Sleep and Wake

Question 1

Insomnia disorder

Answer 1

Characterized by a complaint of poor sleep, with one of the following:
-difficulty either in initiating sleep or maintaining sleep throughout the night, or early morning awakening.
-It is a primary sleep disorder and causes significant impairment in social, occupational or other important areas of functioning.
-Problem occurs at least 3 days a week for 3 months
-Occurs despite opportunity to sleep
-Not attributed to the physiological effects of substances
-Coexisting medical/mental disorders do not adequately explain the complaint of insomnia

Question 2

Sleep Stages

Question 3

Etiology of insomnia:

Answer 3

Medical problems: Pain, medications,
Sleep apnea, Restless leg syndrome
Shift work
Psychiatric disorder
Substance use, abuse, or withdrawal:
Caffeine
Stimulants
Alcohol
Poor sleep hygiene, partner with sleep disorder

Question 4

Primary Insomnia

Answer 4

without a coexisting general medical condition (psychiatric problems are not counted in this consideration).

Question 5

Secondary Insomnia

Answer 5

a symptom of an underlying disorder including physical causes pain disorder, including physical causes, pain

Question 6

Transient insomnia

Answer 6

jet lag, shift work

Question 7

Initial Insomnia

Answer 7

difficulty falling asleep

Question 8

Middle Insomnia

Answer 8

waking frequently during the night

Question 9

Terminal insomnia

Answer 9

waking early

Question 10

TREATMENT OF INSOMNIA

Answer 10

-Treat short-term insomnia early.
-Psychological treatments can alleviate symptoms.

The approaches are to:
1.Treat any precipitating cause
2.Educate about trigger factors for sleep
and reassure that sleep will improve
3. Establish good sleep hygiene
4. Lastly, consider hypnotic medication
(All interventions may occur in same visit depending on patient’s situation).

Question 11

Benzodiazepines
Temazepam etc.

Question 12

Benzodiazepine like drugs (euhypnotics Z-drugs):
Zaleplon, Zolpidem, Zopiclone

Question 13

Zaleplon(Sonata)

Answer 13

zaleplon (Sonata)
Benzodiazepine receptor agonist hypnotic
Formulation: cap 5mg, 10mg

Schedule IV drug (controlled substance)
Alpha 1 isoform agonist (benzodiazepine receptor)
Enhances inhibitory effects of GABA

FDA approved: Short term treatment of insomnia, not intended for long term use
Half-life is ONE HOUR
Can be used for middle of the night awakening;
Sonata 10mg QHS; maximum dose 20mg
Black box warning: May cause sleepwalking, sleep driving or other complex sleep behaviors, even death.
Beers List: Avoid in elderly patients with delirium

Question 14

Zolpidem(Ambien)

Answer 14

Zolpidem (Ambien)
Formulation: tab 5mg, 10mg
CR-ER tab 6.25mg, 12.5mg

Schedule IV drug (controlled substance)
Alpha 1 isoform agonist (subtype of benzodiazepine receptor)
Enhances inhibitory effects of GABA
FDA approved: Short term treatment of insomnia; CR indication not restricted to short-term use
Half life is 2½ hours
Side effects: abnormal dreams, confusion, retrograde amnesia, decreased in CR product

Black box warning: May cause sleepwalking, sleep driving or other complex sleep behaviors, even death.
Beers List: Avoid in elderly patients with delirium

Question 15

Eszopiclone (lunesta)

Answer 15

Eszopiclone (Lunesta)
Formulation: tab 1mg, 2mg, 3mg

Schedule IV drug (controlled substance)
Alpha 1 isoform agonist (benzodiazepine receptor)
Enhances inhibitory effects of GABA
FDA: Insomnia

Initial insomnia: 1mg at bedtime, Terminal insomnia: 2 mg at bedtime
Maximum dose is 3mg at bedtime
Half-life of 6 hours; peaks in one hour
Unpleasant taste is a reported side effect

Black box warning: May cause sleepwalking, sleep driving or other complex sleep behaviors, even death.
Beers List: Avoid in elderly patients with delirium

Question 16

Melatonergic hypnotics:
Ramelteon(Rozerem)

Answer 16

Ramelteon (Rozerem)
Formulation: Tab 8 mg

Not a controlled substance
Melatonin 1 and 2 receptor agonist
FDA: Insomnia-difficulty with sleep onset
Half life 1 to 2 ½ hours
No black box warning

Question 17

Herbal preparations:
Valerian

Question 18

Amitriptyline(Elavil)

Answer 18

Amitriptyline (Elavil)
Formulation: Tabs 25mg, 50mg, 75mg, 100mg, 150mg

Initial dose at 25 mg, increase dose to 50mg-150mg at bedtime
Blocks 5HT2A and 5HT2C
5HT2A receptors associated with improvement of sleep
2D6 substrate
Monitor weight gain and EKG for patients >50
Black box warning: Increased suicidality in children to young adults with major depressive disorder and psychiatric disorders

Question 19

Doxepin(Silenor)

Answer 19

Doxepin (Silenor)
Formulation: Cap 10mg, 25mg, 50mg, Tablets 3 and 6 mg

FDA Approved for insomnia (sleep maintenance)
Histamine H1 receptor antagonist-very selective action at low doses
75 to 150 mg daily as an antidepressant or antianxiety therapy

3 mg to 6 mg at bedtime for insomnia
As a hypnotic may not be associated with weight gain
Monitor weight gain and EKG >50 y/o
Reduced dosing for elderly

Black box warning: Increased suicidality in children to young adults with major depressive disorder and psychiatric disorders

Question 20

Trazodone (desyrel)

Answer 20

Desyrel (Trazodone)
Formulation: Tabs 50mg

5HT2A and 5HT2C receptor antagonist (insomnia)
For primary and secondary insomnia, dosed at 25mg to 50mg at bedtime
Blocks histamine and muscarinic receptors
Short half-life, 6 to 8 hours
May cause priapism

Black box warning: Increased suicidality in children to young adults with major depressive disorder and psychiatric disorders

Question 21

Temazepam

Answer 21

Temazepam (Restoril)
Formulation: cap 7.5mg, 15mg, 22.5mg, 30mg

Schedule IV drug (controlled substance)
FDA approved: Short term treatment of insomnia
Off label use: Night terrors

Half-life 8 to 15 hours (intermediate)
Enhances the inhibitory effect of GABA
Slowly absorbed and elimination; administer the dose 1-2 hours before bedtime

Black box warning: Avoid concomitant use with opioids. Monitor patients for sedation.

Question 22

Modafinil(Provigil)

Answer 22

Modafinil (Provigil)
Formulation: Tabs 100mg, 200mg

FDA Approved: Narcolepsy, obstructive sleep apnea, shift work sleep disorder
Off label use: ADHD, fatigue, adjunct treatment with antidepressant
Dosing: 200mg daily

Stimulant that increases dopamine by blocking dopamine transporting and inhibiting dopamine reuptake
Metabolized by CYP3A4. Inhibits and induces many drugs

Side effects: Increased risk of Tourette syndrome, Steven Johnson syndrome, cardiac arrythmias

Black box warning: Increased suicidality in children to young adults with major depressive disorder and psychiatric disorders

Question 23

Sleep Hygiene Teaching

Answer 23

-Arise at the same time each day
-Limit time in bed. After 20 minutes, if sleepless, get up
-Avoid caffeine, nicotine, stimulants, alcohol
-Avoid daytime napping
-Establish physical fitness routine/exercise
-Avoid evening stimulation
-Try reading, music rather than watching TV
-Warm 20 minutes bath near bedtime
-Avoid large meals near bedtime
-Practice an evening relaxation routine

Question 24

Obstructive Sleep apnea

Question 25

Central sleep apnea

Question 26

Restless Leg syndrom

Question 27

Nightmare disorder

Question 28

Shift Work Sleep Disorder

Question 29

Narcolepsy

Question 30

Cataplexy

Question 31

NREM Parasomnia

Question 32

REM parasomnia

Question 33

Periodic limb movement disorder

Question 34

Circadian rhythm sleep-wake disorders

Question 35

Homeostatic sleep drive