Sleep Disorders Flashcards
What are the 2 Types of Sleep Disorders?
- Primary Sleep Disorders
- Secondary Sleep Disorders
2 Types of Sleep Disorders: What are the 2 Types of Primary Sleep Disorders?
- Dysomnias (initiating, maintaining, excessive)
- Primary insomnia, primary hypersomnia, narcolepsy, breathing or circadian rhythm related
- Parasomnias (abnormal physiology during sleep)
- Nightmare, sleep terror, sleep walking disorders
2 Types of Sleep Disorders: What are the Types of Secondary Sleep Disorders?
- Sleep disorders related to another mental disorder
- Sleep disorders due to general medical condition
- Substance induced sleep disorders
What is Insomnia?
- Insomnia is an impairment of perceived sleep quality that’s often associated with daytime sequale that interferes with many aspects of daytime functioning such as fatigue, irritability, impaired concentration and malaise
If Insomnia is associated with another conditions, what’s it termed?
How is this treated?
- Co-morbid insomnia
- Treat comorbidities to treat insomnia
Medical conditions contributing to insomnia include?
- CVD e.g. IHD, CCF
- Respiratory e.g. OSA, COAD
- Chronic pain
- GI e.g. GORD
- Neurological e.g. delirium, epilepsy
- Pregnancy
Psychiatric conditions contributing to insomnia include?
Depression, mania, anxiety, substance abuse
Medications/Substances contributing to insomnia include?
- Antidepressants e.g. SSRIs
- Beta blockers
- Bronchodilators e.g. B2 agonists
- CNS stimulants e.g. Methylphenidate
- Nicotine
- Corticosteroids
- Diuretics
- Alcohol, caffeine and illicit drugs (e.g amphetamines)
Primary insomnia can be divided into 2 categories, what are they?
- Acute (<30 days duration)
- Chronic (>30 days duration)
Insomnia can also be divided into what?
- Difficulty falling asleep
- Difficult maintaining sleep
- Waking too early
- Poor quality of sleep
Risk factors for development of chronic insomnia include
- Increasing age
- Female
- Psychiatric illness
- Medical co-morbidities
- Impaired social relationships
- Lower socioeconomic status
- Separation from a spouse or partner
- Unemployment
What is the Assessment and Diagnosis of Insomnia?
- Are there diagnostic tests?
- What are quantitative indices for insomnia?
- No definitive diagnostic tests
- Quality generally more important than quantity
- No objective measure of perceived quality
- Quality generally more important than quantity
- Quantitative indices for insomnia
- Sleep-onset latency (>30 mins)
- Sleep efficiency (<85% bed time asleep)
Hypnotic Practice Points
- Can you use more than one at a time?
- Is tolerance common?
- Are some better than the other?
- Little basis for using more than one at a time
- Tolerance
- rare with short term use (1-2 weeks)
- Longer term use (>4 weeks) leads to tolerance and can make insomnia worse
- All hypnotics have the same effect on sleep patterns
Length of Action of Hypnotics: Very Short acting
- not useful for sleeping
- Midazolam
- Triazolam
Length of Action of Hypnotics: Short acting
- Alprazolam
- Oxazepam
- Temazepam
Length of Action of Hypnotics: Medium acting
- Bromazepam
- Lorazepam
Length of Action of Hypnotics: Long acting
- Diazepam
- Clobazam
- Clonazepam
What is important when selecting a hypnotic?
- Match drug to the sleep disturbance reported
- Match the onset and duration of effect with specific sleep disturbance
Factors in selecting hypnotic: Difficulty falling asleep but can maintain sleep
- Very short or short acting hypnotic with quick onset of effect (e.g. zolpidem, temazepam)
Factors in selecting hypnotic: Able to fall asleep, but waking early
- Short acting hypnotic – quick onset not necessary (temazepam, oxazepam, zolpidem SR)
Factors in selecting hypnotic: Difficulty falling and maintaining sleep
- Short acting benzodiazepine with quick onset (e.g. temazepam, zolpidem SR, zopiclone)
What is Benzodiazepine Dependence?
- Strong desire or sense of compulsion to take a substance, difficulty in controlling its use, tolerance and the presence of a withdrawal state
What is advised in long-term users of Benzos?
- A trial of benzodiazepine withdrawal is advised in long-term users
Symptoms associated with abrupt withdrawal of benzos include (more common in the first few weeks)?
- Difficulty sleeping and bizarre dreams
- Fatigue
- Dizziness
- Palpitations/Shakiness/Myoclonic Jerks
- Anxiety and irritability
Withdrawal of Benzos - Short Trial
Cease immediately
Withdrawal of Benzos - Longer Term Users
- Gradual reduction, titrated to withdraw symptoms
What is preferred in Benzo Withdrawal?
- Longer half-life is preferred e.g. diazepam
- Convert to equivalent dosage
- Short half-life = get big peaks and troughs → get therapeutic effects and withdrawal effects within single dosage cycle
- With longer half-life, concentration reduces quite gradually. Not much difference between peak and troughs
What is a reasonable withdrawal plan for benzos?
- 4-6 weeks is a reasonable plan to start with, or reduction in TDD by about 15% every week
- Time required varies between individuals
What is Deprescribing?
The term used to describe the trial cessation of medicines
Is deprescribing easy to do?
- Difficult to do in patient who’s been on medication for a long period of time
- Involves stopping drug, monitoring and support that goes around what’s needed to successfully withdraw a medicine
Deprescribing is easiest to achieve when?
- Deprescribing is easiest to achieve when the process starts during prescribing
- Set limits around treatment duration
- Shared decision making (physician and patient responsibilities)
- Initiate non-drug therapies
