Insomnia Flashcards
What is SL?
sleep latency
-time to fall asleep following bedtime
What is WASO?
wake after sleep onset
-sum of wake times from sleep onset to final awakening
What is TIB?
time in bed
-time from bedtime to getting out of bed
What is TST?
total sleep time
-(TIB-SL-WASO)
How is sleep efficiency percent calculated?
SE=TST/TIB x 100
What are the two basic types of sleep?
rapid eye movement (REM) sleep
non-REM sleep (3 stages)-75% of sleep
What is insomnia?
difficulty falling or staying asleep
Describe the criteria of insomnia disorders from the DSM.
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
What are the types of insomnia?
primary
-insomnia in the absence of a causative factor
secondary
-caused by an underlying medical condition or medication
What are some other sleep disorders?
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
How can we assess insomnia?
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
Describe the epidemiology of insomnia.
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
What are the risk factors for insomnia?
stress
increased age
female sex
comorbid conditions (nocturia, HF, COPD, depression/anxiety, dementia)
shift worker
lower economic status
What are some drugs that may cause sleep problems?
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
Describe the health outcomes associated with insomnia.
cardiovascular
-ischemic stroke, CAD, inflammatory markers
metabolic
-obesity, T2DM
cancer
-breast, colorectal, prostate
accidents
-daytime fatigue and sleepiness=human error
What are the primary goals of therapy for insomnia?
sleep quality and or time
insomnia related daytime impairments like energy, attention or memory difficulties
What are the “other” goals of therapy for insomnia?
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
What sits at the top of the hierarchy for insomnia management?
CBT
What are the components of CBT?
cognitive therapy
stimulus control
sleep restriction
sleep hygiene
relaxation
Describe good sleep hygiene and stimulus control.
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
What are some relaxation techniques?
breathing exercises
progressive muscle relaxation
imagery
meditation
Describe proper sleep restriction.
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
Describe pharmacotherapy for insomnia.
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)
What is the MOA of benzodiazepines and Z drugs for insomnia?
potentiates GABA
-inhibitory neurotransmitter
What are the short-acting benzodiazepines?
alprazolam, midazolam, triazolam
-tend to cause more amnesia, withdrawal sx and potential dependency
What are the medium acting benzodiazepines?
lorazepam, oxazepam, temazepam, clonazepam
-LOT have no active metabolites
-more commonly used for insomnia
What are the long acting benzodiazepines?
bromazepam, diazepam, chlordiazepoxide
-active metabolites that last a long time
What are the Z drugs?
zopiclone
zolpidem
eszopiclone
What are the benefits of the Z drugs and benzos for insomnia?
increase total sleep time by 25 mins
decrease sleep latency by 10 mins
What are the risks of the Z drugs and benzos for insomnia?
falls and motor vehicle accidents
-two times the risk of motor vehicle accidents
What are some counselling points to provide regarding benzodiazepines?
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
What is the MOA of antihistamines for insomnia?
blockade of H1 receptors
-decrease wakefulness
What is the effect of antihistamines for sleep?
minimal effect on SL and total sleep time
tolerance occurs by day 3 to 4 of continuous therapy
not recommended
What are the adverse effects of antihistamines?
dry mouth
constipation
blurred vision
orthostatic hypotension
increased appetite
Which antihistamines are used for insomnia?
diphenhydramine 50mg hs
hydroxyzine 25-100mg hs
Describe melatonin.
hormone produced by the pineal gland
helps regulate sleep/wake cycle
production peaks at night and decreases in morning
levels decline as we age
What is the effect of melatonin on sleep?
may decrease sleep onset by 8min but no effect on sleep efficiency
What are the adverse effects of melatonin?
nausea
headache
dizziness
daytime drowsiness
What is the dosing of melatonin?
0.3-10mg given 30-120min before bed
Which TCAs are used for sleep?
amitriptyline
nortriptyline
What is the effect of TCAs on sleep?
increases sleep length and efficiency
decreases nocturnal disturbances
increases total sleep time
fewer changes in REM parameters, increased drowsiness
Which patients may benefit from a TCA if experiencing insomnia?
depressed patients
What are the precautions with TCAs for insomnia?
anticholinergic effects problematic in the elderly
-cognitive impairment, dizziness, blurred vision
BPH
hypotension
arrhythmia
epilepsy
What is the different MOA of doxepin compared to other TCAs?
high specificity & affinity for H1
-low doses selective for H1
What is the effect of doxepin on sleep?
increases sleep quality, efficiency & time but does not seem to affect sleep latency
How should doxepin NOT be taken?
within 3 hrs of a meal due to delayed absorption and the potential for next day drowsiness
Does doxepin pose a high risk of physical tolerance/dependence?
low risk
What is the dose of doxepin used for insomnia?
3-6mg hs
3mg for elderly
What are the adverse effects of doxepin?
dry mouth
sedation
hypertension
nausea
What is the MOA of trazodone?
weak serotonin reuptake inhibitor
5HT2 antagonist
a1 blocker
What is the dose of trazodone used for insomnia?
without depression: 50-100mg
up to 150mg with a depression diagnosis
What is the effect of trazodone on sleep?
limited evidence but some studies show improvement in sleep initiation & total sleep time
lower risk of morning hangover due to short t1/2
Does trazodone pose a high risk of tolerance/dependence?
minimal risk
What are the adverse effects of trazodone?
daytime sleepiness
excessive sedation
headache
dizziness
hypotension
blurred vision
What are two drugs that are used off-label for insomnia?
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
What are adverse effects of zopiclone?
metallic taste
physical tolerance and dependence
What are adverse effects of zolpidem?
daytime drowsiness
dizziness/vertigo
amnesia
nausea
headache
falls
risk of tolerance and dependence
Which benzo is indicated for insomnia?
temazepam
risk of tolerance and dependence
What is the MOA of lemborexant?
orexin receptor antagonist
-blocks binding of wake promoting neuropeptides orexin A and orexin B to 0X1R and 0X2R
What is the indication for lemborexant?
sleep onset and sleep maintenance in insomnia
What are the adverse effects of lemborexant?
common: drowsiness, fatigue, headache
less common: abnormal dreams, sleep paralysis
rare: mental/mood changes
What dose of lemborexant requires caution in the elderly?
> 5mg due to CNS depression
True or false: lemborexant does not cause rebound insomnia with d/c
true
Z drugs and benzos can
What is the typical dose of lemborexant?
5mg hs
can titrate to 10mg/d
How is lemborexant best taken?
right before bed
-plan for 7hrs prior to awakening
food delays its onset
