Sleep disorders Flashcards
Which hormone secretion increases during sleep and is suppressed by bright light?
Melatonin
Sleep-promoting neurotransmitters
GABA
Wakefulness-promoting neurotransmitters
NE, DA, acetylcholine, histamine, orexin
Which stage do restorative sleep occur?
3&4
Brief description of insomnia
Inability to initiate/maintain sleep, associated with daytime problems (fatigue, impaired concentration/memory etc)
DSM-5 Insomnia (A)
Primary complain of unsatisfying sleep quantity or quality, with presence of 1 or more of the following
1. Difficulty with sleep initiation
2. Difficulty with sleep maintenance
3. Early-morning awakening
DSM-5 Insomnia (B)
Sleep compliant is associated with social, occupational, academic, educational, behavioral or functional distress or impairment
DSM-5 Insomnia (C)
Sleep complaint occurs at least 3 nights per week and has been present for at least 3 months
DSM-5 Insomnia (D)
Sleep difficulties happen even with ample opportunity to sleep.
DSM-5 Insomnia (E)
Sleep complaint is not attributed to or explained by another sleep- wake disorder, the adverse effect of a medication or substance, or a coexisting psychiatric illness or medical condition
DSM-5 Insomnia (F)
Episodic - lasting 1 month to < 3 months
Persistent – lasting ≥ 3 months
Recurrent – experiencing ≥ 2 episodes within 1 year
Management of acute insomnia (1 night - few weeks)
Transient <1 week: Sleep hygiene
Short-term <4 weeks: Sleep hygiene + short PRN course of hypnotic
Management of chronic insomnia (≥3 nights/week
for ≥ 1 month)
Likely secondary/underlying psychiatric/medical problems, investigate!
Pharmacological
Fast-acting anxiolytics/sedatives/hypnotics
Adjunct for SHORT TERM relief! PRN!
At lowest effective dose, short course
Sleep hygiene 1
Avoid use of caffeine content products, nicotine & alcohol especially later in the day
Sleep hygiene 2
Avoid heavy meals within 2 hours of bedtime
Sleep hygiene 3
Avoid drinking fluids after dinner to prevent frequent night-time urination
Sleep hygiene 4
Avoid environments that will make you really active after 5pm (i.e. avoid noisy environments).
Sleep hygiene 5
Only use your bed for sleep. Sit in your chair when you just want to relax.
Sleep hygiene 6
Avoid watching television in bed.
Sleep hygiene 7
Establish a routine for getting ready to go to bed.
Sleep hygiene 8
Set time aside to relax before bed, and utilise relaxation techniques.
Sleep hygiene 9
Create an atmosphere conducive to sleep:
Keep yourself at a comfortable temperature by modifying the number of blankets you use.
Use earplugs if it is too noisy.
Make the room darker if there is too much light (e.g. close the door).
Put an extra mattress on your bed if is uncomfortable.
Sleep hygiene 10
When in bed, relax and think pleasant thoughts to help you fall asleep.
Sleep hygiene 11
Get up at the same time every day, including weekends. Use an alarm clock if it will help.
Sleep hygiene 12
Avoid taking daytime naps. If you have to take them, make sure you do so before 3.00 pm and that
the total napping time does not exceed one hour.
Sleep hygiene 13
Pursue regular physical activities like walking or gardening but avoid vigorous exercise too close to
bedtime.
What classes of drugs are hypnotics?
Benzodiazepines
Z-hypnotics
Antihistamine
Lemborexant
MOA of benzodiazepines
Potentiates GABA; relieves anxiety and insomnia
Side effects of benzodiazepines
Sedation, drowsiness, amnesia
Which benzodiazepines are useful for insomnia?
- Lorazepam
- Diazepam
Dose of Lorazepam
0.5-2mg PRN (limit to 2 weeks)
Dose of diazepam
2-15mg PRN (limit to 2 weeks)
MOA of z-hypnotics
Preferentially binds to benzodiazepine-binding
sites with Y and a1 subunits (causes sedation).
Side effects of z-hypnotics
Taste disturbance (Zopiclone)
Complex sleep behaviours (sleep walking)
Which z-hypnotics are useful for insomnia?
- Zolpidem
- Zopiclone
Dose of Zolpidem
> 18y/o: 10mg PRN
Females: half
Dose of Zopiclone
> 18y/o: 7.5mg PRN
Elderly: 3.75mg PRN
Antihistamines for insomnia
Promethazine
Hydroxyzine
Dose of Promethazine or Hydroxyzine
25-50mg ON PRN
What drug class is Lemborexant?
OX1 & OX2 orexin receptor antagonist
- Turns off wake signal instead of induce sleepiness
Side effects of Lemborexant
Somnolence, nightmare
Contraindication of Lemborexant
Narcolepsy
Severe hepatic impairment
Moderate-strong CYP3A4 inducer/inhibitors
CYP3A4 inducers
Phenytoin
Phenobarbital
Rifampicin
St John’s wort
Glucocorticoids
CYP3A4 inhibitors
Clarithromycin
Erythromycin
Ditiazem
Itraconazole
Ketoconazole
Ritonavir
Verapamil
Antidepressant (off-label) for insomnia
Trazodone (inhibits 5HT reuptake, antagonise 5HT2A, H1, a1 receptors)
Dose of Trazodone
20-50mg PRN
Benzodiazepines & Z-hypnotics should NOT be administered in?
- Acute narrow angle glaucoma,
- Acute pulmonary insufficiency, respiratory depression, myasthenia gravis
