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PHAR253 > Insomnia > Flashcards

Insomnia Flashcards

1
Q

What is SL?

A

sleep latency
-time to fall asleep following bedtime

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2
Q

What is WASO?

A

wake after sleep onset
-sum of wake times from sleep onset to final awakening

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3
Q

What is TIB?

A

time in bed
-time from bedtime to getting out of bed

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4
Q

What is TST?

A

total sleep time
-(TIB-SL-WASO)

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5
Q

How is sleep efficiency percent 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)-75% of sleep

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7
Q

What is insomnia?

A

difficulty falling or staying asleep

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8
Q

Describe the criteria of insomnia disorders from the DSM.

A

a. dissatisfaction with sleep quantity or quality
b. report one of the following:
-difficulty initiating sleep
-difficulty maintaining sleep
-early awakening and difficulty returning to sleep
-non restorative sleep
c. distress of daytime impairment
d. occurs at least 3 nights per week
e. present for at least 3 months
f. sleep difficulty occurs despite adequate opportunity

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9
Q

What are the types of insomnia?

A

primary
-insomnia in the absence of a causative factor
secondary
-caused by an underlying medical condition or medication

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10
Q

What are some other sleep disorders?

A

obstructive sleep apnea
-heavy snorer
restless leg syndrome
circadian rhythm disorder
-sleeping well but at wrong times
narcolepsy
-daytime sleeping without warning
parasomnias
-troubling behaviour associated with sleep

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11
Q

How can we assess insomnia?

A

Athens Insomnia Scale (sleep disorder questionnaire)
instruct patient to complete a sleep diary
assess severity of insomnia using one of the following:
-Insomnia Severity Index
-Epworth Sleepiness Scale
refer to a sleep clinic for further investigation if necessary

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12
Q

Describe the epidemiology of insomnia.

A

prevalence:
-25% of adults are dissatisfied with their sleep
-10-15% report symptoms of insomnia associated with daytime consequences
-6-10% meet criteria for an insomnia disorder
age:
-sleep complaints increase with age
-up to 50% of seniors with sleep problems
gender:
-twice as prevalent in women as in men
comorbidity:
-five times as likely to present with anxiety or depression
-more than twice as likely to present CHF

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13
Q

What are the risk factors for insomnia?

A

stress
increased age
female sex
comorbid conditions (nocturia, HF, COPD, depression/anxiety, dementia)
shift worker
lower economic status

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14
Q

What are some drugs that may cause sleep problems?

A

five most common:
-levodopa, prednisone, venlafaxine, fluvoxamine, rotigotine
others:
-antidepressants (bupropion, SSRIs, SNRIs, MAOIs)
-CV (a-blockers, B-blockers, diuretics, statins)
-decongestants
-opioids (in combo with caffeine)
-respiratory (B2 agonists, theophylline)
-stimulants
-alcohol and nicotine

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15
Q

Describe the health outcomes associated with insomnia.

A

cardiovascular
-ischemic stroke, CAD, inflammatory markers
metabolic
-obesity, T2DM
cancer
-breast, colorectal, prostate
accidents
-daytime fatigue and sleepiness=human error

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16
Q

What are the primary goals of therapy for insomnia?

A

sleep quality and or time
insomnia related daytime impairments like energy, attention or memory difficulties

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17
Q

What are the “other” goals of therapy for insomnia?

A

SL <30 mins
WASO <30mins
decreased frequency of awakenings
TST >6hrs
sleep efficiency >80%
sleep related psychological distress
formation of a positive and clear association between bed and sleeping

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18
Q

What sits at the top of the hierarchy for insomnia management?

A

CBT

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19
Q

What are the components of CBT?

A

cognitive therapy
stimulus control
sleep restriction
sleep hygiene
relaxation

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20
Q

Describe good sleep hygiene and stimulus control.

A

do not spend too much time in bed
-excessive sleep can be fragmented and unrestful
maintain a consistent sleep/wake time
-trains mind and body
get out of bed if unable to fall asleep
-do something boring and try again
exercise regularly
-tiring out the body can deepen sleep
keep bedroom comfortable
-good bed and temperature
dont take problems to bed
-disturbs sleep
avoid caffeine, tobacco and alcohol after lunch
-increased arousal
limit liquids in the evening/dont go to bed hungry
-waking from full bladder
keep bedroom dark and quiet
-less disturbance and arousal
avoid late night screen time
-stimulates the mind, blue light delays melatonin secretion

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21
Q

What are some relaxation techniques?

A

breathing exercises
progressive muscle relaxation
imagery
meditation

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22
Q

Describe proper sleep restriction.

A

dont get into bed unless you feel tired
reduce time in bed to your perceived total sleep time
use sleep logs
1. identify average total sleep time using a sleep diary
2. determine the sleep window
3. set up a waking time
4. set a bedtime
5. stick to the schedule for about 2 wks
6. calculate the average SE
7. adjust the sleep window

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23
Q

Describe pharmacotherapy for insomnia.

A

should be considered as adjunctive to CBT
CBT+pharm may produce faster improvements in sleep than CBT alone
studies that support the use of sedative hypnotics for insomnia limited to short term tx (<4wks)

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24
Q

What is the MOA of benzodiazepines and Z drugs for insomnia?

A

potentiates GABA
-inhibitory neurotransmitter

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25
Q

What are the short-acting benzodiazepines?

A

alprazolam, midazolam, triazolam
-tend to cause more amnesia, withdrawal sx and potential dependency

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26
Q

What are the medium acting benzodiazepines?

A

lorazepam, oxazepam, temazepam, clonazepam
-LOT have no active metabolites
-more commonly used for insomnia

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27
Q

What are the long acting benzodiazepines?

A

bromazepam, diazepam, chlordiazepoxide
-active metabolites that last a long time

28
Q

What are the Z drugs?

A

zopiclone
zolpidem
eszopiclone

29
Q

What are the benefits of the Z drugs and benzos for insomnia?

A

increase total sleep time by 25 mins
decrease sleep latency by 10 mins

30
Q

What are the risks of the Z drugs and benzos for insomnia?

A

falls and motor vehicle accidents
-two times the risk of motor vehicle accidents

31
Q

What are some counselling points to provide regarding benzodiazepines?

A

benefit: may increase sleep by 25mins and may reduce 1 awakening
may cause daytime drowsiness, fatigue, headache, nightmare, nausea, and/or upset stomach
increases risk of traffic accident, a work accident or a fall
-alcohol increases the risk further

32
Q

What is the MOA of antihistamines for insomnia?

A

blockade of H1 receptors
-decrease wakefulness

33
Q

What is the effect of antihistamines for sleep?

A

minimal effect on SL and total sleep time
tolerance occurs by day 3 to 4 of continuous therapy
not recommended

34
Q

What are the adverse effects of antihistamines?

A

dry mouth
constipation
blurred vision
orthostatic hypotension
increased appetite

35
Q

Which antihistamines are used for insomnia?

A

diphenhydramine 50mg hs
hydroxyzine 25-100mg hs

36
Q

Describe melatonin.

A

hormone produced by the pineal gland
helps regulate sleep/wake cycle
production peaks at night and decreases in morning
levels decline as we age

37
Q

What is the effect of melatonin on sleep?

A

may decrease sleep onset by 8min but no effect on sleep efficiency

38
Q

What are the adverse effects of melatonin?

A

nausea
headache
dizziness
daytime drowsiness

39
Q

What is the dosing of melatonin?

A

0.3-10mg given 30-120min before bed

40
Q

Which TCAs are used for sleep?

A

amitriptyline
nortriptyline

41
Q

What is the effect of TCAs on sleep?

A

increases sleep length and efficiency
decreases nocturnal disturbances
increases total sleep time
fewer changes in REM parameters, increased drowsiness

42
Q

Which patients may benefit from a TCA if experiencing insomnia?

A

depressed patients

43
Q

What are the precautions with TCAs for insomnia?

A

anticholinergic effects problematic in the elderly
-cognitive impairment, dizziness, blurred vision
BPH
hypotension
arrhythmia
epilepsy

44
Q

What is the different MOA of doxepin compared to other TCAs?

A

high specificity & affinity for H1
-low doses selective for H1

45
Q

What is the effect of doxepin on sleep?

A

increases sleep quality, efficiency & time but does not seem to affect sleep latency

46
Q

How should doxepin NOT be taken?

A

within 3 hrs of a meal due to delayed absorption and the potential for next day drowsiness

47
Q

Does doxepin pose a high risk of physical tolerance/dependence?

A

low risk

48
Q

What is the dose of doxepin used for insomnia?

A

3-6mg hs
3mg for elderly

49
Q

What are the adverse effects of doxepin?

A

dry mouth
sedation
hypertension
nausea

50
Q

What is the MOA of trazodone?

A

weak serotonin reuptake inhibitor
5HT2 antagonist
a1 blocker

51
Q

What is the dose of trazodone used for insomnia?

A

without depression: 50-100mg
up to 150mg with a depression diagnosis

52
Q

What is the effect of trazodone on sleep?

A

limited evidence but some studies show improvement in sleep initiation & total sleep time
lower risk of morning hangover due to short t1/2

53
Q

Does trazodone pose a high risk of tolerance/dependence?

A

minimal risk

54
Q

What are the adverse effects of trazodone?

A

daytime sleepiness
excessive sedation
headache
dizziness
hypotension
blurred vision

55
Q

What are two drugs that are used off-label for insomnia?

A

mirtazapine
-used with concomitant depression
-significant AE
-low doses=more pronounced sedation
quetiapine
-AAP sedative and hypnotic properties due H1 antagonism
-increase in weight, BMI, BG
-25mg

56
Q

What are adverse effects of zopiclone?

A

metallic taste
physical tolerance and dependence

57
Q

What are adverse effects of zolpidem?

A

daytime drowsiness
dizziness/vertigo
amnesia
nausea
headache
falls
risk of tolerance and dependence

58
Q

Which benzo is indicated for insomnia?

A

temazepam
risk of tolerance and dependence

59
Q

What is the MOA of lemborexant?

A

orexin receptor antagonist
-blocks binding of wake promoting neuropeptides orexin A and orexin B to 0X1R and 0X2R

60
Q

What is the indication for lemborexant?

A

sleep onset and sleep maintenance in insomnia

61
Q

What are the adverse effects of lemborexant?

A

common: drowsiness, fatigue, headache
less common: abnormal dreams, sleep paralysis
rare: mental/mood changes

62
Q

What dose of lemborexant requires caution in the elderly?

A

> 5mg due to CNS depression

63
Q

True or false: lemborexant does not cause rebound insomnia with d/c

A

true
Z drugs and benzos can

64
Q

What is the typical dose of lemborexant?

A

5mg hs
can titrate to 10mg/d

65
Q

How is lemborexant best taken?

A

right before bed
-plan for 7hrs prior to awakening
food delays its onset

PHAR253 (16 decks)

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