Insomnia Flashcards
What is sleep latency?
Time to fall asleep following bedtime
What does the acronym WASO mean?
Wake up after sleep onset
WASO is the sum of wake times from sleep onset to final awakening
What does the acronym TIB mean?
Time in bed
TIB is the time from bedtime to getting out of bed
What does the acronym TST mean?
Total sleep time (TIB-SL-WASO)
How can sleep efficiency be calculated?
SE = TST/TIB x 100
What are the two basic types of sleep?
Rapid eye movement (REM sleep)
Non-REM sleep (3 stages)
What are some sleep cycle trends?
People tend to go through 4-5 cycles per night
REM sleep is often longer in the second half of the night
What neurotransmitters are associated with Non-REM sleep?
- GABA
- Galanin
- Adenosine
- Melatonin
What neurotransmitters are associated with REM sleep?
- Acetylcholine
- Glutamate
- GABA
- Glycine (Muscle atonia)
What is a basic definition of insomnia?
Difficulty falling or staying asleep
Review slide 11 for a formal definition of insomnia according to the DSM-5
What are the different types of insomnia?
Primary (insomnia in the absence of a causative factor)
Secondary (insomnia caused by an underlying medical condition or medication adverse effect)
What are some conditions that present similar to insomnia?
- Sleep apnea
- Restless Legs Syndrome
- Narcolepsy
- Circadian rhythm sleep disorder (CRD)
- Parasomnias
What are the steps to insomnia assessment?
- Consider using a sleep disorder questionnaire
- Instruct patient to complete a sleep diary
- Assess severity of insomnia using one of the following:
a. Insomnia Severity Index
b. Epworth Severity Index - Refer to a sleep clinic for further investigation if necessary
What are some things that patients should record in their sleep diaries?
- Primary insomnia complaint
- Pre-sleep conditions (level of activity)
- Sleep-Wake Schedule
- Nocturnal symptoms
- Daytime activities
What is the prevalence of insomnia?
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
How does age impact prevalence of insomnia?
Up to 50% of seniors have sleep problems
Do men experience insomnia more than women?
No, insomnia is 2x more prevalent in women as in men
Hormonal changes in women could be responsible for more insomnia
What are some comorbidities associated with insomnia?
Nocturia
Heart failure
COPD
Depression/anxiety
Dementia
What are some risk factors for insomnia?
- Stress
- Increased age
- Female sex
- Co-morbid conditions
- Shift worker
- Lower economic status
What are some drug classes that can induce insomnia?
- Antidepressants
- Cardiovascular
- Decongestant
- Opioids
- Respiratory
- Stimulant
- Others (ex. alchohol interrupts progression between stages of sleep)
What drugs are known to disrupt sleep?
- Levodopa
- Prednisone
- Venlafaxine
- Fluvoxamine
- Rotigotine
What are some of the outcomes associated with untreated insomnia?
- Increased CV risk
- Metabolic
- Cancer
- Accidents
What are the primary goals for insomnia management?
- Sleep quality and/or time
- Prevent daytime impairments of energy, attention, or memory
Review slide 28 for the treatment algorithm for insomnia
What is CBTi?
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
What are the five components of CBTi therapy?
- Cognitive therapy
- Stimulus control
- Sleep restriction
- Sleep hygiene
- Relaxation
What is the goal of cognitive therapy in CBTi?
Aims to identify, challenge, and replace dysfunctional beliefs and attitudes about sleep and insomnia
Not focus of pharmacist care, more for psychologists/psychiatrists
What is the goal of stimulus control in CBTi?
Behavioural instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associate bed with other stimulating activities
What is the goal of sleep restriction in CBTi?
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
What is the goal of sleep hygiene in CBTi?
General recommendations relating to environmental factors, physiologic factors, behaviour, and habits that promote sound sleep
What is the goal of relaxation in CBTi?
Any relaxation technique that the patient finds effective can be used to limit cognitive arousal and reduce muscular tension
What does pharmacotherapy for insomnia look like?
- 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)
What is the mechanism of action for benzodiazepine receptor agonists?
They bind to the benzodiazepine site on the neuron and helps potentiate the effects of GABA (inhibitory neurotransmitter)
What are the short-acting benzodiazepines?
Alprazolam, midazolam, triazolam
Tend to cause more amnesia, withdrawl symptoms, and potential dependency (bc drug levels rapidly rise, and crash)
What are the medium acting benzodiazepines?
Lorazepam, oxazepam, temazepam, clonazepam
No active metabolites (preferable in patients with hepatic dysfunction)
What are the long acting benzodiazepines?
Bromazepam, diazepam, chlordiazepoxide
Tend to have long-lasting active metabolites
Usually overkill for insomnia
What are the risks associated with benzodiazepine treatment of insomnia?
- Increased drowsiness, fatigue, headache, nightmares, nausea, GI disturbances and cognitive
- Increased risk of falls and motor vehicle accidents
- 2x risk of motor vehicle accidents
What are the benefits of benzodiazepine treatment of insomnia?
- Sedative hypnotics can increase total sleep time by 25 minutes
- Decrease sleep latency by 10 min
Limited benefit
What is the risk vs. benefit assessment of benzodiazepine therapy for insomnia?
High risk, with low benefits
What are some counselling points for benzodiazepines?
Expect small increases in sleep quality
Can increase risk of accidents (avoid operating heavy machinery)
Alcohol enhances the effect of benzodiazepines
What is the role of H1 antihistamines in insomnia treatment?
Anticholinergic effects (decrease wakefulness)
Associated with other anticholinergic effects (dry mouth, constipation, blurred vision, orthostatic)
What is the role of melatonin in insomnia treatment?
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
What is the role of TCAs in insomnia treatment?
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)
What is the role of Doxepin in insomnia treatment?
It has a high specificity and affinity for histamine
Increases sleep quality, efficiency, and sleep time, but no effect on sleep latency
What is the role of Trazodone in insomnia treatment?
Limited evidence, but some studies show improvement in sleep initiation and total sleep time
Lower risk of hangover vs. benzodiazepines
What is the name of the newer generation insomnia drugs?
Orexin Receptor Antagonists
Block the binding of wake promoting neuropeptides (orexin A and B) to receptors (QX1R & QX2R)
ex. Lemborexant
What are some advantages associated with Lemborexant?
No rebound insomnia with d/c of therapy (can be quit without taper)
Better for sleep maintenance vs. older agents (benzodiazepines)
When should pharmacological treatments for insomnia be deprescribed or reconsidered?
Usually if patient is using benzodiazepine for longer than 1 month usually warrants reevaluation
Need to compare risks vs. benefits
What does a taper down of benzodiazepines look like?
- 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
Review slide 61 for taper down schedule for benzodiazepines
