Insomnia, Drowsiness, & Fatigue Flashcards
What is insomnia?
- Insomnia is a disorder of difficulty falling asleep, staying asleep or waking up too early and unable to return, or not getting a quality sleep even after sleeping an adequate number of hours.
- Insomnia is one of the most common patient complaints that we see in pharmacy settings
How does insomnia impact the health care setting?
- It costs our health system about $20 billion – over $100 billion a year
- Small number of patients consult with their healthcare provider, usually patients prefer to come to the pharmacy and pick up over the counter medications to help them. That’s when our role as pharmacists come in play. We need to engage with our patient to recognize if they’re insomnia is something we can recommend an over counter medication for or refer the patient to a healthcare provider for further evaluation.
How much sleep does the average adult in the US get?
Adults in the U.S. usually get about 6.9 hours/day on workdays & 7.6 hours on non workdays
In 2015:
* About 34% experienced 1 or more sleeping related problem during the last 7 days
* And 13% rarely/never get a good night sleep
* And about 20% of U.S. adults use insomnia medications in a given month
* Of those 20%, about 60% of medications are OTCs – antihistamines
What is the healthy amount of sleep for a 4-12 month old infant?
12-16 hours (including naps)
How many hours of sleep does a 1-2 y.o. need?
11-14 hours (including naps)
How many hours of sleep do 3-5 y.o. need?
10-13 hrs of sleep (including naps)
How many hours do 6-12 y.o. need?
9-12 hours
How many hours of sleep do 13-18 y.o. need?
8-10 hours
How many hours of sleep do over 18 y.o. need?
7 hours or more
What are risk factors for insomnia?
Risk Factors:
* Age – older adults are at a higher risk of experiencing insomnia.
* We also see higher risks with females.
* Also some medical and psychiatric condition could put the patient at a higher risk.
* Shift work (like working night shifts or working both day and night shifts like our patient in the case)
* Stressful event like divorce, financial struggles, death of a family members or an upcoming hard exam.
* Also patient with limited financial and educational resources have higher risks.
What medical disorders put you at higher risk for insomnia?
Among the medical conditions we see a higher risk of insomnia is associated with:
* Arthritis
* Benign prostatic hyperplasia
* Diabetes
* Incontinence that could cause the patients to wake up in the middle of the night to go to the bathroom in the middle of the night
* Acid reflexes
* Irritable bowel syndrome
* Peptic ulcer disease that could cause heart burn and discomfort that wakes up the patient in the middle of the night and sometimes can cause uncomfortable cough.
* Some of those conditions can cause patients to wake up in the middle of the night to go to the bathroom such as BPH, DM, and incontinence as well.
* Also, heart failure can cause shortness of breath and difficulty sleep just like COPD and asthma.
* Psychiatric disorders: anxiety, depression, substance use disorder
* Sleep disorders: obstructive sleep apnea, psychophysiological insomnia, RLS, shift work sleep disorder
* Other conditions- menopause, pregnancy
Which drugs cause drug-induced insomnia?
Alcohol
Anticholinesterase inhibitors (e.g. donepezil)
Antidepressants (Fluoxetine, bupropion)
Diuretics
Stimulants (amphetamines, methylphenidate, phentermine, atomoxetine)
Caffeine
Steroids
Decongestants (pseudoephedrine)
Varenicline
Aripiprazole
Which drugs produce withdrawal insomnia?
Alcohol
Amphetamines
Antihistamines (1st gen)
Barbiturates
Benzodiazepines
Illicit drugs (e.g. cocaine, marijuana, phencyclidine)
Monoamine oxidase inhibitors
Opiates
Tricyclics antidepressants
What is the difference between drug-induced insomnia and a medication that could cause withdrawal insomnia once the pt stops taking them?
Drug-induced insomnia occurs when a substance directly interferes with sleep while it is actively in the system, such as stimulants disrupting normal sleep patterns. Withdrawal insomnia, on the other hand, happens when stopping or reducing a drug that the body has adapted to, leading to sleep disturbances as the brain adjusts to the absence of the substance.
What are the 5 stages of the sleep cycle?
- Stage I Sleep: transitional
- Stage II Sleep: intermediate
- Stage III and IV: deep sleep or delta sleep
- Stage V: REM (rapid eye movement). Neither light nor deep sleep stage and has high dream activity
Cycle is about 90-120 mins long
Each night the body undergoes about 3-7 cycles
Stage I-IV are not REM sleep stages
List the sleep promoting neurotransmitters.
Adenosine
Melatonin
GABA
List the wake promoting neurotransmitters.
Norepinephrine
Serotonin
Histamine
Dopamine
Acetylcholine
Orexin
What are the three main classifications for primary insomnia?
Idiopathic, paradoxical, psychophysiological
Differentiate between idiopathic, paradoxical, psychophysiological insomnia.
- Idiopathic insomnia is an insomnia that begins in early childhood and has no identifiable causes – it is also known as childhood onset insomnia
- Paradoxical insomnia is a rare sleep disorder that causes people to feel they are awake while they are asleep. The causes are unclear but active brain activity during sleep may play a role in sleep walking
- Psychophysiological insomnia is the most common type of chronic insomnia that caused by a combination of psychological factors, such as anxiety about sleep, negative conditioning and learned sleeplessness and physiological factors including physiological arousal
What are other types of insomnia? (2 more)
Adjustment insomnia (short-term)
* inadequate sleep hygiene, acute stressors (acute medical illness, acute anxiety, travel, hospitalization, divorce, or death of a beloved one)
Secondary Insomnia
* another sleep disorder, general condition, psychiatric condition, substance use disorder, or medications
What are the characteristics of short-term insomnia?
- Symptoms less than 3 months
- 30% to 50%
What are the characteristics of chronic insomnia?
- Symptoms ≥ 3 times/week for ≥ 3 months
- 5% – 10%
What are characteristics of recurrent insomnia?
Symptoms ≥ 2 within 1 year
What is needed to diagnose a patient with chronic insomnia disorder?
Diagnostic criteria:
Dissatisfaction with sleep quality or quantity with ≥ 1 of following:
* Difficulty initiating sleep
* Difficulty maintaining sleep
* Early morning awakening with inability to fall back asleep
Significant distress or impairment of functioning (social, academic, behavioral, etc.)
* ≥ 3 nights/week
* ≥ 3 months
Not due to:
* Other sleep disorder
* Co-existing medical condition
* Lack of opportunity to sleep
* Medication or substance use
