insomnia Flashcards
1
Q
What is the optimal sleep duration for most adults to maintain good health?
A
7–9 hours per 24-hour period
2
Q
What adverse outcomes are associated with short sleep duration?
A
Increased mortality
3
Q
What are the two categories of sleep?
A
- Rapid eye movement (REM)
- Non-REM
4
Q
Which neurotransmitters promote wakefulness?
A
- Norepinephrine
- Acetylcholine
- Histamine
- Orexin
- Serotonin
5
Q
Which neurotransmitters promote sleep?
A
- g-Aminobutyric acid (GABA)
- Adenosine
- Melatonin
6
Q
What is the typical duration of a sleep cycle?
A
70–120 minutes
7
Q
What is the incidence of insomnia in older adult patients?
A
As high as 40%
8
Q
What are common sleep-wake disorders recognized by DSM-5?
A
- Insomnia disorder
- Hypersomnia disorder
- Narcolepsy
- Breathing-related sleep disorders
- Parasomnias
9
Q
What is insomnia characterized by?
A
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Early morning awakening
10
Q
How often must sleep difficulty occur for a diagnosis of insomnia?
A
At least 3 nights of the week
11
Q
What nonpharmacologic management can be used for insomnia?
A
Cognitive therapy with behavioral treatments (CBT)
12
Q
What are the treatment goals for insomnia?
A
- Improved sleep quality
- Improved insomnia-related daytime impairments
13
Q
What is the recommended duration for initial pharmacotherapy for insomnia?
A
2–4 weeks
14
Q
What are the risks associated with long-term use of hypnotic medications?
A
- Tolerance
- Dependence
- Residual daytime sedation
- Rebound insomnia
- Anterograde amnesia
15
Q
Which class of medications is primarily used as sedatives for insomnia?
A
Benzodiazepines
16
Q
What differentiates benzodiazepines from one another?
A
- Onset of action
- Metabolism
- Half-life
17
Q
What is the half-life classification of benzodiazepines?
A
- Short acting (less than 6 hours)
- Intermediate acting (6–24 hours)
- Long acting (more than 24 hours)
18
Q
What are Z-drugs used for?
A
Treatment of insomnia
19
Q
Which Z-drug is indicated for chronic insomnia?
A
Eszopiclone
20
Q
What is the role of orexin receptor antagonists in insomnia treatment?
A
Decrease sleep latency and promote sleep maintenance
21
Q
What does the CAGE questionnaire screen for?
A
Alcohol use disorder
22
Q
What are the four questions in the CAGE questionnaire?
A
- Cut down on drinking
- Annoyed by criticism of drinking
- Felt bad or guilty about drinking
- Eye-opener drink in the morning
23
Q
What is the gold standard for treating alcohol withdrawal symptoms?
A
Symptom-driven treatment using the Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar)
24
Q
What is a key nutritional consideration for patients with alcohol use disorder?
A
Thiamine supplementation
25
What dosage of thiamine is recommended for severe cases?
100–250 mg intramuscularly/intravenously daily for 3–5 days
26
What should be administered before glucose to prevent Wernicke-Korsakoff syndrome?
Thiamine
27
What is Korsakoff syndrome?
A chronic neurocognitive disorder caused by thiamine deficiency
28
How is thiamine administered in severe cases of Korsakoff syndrome?
100–250 mg intramuscularly/intravenously daily for 3–5 days, followed by 100 mg by mouth three times daily for 1 week, then 100 mg daily thereafter
29
Why should thiamine be given before glucose in Korsakoff syndrome treatment?
Thiamine is a cofactor for the metabolism of glucose
30
List the nutritional considerations for patients with Korsakoff syndrome.
* Magnesium
* Electrolytes
* Fluids
* Vitamins
31
What role do antiseizure medications play in alcohol withdrawal?
They are adjuncts to benzodiazepines in uncontrolled seizures
32
What is Acamprosate (Campral) used for?
It reduces cravings in alcohol use disorder
33
What are the dosing considerations for Acamprosate based on renal function?
Dose must be decreased for CrCl of 30–50 mL/min; not used if CrCl < 30 mL/min
34
What precautions are associated with Naltrexone?
Precaution for hepatocellular injury; liver function tests should be monitored
35
What are the adverse effects of Naltrexone?
* Nausea
* Diarrhea
* Injection site reactions
* Headache
* Insomnia
* Nervousness
36
What is Disulfiram (Antabuse) used for?
It blocks acetaldehyde dehydrogenase, causing adverse effects if alcohol is consumed
37
What symptoms may occur if alcohol is consumed while on Disulfiram?
* Nausea
* Vomiting
* Flushing
* Headache
38
What is the Clinical Opiate Withdrawal Scale (COWS) used for?
To monitor the severity of opioid withdrawal symptoms
39
What is considered a severe score on the COWS?
A score greater than 36
40
What are the first-line treatments for severe opioid withdrawal?
* Buprenorphine
* Methadone
41
What is the mechanism of action of Methadone?
Full agonist with an affinity for the opioid mu-opioid receptor
42
What is the black-box warning associated with Methadone?
Fatal respiratory depression and prolonged QTc interval
43
What is unique about Buprenorphine's action at the mu-opioid receptor?
It is a partial agonist and an antagonist of the kappa receptor
44
What is the ceiling effect in Buprenorphine?
It displaces other opioids but provides a limited effect with increasing doses
45
What are the phases of Buprenorphine treatment?
* Induction
* Stabilization
* Maintenance
46
What must occur before administering Naltrexone?
The patient must be completely off opioids for 7–10 days
47
What is Lofexidine (Lucemyra) approved for?
Treatment of opioid withdrawal
48
What is the primary benefit of smoking cessation?
Reduces risk of adverse health effects including cardiovascular diseases and cancer
49
What are the five A’s in assessing willingness to quit smoking?
* Ask about tobacco use
* Advise to quit
* Assess willingness to quit
* Assist in quit attempt
* Arrange for follow-up
50
List the seven pharmacologic agents available for smoking cessation.
* Nicotine replacement therapy (5 types)
* Bupropion
* Varenicline
51
What is the recommended starting dose for the nicotine patch for heavy smokers?
21 mg/day for 6 weeks
52
What should patients avoid when using nicotine gum?
Acidic beverages at least 15 minutes before use
53
What is the recommended duration of therapy for nasal spray nicotine replacement?
3–6 months, with tapering
54
What is the primary concern with nicotine nasal spray?
Higher risk of dependency compared to other forms
55
What is Varenicline's mechanism of action?
It is a nicotine receptor partial agonist
56
When should Varenicline be started in relation to the quit date?
1 week before the quit date
57
What is the recommended duration for pharmacologic treatment to increase the chances of quitting smoking?
At least 8 weeks, up to 6 months
## Footnote
Longer treatment duration can enhance the likelihood of successful cessation.
58
What is Varenicline classified as?
A nicotine receptor partial agonist
## Footnote
It blocks the effects of nicotine from smoking.
59
When should Varenicline be started in relation to the quit date?
1 week before the quit day
## Footnote
Patients can choose to quit up to 35 days after starting Varenicline.
60
What is the total duration for which Varenicline should be continued?
12 weeks
## Footnote
If successful, it can be extended for another 12 weeks.
61
What significant warning regarding Varenicline was removed in 2016?
The black boxed warning about neuropsychiatric symptoms
## Footnote
This change reflected updated safety information.
62
Name two other agents used in smoking cessation treatment.
* Clonidine
* Nortriptyline
## Footnote
These can be alternatives if initial pharmacologic therapy is unsuccessful.
63
What should be done for patients who were unsuccessful with one form of pharmacologic therapy?
Try a different method
## Footnote
This approach increases the chances of successful smoking cessation.
64
What organization released guidelines for initiating pharmacologic treatment in tobacco-dependent adults?
The American Thoracic Society
## Footnote
Their guidelines include strong and conditional recommendations.
65
List three strong recommendations made by the ATS for tobacco-dependent adults starting treatment.
* Varenicline over a nicotine patch
* Varenicline over bupropion
* Varenicline plus a nicotine patch over varenicline alone
## Footnote
These recommendations are based on effectiveness.
66
What is recommended for patients who are not ready to quit smoking?
Start varenicline treatment rather than wait
## Footnote
Early intervention can facilitate eventual cessation.
67
What is a conditional recommendation made by the ATS for tobacco-dependent adults with comorbid psychiatric conditions?
Varenicline over a nicotine patch
## Footnote
This is specific to patients with additional psychiatric concerns.
68
What is the recommendation regarding the duration of therapy with Varenicline?
Extended-duration (more than 12 weeks) therapy over standard-duration (6–12 weeks)
## Footnote
Longer treatment may provide better outcomes.
