Sleep Disorders Flashcards
Insomnia : Signs and sx’s
1. SUbjective (4)
2. Objective sleep parameters like ? (5)
3. Day time complaints such as? (3)
- Cant fall asleep (initiation/onset)
Cant stay asleep (maintenance)
multiple awakenings
waking up too early - Sleep Onset latency
-Latency to persistent sleep
-Total Sleep Time
-Wake time after sleep onset
-Sleep efficiency - Sleep is non restorative
-excessive sleepiness/fatigue in day
-malaise
-Difficulty concentrating/memory impairment
Alcohol and Sleep :
1. First half of the night it increases __ and decr __
2. Second half of night it causes A__, W__, R___, Sw___, ___
3. Alcohol may have initial sedative effect, but can also cause
-Incr number of ?
-Decr in __ and __
-Next day __
-Sn__ and __
Insomnia TX : NON PHARM
1) CBT-I such as ?
2) Sleep hygiene such as? !!!!!!!!
3) miscelanneous (3) ?
- non rem sleep, rem sleep
- awakenings, withdrawal sx’s, REM rebound (nightmares), sweating, vivid dreams
- awakenings
-TST, sleep quality
-Somnolence
-Snoring, Apnea - Stimulus control, sleep restriction, relaxation training –> can use apps with psycho-ed about sleep, healthy habits
- exercise often, dont go to bed hunrgy or too full, use bed only for sleep/sex, avoid naps, limit alc, set reg sleep/wake times , min liquid consumption before bed , avoid/minimize caffeine , cover the clock
- Light therapy, exercise, biofeedback
PHARM FDA APPROVED AGENTS : INSOMNIA
- Name 6
BENZODIAZEPINES :
1. Effect on sleep architecture? (2)
2. Use should be limited to how many days?
For each benzo, state the indication, onset, and dose adjustments for geriatric and hepatic :
A. Estazolam
B. Flurazepam
C. Quazepam
D. Temazepam
E. Triazolam (Also state dose)
- BZD’s, Non benzo receptor agonists, Melatonin receptor agonists, dual orexin receptor agonists, TCA’s, antihistamines
- Decr sleep latency and INCR TST
- 7-14 days
A. Onset and maintenance
-SLow onset (2+hrs)
-No recs. Just use caution
B. Onset and maintenance
-RAPID onset (half hour)
-Dont use in geriatric or hepatic impairment
C. Onset and maintenance
-SLow onset
-Dont use in geriatric or hepatic impairment
D. ONSET only
- Onset is intermediate (1-1.5hrs)
-No recs. Just use caution
E. ONSET ONLY
-Intermediate
-0.125-0.25 mg
-No recs. Just use caution
BZD’s : AE’s ? D, H, N, R, P, T, A, W
Warnings/Precuations:
-Abnormal __ and complex __
-Worsening of ?
-Incr effect when combined with ?
-Caution in pt’s with impaired ___
-Use lower doses in __
-Drowsiness
- Headache
- Next-day psychomotor impairment
- Rebound insomnia
- Paradoxical reactions
- Tolerance
- Anterograde amnesia
- Withdrawal effects
Thinking, behaviors
depression and SI
cns depressants
respiratory function
ELDERLY
NBRAS :
1. Effect on sleep latency ?
2. PReserves what kind of sleep ?
For each drug, state the indication, dose, onset, and dose adjustments needed for geriatric or hepatic :
- Eszopiclone (Lunesta)
- Zaleplon (Sonata)
- Zolpidem IR (ambien)
- ZOlpidem CR (ambien CR)
- Zolpidem SL (Intermezzo)
- ZOlpidem Oral Spray (Zolpimist)
- All of these have metabolic pathways using CYP3A4 and Eszopiclone has also CYp2e1
- decr sleep latency
- Stage n3 sleep
- Sleep latency + maintenance
1-3 mg
Onset 10 mins
Ger + Hep : max = 2 mg - Sleep onset for <=30 days
5-10 mg
30 mins
If Mod hepatic impair : 5mg max , severe = AVOID - Sleep onset for <=35 days
5-10 mg
onset 30 mins
Ger + hep max 5mg! - Sleep onset and maintenance for 24 weeks
6.25-12.5 mg
30 mins
Ger+hepatic max = 6.25mg - Sleep onset after middle of night awakenings
1.75-3.5 mg
Ger+Hep : max = 1.75 mg - Sleep onset for <=35 days
5-10mg
Geriatric Max 5mg
NBRA’s : AE’s
D,H, N, R, T, A, W, G!!!!, U!!!!
Warnings/Precautions :
Same as BZD’s
-Drowsiness
- Headache
- Next-day psychomotor impairment
- Rebound insomnia
- Tolerance
- Anterograde amnesia
- Withdrawal effects
- GI discomfort!!!!!!
- Unpleasant taste (eszopiclone)!!!!
Melatonin Receptor Agonists (MRAs) :
1. Decreases ____
2. Ramelteon (Rozerem) : Indication
3. Dose? This dose should be taken in a __
4. Major cyp metabolism ?
5. Can u use in hepatic impairment?
6. DAta supports use up to ?
- Adverse effects?
-M, D, F, N, R, G - Warnings:
-caution in patients with __ or ___
-Chronic use may do what in women and in men ?
-Significant __
- Sleep latency
- Onset for <= 6 months
- 8mg, in fasted state
- CYP1a2
- Yes if mild with caution , Severe, no
- 6 months
- morning drowsy, dizzy , fatigue, next day impairment , rebound insomnia, GI discomfort
- OSA (sleep apnea), impaired respir function
-May incr prolactin in women, decr testosterone in men
-DDI’s
Dual Orexin Receptor Antags (DORAs) : (Like Suvorexant (Belsomra) )
- Indicated for ?
-NO DOSE ADJUSTMENTS! - Taking with food may do what ?
- AE’s? S, H, D, F
- Others such as Daridorexant (Quviviq) and Lemborexant (DayVigo) are also indicated for onset and maintenance)
TCA’s : Doxepin (Silenor)
3. Indicated for?
4. Dose adjustments for geriatric and hepatic use?
OTC ANTIHISTAMINES : Diphenhydramine & Doxylamine
5. warnings and precautions?
- Onset and maintenance for <=1yr
- Delay onset of sleep effects
- somnolence, HA, dizzy, fatigue
- MAINTENANCE for <= 3 months
- Lower doses needed
- Anticholinergic effects.
avoid use in elderly
CNS depression
Incr intraocular pressure/glaucoma
Ocassional use only
TOLERANCE
NON FDA APPROVED for INSOMNIA :
1. Trazodone
-Dosage?
2. Caution in ?
3. Can cause __ but this is rare
4. Additional warnings : BBW suicidal thinking/behavior, CNS depression, Hyponatremia, ortho hypo
- MELATONIN
-Dose? - Its relatively __, but long term use may be associated with ?
- Whats the first line tx for insomnia treatment guidelines?
- 50-200mg
- liver and renal impairment
- Priapism
- 0.5-10 mg
- well tolerated , impairment of HPA axis
- CBT across the board!
Restless Legs Syndrome : Signs and Sx’s
1. Subjective : Restless legs that are relieved by ___, worsens in ___
-Sensations such as?
- Lab findings of serum ferritin < ___
- Commonly includes periodic leg movements in sleep (PLMS) –> occurs in ___, movements separated by > ___
- to be diagnosed, this has to occur at least ____ for __
- movement , evening
-Creepy, crawly, electrical, jittery, burning - 50 mcg/L
- clusters (mins to hrs) , 5 seconds
- 3x/week, 3 months
RLS Risk Factors :
1. Prevalence in female : male
2. Comorbidities w/incr risk ?
-A, P
-H
-Rh
-Chronic ___
-Vit ___/___ deficiency
-D, P, C
-U
-___ deficiency
-P
RLS TX : Non pharm
1. SLeep __ and ____
2. Mod ___ and lower ___
3. __ cessation and avoidance of ___
4. ___ devices
- 1.5-2 : 1 , incr with age
- Advanced age, parkinson’s disease
-hypothyroidism
-rheumatoid arthritis
-bronchitis
-b12/folate
-DM, Periph neuropathy, CKD
-Uremia
-Iron deficiency
-Pregnancy - Hygiene, behavioral modifications
- Exercise, body resistance training
- smoking, caffeine/alcohol
- COmpression
Dopamine Agonists : Pramipexole , Ropinirole, Rotigotine , Cabergoline :
- Indicated for ? Except ___ it’s not fda approved for RLS
- Warnings/Precautions
-H/P
S, A
O, C, S,U,B, D, WOmen > men, - which drug has sulfite sensitivity?
Gabapentinoids
1. Which formulation is FDA approved?
2. BBW?
3. HOw is it cleared?
Other agents :
1. Carbidopa/Levodopa (DArk body fluids, sudden sleep, compulsive behaviors)
2. Opioids like oxy and methadone (risk for dependence, cns depression, respiratory depression)
- Primary RLS
-Cabergoline - Hallucinations/psyhotic like behavior
-Somnolence
-Augmentation
-Ortho hypo, compulsive behaviors, sexual urges, uncontrolled spending, binge eating, dose dependent - Rotigotine
- Gabapentin Enacarbil
- Suicidal ideation/behavior
- Renally
