtime
How long to use benzes and z drugs?
LESS than 4 weeks
How much do the drugs GENERALLY improve sleep?
25 min
SL decrease of 10 min
and lower awakenings
Why is drug therapy not very good?
not super helpful and NNH high
How do benzos and z drugs work?
bind to GABA which inhibits CNS and calms you
What are some benzos?
PAM’s and am’s
What are the short acting benzos
end in am
What side effects are we worried about with midazolam?
amnesia and withdrawal and dependency
Why are we worried with older people with these drugs?
falls and accidents
DO we want a short, medium or long acting benzo?
medium
What are the medium benzos?
LOT
lorazepam, oxazepam, temazepam
clonazepam
Which is better eszopiclone vs zopiclone?
maybe better efficiency in eszopiclone but the same everywhere else
How many awakenings will you have if on z drug or benzo?
1 less
Can you have alcohol while on benzos and z drugs?
fuck no
IS antihistamines good? And what are we concerned about
no, tolerance in 4 days
S/E of antihistamines?
anticholinergic
What value does melatonin have?
8 minute improvement of SL
What is rationale behind melatonin?
levels decline as we age
Where is melatonin produced?
pineal and is increased in dark
Is TCA’s an option?
increase TST, SL, efficiency, lower awake
but not much benefit
Who is a no for TCA?
old people
S/E of TCA
anticholinergic, BPH, hypotension, arrythmias, epilepsy
When may we use TCA?
if they have depression too
What is MOA of doxepin?
H1 may help older with quality, time, efficiency NO for SL
S/E of doxepin?
anticholinergic
What must be said if giving doxepin?
no within 3 hours of meal
and next day drowsy
MOA of trazodone
weak 5 HT reuptake inhibitor
What is a positive of trazodone?
lower risk of morning hangover and tolerance
Is trazodone worth it?
very limited evidence
What is con of mirtazepine?
weight gain
What is pro of mirtazepine?
can get less sedation etc higher doses
Should we use mirtazepine and quetiapine JUST for insomnia?
noooooo
What are the drugs that work on orexin receptor antagonist?
end in orexant
What are some s/e that are more uncommon for orexin drugs?
weird dreams, sleep paralysis, mood changes, suicide
What is a pro with orexin drugs?
no rebound insomnia
Which is better orexin or z drugs?
orexin
When should the patient maybe be informed of deprescribing benzos?
> 65
recent hospitalization
long term car
falls
substance use
How do you deprescribe these agents?
taper- with long acting, by 5 mg of diazepam
no refills so they must see someone
Which is better for tappering benzo or z drug?
neither
When is tapering required?
> 8 weeks
