Sleep disorders Flashcards
Insomnia treatment
Most anxiolytics (sedatives) will induce sleep when given at night and most Hypnotics will sedate when given during the day. Although prescribing of these drugs is widespread, but dependence + tolerance can occur. - This may make withdrawal of the drug difficult after the patient has been taking the drug regularly for a few weeks. Hypnotics and Anxiolytics are therefore reserved for SHORT-COURSES.
most commonly used Anxiolytics and Hypnotics.
Benzodiazepines are the most commonly used Anxiolytics and Hypnotics. They should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress.
Benzodiazepine Withdrawal syndrome
Insomnia, anxiety, loss of appetite + body weight, tremor, perspiration, tinnitus and perceptual disturbance. The original symptoms may return and encourage further prescribing.
- This syndrome may occur at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one.
Short-term users of Benzodiazepines
Short-term users of Benzodiazepines (2-4 weeks only) can usually taper off within 2-4 weeks. However, long-term users should be withdrawn over a much longer period (several months – 1 year or more):
how to withdraw benzodiazepine
- Transfer patient stepwise, one dose at a time over about a week to an equivalent daily dose of diazepam preferably taken at night.
- Reduce diazepam dose usually by 1-2mg every 2-4 weeks (in patients taking high doses, initially it may be appropriate to reduce the dose by up to one-tenth every 1-2 weeks). If withdrawal symptoms occur, maintain this dose until symptoms lessen
- Reduce diazepam dose further, if necessary in smaller steps (steps of 500mcg may be appropriate towards end of withdrawal) … then STOP COMPLETELY.
- Short-acting hypnotics
Short-acting hypnotics are suitable for patients with sleep-onset insomnia when sedation the following day is undesirable or for the elderly patients
- Long-acting hypnotics
Long-acting hypnotics are suitable for patients with poor sleep maintenance (e.g. early morning waking) that causes daytime effects, when an anxiolytic is needed in the day or when sedation the following day is acceptable.
• Transient insomnia
• Transient insomnia may occur in those who normally sleep well and may be due to noise, shift work and jet lag. If a hypnotic is given, one that is rapidly eliminated should be given and only 1 or 2 doses should be given.
Short-term insomnia
• Short-term insomnia is usually related to an emotional problem/serious medical illness. A short-acting hypnotic should be given for a maximum of 3 weeks (preferably 1 week). Intermittent use is desirable with omission of some doses
Chronic insomnia
• Chronic insomnia is rarely benefitted by hypnotics and is commonly caused by anxiety, depression and abuse of drugs + alcohol. The underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia e.g. giving Mirtazapine for depression at night will help aid sleep.
Hypnotics should not be
Hypnotics should not be prescribed indiscriminately, and routine prescribing is undesirable. They should be reserved for short courses in the acutely distressed. Tolerance to their effects develops within 3-14 days of continuous use & long-term efficacy cannot be assured.
A major drawback of long-term use is
- A major drawback of long-term use is that withdrawal can cause rebound insomnia + a withdrawal syndrome
Where prolonged administration is unavoidable, hypnotics should be
- Where prolonged administration is unavoidable, hypnotics should be discontinued as soon as feasible and the patient warned that their sleep may be disturbed for a few days before normal rhythm is re-established. Broken sleep with vivid dreams may persist for several weeks.
Some anxious dental patients may
benefit from the use of hypnotics during dental procedures such as Temazepam or Diazepam. Temazepam is preferred when it is important to minimise any residual effect the following day.
Benzodiazepines used as Hypnotics include
Nitrazepam + Flurazepam which have prolonged action and may give rise to residual effects on the following day. Caution: Paradoxical effects
Loprazolam, Lormetazepam and Temazepam act for a shorter time and they have little or no hangover effect. However, withdrawal phenomena are more common with short-acting benzodiazepines.
If insomnia is associated with daytime anxiety, then the use of a long-acting benzodiazepine anxiolytic such as diazepam given as a single dose at night may effectively treat both symptoms