Insomnia/Sleep Disorder Flashcards
What are the 3 types of insomnia?
Transient, Acute, Chronic
Transient insomnia
symptoms that last a few days to weeks
Acute insomnia (short-term insomnia)
Symptoms persist several nights upto 3 weeks (<3 months)
Chronic insomnia
Lasts for months to years (>3 months)
How long should a diary of insomnia be maintained, to record total sleep time?
1 week
When should a patient be referred to a Dr?
If OTCs are ineffective after 3 nights and are required > 7 days
In MILD chronic or primary insomnia, what are the typical symptoms?
difficulty falling asleep, frequent nocturnal awakenings, and/or early AM awakenings for 7 days per week
how to treat mild insomnia?
sleep hygiene, CBT, otc drugs
how to treat mod-severe insomnia?
if no response after otc for 7 days, continue sleep hygiene + add BZD x 2 weeks
Non-pharms for insomnia
sleep hygiene
relaxation exercises
sleep restrictions, stimulus control
aerobic exercise during the day
sleep hygiene examples
-regular sleep schedule
-avoid daytime napping or horizontal rest extensively
-daily exercise 2-3 hrs before bed
-avoid heavy meals before bedtime
-avoid caffeine and alcohol before bed
-minimize noise, light, heat, and drinking too much fluids
-avoid smoking after 7pm
What are the goals of therapy for insomnia?
-improve daytime functionality
-reduce impairment (fatigue, dysphoria)
-promote restorative sleep
First line treatment for insomnia
CBT
How to treat primary insomnia?
CBT (non-pharm) + hypnotic (1-2 weeks then reassess). if it persists, follow up Q 3-6 months. If effective after 1 month, can taper/stop hypnotic
How often should a patient be assessed if they are on long-term stable dose of hypnotics?
Assess patient q 3-4 months
OTC options for insomnia
- Diphenhydramine (not recommended!)
- L tryptophan > 1 g
- Valerian
- Melatonin
Rx drug options
- short acting BZDs
- barbiturates (but not used due to AEs and narrow tx index)
- TCAs
- Chloral hydrate
Since alcohol can promote sleep, why is it not used as therapy?
It causes sedation, but the sleep has low REM and increased arousals. Not a normal sleep.
If a patient had insomnia for 2 days, never took meds before, what would you recommend?
OTC
Which scenarios indicate the use of OTCs?
- short term insomnia (2-3 days)
- recurrent short-term insomnia (3days-3wks, or chronic > 3 wks)
- jetlag
When is the best time to refer a pt to a physician after trying OTCs?
OTC for 3 days ineffective, or consecutively having to take for 7 days
Which has a faster onset - diphenhydramine or dimenhydrinate?
dimenhydrinate
which otc drug loses efficacy quickly and is not recommended in elderly?
diphenhydramine
what is the recommended duration to use diphenydramine for insomnia?
no longer than 7 consecutive days, and no more than 4 times per week
what are the contents of dimenhydrinate (gravol)?
53-55% diphenhydramine
44-47% chlorotheophylline
what are the DDI/Drug food interactions with diphenhydramine?
avoid with BZDs and alcohol
which OTC is appropriate for jetlag?
melatonin
which OTC/NHP should be avoided in pregnancy and breastfeeding?
Valerian root 400mg tabs
what is the DOC for moderate (constant waking for 7days/wk) to severe insomnia?
Benzodiazepine for 7 days, or Z-drugs
What are the preferred drug options in elderly?
- doxepin < 6 mg/day (maintenance)
- melatonin (initial)
- lemborexant (upto 6 months)
- trazodone, mirtazapine
-Z drugs > BZDs
Drug tx in pregnancy
- Zopiclone, eszopiclone and trazodone PRN (low doses)
-AVOID BZDs in 1st trimester and near-term - avoid zolpidem during pregnancy
Drugs that can be used in breastfeeding
short-term use of low dose short-acting benzos, zopiclone and zolpidem
-trazodone (unlikely to affect infant)
treatment for children with insomnia + ADHD or autism
CBT + melatonin or L-tryptophan
Clonidine (in ADHD)
long half-life benzos
nitrazepam (16-55 hrs)
flurazepam (100 hrs)
how should bzd dose be reduced to prevent withdrawal?
gradually reduce dose over a period of 6-12 weeks. symptoms of withdrawal = severe anxiety, agitation, insomnia, depression
what is a good all-purpose hypnotic without causing hangover effect?
temazepam
Side effects of Zopiclone
bitter/metallic taste
nightmares
Drug interactions with Zopiclone?
Zopiclone is a cyp3a4 substrate.
Use at low dose with 3a4 inhibitors / monitor with inducers
How long is a trial Rx of zopiclone usually?
10-14 days
If benzos must be used in elderly, which are preferred?
(LOT)
Lorazepam
Oxazepam
Temazepam
What are the serious AEs of BZDs?
hallucinations, depersonalization, agitation, bizarre behavior, risk of falls
Which HCP should be collaborated with to prevent falls in elderly?
occupational therapist
Which BZDs have a higher risk of ataxia and falls in seniors?
long acting BZDs such as diazepam, clonazepam, flurazepam
What drugs should be avoided in pregnancy?
sedative antihistamines
BZDs in general. but if she must, then lorazepam or Zopiclone preferrable.
Is benadryl recommended in pregnancy?
not recommended, even if commonly used.
What happens if children take BZDs?
paradoxical CNS stimulation = opposite reaction to the medication, instead of causing sedation, it causes stimulation like agitation, hyperactivity, restlessness, insomnia
Which drug is indicated only for sleep maintenance?
Doxepin
What is the advantage of doxepin?
no fall risk or cognitive impairment
In patients with restless leg syndrome, which medication has been shown to improve sleep?
levodopa/carbidopa
