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PHAR 253 > Insomnia > Flashcards

Insomnia Flashcards

1
Q

What is sleep latency?

A

Time to fall asleep following bedtime

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2
Q

What does the acronym WASO mean?

A

Wake up after sleep onset

WASO is the sum of wake times from sleep onset to final awakening

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3
Q

What does the acronym TIB mean?

A

Time in bed

TIB is the time from bedtime to getting out of bed

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4
Q

What does the acronym TST mean?

A

Total sleep time (TIB-SL-WASO)

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5
Q

How can sleep efficiency be calculated?

A

SE = TST/TIB x 100

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6
Q

What are the two basic types of sleep?

A

Rapid eye movement (REM sleep)

Non-REM sleep (3 stages)

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7
Q

What are some sleep cycle trends?

A

People tend to go through 4-5 cycles per night

REM sleep is often longer in the second half of the night

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8
Q

What neurotransmitters are associated with Non-REM sleep?

A
  • GABA
  • Galanin
  • Adenosine
  • Melatonin
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9
Q

What neurotransmitters are associated with REM sleep?

A
  • Acetylcholine
  • Glutamate
  • GABA
  • Glycine (Muscle atonia)
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10
Q

What is a basic definition of insomnia?

A

Difficulty falling or staying asleep

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11
Q

Review slide 11 for a formal definition of insomnia according to the DSM-5

A
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12
Q

What are the different types of insomnia?

A

Primary (insomnia in the absence of a causative factor)

Secondary (insomnia caused by an underlying medical condition or medication adverse effect)

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13
Q

What are some conditions that present similar to insomnia?

A
  • Sleep apnea
  • Restless Legs Syndrome
  • Narcolepsy
  • Circadian rhythm sleep disorder (CRD)
  • Parasomnias
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14
Q

What are the steps to insomnia assessment?

A
  1. Consider using a sleep disorder questionnaire
  2. Instruct patient to complete a sleep diary
  3. Assess severity of insomnia using one of the following:
    a. Insomnia Severity Index
    b. Epworth Severity Index
  4. Refer to a sleep clinic for further investigation if necessary
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15
Q

What are some things that patients should record in their sleep diaries?

A
  1. Primary insomnia complaint
  2. Pre-sleep conditions (level of activity)
  3. Sleep-Wake Schedule
  4. Nocturnal symptoms
  5. Daytime activities
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16
Q

What is the prevalence of insomnia?

A

25% of adults are disatisfied with their sleep

10-15% report symptoms of insomnia associated with daytime consequences

6-10% meet criteria for an insomnia disorder

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17
Q

How does age impact prevalence of insomnia?

A

Up to 50% of seniors have sleep problems

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18
Q

Do men experience insomnia more than women?

A

No, insomnia is 2x more prevalent in women as in men

Hormonal changes in women could be responsible for more insomnia

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19
Q

What are some comorbidities associated with insomnia?

A

Nocturia
Heart failure
COPD
Depression/anxiety
Dementia

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20
Q

What are some risk factors for insomnia?

A
  • Stress
  • Increased age
  • Female sex
  • Co-morbid conditions
  • Shift worker
  • Lower economic status
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21
Q

What are some drug classes that can induce insomnia?

A
  1. Antidepressants
  2. Cardiovascular
  3. Decongestant
  4. Opioids
  5. Respiratory
  6. Stimulant
  7. Others (ex. alchohol interrupts progression between stages of sleep)
22
Q

What drugs are known to disrupt sleep?

A
  1. Levodopa
  2. Prednisone
  3. Venlafaxine
  4. Fluvoxamine
  5. Rotigotine
23
Q

What are some of the outcomes associated with untreated insomnia?

A
  1. Increased CV risk
  2. Metabolic
  3. Cancer
  4. Accidents
24
Q

What are the primary goals for insomnia management?

A
  • Sleep quality and/or time
  • Prevent daytime impairments of energy, attention, or memory
25
Q

Review slide 28 for the treatment algorithm for insomnia

A
26
Q

What is CBTi?

A

Cognitive Behavioural Therapy for Insomnia

This is a non-pharmacological treatment option for insomnia. It is often employed before pharmacological agents are considered in therapy

27
Q

What are the five components of CBTi therapy?

A
  1. Cognitive therapy
  2. Stimulus control
  3. Sleep restriction
  4. Sleep hygiene
  5. Relaxation
28
Q

What is the goal of cognitive therapy in CBTi?

A

Aims to identify, challenge, and replace dysfunctional beliefs and attitudes about sleep and insomnia

Not focus of pharmacist care, more for psychologists/psychiatrists

29
Q

What is the goal of stimulus control in CBTi?

A

Behavioural instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associate bed with other stimulating activities

30
Q

What is the goal of sleep restriction in CBTi?

A

Behavioural instructions to limit time in bed to match perceived sleep duration in order to increase sleep drive and further reduce time awake in bed

31
Q

What is the goal of sleep hygiene in CBTi?

A

General recommendations relating to environmental factors, physiologic factors, behaviour, and habits that promote sound sleep

32
Q

What is the goal of relaxation in CBTi?

A

Any relaxation technique that the patient finds effective can be used to limit cognitive arousal and reduce muscular tension

33
Q

What does pharmacotherapy for insomnia look like?

A
  • Should be considered adjuctive to CBTi
  • CBTi + pharma may produce faster improvements in sleep vs. CBTi alone
  • Studies that support the use of sedative hypnotics (benzodiazepines, s and z drugs for short term treatment less than 4 weeks)
34
Q

What is the mechanism of action for benzodiazepine receptor agonists?

A

They bind to the benzodiazepine site on the neuron and helps potentiate the effects of GABA (inhibitory neurotransmitter)

35
Q

What are the short-acting benzodiazepines?

A

Alprazolam, midazolam, triazolam

Tend to cause more amnesia, withdrawl symptoms, and potential dependency (bc drug levels rapidly rise, and crash)

36
Q

What are the medium acting benzodiazepines?

A

Lorazepam, oxazepam, temazepam, clonazepam

No active metabolites (preferable in patients with hepatic dysfunction)

37
Q

What are the long acting benzodiazepines?

A

Bromazepam, diazepam, chlordiazepoxide

Tend to have long-lasting active metabolites

Usually overkill for insomnia

38
Q

What are the risks associated with benzodiazepine treatment of insomnia?

A
  • Increased drowsiness, fatigue, headache, nightmares, nausea, GI disturbances and cognitive
  • Increased risk of falls and motor vehicle accidents
  • 2x risk of motor vehicle accidents
39
Q

What are the benefits of benzodiazepine treatment of insomnia?

A
  • Sedative hypnotics can increase total sleep time by 25 minutes
  • Decrease sleep latency by 10 min

Limited benefit

40
Q

What is the risk vs. benefit assessment of benzodiazepine therapy for insomnia?

A

High risk, with low benefits

41
Q

What are some counselling points for benzodiazepines?

A

Expect small increases in sleep quality

Can increase risk of accidents (avoid operating heavy machinery)

Alcohol enhances the effect of benzodiazepines

42
Q

What is the role of H1 antihistamines in insomnia treatment?

A

Anticholinergic effects (decrease wakefulness)

Associated with other anticholinergic effects (dry mouth, constipation, blurred vision, orthostatic)

43
Q

What is the role of melatonin in insomnia treatment?

A

Hormone released by pineal gland that regulates sleep/wake cycle

Melatonin may decrease sleep onset latency by 8 minutes (but no effect on sleep efficiency)

Limited benefit, so not commonly used

44
Q

What is the role of TCAs in insomnia treatment?

A

Increase sleep length and efficiency, decrease nocturnal disturbances

Halpape does not reccomend using in patients that do not have another indication for TCAs (ex. depression)

45
Q

What is the role of Doxepin in insomnia treatment?

A

It has a high specificity and affinity for histamine

Increases sleep quality, efficiency, and sleep time, but no effect on sleep latency

46
Q

What is the role of Trazodone in insomnia treatment?

A

Limited evidence, but some studies show improvement in sleep initiation and total sleep time

Lower risk of hangover vs. benzodiazepines

47
Q

What is the name of the newer generation insomnia drugs?

A

Orexin Receptor Antagonists

Block the binding of wake promoting neuropeptides (orexin A and B) to receptors (QX1R & QX2R)

ex. Lemborexant

48
Q

What are some advantages associated with Lemborexant?

A

No rebound insomnia with d/c of therapy (can be quit without taper)

Better for sleep maintenance vs. older agents (benzodiazepines)

49
Q

When should pharmacological treatments for insomnia be deprescribed or reconsidered?

A

Usually if patient is using benzodiazepine for longer than 1 month usually warrants reevaluation

Need to compare risks vs. benefits

50
Q

What does a taper down of benzodiazepines look like?

A
  • Schedule follow-up visits every 1-4 weeks
  • Monitor patient for taper success or failure
  • Provide quantity limited refills to encourage follow up
  • d/c or reverse taper if severe anxiety, depression, or withdrawal symptoms occur
51
Q

Review slide 61 for taper down schedule for benzodiazepines

A

PHAR 253 (10 decks)

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