Insomnia Flashcards
What is 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 - WASA
how is sleep efficacy calculated?
TST/TIB x 100
what are the 4 stages of sleep?
- the lightest sleep stage and easiest to be woken from
- a deeper sleep state and most of our sleep occurs in this phase
- the deepest stage of sleep and it is the hardest to wake from
- REM sleep stage: where dreaming occurs
what are the 2 basic types of sleep?
REM sleep and non REM sleep
What percent of sleep is REM sleep?
25%
What neurotransmitters are wake promoting?
glutamate
ACh
dopamine
NE
serotonin
histamine
orexin/hypocretin
what neurotransmitters promote non REM sleep?
GABA
galanin
adenosine
melatonin
what neurotransmitters promote REM sleep?
ACh
glutamate
GABA
glycine
What is required for an insomnia diagnosis (DSM-5)
A. predominant complaint of dissatisfaction with sleep quantity or quality made by patient
B. report one or more of the following sx:
- difficulty initiating sleep
- difficulty maintaining sleep
- early morning awakening with inability to return to sleep
- non restorative sleep
- persistent resistance to going to bed
C. the sleep complaint is accompanied by great distress or impairment in the daytime by report of one of the following:
- fatigue or low energy
- daytime sleepiness
- cognitive impairment
- mood distubrances
- behaviour difficulties
- impaired occupational/academic functioning
- impaired interpersonal/social function
- negative effect on caregiver or family functioning
D. the sleep difficulty occurs at least 3 nights a week
E. the sleep difficulty is present for at least 3 months
F. the sleep difficulty occurs despite adequate opportunity for sleep
What is the duration of acute, sub chronic and persistent insomnia?
acute insomnia = <1 month
sub-chronic insomnia = 1-3 months
persistent insomnia = >3 months
what is the clinical definition of insomnia?
SL >30 mins
WASO >30 mins
SE <80%
TST <6.5 hours
occurring at least 3 nights per week
what is primary insomnia vs secondary insomnia?
primary insomnia: insomnia in the absence of a cumulative factor
secondary insomnia: insomnia caused by an underlying medical condition or medication adverse effect
what question could you ask to rule out sleep apnea?
“are you a heavy snorer? does your partner say that you sometimes stop breathing at night”
what question could you ask to rule out restless leg syndrome?
“when you try to relax in the evening or sleep at night, do you ever have unpleasant restless feelings in your legs that can be relieved by walking or movement?”
what question can you ask to rule out narcolepsy?
“do you sometimes fall asleep in the daytime completely without warning? do you have collapses or extreme muscle weakness triggered by emotion, for instance when you are laughing?”
what question can you ask to rule out circadian rhythm sleep disorder?
“do you tend to sleep well but just at the ‘wrong times’ and are these sleeping and waking times regular?”
what question can you ask to rule out parasomnias?
“do you have unusual or unpleasant experiences or behaviours associated with your sleep that trouble you or are dangerous?”
Differential diagnosis of insomnia
obstructive sleep apnea syndrome (OSAS)
restless leg syndrome (RLS)
narcolepsy
circadian rhythm sleep disorder (CRSD)
parasomnias
what does your score on the Athens insomnia scale mean?
0-5 = absence of insomnia
6-9 = mild insomnia
10-15 = moderate insomnia
16-24 = severe insomnia
What kind of questions does the Epworth sleepiness scale ask?
“how likely are you to fall asleep in the following situations?”
What score on the Epworth sleepiness scale is of concern?
10 or greater
T or F
sleep complaints increase with age
true
T or F
insomnia is more common in men than it is in women
false
twice as prevalent in women
what are some risk factors for insomnia?
stress
increased age
female sex
lower economic status
medical comorbidities: nocturia, HF, COPD, depression/anxiety, dementia
shift worker
Which drugs may cause insomnia?
antidepressants: bupropion, MAOIs, SNRIs, SSRIs
CV: alpha blockers, beta blockers, diuretics, statins
decongestants
opioids
respiratory: beta agonists, theophylline
stimulants
others: acetylcholinesterase inhibitors, alcohol, antineoplastics, CSs, dopamine receptor agonists, nicotine, medroxyprogesterone, phenytoin, thyroid supplements
what are the 5 most common medications that disturb sleep?
levodopa
prednisone
venlafaxine
fluvoxamine
rotigotine
what are the health outcomes associated with insomnia?
CV: stroke, CHD, inflammatory markers
metabolic: obesity, T2D, impaired glucose tolerance
cancer
accidents
what are our primary goals of therapy for insomnia?
sleep quality and/or time
insomnia related daytime impairments like energy, attention, or memory impairment
what are secondary goals of therapy for insomnia?
SL <30 mins
WASA <30 mins
decrease frequency of awakening
TST >6 hours and/or SE >80-85%
sleep related psychological distress
formation of a positive and clear association between bed and sleeping
what are the actions to promote sleep in insomnia? (bottom of pyramid)
- optimize management of comorbid medical and psychiatric conditions
- initiate daytime behaviour modifications
- adjust sleep environment
- set specific sleep and wake times
- decrease arousal/anxiety
- initiate cognitive therapy
what are the components of CBT-i?
cognitive therapy
stimulus control
sleep restriction
sleep hygiene
relaxation
what is the cognitive therapy portion of CBT-i?
aims to identify, challenge, and replace dysfunctional beliefs and attitudes about sleep and insomnia
what is the stimulus control portion of CBT-i?
behavioural instructions aimed at strengthening the association between bed and sleep and preventing conditioning of the patient to associated bed with other stimulating activities
what is the sleep restriction portion of CBT-i?
behavioural instructions to limit time in bed to match perceived sleep duration in order to increase sleep drive and further decrease time awake in bed
what is the sleep hygiene portion of CBT-i?
general recommendations relating to environmental factors, physiologic factors, behaviour and habits that promote sound sleep
what is the relaxation portion of CBT-i?
any relaxation technique that the patient finds effective can be used to limit cognitive arousal and decrease muscular tension to facilitate sleep
what are some instructions for good sleep hygiene?
do not spend too much time in bed
maintain a consistent sleep/wake time
get out of bed if unable to fall asleep
exercise regularly
keep bedroom comfortable
dont take problems to bed
avoid caffeine, tobacco and alcohol after lunch
limit liquids in the evening/dont go to bed hungry
keep bedroom dark and quiet
avoid late night screen time
what are some relaxation techniques for insomnia?
breathing exercises
progressive muscle relaxation
imagry
medication
T or F
pharmacotherapy should be considered only as an adjunct to CBT-i
true
How long should z-drugs and benzos be used for?
<4 weeks
what happens when drugs bind to GABA receptors?
GABA exerts a calming effect on the CNS
increase the efficiency of GABA to decrease the excitability of neurons
what are the short acting benzos?
alprazolam
midazolam
triazolam
what are the characteristics of short acting benzos?
tend to cause more amnesia withdrawal sx and potential dependency
what are the medium acting benzos?
lorazepam
oxazepam
temazepam
clonazepam
which benzos have no active metabolites?
LOT
lorazepam
oxazepam
temazepam
what are the long acting benzos?
bromazepam
diazepam
chlordiazepoxide
which benzos have the highest risk of dependency?
short acting
T or F
eszopiclone was shown to be superior to zopiclone
false
how long do benzos increase you sleep time by?
25 minutes and decrease 1 nighttime awakening
what are some side effects of benzos?
daytime drowsiness
fatigue
headache
nightmares
nausea
upset stomach
increased risk of falls
T or F
increased risk for accidents associated with benzos increase with alcohol use
true
how to antihistamines work for sleep?
block H2 receptors which decreases wakefulness
what is the efficacy of antihistamines in insomnia?
minimal effect on SL and TST
how long does it take to build a tolerance to the sleeping effects of antihistamines?
3 to 4 days of continuous therapy
what are some adverse effects of antihistamines?
dry mouth
constipation
blurred vision
orthostatic hypotension
increased appetite
what antihistamines and doses are recommended for sleep?
diphenhydramine 50 mg HS
hydroxyzine 25-100mg HS
T or F
antihistamines are recommended for insomnia
false
what is the MOA of melatonin?
hormone produced by the pineal gland that helps regulate the sleep/wake cycle
what is the efficacy of exogenous melatonin?
decrease SL by 8 mins but no effect on SE
what are some AEs of melatonin?
nausea
headache
dizziness
daytime drowsiness
which TCAs are used in insomnia?
amitriptyline and nortriptyline
what is the efficacy of TCAs in insomnia?
increased sleep length and efficacy, decreased nocturnal disturbances and increased TST
fewer changes in REM parameters
what is the dosing of TCAs for insomnia patients without depression?
25-50 mg HS
what are some precautions with TCAs?
problematic in elderly (anticholinergic)
BPH, HTN, arrhythmia, epilepsy
