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Insomnia Flashcards

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1
Q

By definition, what is required for the diagnosis of insomnia?

A
  • Difficulty initiating sleep, maintaining sleep or early waking
  • Occurs despite opportunity for sleep
  • Impairs daytime function
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2
Q

What is the DSM-5 definition of an insomnia disorder? (TOP)

A
  • Dissatisfaction with sleep quality or quantity along with a complaint of difficulty initiating sleep (initial insomnia), maintaining sleep (middle insomnia) and/or waking up too early in the morning (late insomnia)
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3
Q

What 5 criteria are also required for the DSM-5 definition of an insomnia disorder? (TOP)

A
  • The sleep disturbance causes clinically significant distress or impairment in functioning
    • It occurs at least 3 nights per week
    • It is present for at least 3 months
    • It occurs despite adequate opportunity for sleep
    • It is not better explained by another sleep-wake disorder
    • It is not attributable to the physiological effect of a substance
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4
Q

What is the definition of acute/adjustment insomnia? (TOP/PBSG)

A
  • Sudden onset and a short course of insomnia, generally less than 3 months
    • <4 weeks according to PBSG
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5
Q

What is the definition of chronic insomnia? (TOP)

A
  • Lasting 3 months or longer for at least 3 nights each week
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6
Q

What is comorbid insomnia? (TOP)

A
  • Insomnia that occurs as a consequence of a medical or psychiatric condition
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7
Q

What are the 4 most common risk factors for insomnia? (TOP)

A
  • Age
    • Middle-aged adults 2x as likely to have insomnia compared to young adults
  • Female sex (1.2-1.5x more likely than males to seek help, 2x as likely to suffer from insomnia)
    • Highest among 1st degree relatives – especially mother-daughter
  • Comorbid medical or psychiatric conditions
  • Social (divorce/separation, unemployment, lower education)
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8
Q

What is the association between insomnia and depression? (NEJM)

A
  • 50% of those with insomnia have a psychiatric disorder (mood or anxiety)
  • Persistent insomnia doubles the risk of incident major depression (meta-analysis)
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9
Q

What is the definition of sleep-onset latency and what is considered normal? (DFCM Open)

A
  • Time it takes to fall asleep
  • Normal <30 minutes
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10
Q

What are 4 examples of circadian rhythm disorders?

A
  • Delayed Sleep Phase (physiological)
  • Advanced Sleep Phase (physiological)
  • Shift Work Sleep Disorder
  • Jet Lag
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11
Q

In whom is delayed sleep phase most commonly seen?

A
  • Teenagers
  • Problems falling asleep at an appropriate time, and thus waking as well
  • Worse with poor sleepy hygiene – video games, music, texting
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12
Q

In whom is advanced sleep phase most commonly seen?

A
  • Elderly
  • Falling asleep at a socially “early” time and associated with early rising
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13
Q

What are 3 management options for patients with Circadian rhythm disorders?

A
  • Behavioural strategies
  • Light therapy
  • Melatonin 0.3 – 5 mg taken 60 minutes before bedtime
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14
Q

What is the M:F ratio for OSA? (AFP)

A
  • M:F = 3:1
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15
Q

What are 8 risk factors for OSA? (AFP)

A
  • Age (40 to 70 years)
  • Commercial motor vehicle driver
  • Family history of OSA
  • Male sex
  • Obesity (BMI >35)
  • Postmenopausal woman not taking hormone therapy
  • Preoperative for bariatric surgery
  • Retrognathia
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16
Q

What is the typical presentation (5) of patients with obstructive sleep apnea?

A
  • Loud snoring
  • Choking/gasping episodes during sleep
  • Daytime sleepiness
  • AM headaches
  • Large neck
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17
Q

What are 5 conditions associated with OSA? (AFP)

A
  • Hypertension
  • CAD
  • CHF – OR 2.4
  • Stroke
  • Atrial fibrillation (Cardiac arrhythmias) – OR 4
  • Diabetes
  • Depression – OR 2.6
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18
Q

What tool can be used to screen for OSA? (TOP)

A
  • STOPBANG Screening Questionnaire
    • Snoring
    • Tired
    • Observed
    • Pressure
    • BMI
    • Age <50
    • Neck size
    • Gender = Male
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19
Q

What “sign” is associated with OSA? (AFP)

A
  • “Elbow sign” – being elbowed by one’s bed partner due to snoring
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20
Q

In a patient suspected of having OSA, what management should be done?

A
  • Refer for sleep study
  • CPAP
  • Weight loss
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21
Q

What evidence is there for a benefit from CPAP with OSA (5)? (AFP)

A
  • Lowers BP
  • Lowers rates of arrhythmia
  • Lowers rates of stroke
  • Improves LVEF in patients with CHF
  • Reduces fatal and nonfatal cardiovascular events
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22
Q

What is an alternative treatment for OSA in patients who prefer it or cannot tolerated CPAP (e.g. discomfort, skin irritation, noise, claustrophobia)? (AFP)

A
  • Mandibular advancement device
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23
Q

Name 2 movement disorders of sleep.

A
  • Periodic Limb Movements in Sleep (PLMS)
  • Restless Leg Syndrome (RLS)
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24
Q

At what age does PLMS most commonly occur?

A
  • < 45 years (can occur at any age)
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25
**How does PLMS typically present?**
* Associated with brief arousals (most people don’t complain about sleep) * Only diagnosis when affecting daytime sleepiness)
26
**How does RLS typically present and what aspect of sleep does it typically affect?**
* Delay in Sleep Initiation (prolonged Sleep Latency) * Uncomfortable sensation in the limbs that comes on at rest and is relieved by movement (such as walking) * Often co-exists with PLMS
27
**What are 4 things that need to be ruled out in patients presenting with RLS?**
* Iron deficiency * Renal failure * Pregnancy * SSRI use
28
**What are the two treatment classes for RLS?**
* Dopaminergic agents * Pramipexole (Mirapex) * Ropinirole (Requip) * Alpha-2-delta subunit calcium channel ligands * Gabapentin * Pregabalin
29
**What notable adverse effect is associated with dopa agonists? (PBSG)**
* Impulsive behavior à gambling, shopping, eating, sex
30
**What other adverse effects are associated with pramipexole and ropinirole? (AFP)**
* Pramipexole * Nausea * Somnolence * Nasopharyngitis * Ropinirole * Nausea and Vomiting * Headache * Dizziness * Somnolence
31
**In a patient presenting with insomnia, what needs to be ruled out?**
* Primary Sleep Disorders (**CAL**) * **C**ircadian rhythm * Sleep **A**pnea * Restless **L**egs
32
**What 4 secondary causes of insomnia need to be ruled out?**
* **MMMS** * **M**ood * **M**edical * **M**edications * **S**ubstance Abuse
33
**What are 5 red flags to be aware of in patients presenting with insomnia? (DFCM Open)**
* Depression * Bipolar * GAD or Panic Disorder * Excessive daytime sleepiness – unexpected or irresistible * Substance abuse
34
**What are 5 medical disorders that need to be ruled out in a patient presenting with insomnia?**
* Chronic pain syndromes * Menopause * GERD/PUD * COPD/Asthma/CHF * BPH
35
**What are 8 medications that should be asked about in patients presenting with insomnia?**
* Nicotine patches * Antidepressants * Corticosteroids * Stimulants – medical and recreational * Bronchodilators (beta-agonists) * Decongestants – Pseudoephedrine * Thyroid hormone (excessive) * SSRIs
36
**What are 4 recreational drugs that should be asked about in patients presenting with insomnia?**
* Cigarettes * Coffee * Alcohol – promotes sleep onset, but shortens total sleep * Cocaine/Stimulants
37
**In a patient presenting with acute insomnia, what should you assess for?**
* Trigger * If present, then identify and manage
38
**What are 9 common triggers that can cause acute or adjustment insomnia? (TOP/PBSG)**
* Noise * Extreme temperature * Caring for a newborn * Jet lag * Daylight savings/time change * “Sunday night” insomnia * Death in family * Job loss * Relationship ends
39
**What should you ask patients in regards to the quality of their sleep when presenting with insomnia? (PBSG)**
* Onset * Circumstances * Duration * Severity * Current sleep hygiene * Complaints from sleep partner * QOL (decline in work performance, difficulty concentrating, increased clumsiness or minor injury to self and/or others because of daytime symptoms) * OTC medications (melatonin, antihistamines for night-time) * Recent travel * Night-time or rotating shifts * Usage of screen devices
40
**Why should patients be advised to avoid use of light emitting devices in the hour before bedtime? (PBSG)**
* Light suppressed the hormone melatonin, which promotes sleep, and negatively affects the timing of REM sleep * May result in sleep deficiency and disturb circadian rhythms
41
**What symptoms should be asked about in patients presenting with insomnia? (PBSG)**
* Pain * Dyspnea * Nocturia * Cough * Nasal congestion * GERD * Menopause (e.g. vasomotor) * Anxiety * Stress * Depression * RLS/PLMD
42
**What can be used to determine the severity of the sleep disorder and to monitor the effect of treatment interventions? (TOP)**
* Insomnia Severity Index (ISI)
43
**What investigations might you consider in a patient presenting with insomnia? (PBSG)**
* Ferritin * Magnesium * Renal function * B12 level * Nocturnal polysomnography (PSG) if suspecting sleep apnea, PLMS or sleep-state misperception
44
**When would you consider treating acute insomnia? (TOP)**
* Substantial negative impact on daytime performance
45
**How long should pharmacotherapy be given for acute insomnia? (TOP)**
* Short term (e.g. 2 weeks) with close follow-up
46
**What is first-line therapy for the management of insomnia? (TOP/PBSG)**
* Non-pharmcologic therapies (i.e. CBT-I)
47
**How can a patient evaluate their insomnia and monitor their progress?**
* Sleep diary
48
**What are 8 suggestions that can be made for a patient to improve their sleep hygiene?**
* No PM coffee or tobacco * No alcohol within 6 hours of sleep * Exercise, but not within 3 hours of sleep * No late evening fluids * Minimize bright light before going to bed, including all technology * Stimulus control – quiet, dark, safe and comfortable room * Routine sleep and wake times * Don’t go to bed too early – go to bed when you are sleepy * Maintain a regular sleep schedule * Relaxation therapy – 1 hour before bed to unwind, stretch, yoga, abdominal breathing, etc.
49
**What is the evidence supporting regular exercise to help with insomnia? (PBSG)**
* Total sleep time * Sleep efficiency * Sleep onset latency
50
**Why is alcohol considered a stimulant in the management of insomnia? (PBSG)**
* Alcohol promotes sleep onset in the first half of the night * Moderate to high doses reduce total REM sleep % during the night
51
**What effect does nicotine (and nicotine agonist products) have on sleep? (PBSG)**
* Longer sleep latency * Shorter overall sleep period * Higher REM activity
52
**What are 4 components of CBT-I for insomnia? (TOP)**
* Sleep restriction therapy – build up the homeostatic sleep drive * Stimulus control therapy * Cognitive therapy * Relaxation techniques
53
**What are the 5 steps of CBT-I for insomnia that should be discussed with patients? (PBSG)**
* Step 1 – discuss sleep hygiene and determine patient’s commitment to making necessary changes to improve sleep * Step 2 – recommend that patients keep a sleep diary * Step 3 – encourage patients to maintain a strict and constant routine of going to bed and getting up * Step 4 – strength appropriate thoughts about sleep * “Sleep needs to be allowed to occur, which ca be very difficult for people who are trying desperately to enter that state.” * Consider stimulus control to reduce those states of arousal, through strategies that include deep breathing and meditation * Step 5 – education about sleep restriction * May seem counterintuitive to patients who feel that extension (not restriction) of sleep time makes more sense * Important to avoid daytime napping
54
**What is the evidence for the 5-component approach to CBT-I? (CMA POEM)**
* Meta-analysis (Ann Intern Med 2015) * Onset of sleep 19 minutes earlier * Minutes spent awake after first falling asleep 26 minutes shorter * NO change in overall sleep time
55
**What is an effective behavioural method for patients to improve their sleep?**
* Sleep Restriction
56
**How does sleep restriction help with insomnia? (TOP)**
* Helps build up the homeostatic sleep drive, and counters the unproductive strategy of going to bed early in an attempt to gain more sleep * Strengthens the circadian rhythm of sleep regulation
57
**How is sleep restriction applied for patients with insomnia? (PBSG/TOP)**
* Have patients estimate actual time spent sleeping each night * Have patients choose a wake time each morning – advised patients not to vary the time, no matter the bedtime, even on weekends * Have patients deliberately delay bedtime to coincide actual time spent in bed with estimated time spent asleep (within 20-30 minutes) * Not to be less than 5 hours * Once sleep efficiency has improved to ~90%, can lengthen time in bed if needed based on tiredness
58
**What is the NNT for sleep restriction based on a RCT? (CMA POEM)**
* NNT = 4 (Falloon et al Br J Gen Pract 2015)
59
**Which online CBT-I program are evidence-based (RCT), effective and recommended for use with patients with insomnia? (TOP)**
* SHUTi * Sleepio
60
**If considering pharmacotherapy for insomnia, how long should it be prescribed? (TOP)**
* \< 7 nights (to break cycle) OR 3x/week if long-term * 3-5 doses per week ideal (TOP)
61
**Should OTC agents be prescribed for insomnia? (TOP/PBSG)**
* No – potential harms from anticholinergic properties, rapid tolerance, cognitive impairment * Health Canada has diphenhydramine (Benadryl) listed for relieving **occasional** sleeplessness, for aid with falling asleep, and/or for occasional use when sleeplessness is caused by overwork, tiredness or fatigue
62
**What potential AE are associated with diphenhydramine use? (PBSG)**
* Confusion * Urinary retention * Diminished cognitive function
63
**What are four first-line pharmacotherapy options for insomnia and their hangover effect? (TOP)**
* Zopiclone (Imovane) 3.75 – 7.5 mg * Short half-life – low hangover effect * Metallic after-taste * 5 mg max dose for elderly, kidney/liver disease * Risk of physical tolerance and dependence * Zolpidem (Sublinox) 5 – 10 mg * Rapid onset of action * Risk of physical tolerance and dependence * Doxepin (Silenor) 3 – 6 mg * Temazepam (Restoril) 15 – 30 mg * Low to moderate hangover effect (intermediate half-life) * Risk of physical tolerance and dependence
64
**Which benzodiazepine is the best to prescribed for insomnia and why? (PBSG)**
* Temazepam * Less rebound insomnia than other benzodiazepines such as lorazepam (which could result in significant anxiety and tension)
65
**How do the half-lives of temazepam compare to diazepam, lorazepam and clonazepam? (NEJM)**
* Temazepam = 8-10 hours * Lorazepam = 8-12 hours * Diazepam = 44-48 hours * Clonazepam = 40 hours
66
**How effective are benzodiazepines for patients with chronic insomnia without coexisting conditions? (NEJM)**
* Sleep Latency = -22 minutes * Time awake after sleep onset = -13 minutes * Total sleep time = +22 minutes
67
**What adverse effects (8) are associated with benzodiazepines for insomnia? (NEJM)**
* Daytime sedation/drowsiness * Delirium * Ataxia * Anterograde memory disturbance * Complex sleep-related behaviors (e.g. sleepwalking and sleep-related eating) * MVAs * Falls and fractures in the elderly * Dementia
68
**What is the NNT and NNH for benzodiazepines with insomnia? (CMAJ)**
* NNT = 13 * NNH = 6
69
**What is a potential strategy for tapering off of benzodiazepines? (PBSG)**
* Consider switching to a long-acting agent (e.g. diazepam) * Taper ~25% of the original dose every 2 weeks * Slow supervised schedule **Length of Use** **Recommended Taper Length** \< 6 to 8 weeks Taper may not be required 8 weeks to 6 months Slowly over 2-3 week periods 6 months to 1 year Slowly over 4-8 weeks \> 1 year Slowly over 2-4 months
70
**What is the risk of tapering off of benzodiazepines when length of use has been longer than 8 weeks? (PBSG)**
* Rebound insomnia * Agitation * Seizures
71
**For patients prescribed a Z-drug for insomnia, what is the minimum time that a patient should be in bed at night? (TOP)**
* At least 8 hours in bed
72
**Which Z-drug has a lower chance of morning hang-over effect? (TOP)**
* Zolpidem
73
**What is the half-life for the two Z-drugs used in insomnia? (PBSG/NEJM)**
* Zolpidem = 2.5-3 hours * Zopiclone = 6-9 hours
74
**What is the evidence for Z-drugs in patients with insomnia? (TFP)**
* Help people fall asleep faster (~13-22 minutes) * Get ~5% more time sleeping while in bed
75
**What are the potential risks of Z-drugs in patients with insomnia? (TFP/PBSG)**
* Headache, GI upset or dizziness (PBSG) * Increased risk of infections (NNH = 43, most mild – pharyngitis) * Moderate negative effects on verbal memory (zopiclone and zolpidem) and attention (zolpidem)
76
**What other adverse effects are specific to zolpidem and not zopiclone? (PBSG)**
* Neuropsychiatric – hallucinations, amnesia, parasomnia, dementia
77
**What was the safety review on zopiclone recently issued by Health Canada? (PBSG)**
* Next day impairment * Decreased ability to be alert within 12 hours of taking the medicine * Includes daytime sleepiness, impaired hand-eye coordination, decreased mental sharpness and related motor functions
78
**What type of medication is doxepin? (TOP)**
* Tricyclic (H1 antagonist)
79
**What is doxepin specifically indicated for with insomnia? (TOP)**
* Sleep maintenance and sleep duration * No effect on sleep onset
80
**What are 3 advantages of doxepin in regards to the side effect profile? (TOP/PBSG)**
* Avoids next-day residual effects or termination effects * No fall risk or cognitive side effects * Minimal risk of physical tolerance/dependence
81
**What is the concern with higher doses of doxepin (\>10 mg) for insomnia? (TOP)**
* Traditional TCA side effect profile * Sedation * Fatigue * Weakness * Lethargy * Dry mouth * Constipation * Blurred vision * Headache
82
**What dose of doxepin would you start patients on with insomnia? (PBSG)**
* 6 mg qhs for adults * 3 mg qhs for elderly (≥65 years)
83
**What is a second-line pharmacotherapy option for insomnia and its hangover effect?**
* Trazodone (Desyrel) 25 – 100 mg * Low hangover effect (short half-life) * Minimal risk of tolerance/dependence
84
**What are 3 potential adverse effects of trazodone for insomnia? (TOP)**
* Orthostatic hypotension * Rarely priapism and cardiac conduction issues
85
**What is the new medication approved in 2014 by the FDA (not Canada yet) for insomnia? (NEJM)**
* Suvorexant (Orexin antagonist) * Major AE is morning sleepiness
86
**What is the evidence for cannabinoids for treating insomnia? (PBSG)**
* Systematic review found no evidence that it improves insomnia * May interrupt normal sleep cycles
87
**What is a nonprescription medication that can be given for insomnia and what dose? (TOP)**
* Melatonin 0.3 – 5 mg
88
**At what doses of melatonin can there be a higher risk of daytime sleepiness? (TOP)**
* \>4 mg
89
**What possible adverse effects can occur with melatonin for insomnia? (TOP)**
* Dizziness * Headache * Nausea * Sleepiness
90
**When should melatonin be taken for insomnia? (TOP)**
* Shift Circadian Rhythm à Lower dose 4-5 hours before bed * Hypnotic à 30 – 90 min before bed
91
**For what circumstance did a Cochrane review find melatonin to be effective? (PBSG)**
* Preventing or decreasing jet lag when it involves crossing more than 5 time zones, particularly going west to east
92
**What is the evidence for melatonin in patients with insomnia? (TFP)**
* Help people fall asleep faster (~10 minutes) * Spend more time asleep (~15 minutes) * ~18.2 minutes in jet lag/shift workers * Evidence generally poor and at high risk of bias
93
**By how much do benzodiazepines, non-benzodiazepines, antidepressants and melatonin reduce sleep onset latency? (TFP)**
* Benzodiazepines = 10-20 minutes * Z-drugs = 13-17 minutes * Antidepressants = 7-12 minutes * Melatonin = 10 minutes
94
**What can be prescribed for patients with both depression and insomnia? (TOP)**
* Mirtazapine
95
**What can be prescribed for patients with pain related to fibromyalgia, neuropathic pain syndromes or restless leg syndrome (RLS) and insomnia? (TOP)**
* Gabapentin * Pregabalin
96
**What can be prescribed for patients with resistant bipolar disorder or schizophrenia and insomnia? (TOP)**
* Chlorpromazine * Loxapine
97
**What can be prescribed for patients with bipolar disorder, schizophrenia, resistant depression and anxiety and insomnia? (TOP)**
* Risperidone * Olanzapine * Quetiapine (Anxiety)
98
**What should be done if there is no improvement in managing a patient’s insomnia after 12 weeks? (TOP)**
* Referral to sleep medicine * Literature states to refer if no improvement with CBT-I within 6 weeks
99
**What is the preferred treatment option for chronic insomnia in the elderly? (TOP)**
* Non-pharmacological interventions
100
**What is the first-line medication for chronic insomnia in the elderly? (TOP)**
* Doxepin (Silenor) – low-dose
101
**What are two other medications that can be considered for chronic insomnia in the elderly? (TOP)**
* Melatonin * Short-acting GABA-A agonist (e.g. Sublinox)
102
**What is the concern with long-term use of benzodiazepines for insomnia in elderly patinets? (PBSG)**
* Adverse cognitive effects * Memory impairment * Mental depression * Confusion * Difficult to reduce or withdraw
103
**What can be done for pregnant women with insomnia concerned that their insomnia is negatively impacting their baby’s growth and development? (TOP)**
* CBT-I – reassure that no evidence that, in the absence of other medical or psychiatric factors, insomnia results in fetal damage * Normalize the sleep disturbance and minimize the anxiety for these women
104
**Which benzodiazepine is recommended if being prescribed for insomnia in pregnant or breastfeeding women? (TOP)**
* Lorazepam
105
**Why is lorazepam the recommended benzodiazepine for pregnant or breastfeeding women? (TOP)**
* Lacks active metabolites and is less likely to be associated with a withdrawal syndrome in the neonate * Low levels in breast milk and does not appear to cause any adverse effects in breastfed infants with usual maternal dosages
106
**What 2 antidepressants are considered safe to be prescribed for insomnia in pregnancy? (TOP)**
* Nortriptyline * Trazodone (reduces sleep-onset latency)
107
**What is the risk of using nortriptyline for insomnia in pregnancy? (TOP)**
* Neonatal (withdrawal) adaptation syndrome
108
**Should melatonin be recommended for pregnant women with insomnia? (TOP)**
* No – limited data currently regarding clinical benefit or risk of adverse events

Primary Care (12 decks)

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