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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
Q

max durations for the Z drugs

A

Zaleplon - 2 weeks
Zolpidem - 4 weeks
Zopiclone - 2-3 weeks

26
Q

ADRs of Z drugs

A 
GI disturbances
paradoxical effects
dizziness/drowsiness - falls risk
dry mouth
confusion/hallucinations/nightmares
perceptual disturbances/diplopia
27
Q

interactions with Z drugs

A
  • alcohol/opioids: sedation
  • centrally acting drugs: CNS depression
  • CYP450 inhibitors: enhance Z drug effects
  • phenytoin - altered phenytoin levels
28
Q

What is melatonin?

A

pineal hormone involved in regulation of circadiam rhythm

production declines with age

29
Q

When is melatonin used?

A

insomina in over 55yrs

30
Q

What type of melatonin is used for insomnia?

A

PR melatonin

31
Q

licensing of melatonin

A

ST Tx of insomnia in adults over 55yrs

32
Q

melatonin dose

A

2mg OD taken 1-2hrs before bedtime for up to 13 weeks

  • recommended initial duration is 3 weeks
33
Q

adverse effetcs of melatonin

A 
headache
dizziness
nausea
drowsiness
falls risk
34
Q

counselling for melatonin

A
  • avoid alcohol: less effetcive and additonla CNS depression effects
  • may affect ability to drive/operate machinery
35
Q

sedating antidepressants for insomnia

A
  • not usually recommended
  • co-exists with mood disorder then might consider
  • low doses of TCAs can be used LT
36
Q

TCA (sedating antidepressants) that can be used for insomnia

A

amitriptyline 10-25mg at ON

37
Q

How to discontinue hypnotics?

A

slowly taper down

38
Q

effects when discontinuing hypnotics

A
  • temp worsening of sleep, takes longer to fall asleep with GABAergic drugs
  • psychological dependence
39
Q

recommended duration of hypnotics

A

2-4 weeks max

40
Q

how to help with discontinuing a hypnotic

A

CBT

41
Q

symptoms of WD from hypnotics

A 
anxiety/agitation (most common)
insomnia
dizziness
headache
perception abnormalities
tremor
sweating
tinnitus
N&V
sometimes psychosis/convulsions
42
Q

How to withdraw hypnotic drigs for insomnia?

A

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
Q

What can you switch to when withdrawing hypnotic?

A

diazepam

long half life (20-100hrs) so avoids fluctuating levels

44
Q

When to switch to diazepam when withdrawing?

A
  • 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
Q

How to switch to diazepam

A

gradually, stepwise

1st switch in night time dose to avoid daytime sedation

46
Q

patient advice for insomnia

A
  • 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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