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