Insomnia Flashcards
EPIDEMIOLOGY of insomnia:
- Affects approximately one third of the UK population per year
- Women, elderly and those with medical/psychiatric co-morbidities at higher risk
- Insomnia is a known risk factor for depression and anxiety, obesity and hypertension
AETIOLOGY:
Can be caused by other factors:
- Drugs e.g. beta blockers
- Life events
- The environment
- Illnesses
People may perceive that they are not getting enough sleep
- Sleep requirements decrease with increasing age??
- Increased day time napping and wakefulness in the night also more common as age increases, linked to dementia/stroke
Describe the sleep cycle:
Awake REM Non REM 1 Non REM 2 Non REM 3 Non REM 4
REM = vivid dreams
Non rem = deep sleep
As you get older, more REM sleep and less non REM sleep
Symptoms of insomnia:
Can be transient, acute or chronic insomnia
- Transient – sleep well usually. Jet lag, shift work, noise/light disturbance
- Short term – may last for a few weeks, bereavement, physical illness
- “Chronic insomnia can be defined as an inability to achieve or maintain sleep satisfactorily on the majority of nights over a period of at least three months, despite adequate opportunity, with subsequent adverse consequences on daily functioning”
Patients may report one or more of the following:
- Difficulty in falling asleep
- Frequent waking during the night
- Early morning waking
- Daytime sleepiness
- General loss of well-being due to bad night’s sleep
Could increase the risk of industrial and road traffic accidents
Could increase the risk of falls, cognitive decline and mortality in the elderly
Treating insomnia with medications – core principles
Drug treatments for insomnia are termed hypnotics – BZDs and ‘Z drugs’
Before using hypnotic drug treatments for insomnia, consider treating any underlying causes i.e. depression, anxiety
Drug treatments are only used for severe insomnia interfering with daily life
Before using hypnotic drug treatments, consider sleep hygiene approaches and CBTi (chronic) unless urgent treatment required (then do both!)
It is really important to explore sleep habits and patterns with the patient
Hypnotic drugs cannot cure insomnia – treat underlying cause(s) if present
Treating insomnia – using medications in practice
Use pharmacological ‘hypnotic’ agents:
For the shortest time period (usually 2 weeks, max 4 weeks, see SmPCs)
For one or two doses, or intermittently if possible
At the lowest effective dose
If severe transient/short term insomnia, a few doses may be sufficient
Additive sedative effects with alcohol and other sedating drugs (e.g. clozapine)
No difference between BZDs and ‘Z drug’ hypnotics in terms of efficacy
Prescribe the agent with the lowest acquisition cost
Could use shorter acting agent if difficulty falling asleep
But increased risk of tolerance/dependence and late night rebound insomnia
Temazepam (Benzodiazepine), Zolpidem (Z drug)
Could use longer acting agent if frequent and/or early morning wakening
Be mindful of next day sedation and loss of co-ordination (‘hangover’ effect)
Long acting agents less likely to cause rebound insomnia
Nitrazepam (Benzodiazepine), Zopiclone (Z drug) (5 or 6 hours)
Reduce doses slowly if patients have used hypnotics for a prolonged period
Monitor carefully for rebound insomnia and withdrawal symptoms
The risks of treating older people with hypnotics may outweigh the benefits
Treating insomnia – sleep hygiene approaches
- Determine whether expectations of sleep are realistic
- Increase daily exercise (not in the evenings/within 4 hours of bedtime)
- Stop daytime naps
- The bedroom should be at the right noise and light levels, at the right temperature
- Reduce consumption of certain substances in the evenings (e.g. food and fluids, alcohol (less time in non rem 1 and 2) chocolate, smoking, avoid caffeine after midday)
- Use the bed only for sleeping/sex, avoid TV/computers/devices in the bedroom
- Use relaxation techniques (e.g. Audio tools, breathing, counting methods)
- Develop a routine for rising and going to bed
- If you cannot sleep after 30 minutes, get up and do something else, then return to bed
- Keep pets that disturb sleep out of the bedroom
Benzodiazepines (BZDs) and insomnia:
- BZDs are the most widely prescribed hypnotic agents
temazepam, nitrazepam - Use short or long acting agents depending on symptom presentation
- Patient counselling important: driving/operating machinery, issuing prescriptions
- They can reduce stage 3 and 4 non-REM sleep
- Extreme caution in the elderly, previous addiction
Rebound insomnia common
- > Risk factors: shorter acting agents, higher doses, prolonged treatment
- > Rebound insomnia can increase the likelihood of drug dependence
‘Z drug’ hypnotics and insomnia:
Zopiclone, Zoplidem – little difference in efficacy between ‘Z drugs’
Shorten stage 1 sleep, but increase stage 2, little effects on stage 3/4
Stimulate activity at GABAA receptor in a similar way to BZDs (see Mike Harte’s lecture)
Appear just as effective as BZDs, but may also be possible to produce rebound insomnia, tolerance/dependence and neuropsychiatric reactions
Similar cautions to BZD – withdrawal reactions, driving/operating machinery, prescriptions
Need to withdraw gradually if prolonged use
NICE Technology Appraisal TA77
If patients fail to respond to one ‘Z drug’ do not offer another (same is true for BZDs)
Other drug treatments for insomnia:
CBT-I may be better than hypnotics longer term
Melatonin
- Mimics natural melatonin: not addictive and well tolerated, does not cause tolerance
- Usual dose 2mg daily, licensed as monotherapy for over 55’s, very short acting (often appears as MR prep) – promotes sleep initiation and uninterrupted sleep
Sedating antihistamines
- Diphenhydramine, chlorphenamine and promethazine
- Can be purchased OTC, have mild-moderate effects but commonly produce ‘hangover’ ADRs and tolerance can develop to effects
Clomethiazole
- Dependence/tolerance and respiratory depression in overdose limit use
Over the counter (OTC) preparations
- Very small evidence base
- Valerian-hops combinations
- Passion-flower
- Jamaica Dogwood
Medicines optimisation in insomnia - summary
Try non-pharmacological methods first unless severe
Try to avoid BZD and Z drugs in high risk groups
Choose hypnotic agents based of half life and symptom presentation
Enforce practical prescribing of BZD and Z drugs
Patient counselling r.e. appropriateness of BZD and Z drugs for insomnia
Patient counselling r.e. alternative treatments for insomnia (e.g. OTCs)
Education r.e. effectiveness & tolerance/dependence with BZD/Z drugs
