sleep disorder Flashcards
sleep wake cycle
- reset of internal body clock by cues (Day light)
- melatonin: secretion increased during sleep and suppressed by bright light
- neurotransmitters
** sleep promoting: GABA
** wakefulness promoting: NE, DA, acetylcholine, histamine, orexin
normal sleep architecture
states:
1) wakefulness
2) non-rapid eye movement (NREM) (75%)
- low HR, BP, RR
- stage 1: light sleep
- stage 2: deeper sleep
- stage 3 & 4: Delta sleep, restorative sleep
3) rapid eye movement (REM) (25%)
- dreaming phase, memory consolidation
- HR, BP, RR can fluctuate
DSM-5 criteria for insomnia
1) primary complain of unsatisfying sleep quantity/quality with presence of >/= 1 of
- hard to sleep
- hard to continue sleep
- early morning awakening
2) social, occupational, academic, educational, behavioural, functional distress or impairment
3) sleep complaint occur at least 3 nights per week and present for at least 3 months
4) sleep difficulties occur even with ample opportunities to sleep
5) not attributed to another sleep-wake disorder, AE of meds/substance or co-existing psychiatric/mental condition
acute insomnia
- likely due to acute stressors
- transient (< 1 wk): self-limiting, sleep hygiene
- short term (< 4 wks): sleep hygiene, short PRN course hypnotics (7-10 days)
chronic insomnia
- duration: > four wks
- likely secondary to underlying psychiatric +/- medical conditions
** poor sleep hygiene, substance abuse, primary sleep disorder (apnoea) - management
** investigate and manage underlying cause/concern
** sleep hygiene
** discourage long term use of hypnotics
non pharmaco for insomnia
Sleep hygiene (1st line)
1) Avoid use of caffeine containing products, nicotine, alcohol esp later in day
2) avoid heavy meals within 2 hrs of bedtime
3) avoid drinking fluids after dinner to prevent freq night time urination
4) avoid environments that make you active after 5pm
5) establish routine for getting ready for bed
6) avoid taking afternoon naps, if need then < 1 hr and before 3pm
7) regular physical activities
Behavioural intervention
1) CBT-I
2) relaxation therapy
3) sleep restriction therapy
4) stimulus control therapy
principles of pharmacological therapy for insomnia
low dose fast acting anxiolytics, sedatives, hypnotics PRN 1 - 2 wks for short term relief of distressful insomnia/anxiety
anxiolytics for insomnia
induce sleep when given at night
hypnotics general for insomnia
sedate when given in the day
types of hypnotics for insomnia
1) benzodiazepine (1st line)
2) Z-hypnotic
3) antihistamine
4) lemborexant
5) melatonin
benzodiazepine MOA
potentiate GABA -> relieve anxiety and insomnia
benzodiazepine SE (insomnia)
sedation, drowsy, amnesia
benzodiazepine dosing (insomnia)
2 wks PRN to prevent dependence
benzodiazpine CI
pregnancy, acute narrow arrow glaucoma, acute pulmonary insufficiency, respi depression, sleep apnoea, myasthenia gravis
benzodiazepine precaution
- avoid if severe liver/renal impairment in child, old, debilitated
- avoid pregnant/breastfeed unless benefit > risk
- history of drug/alcohol abuse or psychiatric disorder
- avoid prolonged usage and abrupt discontinuation
- omit benzo before ECT
- avoid use with opioid to prevent mortality
