Insomnia Flashcards
What is Insomnia?
In the DSM-V, insomnia is defined as difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning.
How does the cause of acute vs chronic insomnia differ?
Acute insomnia is more typically related to a life event and resolves without treatment. Chronic insomnia may be diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer.
What risk factors influence insomnia?
- Female gender
- Increased age
- Lower educational attainment
- Unemployment
- Economic inactivity
- Widowed, divorced, or separated status
- Alcohol and substance abuse
- Stimulant usage
- Medications such as corticosteroids
- Poor sleep hygiene
- Chronic pain
- Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
- Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
What features are typical in insomnia?
Patients typically present with decreased daytime functioning, decreased periods of sleep (delayed sleep onset or awakening in the night) or increased accidents due to poor concentration. Often the partner’s rest will also suffer. It is important to identify the aetiology of the insomnia, as management can differ.
Daytime napping
Enlarged tonsils or tongue
Micrognathia (small jaw) and retrognathia
Lateral narrowing of oropharynx
How should insomnia be investigated?
Sleep diaries and actigraphy may aid diagnosis. Actigraphy is a non-invasive method for monitoring motor activity.
Polysomnography is not routinely indicated. It may be considered in patients with suspected obstructive sleep apnoea or periodic limb movement disorder, or when insomnia is poorly responsive to conventional treatment.
How is insomnia managed in the short term?
Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene.
Advise the person not to drive while sleepy.
Only consider use of hypnotics if daytime impairment is severe.
Are hypnotic drugs useful for treating insomnia?
There is good evidence for the efficacy of hypnotic drugs in short-term insomnia. However, there are many adverse effects e.g. daytime sedation, poor motor coordination, cognitive impairment and related concerns about accidents and injuries. In addition, tolerance to the hypnotic effects of benzodiazepines may be rapid (within a few days or weeks of regular use).
When should hypnotic drugs be used in insomnia?
Use the lowest effective dose for the shortest period possible.
If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given.
It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT).
Which drugs are used as hypnotics for insomnia?
The hypnotics recommended for treating insomnia are short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon).
When are benzos indicated for insomnia?
Diazepam is not recommended unless the insomnia is linked to daytime anxiety.
Which benzos are indicated in insomnia?
Should only use short acting so Lorazepam
How long should hypnotics be prescribed for?
Use for only 2 weeks and take for only 5/7 days each week to reduce potential for tolerance
Which non benzo drugs are used as hypnotics?
The Z drugs
Zopiclone
Zolpidem
Zaleplon
