Insomnia

Question 1

What is insomnia

Answer 1

• difficulty falling asleep
  -difficulty maintaining it
  -early wakening
  -non-restorative sleep

All causing daytime-impairment

Question 2

how does NICE do with insomnia management

Answer 2

divides it into short term (<3 months) & chronic one (>3 months several days a week)

Question 3

lines of treatment for short term insomnia as per NICE

Answer 3

• sleep hygiene and sleep diary
  -combining that in short term stressor with non-benzo hypnotic medication (z-drug) (3-7 days)
  -If that did not work, over CBT-I +/- z-drug)

Question 4

how long can z-drug be given to short term insomnia

Answer 4

3-7 days (max 14 days)

Question 5

in whom hypnotic should be avoided?

Answer 5

old people

Question 6

what can replace z-drugs in combination of cbt-i in elderly?

Answer 6

prolonged release melatonin

Question 7

lines of treatment for Chronic insomnia as per NICE

Answer 7

• CBT-I
  -No medication unless severe symptoms or acute exacerbation

Question 8

what medication can be used in combination of CBT-I in chronic insomnia if there were severe symptoms and acute exacerbation?

Answer 8

z-drugs —adults
prolonged release melatonin in elderly & children

Question 9

what new medication is approved for chronic insomnia?

Answer 9

Daridorexant (orexin inhibitor)

Question 10

Where orexin inhibitors (daridorexant) are suggested by NICE?

Answer 10

chronic insomnia >3 months
several nights /week
no CBT-I response/ unsuitability

Question 11

what is prolonged release melantonin lincesed for?

Answer 11

children - delayed sleep phase syndrome or sleep onset insomia
elderly with insomnia or jet lag

Question 12

NICE thoughts on sleep hygiene alone?

Answer 12

insufficient evident
but
but
widely accepted by experts

Question 13

NICE thoughts on z-drugs?

Answer 13

good evidence but there are side effects

Question 14

Tolerance to hypnotic effects of bezodiazepine?

Answer 14

Rapid
or
in days and weeks of regular use

Question 15

Dependence risk benzodiazepines?

Answer 15

• long term use
  -high dose
  -short acting agents
  -more potent
  -anxiety

Question 16

Which benzos are not generally recommended? and why?

Answer 16

Diazepine —->
Nitrazepam —-> Next-day resitual effects, that’s why
Flurazepam —->

Question 17

Evidence quality of acupuncture

Answer 17

may be benficial but not good evidence to be sure

Question 18

evidence quality of herbs like valerian?

Answer 18

insignificant to make a good recommendation

Question 19

Insomnia in pregancy

Answer 19

• Relaxation before bed
  -no caffeine before bed
• if above not enough, promethazine