Insomnia & Drowsiness Flashcards
Stages of Sleep
- Stage 1: transitional, as falling asleep
- Stage 2: light sleep, 50% of time
- Stage 3 & 4: deep/delta sleep
- Rapid eye movement (REM): neither light nor deep sleep
*changes with increasing age
Insomnia Classifications
• Short-term (<3 months)
- Recent loss of a loved one, divorce, job loss, surgery recovery
• Chronic (≥3 months+symptoms ≥3x/week )
- Often secondary due to medical problems, psychiatric disorders, substance abuse, pain syndromes
- Generally not responsive to OTC agents
Insomnia Symptoms
- Difficulty falling asleep
- Frequent awakening
- Early morning awakening
- Inability to fall back to sleep
- Disturbed quality of sleep
- May complain takes >30 minutes to fall asleep
- May complain duration of sleep <6-7 hours
- Some impairment of daytime functioning
Insomnia Risk Factors
- Life stressors
- Shift work
- Nighttime workers
- Alcohol
- Nicotine
- Late night exercise
- Late evening meals
- New surroundings
- Medical or psychiatric disorders
- Medications
- Caffeinated beverages late in the day
- Environmental (noise, lighting, temperature)
Insomnia: Exclusions for Self-Treatment
- <12 years of age
- ≥65 years of age
- Pregnancy or breastfeeding
- Frequent nocturnal awakenings or early morning awakenings
- Chronic insomnia (>3 months)
- Sleep disturbance secondary to psychiatric or medical disorders
Non-pharmacologic Therapy
• Try first before pharmacologic treatment
• Cognitive behavioral therapy for insomnia (CBI)
• Addresses dysfunctional behaviors and beliefs that
contribute to insomnia
• 1st line therapy for ALL patients
• Good sleep hygiene - for ALL patients
Good Sleep Hygiene
- Use bed for sleeping or intimacy only
- Go to bed and arise at same time, even on weekends
- Make bedroom comfortable for sleeping (avoid temp extremes, noise, and light)
- Engage in relaxing activities before bedtime
- Avoid using electronic devices at bedtime
- Exercise regularly but not within 2-4 hours of bedtime
- If hungry, eat a light snack, but avoid eating (heavy) meals within 2 hours of bedtime
- Avoid daytime napping
- Avoid using caffeine, alcohol, or nicotine for at least 4-6 hrs before bedtime
- If can’t sleep, don’t continue to try to sleep; do a relaxing activity until tired
- Do not watch the clock at night
Pharmacologic Therapy
• Antihistamines (block H1 and muscarinic receptors)
- Diphenhydramine - only recommend this for sleep
- Doxylamine - value not established for sleep
• Ethanol
Diphenhydramine - General
- Rapid onset (1-4 hrs); T1/2: 2.4-9.3 hrs (max sedation after 3-6 hrs)
- Metabolized in liver (delayed half-life in liver dysfunction)
- Positive dose relationship between concentration and drowsiness
- For transient and short-term use, particularly with occasional problems falling asleep (poor efficacy in chronic insomnia)
- Tolerance develops quickly, within days of repeated use (take 3 nights, then skip dose for a night)
- Max 7-10 consecutive nights of use
- Combo products w/ APAP, aspirin, or ibuprofen but no evidence that helps insomnia d/t pain
Diphenhydramine - Dosing
- Capsules, gelcaps, tablets, chewable tablets, solutions, and elixirs
- Dose: 25-50 mg HS
- Pregnancy → refer to provider
- Nursing moms: not recommended (may slow milk production and harm baby)
Diphenhydramine - Adverse Effects
• Sedation/hangover effect
• Anticholinergic symptoms/toxicity
• Dry mouth, constipation, blurred
vision, urinary retention, tinnitus
• Inability to concentrate, cognitive impairment
• Tachycardia/QT prolongation
• Paradoxical CNS stimulation (excitation in children and elderly)
Diphenhydramine - Contraindications + Interactions
• Contraindications
- Men with BPH and difficulty urinating
- Angle-closure glaucoma
- Angina or arrhythmias
- Dementia
- Children <6 years old OR with family hx of SIDS or sleep apnea
• Drug-drug interactions
- ↓ clearance of metoprolol especially in women
- May enhance CNS depression of alcohol and opioids
- May enhance adverse effects of glucagon
- Avoid with solid potassium supplements (may cause ulceration)
• Avoid driving, cooking, and operating machinery until response is known
Patient Education for Diphenhydramine
- Take diphenhydramine 30-60 min before sleep
- Do not take more than 50 mg/night
- After 3 consecutive nights, skip for 1 night to see if relieved
- Don’t use longer than 10 days
- Can cause morning grogginess or excessive sedation, dry mouth, blurred vision, constipation, and difficulty urinating
- Do not take with alcohol
- Do not take with prescription sleep aids
- Caution with children/teens in home
Ethanol
- Alcohol use is common in chronic insomnia
- In both low and high quantities, initially improves sleep
- Sleep disturbances occur in 2nd half night at high doses
- Tolerance builds after initial effects
- Heavy/continuous use causes restless sleep, awakening within 2-4 hours, and reduced sleep duration
- Chronic alcoholics have marked disorganization of the sleep cycle
- Worsening of sleep or rebound insomnia when alcohol use ends
• Non-rx combination cold products (up to 10%) marketed for sleep
- NyQuil Liquid® - data is limited regarding safety/efficacy
- Multiple ingredients ↑ risk of adverse effects and drug interactions
Melatonin
- Hormone secreted by pineal gland, may affect circadian rhythm and decrease sleep latency (10 min)
- Evidence is conflicting; possibly effective for short-term jet-lag
- Usual dose: 3-5 mg HS
- Risk for bone fractures, may exacerbate epilepsy and asthma
- Probably safe in pregnancy and short-term use during lactation
- Non-consistent standards in purity and potency
- May help elderly with low melatonin levels
- Note: Elavil OTC Sleep®
