Insomnia Flashcards
What is sleep latency? (SL)
The time it takes to fall asleep following bed time
What is wake after sleep onset? (WASO)
Sum of wake times from sleep onset to final awakening
What is Time in Bed? (TIB)
Time from bedtime to getting out of bed
How do you calculate total sleep time? (TST)
TST = TIB - SL - WASO
How do you calculate sleep efficiency percent? (SE)
SE = TST / TIB x 100
What are the 2 basic types of sleep? what stages are in each?
Rapid eye movemend (REM) sleep –> only stage 4
Non-REM sleep –> stages 1-3 75% of sleep
What is stage 1 of sleep?
Lightest sleep, easiest to be woken from
What is stage 2 of sleep?
A deeoer sleep state than stage 1 and most of sleep occurs in this phase
What is Stage 3 of sleep?
Deepest stage of sleep, hardest to be woken from
What is stage 4 of sleep?
REM sleep, dreaming occurs in this phase
What are the wake-promoting NT’s? (7)
Glutamate
Acetylcholine
Dopamine
Norepinephrine
Serotonin
Histamine
Orexin/hypocretin
What are the non-REM NT’s? (4)
GABA
Galanin
Adenosine
Melatonin
What are the REM NT’s? (4) Which is for muscle atonia?
Acetylcholine
Glutamate
GABA
Glycine (Muscle atonia)
What is the definition of Insomnia?
Difficulty falling or staying asleep
Roughly Explain the DSM-5.
- Complaint of quality or quantity of sleep
- Report one of:
-difficulty intiating sleep
- difficulty maintaining sleep
- early morning awkaening and inability to fall back asleep
- non-restorative sleep - Sleep complaint results in distress/impairment in daytime function w/ one of following:
- fatigue/low energy
- cognitive impairment
- mood disturbances
- impaired social function - sleep difficulty occurs atleast 3 nights per week
- sleep difficulty present for atleast last 3 months
- difficulty occurs despite adequate oppurtunity for sleep.
Duration –> acute, sub-chronic, or persistant - Comorbid disorders?
- Psychiatirc, Medial, Other
WHat is the duration for acute, sub-chronic, and persistant insomnia?
< 1 month
1-3 months
> 3 months
What is primary insomnia?
Insomnia in the absence of a causative factor
What is secondary Insomnia?
Insomnia caused by an underlying medical condition or medication adverse effect
What % are dissatisfied with their sleep?
25%
What % report symptoms of insomnia associated with daytime cosequences?
10-15%
What % meet criteria for an insomnia disorder?
6-10%
Is Isomnia more prevalent in men or women?
Twice as prevlaent in women
What % of seniors have sleep problems?
Up to 50%
How much more likely are pts with insomnia to have anxiety or depression?
5x more likely
How much more likely are pts with insomnia to have congestive heart failure?
2x more likely
What are risk factors for insomnia?
Stress
Increased age
Female
Co-morid condition
- HF
- COPD
- Nocturia
- Depression/anxiety
- Dementia
Shift work
Lower economic status
What are the 5 most common medications liekly to distrub sleep?
Levodopa
Prednisone
Venafaxine
Fluvoaxamine
Rotigotine
What are the primary goals of therapy?
Improve:
- Sleep quality and or time
- Insomnia related impairments such as energy, attention, or memory difficulties
What are some other (non-primary) goals of therapy?
decrease frequency of awakenings
TST of 6 hrs or SE of 80-85%
SL of 30 minutes
WASO of 30 minutes
Reduced sleep-related psychological distress
Formation of positive and clear associated between bed and sleeping
What are the 10 sleep hygiene components?
- Do not spend to much time in bed
- Maintain a consistent sleep/wake time
- Get out of bed if unable to fall asleep
- Exercise regularly
- Keep bedroom comfortable
- Don’t take problems to bed
- Avoid caffeine, tobacco, and alcohol after lunch
- limit liquids in the evening and don’t go to bed hungry
- keep bedroom dark and quiet
- Avoid late night screen time
What are 4 relaxation techniques?
- Breathing exercises
- Progressive muscle relaxation; closing eyes, focus on tensing and relaxing each muscle group for 3-6 seconds starting from head to toe while maintaining slow deep breaths
- Imagery; thinking and picturing something soothing, pleasant, relatively uninteresting
- Meditation
What are the sleep restriction instructions?
Do not get into bed unless you fell tired
Reduce time in bed to your perceived total sleep time
Use sleep logs
How do Bnezodiazepine recpetor agonists work for sleep therapy?
Bind to GABA receptors, inhibition of CNS, binding GABA receptors increase efficiency of GABA to decrease excitability of neurons
What are the short-acting benzo’s and what is a feature to be aware of with them?
Alprazolam, Midazolam, Triazolam
Tend to cause more amnesia, withdrawal symptoms and potential dependancy
What are the medium-acting benzo’s and what is a feature to be aware of with them?
Lorazepam, Oxazepam, Temazepam, Clonazepam
Lorazepam, Oxazepam, and temazepam have no acive metabolites
What are the long-acting benzo’s and what is a feature to be aware of with them?
Bromazepam, Diazepam, Chlordiazepoxide
Tend to be drugs that have active metabolites which last a long time
What are some of the risks with using benzo’s?
Falls, sedation, motor vehicle accidents
What are some benefits of using benzo’s?
Increase sleep time by 25 minutes, decrease sleep latency by ~10 minutes, decrease number of awakenings
What are some key counselling points w/ benzo’s?
Benefits of increased sleep time of 25 minutes, 1 less awkaening
Can cause some daytime drowsiness, fatigue, headache, nightmares, Nausea/upset stomach
Medication increases risk of traffic accident, work accident/falls and this risk is higher w/ alcohol use during medication use.
Are antihistamines recommended for sleep aid?
NO
What are some adverse effects of antihistamines?
dry mouth, constipation, blurred vision, orthostatic hypotension, increased apetite
At what day do antihistamine tolerance with continual use?
3-4 days of continuous therapy
What is the dosing for diphenhydramine for sleep?
50mg hs
How does Doxepin work for insomnia?
high specificity and affinit for H1, low dose selective for H1.
What is doxepin’s effect on sleep?
increase sleep quality, efficiency and time but does not seem to affect sleep latency
What is the risk for dependance with doxepin?
very minimal risk
Can you take doxepin with food?
Shouldn’t take within 3hrs of meal b/c delayed absorption
What are AE’s of doxepin?
Dry mouth, sedation, hypertension, naseau
What is dosing? Cost?
3-6 mg hs (3 for elderly)
Costs >$40/month
How does Trazodone work for insomnia?
weak Serotonin reuptake inhibtor (5HT2 receptor antagonist & alpha 1 blocking)
What is the dosing for trazodone?
50-100mg w/out depression diagnosis, up to 150mg w/ depression diagnosis
What are some AE’s with trazodone?
daytime sleepiness, excesive sedation, headache, dizziness, hypotension, blurred vision.
Less risk of morning hangover b/c shorter half-life
What is mirtazapine used concomitantly w/ insomnia?
depression, insomnia off label use
AE’s of mirtazipine?
wt gain, drowsiness, dizziness, dry mouth
Is sedation more prevalent with low or higher doses of mirtazipine?
lower doses
What are the insomnia treatment w/ quitiapine attributed too?
Antagonism of H1 receptor
WHat are AE’s of quetiapine?
wt gain/BMI/FBG, dizziness
Dosing for quetiapine?
25mg, >150mg for mood/psychotic diagnosis
What is a weird AE of zopiclone?
metalic taste
Dosing for zopiclone?
3.75-7.5 mg
Is there a risk for tolerance/dependance with zopiclone?
yes
How does zopiclone impact sleep?
improve sleep latency, total sleep time, decreases wake after sleep
Howdoes Lemborexant (ORA) work?
blocks binding of orexin A and B to receptor OX1R and OX2R (wake promotion)
What are AE’s of Lemborexant?
Dorwsiness, fatigue, headache, abnormal dreams, sleep paralysis,
Rare: mood change, hallucinations, suicidal ideation
Is there rebound insomnia w/ lemborexant d/c?
No
What is dosing for Lemborexant?
5mg can be titrated to 10mg; 5mg for elderly b/c of CNS depression
When do you take lemborexant?
right before bed, take 7hrs before planned awakening
