Insomnia Lecture Flashcards
Types of insomnia
Difficulty falling asleep (sleep onset)
Difficulty maintaining sleep (sleep maintenance)
Early morning awakening (sleep offset)
Unrefreshing sleep (non-restorative sleep)
Insomnia facts?
33% experience insomnia
$14 billon on medical costs
$325.8 million nonprescription meds
Prevalence increases with age and with women
26% try natural products
5X more likely to present with anxiety and or depression
Can be due to another medical disorder
Classification of insomnia
Transient
Short-term
Chronic
Define transient
Self-limiting
<1 week
Travel, hospitalization or upcoming stress
Define short-term
1-3 weeks
More serious stressor (death, unemployment, divorce)
Define chronic
Almost every night for >3 weeks
Result of an underlying cause
Define insomnia disorder
- Predominant complaint of dissatisfaction with sleep quantity/quality associated with one or more: difficulty initiating sleep, maintaining, early-morning awakenings
- Sleep disturbances causes clinically significant distress or impairment in other parts of the life
- More than 3 nights per week
- At least 3 months
- Difficulty occurs even when sleep is an option
- No other explanation
- Not attributable to physiological effects of substance <drug abuse, alcohol, etc)
- No other coexisting mental disorder or conditions
Define situational/acute insomnia
Last a few days/weeks, associated with life events or rapid changes in sleep/environment
- Daytime napping
- Activity before sleep (eating and exercise)
- Jet lag
- Sift work
- Stress
- Poor sleep hygiene
Medications of insomnia?
Albuterol Anti (depressants, psychotics, convulsants, parkinson's) Alcohol Nicotine Decongestants Theophylline Steroids Stimulants (caffeine, amphetamines) Clonidine Methyldopa Beta blockers
What are complications of sleep disorders?
Worsening health (depression, headaches, heart disease) Substance abuse Daytime drowsiness Decreased productivity Car accidents
Signs and symptoms of insomnia?
Complaint of difficulty falling or staying asleep Daytime fatigue Poor concentration Impaired memory Irritability
Assessment of insomnia?
Consider: symptoms, onset, duration, severity, history, pre-sleep conditions, sleep schedule, daytime functioning, drug or substance abuse
What are supportive of insomnia?
Do you take longer than 30 minutes to fall asleep?
Wake up and stay awake for more than 30 minutes
Sleep less than 50% of the time you are in bed
Less than 6.5 hours
Falling asleep at work or at school?
What are exclusions for self treatment of insomnia?
Less than 12 or older than 65
Pregnant
Nocturnal awakenings or early morning awakening
Chronic insomnia
Sleep disturbances at night for several days
Secondary to a other medical disorders (sleep apnea, narcolepsy, restless leg syndrome)
What are goals of treatment?
Alleviate symptoms Minimize adverse effects Improve quality of life and function Id and address cause of insomnia Outcomes: decreased time to fall asleep, sleep quality, decrease daytime fatigue and drowsiness, normal sleep cycle
What is cognitive behavioral therapy?
Stimulus control Sleep restriction Relaxation Cognitive therapy Sleep hygience Session for 4-6 weeks Few of the above at a time
Preferred non-pharmacological therapies?
Try to ID the cause
Evidence shows CBT works and is safe
Improves sleep over time
Try before initiating pharmacotherapy
What does good sleep hygiene mean?
Stick to a schedule Exercise regularly Turn off worries Make bedroom quiet, dark, safe and comfortable Not too cold or hot No large meals before bed Not lots of food before bed Do not read or watch tv in bed -- Sleep and sexual activity only If you can't sleep, get up after 10 minutes Remove the clock Avoid or limit daytime naps Reduce alcohol, nicotine and caffeine use Avoid using sedatives frequently
Antihistamines drug products?
Diphenhydramine- Benadryl
Doxylamine- Unisome, Nyquil
– often contain acetaminophen or ibuprofen
Antihistamines drug MOA?
Ethanolamine antihistamine
Block histamine 1 and muscarinic receptors
Newer are less lipophilic exert few CNS effects
Antihistamines drug adverse effects?
Sedation Morning hangover effect Dry mouth/throat Constipation Blurred vision Urinary retention Diminished cognitive function
Antihistamines drug reactions?
Anticholinergic meds
CYP450 2D6
Antihistamines drug precautions/contraindications?
Males of advanced age Angle closure glaucoma Dementia Cardiovascular disease Prolonged half-life with cirrhosis
Antihistamines drug conseling?
May develope tolerance
Use cation in tasks that require alertness
Do not drink alcohol
Paradoxical effects
How does alcohol affect insomnia?
Improves sleep in nonalcoholics
Tolerance develops quickly
Chronic drinkers have disturbed sleep cycles
Experience: fall asleep faster, more restless, wake up after 2-4 hrs, reduces total sleep time
Define complementary therapy?
May promote health and relaxation
58% of patients do not discuss use of complementary therapy with their PCP
Complementary therapies include: acupuncture, music therapy, light therapy, herbs and natural products
Valerian indications and MOA?
Most studied
Benzodiazepine-like effects
Increase GABA activity in CNS by inhibiting an enzyme that metabolizes GABA
Valerian clinical effects?
Reduce time to sleep onset
Take several nights to weeks to work
Valerian adverse effects?
Headache, excitability, paradoxical insomnia
Cause uterine contractions in pregnant women
Valerian precautions?
Few cases of hepatotoxicity
Interactions possible with CYP450 3A4
Melatonin MOA?
Increases endogenous production by pineal gland
May allow for rapid adjustment of circadian rhythm after changing time zones
Melatonin clinical effects?
Evidence for jet lag
Increase REM, decrease latency
Low risk of dependence or abuse
Melatonin adverse effects and precautions?
headache, tachycardia, irritability, “hangover”
Do not use in pregnancy or lactaion
No elderly
Drug interactions
Define german chamomile
Bedtime tea –> takes time to work
May affect GABA receptors
May be beneficial in patients with anxiety
May interact with CYP450 3A4
Avoid in patients with ragweed or similar allergies
Define passionflower
Once was an OTC sleep aid
Now a dietary supplement
May cause sedation by affecting benzodiazepine receptors
No evidence
Define KAVA
Efficacy: insufficient evidence
Safety: possibly unsafe due to severe hepatotoxicity
NOT APPROVED FOR INSOMNIA
Define L-tryptophan
Efficacy: insufficient evidence
Safety: possibly unsafe –> recalled
NOT APPROVED FOR INSOMNIA
Define 5-HTP
Efficacy: insufficient evidence
Possibly unsafe
NOT APPROVED FOR INSOMNIA
Define coenzyme Q-10
Efficacy: possibly effective
Safety: likely safe
Bottom line: helps with insomnia due to heart failure, discuss with physician first
Insomnia in elderly
Duration of sleep is shorter # of nocturnal awakenings increases Less time in stage 4 and REM sleep Normal sleep latency Diphenhydramine can cause increased cognitive impairment and falls
Insomnia in children
Asked about caffeine and alcohol intake
Nonpharmacologic therapy first line
Anthistamines not indicated to treat insomnia in less than 12 years old
Not recommended to induce sleep in infants
Use of melatonin is controversial
Insomnia in pregnancy?
Diphenhydramine Category B
Should be referred for evaluation
Herbals not recmmended
Insomnia in lactating women?
May limit lactation
Increase infant drowsiness
Herbals not recommnded
