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CNS lectures (Bal) > Module 1.3 (Insomnia) > Flashcards

Module 1.3 (Insomnia) Flashcards

1
Q

What is insomnia?

A

Insomnia „

  • The inability to initiate or maintain sleep, or lack of refreshing sleep „
  • Associated with daytime symptoms:„

Fatigue, sleepiness, inattention, mood disturbance and impaired performance

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2
Q

What are the two stages of sleep?

A

NREM „

  • 75-80% total sleep time „
  • N1-N3 (deep sleep) „

REM

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3
Q

What are the four causes of insomnia?

A
  • An insomnia disorder

> Adjustment sleep disorder –> acute emotional stressors

> Psychophysiologic insomnia –> Insomnia that persists beyond resolution of precipitating factors

  • Inadequate sleep hygiene

1Caffeine/stimulant medication in afternoon/evening. Exercise or other stimulating activity (eg Netflix!) in the evening. Irregular sleep wake schedule

  • Psychiatric disorder (esp depression, anxiety and substance-use disorder)
  • Medical disorder (eg pulmonary, musculoskeletal, chronic pain)
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4
Q

What are the AE of insomnia?

A

Decreased quality of life

  • Fatigue, anxiety, depression, sick days, medical issues

Subjective decrease in cognitive function and performance „

Self medication „

Association with suicide „

Increased cardiovascular risk

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5
Q

What can insomnia be a part of?

A

Insomnia can also be a part of some other disorders such as sleep apnoea and episodic movement disorders (eg restless legs syndrome)

secondary insomnia: depression, pain, substance use disorder

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6
Q

What are the individual factors associated with an increased risk of insomnia?

A
  • Older age „
  • Female gender (esp peri- and post-menopausal) „
  • Previous episode of insomnia „
  • Family history „
  • “light sleeper
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7
Q

What are some psychiatric conidtions and medical conditions that can lead to chronic insomnia?

A
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8
Q

What are medications and substances are risk factors and co-morbidities for insomnia?

A
  • CNS stimulants – caffeine, methylphenidate, dexamphetamine, modafinil „
  • Respiratory stimulants – theophylline „
  • Appetite suppressants – phentermine „
  • Antidepressants „

MAOI’s – insomnia in ~70% „ SSRI’s – insomnia in ~5-35% „ SNRI’s – insomnia in 4-18% „ Anticonvulsants – eg phenytoin

  • Beta-blockers – sleep onset insomnia, increased awakenings and vivid dreams - eg propranolol and metoprolol (lipid soluble)
  • Glucocorticoids – increased wakefulness (insomnia in 50- 70% on prednisolone)
  • OCP
  • Thyroid hormones
  • Alcohol – misuse and withdrawal
  • Tobacco and NRT
  • OTC – eg pseudoephedrine
  • „ Withdrawal of medication – sedatives, hypnotics, antidepressants, illicit drugs and glucocorticoids
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9
Q

What are THREE components that are required for diagnosis?

A
  1. Persistent sleep difficulty
  2. Adequate sleep opportunity
  3. 3Associated daytime dysfunction
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10
Q

What are the THREE main components of of insomnia diganosis?

A
  1. Persistent sleep difficulty

> Poor sleep quality or insufficient quantity due to difficulty initiating or maintaining sleep, or waking up too early

> May be variable

  1. Adequate sleep opportunity
  2. Associated daytime dysfunction

> Fatigue

> Poor concentration

> Social/vocational/educational dysfunction

> Mood disurbance

> Daytime sleepiness

> induced motivation/energy

> increased errors

> behavioural problems eg aggression

> on going worry about sleep

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11
Q

What are the types of insomnia?

A
  • Short-term

> Days to weeks (usually <1 mth, definitely <3months)

> In response to an identifiable stressor

  • Chronic

> Sx >3x/week for >3 months

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12
Q

What are the differential diagnosis for insomnia?

A
  • Short sleep duration ƒ
  • Chronic sleep insufficiency ƒ
  • Delayed sleep-wake disorder ƒ
  • Advanced sleep-wake disorder
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13
Q

What are the evaluation tools for insomnia?

A
  • Sleep history „
  • Sleep diary „
  • Self-report screening tools „
  • Validated questionnaires „
  • Consider contributing factors

Physical examination/laboratory test for comorbid conditions

  • Screen for depression/anxiety
  • Sleep apnoea/RLS –> Polysomnography „
  • Caffeine/other medication
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14
Q

Summary of insomnia

A

The inability to initiate or maintain sleep, or lack of refreshing sleep „

Associated with daytime symptoms

One of the most common presentations to a doctor

Most commonly caused by

  • Insomnia disorder „
  • Inadequate sleep hygiene „
  • Psychiatric disorder „
  • Medical disorder

Adverse outcoms of insomnia

  • ​Decreased QOL, decrease in cognitive function, self medication, association wiith suicide and increased cardiovascular risk

Risk factors and co-morbidities – complex relationship with insomnia

  • Psychiatric, medical and neurological conditions, other sleep disorders, medications and other substances, environmental factors

Diagnosis

  1. Persistent sleep difficulty
  2. Adequate sleep opportunity
  3. Associated daytime dysfunction

> Short term vs chronic mania

Evaulation

  • Sleep history
  • Sleep diary
  • Self-report screening tools
  • Validated questionnaires
  • Consider contributing factors
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15
Q

What are the FOUR goals of treatment for insomnia?

A

Aim to improve sleep quality and quantity, and relieve insomnia-related daytime impairment

  1. Management of underlying problems (e.g. GORD treat with PPI or comorbid depression treat with SSRI) –> address the underlying condition and you may assist the insomnia
  2. Good sleep practices
  3. Psychological and behavioural interventions
  4. Pharmacological treatment
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16
Q

For good sleep practices, what are examples of

A) sleep-wake activity regulation

B) sleep setting and influences

C) sleep-promoting adjuvants

A

A)

  • go to bed same time each day
  • arise at regular time
  • avoid overlseeping

B)

  • avoid heavy meals within 3 hours of bedtime
  • seek exposure to bright light after rising
  • avoid tobacco, especially in the evening
  • avoid caffeine after midday

C)

  • Have a light snack or a warm milk drink ebfore bed
  • Have a warm bath before bed
  • Ensure comofortable temperature for sleep and maximal darkness
17
Q

For psychological and behavioural interventions

A) What is it the msot effective treatment for?

B) What are the four types?

A

A)

  • These are the most effective treatments for chronic insomnia

Psychological and behavioural interventions are effective treatments for insomnia. CBT and brief behavioural therapy are evidenced based treatments for chronic insomnia and first line

B)

  • Relaxation therapies –> hypnosis, meditation, deep breathing, progressive muscle relaxation
  • Cognitive therapy –> reassure people that those with insomnia get more sleep than they perceive
  • Stimulus control –> learn to associate bedroom only with sleep
  • Sleep restriction –> suitable for people who have difficulty staying asleep due to poor sleep drive
18
Q

What are the pharmacological treatment options for insomnia if the previous options were not effective?

A

Pharmacological treatment with a hypnotic drug (a benzodiazepine, zolpidem or zopiclone) or melatonin may be indicated for short-term management of acute insomnia, and for chronic insomnia where the above strategies are not effective.

  • Temazepam before bedtime
  • Zolpidem controlled release at bedtime
  • Zolpidem immediate release at bedtime
  • Zopiclone before bedtime OR melatonin prolonged release 2mg before bedtime
19
Q

What guides the decision to prescribe a hypnotic or melatonin?

A
  • The cause of insomnia
  • The level of distress caused by the lack of sleep
  • The degree of impairment from the daytime sequelae of insomnia
  • Likely benefits balanced against the possible harms of treatment
20
Q

What are potential problems of using benzodiazepines and zolpidem/zopiclone?

A
  • Impaired daytime alertness „
  • Tolerance and dependence with long-term use „
  • Falls risk
  • Sleep may not be “refreshing” „
  • Watch for contraindications (eg OSA)
21
Q

Timeframe if treatment prescribed for benzodiazepines and zolpidem/zopiclone?

A

Shortest possible timeframe (preferably dosed intermittently and for <2weeks)

  • Intermittent tx for long-standing treatment resistant insomnia may be considered
  • A definite duration of use agreed with the patient at the outset
22
Q

When does rebound insomnia occur?

A
  • Broken sleep with vivid dreams may occur when hypnotics ceased „
  • May take days-weeks for sleep patterns to be re-established

> May be misinterpreted as needing more medication

23
Q

Outline why temazapem may be used and when it may not be appropriate for certain options

A

Why should be used

  • Preferred option for insomnia (per eTG) „
  • Rapid onset and short t ½ „
  • May be used short term in the management of insomnia –> when starting SSRI

Why should not be used

  • May still cause daytime drowsiness the next day –> avoid BZD with longer half life
  • Benzodiazepines can cause cognitive dysfunction with longterm use which may not be fully reversible
  • Elderly patients are at increased risk of over-sedation, ataxia, falls, memory impairment and respiratory depression

> use lowest dose for shortest possible time

> avoid longer acting agents

24
Q

Compare zolpidem and zopiclone with other BZDs

A

Similar hypnotic properties

  • „ Minimal anxiolytic, muscle relaxant and anti-epileptic properties „
  • Less morning sedation and less disruptive effect on sleep patterns? elderly still sedated in morning and women
  • Dependence, tolerance, withdrawal and misuse can still occur
  • black box warning - zolpidem –> see attached image

Both zolpidem and zopiclone are contraindicated with concomitant alcohol intake

25
Q

How to manage long-term hypnotic use?

A
  • Patient may have unwittingly become dependant „
  • Discuss and trial a cessation of long-term hypnotic where possible

> Regular contact between patient and Dr „

> Tailored dose reduction „

> Non-pharmacological treatments „

> Lots of support and encouragement

26
Q

when can continued treatment of hypnotics be acceptable?

A

May be acceptable in rare situations

  • Detailed history shows no adverse effects „
  • Patient is aware they may be dependent „
  • Reduction program has been unsuccessful or is against patients wishes
27
Q

What are other options besides hypnotics mentioned previously?

A

Melatonin „

  • Reduces sleep-onset latency in >55 years
  • Long term safety and efficacy not established

Suvorexant

  • May be useful for sleep-maintenance insomnia
  • Uncertain benefit for sleep-onset insomnia

Other agents

  • TCAs, sedating antihistamines, chloral hydrate, antipsychotics, mirtazapine

> not recommended, especially not in the elderly

> toxicity/risk of adverse effects

> DO NOT use antipyschotics for insomnia

Valerian

  • Complementary medication for sleep
28
Q

What are the indications for melatonin? What are the practice points?

A

Indication

  • Short-term monotherapy in primary insomnia with poor sleep quality „
  • Trials only included those >55yrs„ No data in hepatic impairment

Practice points

  • Limited evidence it may improve sleep quality
  • There do not appear to be any dependence or withdrawal effects, or rebound insomnia

Melatonin is an endogenous hormone associated with the control of circadian rhythms and sleep regulation. Melatonin levels may be reduced in middle-aged and elderly patients with insomnia. Supplementation with melatonin has been shown to improve limited aspects of sleep in 30–50% of patients over 55 years of age

29
Q

For suvorexant

A) MOA

B) Indication

C) AE

D) Practice points

A

A)

Orexin receptor antagonist

B)

Treatment of chronic insomnia

  • People with neruological or physcological issues excluded from trials

C)

  • Common – somnolence, headache
  • Infrequent – abnormal dreams, sleep paralysis, hallucinations in sleep „
  • Rare – sleepwalking, suicidal ideation

D)

  • May be useful for sleep-maintenance insomnia
  • Avoid in combination with CYP3A4 inhibitors or inducers
  • Only take if intending to get a full nights rest (at least 7 hours)
  • May be drowsy the following day (don’t drive for at least 9 hours) „
  • Assess response to treatment after 7–10 days; reassess after 3 months
30
Q

Why is there a concern with BZD use in the elderly?

A
  • Elderly are the most at risk of harm from adverse effects

> Falls, cognitive impairment, incontinence, confusion, dependence

31
Q

How is insomnia in dementia presented? What treatment is recommended?

A

Often have marked sleep fragmentation

  • Dozing during day
  • Sundowning (agitated, wandering and wakeful early evening/night)

Non pharmacological interventions recommended

32
Q

For Jet Lag:

A) What happens?

B) What is the treatment?

A

A)

  • Body clock out of sync with local time

> Worsens depending on how many time-zones crossed

> Worse in an easterly direction

  • Co-existing sleep loss due to flight times and environmental factors
  • Commonly affects travellers who cross several time-zones

B)

  • Adjust to new time zone as quickly as possible –> Exercise and early morning light
  • Melatonin – taken at target bedtime at destination decreases jet lag
  • Short-acting hypnotic (tamazepam) on flight and for 3 consecutive nights at bedtime

> increased DVT risk if taken on plane

> may be additive sedation if used with melatonin

33
Q

INSOMNIA SUMMARY

A

4 STEPS

1. Management of underlying problems

2. Good sleep practices

  • Sleep wake activity regulation
  • Sleep setting and influences
  • Sleep promoting adjuvants

3. Psychological and behavioural interventions

  • Relaxation therapies
  • Cognitive therapy
  • Stimulus control
  • Sleep restriction

4. Pharmacological Treatment

  • Hypnotics

> Benzodiazepines (temazepam)

> Zolpidem/zopiclone – BLACK BOX WARNING - potentially dangerous complex sleep-related behaviours

> Risk of dependence and tolerance

  • Melatonin – primary insomnia with poor sleep quality
  • Suvorexant – NEW MEDICATION – sleep paralysis, suicidal ideation. Sleep maintenance insomnia
34
Q

INSOMNIA SUMMARY PT 2

A

Treatment considerations with hypnotics

  • Impaired daytime alertness „
  • Tolerance and dependence with long-term use „
  • Rebound insomnia „
  • Falls risk „
  • Sleep may not be “refreshing” „
  • Watch for contraindications

> use lowest possible dose for shortest possible duration

Management of jet leg

Adjust to new time zone asap

  • Melatonin
  • Short term hypnotic

CNS lectures (Bal) (29 decks)

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