Sleep Disorders Flashcards
Stages of Sleep
Falling asleep
Light sleep
Deep sleep
How long is the NREM-REM cycle?
70-120 minutes and we do it 4-6x a night
What neurotransmitters promote sleep?
GABA
Melatonin
Adenosine
Dyssomnias
1˚ sleep disorders
1˚ insomnia
Breathing related sleep disorder
Unspecified
Parasomnias
Strange behavior while asleep
1˚ Insomnia Dx Criteria
Difficulty with the following for ≥1 month: Sleep onset Sleep maintenance Waking too early Poor sleep quality
Risk Factors for Insomnia
Women
Age - quality decreases
What is the difference between acute and chronic 1˚ insomnia
4 weeks is the turning point
Before then, give PRN sleep aids and improve sleep hygiene
When is pharm therapy reserved for insomnia?
After adequate trials of non-pharm measures
Major Sedative/Hypnotic Counseling Pts
Empty stomach No pregnancy Careful in depression, lung, liver or heart dys Try for 2-4 weeks and re-eval Taper/CBT when d/cing
BZDs MOA
GABA Agonists
Is there tolerance with BZDs?
Potential
Most are effective for up to 2-4 weeks
Intermittent dosing reduces likelihood of tolerance
BZDs in Elderly
Not recommended
If used - give 1/2 to 1/3 normal adult dose of SHORT ACTING BZDs
Shortest and Longest Onset BZD
Shortest: triazolam and estazolam
Longest: flurazepam
Shortest and Longest Acting BZD
Shortest: triazolam
Longest: Flurazepam (active metabolite)
BZD Withdrawal
Rebound sx w/in hours to days
Can cause delirium
Especially high dose
BZDRAs
BZD Receptor Agonists
Bind BZD receptor on GABA
Advantages of BZDRAs
Stage 3 preserved
Sedative effects only
Less dependence/tolerance
Ambien Counseling Points
Diarrhea may resolve in 2 weeks
Use up to 35 days
Dosing Considerations with BZDRAs
Women, >65, and liver probs = lower dose
Intermezzo
IR SL zolpidem
PRN when wake up and still have at least 4 hours of sleep left
Zaleplon
Sonata
Max 30 days
Only for onset
High doses (while effective for increasing total sleep time) are not recommended
Temazepam Brand
Restoril
Triazolam Brand
Halcion
Flurazepam Brand
Dalmane
Eszopiclone
S-enantiomer
Lunesta
BZDRA Counseling Pts
Empty stomach right before bed
Shortest onset BZDRA
Sonata
Shortest and Longest Acting BZDRA
Shortest: Sonata
Longest: Lunesta
Melatonin Receptor Agonist
Ramelteon (Rozerem)
Melatonin
Secreted by pineal gland - less with age
Sleep/wake cycle
Agonism = sleep
Weird Lunesta Dosing
Onset: 1mg
Maintenance: 2mg
Rozerem
CI with fluvoxamine (1A2)
Empty stomach right before bed
TCA Approved for Sleep
Doxepin (Silenor)
Suicide potential
Anti-Ach AEs - H1 antagonist
w/in 30 min of bed empty stomach
Off-Label Use for Insomnia
Trazodone Mirtazapine SSRIs TCAs SGAs
Sleep bruxism
Teeth grinding
OTC options
Benadryl Valerian Melatonin Kava 5-HT
Central Sleep Apnea
No airflow due to no ventilation
Male, DM, CHF, old age, stroke
Obstructive Sleep Apnea
No airflow, despite ventilation
Consequences of OSA
Heart complications and increased mortality
Screening tool for OSA
ISNORED Insomnia Snoring Nighttime awakenings Obesity Restorative sleep? Excessive sleepiness in day Drugs affecting sleep
Drugs for OSA
Change drugs promoting weight gain/CNS depression
Nothing approved
Modafinil for daytime sleepiness if using CPAP
Restless Leg Syndrome
Risk - women, PD
1˚ and 2˚ - due to low Fe, pregnancy, kidney failure
Avoid stimulants or DA blockers
RLS Treatment
DA Agonists
Ropinirole
Pramipexole
Gabapentin ER - prodrug
