Insomnia Flashcards
Define SL
SL = Sleep latency
- time to fall asleep following bedtime
Define WASO
WASO = Wake after sleep onset
–> sum of wake times from sleep onset to final awakening
Define TIB
TIB = Time in bed
–> time from bedtime to getting out of bed
Define TST. How is it calculated?
TST = total sleep time (TIB – SL – WASO)
How to calculate Sleep efficiency percent?
Sleep efficiency percent (SE = TST/TIB x 100
What are the 2 basic types of sleep? What stage is dominant?
Rapid eye movement (REM) sleep
Non-REM sleep (3 stages) - 75% of sleep
What stage of sleep is it hardest to wake a person up?
REM
In what stage of sleep does dreaming occur?
REM
Describe the sleep cycle
What are the wake-promoting neurotransmitters?
Glutamate
Acetylcholine
Dopamine
Norepinephrine
Serotonin
Histamine
Orexin/hypocretin
Substance P
Corticotropin
RAS (reticular activating system) which also contributes to arousal and wakefulness is under the control of DA
—> ⇓DA promote sleep
What are the Non-rem neurotransmitters?
NonREM appears to associated with GABA and adenosine in different regions of the brain
GABA
Galanin
Adenosine
Melatonin
What are the REM neurotransmitters?
REM appears to be turned on by cholinergic cells but turned off by the locus coeruleus which is activated by the noradrenergic system
Acetylcholine
Glutamate
GABA
Glycine (muscle atonia)
Define insomnia
Difficulty falling or staying asleep
What is insomnia defined as clinically?
sleep latency of more than 30 minutes
remaining awake after sleep onset for more than 30 minutes
sleep efficiency of less than 85%
OR
less than 6 to 6.5 hours total time asleep
occurring on three nights per week or more.
What is the clinical description of insomnia in the DSM-5?
How does the DSM-5 define insomnia?
Acute Insomnia <1 month
Sub chronic Insomnia 1-3 months
Persistent insomnia >3 months
What are the types of insomnia?
Primary –> insomnia in the absence of a causative factor
Secondary –> insomnia caused by an underlying medical condition or medication adverse effect
How can a pharmacist eliminate other sleep disorders?
Snoring –> OSA
Unpleasent, restless feelings in legs in eveing or at night –> Restless leg syndrome
Fall asleep in day without warning –> Narcolepsy
Sleep well but at wronfg times –> Circadian rythym sleep disorder
Unusual/unpleasent experiences associated with sleep that trouble you or are dangerous –> Parasomnias
How can one conduct an insomnia assesment?
1) Consider using a sleep disorder questionnaire such as the Athens Insomnia Scale
2) Instruct patient to complete a sleep diary
3) Assess severity of insomnia using one or more of the following:
–> Insomnia Severity Index
Epworth Sleepiness Scale
4) Refer to a sleep clinic for further investigation if necessary
What are the main categories to evaluate in an insomnia assesment?
Primary Insomnia Complaint
Pre-sleep Conditions
Sleep-Wake Schedule
Nocturnal Symptoms
Daytime activities and function
What is the prevalence of insomnia?
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 and Insomnia Relationship
Sleep complaints increase with age
Up to 50% of seniors with sleep problems
Gender and Insomnia Relationship
Twice as prevalent in women as in men
Insomnia Comorbidities
Individuals with insomnia were more than five times as likely to present with anxiety or depression
more than twice as likely to present congestive heart failures as individuals without insomnia
Why is insomnia more pronounced in woman?
Woman –> Hormone changes (menopause), menstruation, pregnancy
What are some risk factors for insomnia?
Stress –> Relationships, work, school
Increased Age
Female Sex
Co-morbid conditions
Shift Worker
Lower socioeconomic status
What are some comorbid conditions that are risk factors for insomnia?
Nocturia –> BPH in men, bladder instability in women
Heart Failure
COPD
Depression/anxiety
Dementia
What are some drugs that may cause fragmented sleep, nightmares, nocturia, or stimulation?
What are the five most common medications likely to disrupt sleep?
Levodopa
Prednisone
Venlafaxine
Fluvoxamine
Rotigotine
What are some health outcomes of insomnia?
CV:
- Ischemic Stroke
- Coronary Heart Disease
- Inflammatory markers (c-reactive protein, tumour necrosis factor)
Metabolic
- Obesity
- Type 2 diabetes
- Impaired glucose tolerance
Cancer
- Breast cancer
- Colorectal cancer
- Prostate cancer
Accidents
- Daytime fatigue and sleepiness leading to human error related accidents
What are the primary goals of therapy for insomnia?
Improvements on:
Primary:
- Sleep quality and/or time
- Insomnia related daytime impairements like energy, attention, or memory difficulties
What are some other goals for insomnia?
Improvement on:
SL (30 mins) and/or
WASO (30 mins) and/or
Decreased frequency of awakenings and/or
TST >6 hours and/or
Sleep efficiency 80-85%
Sleep related psychological distress
Formation of a positive and clear associated between bed and sleeping
Describe the management of insomnia
What are the componenets of CBT-i? What types are there?
Cognitive therapy
Stimulus Control
Sleep Restriction
Sleep Hygiene
Relaxation
Cognitive only encompasses one component of CBT-i. Focus on the other four aspects.
