INSOMNIA Flashcards
What are the symptoms of insomnia?
- Difficulty falling a sleep
- Frequent waking during the night
- Early morning waking
- Daytime sleepiness
- General loss of well-being due to a bad night’s sleep
Causes
- Primary insomnia
- No identifiable cause - Secondary insomnia
- Sleep apnoea
- Circadian rhythm disorders
- Stress/anxiety/depression
- Meds
Which medications can cause insomnia (as a side-effect)?
- Anti-depressants
- SSRIS, Venlafaxine, Bupropion, Duloxetine, MOAIS - Antiepileptics
- Lamotrigine, Phenytoin - Antihypertensives
- BB (e.g. Lipid soluble), CCBs - Hormones
- CS, thyroid hormones - NSAIDs
- Stimulants
- Sympathomimetics
- Salbutamol, salmeterol, theophylline, pseudoephedrine
What are the different types of insomnia?
- Transient - shift, jet lag
- Acute - 1-4 weeks
- Chronic - more than 4 weeks
Management
- Cause?
- Good sleep hygiene
- ONLY consider short-term hypnotic if symptoms are severe
- Refer to psychological services e.g. CBT (if chronic insomnia)
What constitutes
“good sleep hygiene”?
- Fixed bedtime
- Maintain a comfortable sleeping environment (e.g. not too cold or hot, noisy or bright)
- AVOID napping during the day
- AVOID caffeine, nicotine and alcohol within 6 hours of going bed
- AVOID exercise within 4 hours of bedtime
- AVOID eating a heavy meal at night
- AVOID watching or checking the clock throughout the night
- Only use the bedroom for sleep and sexual activity
Drug treatment
Hypnotics:
- Benzodiazepines
OR
- Z-drugs (e.g. Zopiclone)
When do you give pharmacological treatment for insomnia?
- ONLY if symptoms are severe and debilitating and interfere with normal daily living
How long do you give pharmacological treatment for insomnia? And why?
- MAX 4 weeks(although you may not necessarily see this in practice!)
- Because there is a risk of dependence
- Rebound insomniaonce you try to stop (as withdrawal symptom), resulting in a vicious cycle of starting the drug again (relapse)
If someone has transient insomnia, e.g. due to shift work or jet lag, can you give them medication?
- Yes
- BUT ONLY 1 or 2 doses
Do patients with chronic insomnia benefit from hypnotics?
- Yes, but ONLY max 4 weeks
- The real cause of insomnia should be established in order to cure it in the long-term
What are the common causes of chronic insomnia and what can be done to cure it?
Common causes:
- Psychiatric disorders
- Depression
Address underlying cause:
- depression = sedating antidepressant e.g. mirtazipine
What are the other treatments for insomnia (apart from hypnotics)?
- Melatonin
- Helps to correct circadian rhythm - Sedating antihistamines
- Chlorphenamine
- Promethazine
- Diphenydramine - Chlomethiazole
- Herbal (very small evidence)
- Valerian
- Passion-flower
- Jamaica dogwood
What is the usual dose of Melatonin and who can take it?
- 2mg MR OD
- Adults 55 years old and over
- Children = specialist only
- NOTE: You will see doses higher than 2mg OD e.g. up to 10mg daily
Is melatonin addictive?
Melatonin mimics natural melatonin and it is not addictive and well tolerated
Who normally is indicated for Clomethiazole? And why?
- Elderly patients
- Because they don’t get a hangover effect the next day
- However, dependence/ tolerance can still occur, and respiratory depression in overdose
