Lecture 10: Insomnia, Fatigue, Bites, Stings and Pediculosis Flashcards
Sleep characteristics
- Most adults require at least 8 hours of sleep: true avg 6.7 hours
- 64% of adults experience sleep issues a few nights a week
Common management techniques: - Alcohol (7%)
- NonRX sleep aid (7%)
- Prescription hypnotic (8%)
Insomnia
Issues with any of the following:
- falling asleep
- Staying asleep
- Waking up too early
- Not feeling refreshed after sleep
Insomnia Clinical Presentation
- Difficulty falling asleep (more than 30 min)
- Awakening w/o falling back asleep
- disturbed quality of sleep
poor sleep
Insomnia Daytime symptoms
- Fatigue
- naps
- decreased attention and concentration
- mood alterations
- impacted ADLs (activities of daily living)
Insomnia contributing factors
- Life events like stress/ anxiety, sickness/illness, sleep hygiene and shift work
- Comorbidities (simultaneous presence of two or more disease in a patient)
- meds
- caffeine
- nicotine
- meals
- exercise
- increased age
Disorders contributing to insomnia
- Allergies
- Arthritis
- BPH (Benign prostatic hyperplasia
- Chronic pain
- DM
- HF
- Asthma/ COPD
- Pregnancy
- Menopause
- Depression/ Anxiety
- Restless leg syndrome
- Obstructive Sleep apnea
Insomnia exacerbating drugs
- Alcohol
- Certain antidepressants. (bupropion, fluoxetine, venlafaxine)
- Certain anticonvulsants
- Amphetamines
- Anorexiants
- Albuterol
- Decongestants
- Diuretics
- Nicotine
- Caffeine
Transient Insomnia
less than a week
Short-term insomnia
1-3 weeks
Chronic insomnia
more than 3 weeks
Primary insomnia
not a symptom of another condition
Secondary Insomnia
symptoms of another condition
Initiation insomnia- Type
more than 30 min to fall asleep
Maintenance insomnia Type
frequent awakenings
Exclusions to self care - insomnia
- younger than 12 yo or greater than 65 yo
- pregnant/breastfeeding- check w provider first
- frequent awakenings or early morning awakenings (maintenance insomnia)
- chronic insomnia
- secondary insomnia such as narcolepsy, obstructive sleep apnea and/or restless leg syndrome
- diphenhydramine contraindication
Non-pharmacologic options
Improve sleep hygiene and change daily activities
- Review sleep log
Institute 1-2 changes at a time
Sleep Hygiene
First line option before trying pharmacologic option: consists of sleep environment and pre-sleep activities
Sleep environment (sleep hygiene)
- bed should be for sleeping and intimacy
- follow regular sleep schedule 7 days a week
- comfortable cool environment
- avoid visible clocks
Pre-sleep activities (sleep hygiene)
- avoid electronics
- do relaxing activities
- light snacks only
- no caffeine, alcohol or nicotine 4-6 hrs before
Daily activities (non-pharmacologic)
- Regular exercise in morning or early afternoon
- avoid naps or limit to 20-30 min and before 5 pm
Natural light
Pharmacologic treatment for insomnia
- Diphenhydramine (first generation antihistamine)
- Doxylamine
- recommended for short term use b/c tolerance develops quickly
- improves sleep efficiency vs placebo
- self- perceived insomnia severity
Diphenhydramine for insomnia
- standard dosing 25-50mg
- start with a low dose at bedtime
- use for 3 days with an off night
- use no more than 7-10 night in a row
Diphenhydramine side effects
For older patients: Increased fall risk and medication interactions
- Can interfere with cooking/ driving
- avoid alcohol
- can cause morning grogginess/ sedation
Diphenhydramine contraindications
Narrow angle glaucoma
- Use of MAOI medications
- Lactation ( regular use)
Diphenhydramine interactions
Sedatives
Alcohol
Opioids
Other anticholinergic agents
Diphenhydramine Special populations
- Pregnancy- Caution, refer
- Breastfeeding/ Lactation
• Increased CNS effects in infants, decreased milk production
Children/ Adolescents: - Ask about sleep hygiene and Refer if less than 12
Older adults:
Beers criteria recommend avoiding use of anticholingeric agents and refer is older than 65
Complementary and Alternative therapy
for insomnia
Agents that can be used?
Melatonin (2-10 mg/day)
- May decrease time to fall asleep (7mins) and increase total length of sleep (8 minutes); improved sleep quality
- Relatively safe
- Valerian root (only for chronic)
- withdrawal is possible
Kava- (avoid b/c hepatotoxicity)
Drowsiness and Fatigue Goals and Approach
- Identify and eliminate underlying cause
- Prioritize sleep hygiene
- avoid chronic caffeine
- You can use some caffeine
Drowsiness and fatigue exclusions to self care
- younger than 12
- pregnancy/ lactation
- heart disease
- anxiety, medication
- Medication induced drowsiness
- chronic fatigue
Caffeine characteristics
- nonselective adenosine antagonist at A1 and A2A receptors
- The only FDA approved non-prescription stimulant
- low/moderate doses increase arousal, decrease fatigue, elevate mood, increase in BP and HR
- high doses may cause anxiety, nausea, jitteriness and nervousness
- Completely absorbed: Peak in 30-75 mins
T1/2≈ 5 hours (3-7)
Caffeine dosing
- 100-200mg every 3-4 hours as needed
- consuming less than 400mg/day is not associated with adverse effects in healthy adults
- Withdrawal (1-5 days)
- Not a substitute for sleep
- Occasional restoration of mental alertness or wakefulness
Caffeine contraindications
- coronary artery disease
- uncontrolled hypertension
- cardiac arrhythmias
- ## concurrent MAOI use
Caffeine Drug Interactions
- Adenosine
- Cannabinoid
- Ciprofloxacin
- Lithium
- Tobacco smoking
Products with caffeine
- Migraine relief
- Menstrual analgesics
- Energy drinks
- Dietary supplements
Caffeine Special pops
- Pregnancy- Less than 200mg/ day MDD )crosses placenta
- Breastfeeding/Lactation- Usual dietary doses are ok
- Children are more susceptible to cardiovascular and CNS effects
- Older adults have increases pharmacologic effect
Insect Bites and stings characteristics
Often local reactions: erythema, pruritus, swelling
- Systemic toxicity possible
- allergy/ sensitivity
Insects, mites, parasites-> non-venomous
Spiders: venomous-> may cause anaphylaxis
secondary infection, vector transmission
Death (rare): multiple simultaneous stings
Prevention > treatment
Mosquito bites
Exposure: Humid and warm climates
- Bites often develop into wheal with redness and itching
