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PHA333 > insomnia in practice > Flashcards

insomnia in practice Flashcards

1
Q

What is insomnia?

A

charcterised by unsatisfactory sleep

  • sleep onset insomnia (younger)
  • frequent nocturnal waking (older)
  • early waking

AND poor daytime functioning with affected mood

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2
Q

chronic insomnia

A

3 months of persistent poor sleep

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3
Q

bad effects of insomnia

A 
dec QoL
dec productivity/accidents
depression risk
impaired function
DM risk
hpt risk
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4
Q

Qs for insomnia assessment

A
  • sleep habits?
  • sleep schedule?
  • intake of substances that disturb sleep?
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5
Q

other sleep disorders

A
  • obstructive sleep apnoea
  • restless leg syndrome
  • parasomnias
  • circadiam rhythm sleep disorder

-> SPECIALIST REFERRAL

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6
Q

management of ST insomnia (< 3mths)

A
  • manage ID causes if possible - sleep hygiene
  • hypnotic if daytime imapirment severe
  • > lowest dose for shortest time (not >2 weeks)
  • persists - CBT
  • short acting BDZ or Z drug
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7
Q

What BDZs not used for insomnia and why?

A

diazepam, nitrazepam, flurazepam

  • long half lives gives next day residual effects
  • repeated doses are cumulative
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8
Q

management of LT insomnia

A
  • manage underlying causes -> sleep hygiene
  • refer to psychological servises for CBT
  • pharmacological not recommended for LT
  • > tolerance to hypnotics reduces effectiveness
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9
Q

Tx for severe symptoms or acute exacerbation of persistent insomnia

A

short course (2 weeks, sometimes 4) of hypnotic drug considered for immediate relief of symptoms

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10
Q

Tx for >55yrs with persistent insomnia

A

Tx with MR melatonin

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11
Q

non-drug Tx

A
  1. CBT

2. sleep hygiene

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12
Q

sleep hygiene

A
  • fixed bed/waking times
  • relax before bed
  • confortable sleeping environment, not too hot/cold/noisy/bright
  • avoid caffeine/nicotine/alcohol 6hrs of bed
  • avoid exercise 4hrs of bed
  • avoid heavy meal late at night
  • don’t watch/check clock
  • only use bedroom for sleeo
  • elemination of caffeine from diet, consider
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13
Q

What drugs usually have a hang over effect associated with them?

A

half lives > 6hrs

eg. nitrazepam

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14
Q

short acting drugs good for sleep onset insomnia

A

zolpidem

melatonin

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15
Q

drugs with longer duration good for waking through night insomnia

A

zopiclone

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16
Q

NTs that promote sleep

A

GABA

adenosine

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17
Q

What do BDZs and Z drugs enhance the effects of?

A

GABA at the GABAa receptor

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18
Q

NTs that do not promote sleep

A 
noradrenaline
serotonin
acetylcholine
histamine
orexin
dopamine
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19
Q

example of drugs that dec NTs which promote sleep

A

sedative antihistamines

- cross BBB and promote sleep

20
Q

When should BDZs only be used for insomnia?

A

only if daytime impairment is severe

21
Q

examples of short acting and long acting BDZs

A

short acting

  • temazepam
  • loprazolam
  • lormetazeoam
  • lorazepam

long acting

  • nitrazepam
  • flurazepam
  • diazepam
22
Q

ADRs of BDZs

A
  • tolerance and dependence
  • cognitive/psychomotoe impairment
  • depression
  • emotional blunting
  • paradoxical anxiety/aggression/hyperactivity
  • elderly: falls, # risk
  • inc road accidents
23
Q

interactions with BDZs

A
  • alcohol/opiates: sedation
  • centrally acting drugs: CNS depression (neuroleptics, antipsychotics, barbiturates)
  • antihypertensives, vasodilators, diuretics: enhance hypotensive effect
  • CYP450 inducers: dec benzo effect
  • phenytoin: altered levels of phenytoin
24
Q

examples of z drugs

A

Zaleplon
Zolpidem
Zopiclone

25
max durations for the Z drugs
Zaleplon - 2 weeks Zolpidem - 4 weeks Zopiclone - 2-3 weeks
26
ADRs of Z drugs
``` GI disturbances paradoxical effects dizziness/drowsiness - falls risk dry mouth confusion/hallucinations/nightmares perceptual disturbances/diplopia ```
27
interactions with Z drugs
- alcohol/opioids: sedation - centrally acting drugs: CNS depression - CYP450 inhibitors: enhance Z drug effects - phenytoin - altered phenytoin levels
28
What is melatonin?
pineal hormone involved in regulation of circadiam rhythm production declines with age
29
When is melatonin used?
insomina in over 55yrs
30
What type of melatonin is used for insomnia?
PR melatonin
31
licensing of melatonin
ST Tx of insomnia in adults over 55yrs
32
melatonin dose
2mg OD taken 1-2hrs before bedtime for up to 13 weeks - recommended initial duration is 3 weeks
33
adverse effetcs of melatonin
``` headache dizziness nausea drowsiness falls risk ```
34
counselling for melatonin
- avoid alcohol: less effetcive and additonla CNS depression effects - may affect ability to drive/operate machinery
35
sedating antidepressants for insomnia
- not usually recommended - co-exists with mood disorder then might consider - low doses of TCAs can be used LT
36
TCA (sedating antidepressants) that can be used for insomnia
amitriptyline 10-25mg at ON
37
How to discontinue hypnotics?
slowly taper down
38
effects when discontinuing hypnotics
- temp worsening of sleep, takes longer to fall asleep with GABAergic drugs - psychological dependence
39
recommended duration of hypnotics
2-4 weeks max
40
how to help with discontinuing a hypnotic
CBT
41
symptoms of WD from hypnotics
``` anxiety/agitation (most common) insomnia dizziness headache perception abnormalities tremor sweating tinnitus N&V sometimes psychosis/convulsions ```
42
How to withdraw hypnotic drigs for insomnia?
gradually over 4-8 weeks after LT, can take up to 1yr dose tapering 5-10% reduction every 1-2 weeks or 1/8th of dose every 2 weeks according to severity of WD symptoms
43
What can you switch to when withdrawing hypnotic?
diazepam long half life (20-100hrs) so avoids fluctuating levels
44
When to switch to diazepam when withdrawing?
- short acting potent BDZs - preps that don't easily allow for small dose reductions - temazepam or nitrazepam - difficulty withdrawing directly from temazepam, nitrazepam, Z drugs due to high dependency/high dose/Hx of anxiety
45
How to switch to diazepam
gradually, stepwise 1st switch in night time dose to avoid daytime sedation
46
patient advice for insomnia
- sleep hygiene - hypnotics: don't drive is sleepy - law about dribing and BDZs - tolerance/dependence - alcohol/illicit drugs

PHA333 (27 decks)

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