Lecture 4 - Insomnia Flashcards
Risk factors for insomnia
Women
advancing age
Comorbid conditions = pulmonary, neurologic disease, HF
some meds = corticosteroids, stimulant, withdrawal
stressors
Primary insomnia
no clear cause, abnormality of sleep-wake cycle or circadian rhythm
Secondary insomnia
due to other factors
secondary insomnia meds
anticonvulsants
stimulants
antidepressants
diuretics
central adrenergic blockers
corticosteroids
opioids
substance withdrawal
Acute vs Chronic insomnia
Acute = < 3 months
Chronic = > 3 months
initial insomnia
difficulty falling asleep
inc time ( >30min) to sleep onset
Middle insomnia
difficulty maintaining sleep
frequent awakenings during the night
Terminal insomnia
early morning awakening
total sleep time < 6hs
common in depression
Excessive daytime sleepiness & non-restorative sleep
results in fatigue throughout the day
3 components of CBT-I
Education
Cognitive therapy
Behavioral therapy
1st line therapy for insomnia
CBT-I
negative of sleep restriction therapy
will cause day time sleepiness for people
adjust sleep time based on amount of time it takes to fall asleep
who shouldn’t use sleep restriction therapy?
seizure disorders
little sleep can lower seizure threshold
Who can use Somryst
> 22 yrs old w/ chronic insomnia
have access to mobile device + app
under supervision of HCP
Who shouldn’t use Somryst
pts w/ bipolar, schiz disorder
pts w/ untreated OSS
pts w/ epilepsy, high risk falls, pregnant, parasomnias
pts w/ stuff thats worsened by less sleep
Sleep Hygiene
Set regular time to go to bed
avoid napping
avoid watching TV,working, eating in bed
dont exercise within 6hrs of bedtime
avoid ehavy/spicy food in evening
avoid drinking lots of fluid in evening
minimize tobacco, caffeine, alc in evening
Cognitive Therapy (CBT-I)
change dysfunctional beliefs about sleep
reduce anxiety surrounding sleep
confront fear of not sleeping
Stimulus control therapy
only go to bed when tired
only use bed for sleep and sex
avoid daytime naps
schedule “worry time” during day
avoid lighted screens before bed
hide clock
set alarm same time every morning
relaxation training (CBT-I)
deep breathing
meditation
mindfulness therapies
1st gen antihistamine for sleep
Diphenhydramine + doxylhamine
ADE: anticholinergic
DI: sedating agents, other anticholinergic, alc
Precaution: CNS depression, BPG, glaucoma
Monitor: improve sleep n ADE
Pt ed: can cause grogginess next morning
tolerance quickly, not good for chronic insomnia ( ~ 10 days)
not best in older adults or liver disease
Doxylamine safe for pregnancy
Herbal products for insomnia
Tryptophan
Valerian- 3-4wk for benefit
Melatonin info
Take 30min before bedtime
OTC not FDA approved
** most helpful pts w/ Jet lag, delayed sleep phase syndrome or low melatonin**
** may help w/ sleep onset**
safe for short-term use
Ramelteon (Rozerem)
8mg 30min before bed (not after high-fat meal)
CI strong CYP1A2 inhib (Fluvoxamine)
$$$, 3 wks for effect, helpful in elderly
melatonin receptor agonist
Benzos for Insomnia
Triazolam (Halcion) + Temazepam (Restoril)
Temazepam = longer acting, help with maintenance
Triazolam = good for onset
Benzo insomna prestations
should be used for no more than 7-10 days
tolerance likely within ~4 weeks, (2wks w/ Triazolam)
can have rebound insomnia once stop
** Dont use w/ sleep apnea, substance use disorder, pregnancy **
** Inc risk of falls n hip fractures in elderly **
reduces sleep latency, inc stage 2 sleep, reduces stages 3,4, & REM sleep, inc total sleep time
which drugs work on GABA A subunit?
Z-drugs
Z-drugs
Zaleplon (Sonata)
Zolpidem (Ambien)
Eszopiclone (Lunesta)
Zolpidem info
women req lower starting dose than men
Highest affinity for alpha-1 subunit
Eszopiclone info
max of 2mg in hepatic impairment or use with CYP3A4 inhibitors
Z-drugs used for onset vs maintenance
onset = Zaleplon
Maintenance = Zolpidem, Eszopiclone
Z-drug patient education
devote >7-8h to sleep for zolpidem ER/eszopiclone
if using Zaleplon or Zolpidem SL for middle of night awakenings, ensure has >4h of sleep
take on empty stomach, food delays absorption
risk of complex sleep-related behaviors, tell doc if they occurs
impairment maybe present even if feeling awake
Z-drug clinical considerations
possibly less tolerance and less rebound insomnia
should limit to < 4 wk to dec risk of tolerance and dependence
eszopiclone FDA approved for up to 6 months
Trazadone for insomnia
good for onset and maintenance
can improve sleep continuity
not FDA approved
low dose = 25mg
Doxepin (Silenor) for insomnia
FDA approved for insomnia
good for sleep maintenance
3-6mg empty stomach w/in 30min bedtime
Mirtazapine for insomnia
7.5-15mg QHS
not FDA approved
good option if pt has depression/anxiety
Dual Orexin Receptor Antagonist (DORA)
Suvorexant (Belsomra)
Lemborexant (Dayvigo)
Daridorexant (Quviviq)
DORA info
issues with liver dysfunction + CYP3A4
Precaution: pts with depression
CI: pt with narcolepsy
monitor insomnia six after 7-10 days
avoid alc, faster onset taken w/o meal, next day somnolence
