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825 > Sleep Disorders (Exam 3 Cut Off) > Flashcards

Sleep Disorders (Exam 3 Cut Off) Flashcards

1
Q

Insomnia Facts

A
  • Most common sleep disorder: 10% of U.S. population
  • High prevalence among women and elderly
  • Connected to increased risk of developing obesity, heart disease, kidney disease, HTN, and DM
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2
Q

Insomnia Diagnosis

A

Dissatisfaction with sleep quantity/quality in on or more of the following:

  • Difficulty in initiating sleep
  • Difficulty in maintaining sleep
  • Early-morning waking with inability to return to sleep
  • Clinically significant distress or impairment in areas of functioning
  • Occurs at least 3 nights a week for at least 3 months
  • Not due to lack of opportunity or because of a mental/medical condition
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3
Q

Insomnia Contributing Factors

A
  • Medical illness
  • Psychiatric illness
  • Medications/illicit substances
  • Situational Factors
  • First world problems
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4
Q

Medical Illness + Insomnia

A
  • SOB: asthma, COPD, sleep apnea, heart failure
  • Pain: arthritis, fibromyalgia, trauma/injury, neuropathy
  • Urinary/fecal urgency: BPH, CKD, spincal cord injury, DM
  • Hormonal dysregulation: menopause, thyroid imbalance
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5
Q

Psychiatric Illness + Insomnia

A
  • Depressive disorders
  • Anxiety disorders
  • Psychotic disorders
  • PTSD
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6
Q

Medications/Substances + Insomnia

A
  • Diuretics
  • Amphetamines
  • Alcohol
  • Corticosteroids
  • Caffeine
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7
Q

Situational Factors + Insomnia

A
  • Travel
  • Employment Schedule
  • Poor sleeping environment
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8
Q

Treatment Targets for Insomnia

A
  • Shortening sleep latency (SL) - time from laying down to falling asleep
  • Lengthen total sleep time (TST) - amount of time actually spent asleep, not in bed
  • Minimize waking after sleep onset (WASO) - combined time of all awakenings from initial sleep onset to final waking
  • Improving sleep quality (QOS) - subjective measure of satisfaction gathered by use of scales
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9
Q

Sleep Efficiency

A

TST / Time in bed

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10
Q

Non-Pharm + Insomnia

A
  • Sleep hygiene education
  • Stimuli control
  • Relaxation/meditation
  • Sleep restriction therapy
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11
Q

Insomnia Gold Standard

A
  • Cognitive Behavioral Therapy for Insomnia (CBT-I)
  • Incorporates above behavioral skills with cognitive therapy from psychologist
  • Proven efficacious in reducing SL, decreasing WASO, and improving sleep efficiency
  • Only limitation is lack of availability
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12
Q

Pharm Options for Insomnia

A
  • Antihistamines (first gen)
  • Antidepressants
  • Melatonin Receptor Agonists
  • Orexin Antagonists
  • Gabapentin
  • Sedative-hypnotics
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13
Q

Antihistamines

A
  • Antagonize CNS H1 receptors inducing sedation
  • Effective for short-term/intermittent treatment of insomnia for up to a week
  • AVOID in elderly due to anticholinergic SE (dizziness, confusion, constipation)
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14
Q

Antihistamine Options

A
  • Diphenhydramine (Sominex, Zzzquil): 25-50 mg
  • Doxylamine (Unisom): 25 - 50 mg
  • Hydroxyzine Pamoate (Vistaril)/HCl (Atarax): 25-100 mg, lowest anticholinergic burden
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15
Q

TCA

A
  • Doses for insomnia are lower than what is effective for antidepressant
  • Lowerrisk fo anticholinergic effects, QT prolongation, serotonin syndrome
  • Majority of sedation comes from antagonizing H1 receptors
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16
Q

TCA Options

A
  • Doxepin (Silenor, Sinequan): 3 and 6 mg tablets for insomnia (FDA-approved), but can use 10 mg tablet to save on cost
  • Amitriptyline: 10-25 mg at bedtime, also effective for neuropathic pain at hypnotic doses
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17
Q

Atypical Antidepressants

A
  • Trazodone (Desyrel): 12.5-200 mg at bedtime, 5-HT antagonist and weak H1 antagonis
  • AE: priapism, orthostasis
  • Mirtazapine (Remeron): 7.5-15 mg at bedtime, higher doses are less sedating, H1 and 5-HT antagonist
  • SE: hypertriglyceridemia, weight gain (appetite stimulant)
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18
Q

Melatonin Receptor Agonists

A

-Ramelteon (Rozerem): 8 mg within 30 minutes of bedtime on an empty stomach, adjust with hepatic impairment (CYP1A2 substrate), reduces SL

  • Melatonin: intrinsic production is ~0.5 mg per day, declines with age, take 1-10 mg 1-3 hours before bedtime
  • Small decrease in SL in primary insomnia
  • Significant reduction in SL and increase in TST in autistic children
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19
Q

Suvorexant

A
  • Belsomra
  • Only FDA-approved orexin antagonist
  • Improves SL, sleep maintenance, and TST
  • Dose: 5-20 mg within 30 minutes of bedtime
  • SE: headache, residual daytime drowsiness
  • Onset delayed when taken with food
  • Schedule IV, but assumed less abuse potential
  • Increased reports of suicidality decreased its use (later disproved)
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20
Q

Gabapentin

A
  • Works on voltage-dependent calcium channels, NOT GABA receptors
  • Causes generalized inhibition of CNS
  • Shortens sleep latency and increases stage 3/4 of sleep (slow wave)
  • Dose: ~200-1800 mg
  • Useful for those with concurrent neuropathic pain or alcohol use disorder
  • ADJUST for renal function
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21
Q

Benzos

A
  • Benzene rings connected to diazepine ring
  • GABA-A agonist, enhance the effect of endogenous GABA
  • All are effective for insomnia but temazepam and triazolam are the most common of the FDA-approved for insomnia
  • Temazepam dose: 7.5-30 mg (also effective antidepressant dose)
  • SE: daytime sedation, amnesia, cognitive impairment, respiratory depression with opioid use
22
Q

BDRA

A
  • Same clinical effect as benzos
  • Shorter half life than benzos but daytime drowsiness is still a concern
  • No evidence of lower risk compared to benzos
  • AE: sleepwalking, sleep-driving, sleep-eating, psychological/physiological dependence
23
Q

BDRA Examples

A
  • Zolpidem (Ambien)
  • 5-10 mg at bedtime prn, higher doses do NOT give more effective sedation
  • ER not shown to be more effective in improving sleep maintenance compared to IR
  • Eszipiclone (Lunesta)
  • 1-3 mg at bedtime as needed
  • Approved for up to months of continuous use
  • Longest half life of the BDRAs, improves sleep maintenance
  • Zaleplon (Sonata)
  • 5-20 mg at bedtime as needed
  • Shortest half life so only good for decreasing SL
  • Lower risk of rebound insomnia
24
Q

Risks of Benzos/BDRAs

A
  • Increased overall mortality
  • Increased risk of developing dementia with prolonged therapy
  • Higher risk of falls and fractures
  • Psychological/physiological dependence from abuse/misuse and withdrawal effects
  • Gradually taper over weeks to months to “successfully” discontinue
25
Q

Insomnia Treatment Guidelines

A
  1. CBT-I
  2. Shared decision making to discuss risks and harms of pharmacotherapy, ALL weak recommendations

Summary: DON’T WANT TO RECOMMEND PHARM

26
Q

Sleep Maintenance Insomnia Drug Options

A
  • Suvorexant (Belsomra)

- Doxexpin (Silenor)

27
Q

Sleep Onset/Maintenance Insomnia Drug Options

A
  • Eszopiclone (Lunesta)
  • Zolpidem (Ambien)
  • Temazepam (Restoril)
28
Q

Sleep Onset Insomnia Drug Options

A
  • Zaleplon (Sonata)
  • Triazolam (Halcion)
  • Ramelteon (Rozerem)
29
Q

DO NOT USE

A
  • Trazodone (Desyrel)
  • Diphenhydramine (Benadryl)
  • Tiagabine (Gabitril)
  • Melatonin
  • Tryptophan
  • Valerian
30
Q

Circadian Rhythm Sleep-Wake Disorders

A
  • Misalignment between endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social/professional schedule
  • Causes insomnia and/or excessive sleepiness
  • Results in significant impairment of social/occupational functioning
  • Delayed (night owls) or advanced (early birds)
  • Shift work
  • Non-24: sleep-wake cycle not in sync with a 24-hours schedule, common in blind individuals
31
Q

Advanced Circadian Rhythm Disorder Treatment

A

-Bright light therapy for 2-3 hours starting at usual onset of somnolence

32
Q

Delayed Circadian Rhythm Disorder Treatment

A
  • Behavioral modification (avoiding stimulants and bright lights at night)
  • Sleep-wake scheduling (maintaining same bed and wake times every day)
  • Melatonin hgihly effective in advancing sleep onset and reducing SL
33
Q

Shift Work Rhythm Disorder Treatment

A
  • Behavioral modification is first line
  • Light therapy during shift and light restriction after shift
  • Modafinil (Provigil) and armodafinil (Nuvigil) approved for residual sleepiness
34
Q

Non-24 Rhythm Disorder Treatment

A
  • Melatonin: as low as 0.5 mg at schedule time each night is effective
  • Decreased SL and increased TST by about 30 minutes
  • Tasimelteon (Hetlioz)
  • Only FDA-approved treatment but EXPENSIVE
35
Q

Sleep Apnea Diagnosis

A
  • All types are diagnosed by Apnea-Hypopnea Index (AHI)
  • Number of episodes occuring per hour of sleep
  • AHI >= 30: severe sleep apnea
  • AHI 15-20: moderate sleep apnea
  • AHI 5-14: mild sleep apnea
  • IF API is less than 30, they must also have daytime symptoms of sleepiness
36
Q

Primary Sleep Apnea Treatment Targets

A
  • Eliminate or reduce apneic episodes
  • Maintain blood oxygenation
  • Improve sleep quality
  • Reduce daytime fatigue and improve function
37
Q

Secondary Sleep Apnea Treatment Targets

A
  • Improve blood pressure control
  • Decrease morbidity and mortality
  • Enhance quality of life
38
Q

Sleep Apnea Treatments

A
  • Weight Loss
  • CPAP **
  • APAP
  • Oral appliances if intolerant to APAP or CPAP
  • Modafinil for daytime sleepiness/fatigue: 100-400 qam only AFTER maximizing CPAP/APAP therapy
39
Q

Nightmares

A
  • Often a symptom with anxiety or trauma-related disorder
  • PTSD or generalized anxiety disorder
  • Medication induced is a possibility as well
  • Non-pharm: IRT, progressive deep muscle relaxation
  • Pharmacotherapy only studied for PTSD-associated nightmares
40
Q

Prazosin

A
  • Most widely studied for nightmares
  • Blocks CNS alpha receptors to lessen chance of full awakening traumatic dreams and therefore less remembrance of the experience
  • Highly lipophilic with short duration so preferred to other alpha blocks
  • Slower titration to minimize orthostatic hypotension
  • Controversy on whether it is truly efective
41
Q

Prazosin Dosing

A
  • Start 1-2 mg at bedtime na dincrease every 2-3 nights in 1 mg increments as needed and tolerated
  • Daytime doses can be added to treat hyperarousal/anxiety, hypertension, or BPH
  • Okay to use concurrently with other alpha blockers
42
Q

REM Sleep Behavior Disorder

A
  • Occurs when patients lack normal muscle paralysis during REM sleep
  • Acting out dreams without waking, differs from sleep walking/night terrors since those are non-REM sleep
  • Most are male and over 50 y.o.
  • Up to 65% diagnosed Parkinson’s later
43
Q

REM Sleep Behavior Disorder

A

Environment Modification

  • Removing potentially dangerous objects from bedroom
  • Sleeping separate space

Clonazepam

  • Most studied agent to date
  • Recommended dose: 0.25-2 mg at bedtime

Melatonin

  • Less studied, same level recommended by AASM
  • Recommended dose: 3-12 mg at bedtime
44
Q

Substance-induced Sleep-Wake Disorder

A
  • Sleep-wake disorder while using or withdrawing from a substance
  • Benzos, BDRAs, barbs, opioids, SSRIs, SNRIs, MAOIs, TCAs, anticonvulsants, antipsychotics: all decrease stage 1 and REM sleep
  • Alcohol initially decreases SL and leads to rebound insomnia
  • Nicotine increases SL and decreases stage 3 sleep
  • Melatonin shown to help, especially during benzo tapering
45
Q

Insomnia Take-Home Points

A
  • Pharmacotherapy is never first-line

- Benzos and BDRAs are bad

46
Q

Sleep Phase Disorders Take-Home Points

A
  • Behavioral modification

- Melatonin

47
Q

Sleep Apnea Take-Home Points

A
  • CPAP

- APAP

48
Q

Nightmares Take-Home Points

A

-Prazosin

49
Q

REM Sleep Behavior Disorder Take-Home Points

A
  • Clonazepam

- Melatonin

50
Q

Substance-induced Disorder Take-Home Points

A
  • Melatonin may help in some cases

- Usually takes weeks to resolve once offending agent is removed

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