Sleep and Wake Flashcards
Insomnia disorder
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
Sleep Stages
Etiology of insomnia:
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
Primary Insomnia
without a coexisting general medical condition (psychiatric problems are not counted in this consideration).
Secondary Insomnia
a symptom of an underlying disorder including physical causes pain disorder, including physical causes, pain
Transient insomnia
jet lag, shift work
Initial Insomnia
difficulty falling asleep
Middle Insomnia
waking frequently during the night
Terminal insomnia
waking early
TREATMENT OF INSOMNIA
-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).
Benzodiazepines
Temazepam etc.
Benzodiazepine like drugs (euhypnotics Z-drugs):
Zaleplon, Zolpidem, Zopiclone
Zaleplon(Sonata)
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
Zolpidem(Ambien)
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
Eszopiclone (lunesta)
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
Melatonergic hypnotics:
Ramelteon(Rozerem)
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
Herbal preparations:
Valerian
Amitriptyline(Elavil)
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
Doxepin(Silenor)
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
Trazodone (desyrel)
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
Temazepam
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.
Modafinil(Provigil)
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
Sleep Hygiene Teaching
-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
Obstructive Sleep apnea
Central sleep apnea
Restless Leg syndrom
Nightmare disorder
Shift Work Sleep Disorder
Narcolepsy
Cataplexy
NREM Parasomnia
REM parasomnia
Periodic limb movement disorder
Circadian rhythm sleep-wake disorders
Homeostatic sleep drive
