Sleep Flashcards
What is a disorder characterized by complaints of difficulty falling asleep, difficulty staying asleep or experiencing non-restorative sleep?
Insomnia
What is non-REM sleep?
Quiet sleep
What is REM sleep?
Hyperactive brain in paralyzed body
What are the stages of non-REM “Quiet Sleep”?
Stage 1- light sleep
Stage 2 “true sleep”
Stage 3- deep sleep
Stage 4- Very deep sleep
What are the stages of REM “hyperactive brain in paralyed”?
Stage 5; dreams
How does sleep change for teenagers?
Known for daytime drowsiness
Most teenagers need an hour more sleep than children; however most get an hour LESS
How does sleep change for adults?
Between 20-30 years, amount of deep sleep drops and nighttime awakeness doubles
By age 40, later stages of sleep begin to diminish
How does sleep change for the elderly?
Deep sleep accounts for ~5% of sleep
Falling asleep takes longer
What is acute insomnia?
- Several days up to 4 weeks
- Results from acute stress of changes in the environment
What are common precipitating conditions for acute insomnia?
Unfamiliar / uncomfortable sleep environment
Medical Illness
Shift work
Jet lag
Caffeine, EtOH, nicotine, or ADR’s
Life stressors (moving, divorce, marriage, bereavement, holidays ect.)
What is chronic insomnia?
- Greater than 4 weeks duration (physical/emotional illness, RLS, sleep apnea)
- Maybe be caused by medications, EtOH, or illicit drugs
- Substance abuse-10%
- Conditioned anxiety
What are the risk factors for insomnia?
- Women, elderly, stressful lives
- Lower socioeconomic or educational background
- Separated, widowed, unemployed
- Previous episodes of insomnia
- Psychiatric/ mental conditions
Who is the largest group of the growing community with sleep disorders?
College students
Sunday=insomnia night; Wednesday- most efficient day of the week for sleeping
What is the diagnosis for primary sleep disorders based on?
–> 2 of the following for at least 1 month
Difficulty initiating sleep
Difficulty maintaining sleep
Poor sleep efficiency
Sleep disturbances on > 3 nights/week
Significant impairment in social, occupational, or other areas of functioning
–Social History-EtOH, caffeine, illicit drugs, marital status, living arrangement
–Review of Systems- Weight gain, angina, wheezing, nocturia, dyspnea, leg cramps
–Polysomnography- Used to assess and record variables that characterize sleep and aid in diagnosis of sleep disorders
Only if other sleep disorders are suspected
–Pharmacologically induced insomnia
What is insomnia that occurs following the discontinuation of sedative substances?
Rebound insomnia
What drugs are offenders of rebound insomnia?
Insomnia can be a symptom of withdrawal when “rebounding” from effects of sedative
EtOH, antihistamines, BZD’s, older hypnotics (chloral hydrate)
Antidepressants
TCA’s, MAOI’s, SSRI’s
Abused substances
Opiates, Marijuana, Cocaine
What are the screening questions for insomnia?
REST Restorative sleep? Excessive daytime sleepiness, tiredness or fatigue Snoring nightly? Total sleep time?
What is the treatment goal of insomnia?
Normalize sleep patterns as quickly as possible.
Fast onset of sleep, decrease night-time awakenings, improve day-time quality of life.
What are the non-pharmacologic treatment options?
- Cognitive therapy: Stimulus control, sleep hygiene, sleep restriction, CBT
- Behavioral or supportive therapy- relaxation techniques
- Sleep diary
What is sleep hygiene treatment?
Avoid exercise to close to bed Sleep in a comfortable environment Avoid alcohol and stimulants Avoid caffeine and nicotine for at least 6 hours prior to bedtime Avoid going to bed excessively hungry Spend time prior to bedtime relaxing Establish a regular sleep schedule
What is stimulus control treatment?
Go to bed only if you feel sleepy
Avoid activities in your bedroom that keep you awake, other than sex
Sleep only in your bedroom
Leave the bedroom when awake, return only when sleepy
Arise at the same time each morning regardless of amount of sleep obtained
Avoid daytime napping
What are the pharmacologic treatment options for insomnia?
Antihistamines- (First go to because they are available OTC advertising help with sleep)
Sedative hypnotics
Antidepressants- TCA’s, Trazadone, Mirtazapine
Herbal products
What are the antihistamines used to treat insomnia?
- Diphenhydramine [Benadryl]
- Hydroxyzine [Atarax]
- Doxylamine [Unisom]
Antihistamines (Diphenhydramine, hydroxyzine, doxylamine)- Indications
Insomnia, Anxiety, allergy
Antihistamines (Diphenhydramine, hydroxyzine, doxylamine)- MOA
Suppress REM sleep, may produce rebound upon withdrawl
Antihistamines (Diphenhydramine, hydroxyzine, doxylamine)- ADRs
Anticholinergic effects (problamatic esp. in elderly) Dizziness, confusion, next day sedation
What are the z-hypnotics?
Zolpidem (Ambien, Ambien CR)
Zaleplon (Sonata)
Eszopiclone
Z-hypnotics (Zolpidem, Zaleplon, Eszopiclone)- MOA
Newer therapies for insomnia
Selective for BZ-1 receptor of GABAa receptor (receptors important for depression throughout the brain)
Zolpidem (Ambien and ambien CR)- Indications
Z-hypnotics
Used only as a hypnotic (only indication for this)
Should only be used short-term 7-10 days
Zolpidem (Ambien and ambien CR)- Advantages
No withdrawal
Minimal rebound insomnia
Little or no tolerance
Immediate-release and extended release formulas
Zolpidem (Ambien and ambien CR)- ADRs
GI upset- biggest ones
Agitation, HA, nightmares, dizziness, daytime drowsiness (biggest ones)
Zolpidem (Ambien and ambien CR)- Drug interactions
P450 metabolism
Rifampin shortens t1/2
Zaleplon (Sonata®)- indications
Z-hypnotics
Similar to Ambien in hypnotic actions
Ideal agent for sleep latency
Zaleplon (Sonata®)- pharmacokinetics
Fewer residual effects on psychomotor and cognitive functions rapidly eliminated with t1/2 <1hr
CYP3A4 metabolism
Zaleplon (Sonata®)- ADRs
ADR: HA, nausea, dyspepsia
Eszopiclone (Lunesta®)- indications
Z-hypnotics
Proven to fall asleep quickly, maintain sleep through the night
Eszopiclone (Lunesta®)- ADRs
Side effects include anxiety, dry mouth, chest pain, HA, migraine, peripheral edema, somnolence, unpleasant taste
Eszopiclone (Lunesta®)- Advantages
Low abuse potential
No tolerance for up to 12 months
No withdrawal
Rarely associated with behavior changes ie., agitation, confusion, depression, suicidal thoughts, memory loss
Ramelteon (Rozerem)- MOA
Z-hypnotics
Melatonin receptor agonist
More potent at MT1 and MT2 than MT3
No appreciable activity at GABA receptor
Ramelteon (Rozerem)- indications
Indicated for use in treatment of insomnia characterized by difficulty with sleep onset
Approved for chronic use
Not a controlled substance
Ramelteon (Rozerem)- Precautions and Warnings
Precautions
Do not give in conjunction with or shortly after high fat meals
Warnings
Use with caution in patients with moderate hepatic impairment
Do not use with severe hepatic impariment
Ramelteon (Rozerem)- ADRs
Somnolence, FATIGUE, DIZZINESS nausea, myalgia
Benzodiazepines- Indications
Not all good hypnotics
Balance sedative effect at bedtime with residual sedation on awakening
Flurazepam- not FDA approved for this indication
Reduces sleep-induction and number of awakenings
Increases duration of sleep
Benzodiazepines- MOA
Effective up to 4 weeks
T1/2 85hr…daytime sedation and accumulation of drug
What are the benzodiazepines?
Flurazepam
Temazepam
Triazolam
Temazepam
Doesn’t help fall asleep real fast unless you take it 2-3 hours before sleeping
Reduces number of awakenings
Peak sedative effect 2-3 hours after oral dose
Triazolam
Induces sleep
Tolerance develops with days
Withdrawal of drug results in rebound insomnia
What are the antidepressants used for insomnia?
5HT2 blockers- Nefazodone, Mirtazapine, Trazodone
TCAs
5HT2 (Serotonin) blockers (Nefazodone, Mirtazapine, Trazodone)- Indications
Best documented if used for restoring sleep in SSRI- induced insomnia
Increase sleep continuity and time
5HT2 (Serotonin) blockers (Nefazodone, Mirtazapine, Trazodone)- ADRs
Nausea, xerostomia, constipation, drowsiness, HA, rebound insomnia, priapism
What are the TCAs that are used as antidepressants?
Doxepin and Amtriptyline
TCAs (Doxepin and Amtriptyline)- Indication
Not FDA indicated for insomnia
Efficacy in insomnia has not been proven except for specific diagnoses: Anxiety and Depressive Disorders
TCAs (Doxepin and Amtriptyline)- ADRs
Increase with dosage; orthostatic hypotension, dizziness, sedation, xerostomia, blurred vision, constipation, urinary hesitancy
What are the natural products used for insomnia?
Melatonin
Valarian Root
Melatonin- Indications
Hormone released by pineal gland to regulate circadian rhythm
Potential effectiveness: Jet lag, shift work, elderly
Melatonin- ADRs
Abdominal cramps (big one), HA, irritability
Valarian Root- Indications
Increases GABA (Depressive transmitter) in synaptic cleft Mild hypnotic, improves sleep latency and quality of sleep
Valarian root- ADRs
Severe HA
What is a condition during sleep in which respiration ceases for relatively brief periods of time?
Sleep Apnea
What is involved in sleep apnea to help the diagnosis?
> 2 or more of the following: Choking or gasping sleep Recurrent awakenings from sleep Non-restorative Sleep Daytime fatigue Impaired concentration
What is diagnostic of sleep apnea?
Overnight monitoring demonstrating > 5 obstructed breathing events / hour during sleep
What are the risk factors for sleep apnea?
Males, age (as you get older), obesity (central), craniofacial abnormalities
What is the non-pharmacologic treatment of sleep apnea?
Weight loss, positional change, continuous positive airway pressure (CPAP)
What is the pharmacologic treatment of sleep apnea?
Modafinil (C-IV)
Approved for treatment of residual daytime sleepiness despite traditional approaches (eg CPAP)
What is the standard of therapy for sleep apnea (first choice)?
CPAP
What is a creepy, crawly sensation in the legs at rest, relieved by movement that is worse in the evening and at night?
Restless leg syndrome
What is repetitive, rhythmic limb movement in series that lasts minutes, with movements occurring every 20-40seconds?
Periodic limb movement disorder
What is the pharmacologic treatment of restless leg syndrome and PLMD?
Ropinirole, Pramipexole
Off label therapy for these meds. These are dopamine drugs also used in parkinsons
