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
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
3
Q
Insomnia Contributing Factors
A
- Medical illness
- Psychiatric illness
- Medications/illicit substances
- Situational Factors
- First world problems
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
5
Q
Psychiatric Illness + Insomnia
A
- Depressive disorders
- Anxiety disorders
- Psychotic disorders
- PTSD
6
Q
Medications/Substances + Insomnia
A
- Diuretics
- Amphetamines
- Alcohol
- Corticosteroids
- Caffeine
7
Q
Situational Factors + Insomnia
A
- Travel
- Employment Schedule
- Poor sleeping environment
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
9
Q
Sleep Efficiency
A
TST / Time in bed
10
Q
Non-Pharm + Insomnia
A
- Sleep hygiene education
- Stimuli control
- Relaxation/meditation
- Sleep restriction therapy
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
12
Q
Pharm Options for Insomnia
A
- Antihistamines (first gen)
- Antidepressants
- Melatonin Receptor Agonists
- Orexin Antagonists
- Gabapentin
- Sedative-hypnotics
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)
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
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
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
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)
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
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)
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
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
Insomnia Treatment Guidelines
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
Sleep Maintenance Insomnia Drug Options
- Suvorexant (Belsomra)
| - Doxexpin (Silenor)
27
Sleep Onset/Maintenance Insomnia Drug Options
- Eszopiclone (Lunesta)
- Zolpidem (Ambien)
- Temazepam (Restoril)
28
Sleep Onset Insomnia Drug Options
- Zaleplon (Sonata)
- Triazolam (Halcion)
- Ramelteon (Rozerem)
29
DO NOT USE
- Trazodone (Desyrel)
- Diphenhydramine (Benadryl)
- Tiagabine (Gabitril)
- Melatonin
- Tryptophan
- Valerian
30
Circadian Rhythm Sleep-Wake Disorders
- 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
Advanced Circadian Rhythm Disorder Treatment
-Bright light therapy for 2-3 hours starting at usual onset of somnolence
32
Delayed Circadian Rhythm Disorder Treatment
- 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
Shift Work Rhythm Disorder Treatment
- Behavioral modification is first line
- Light therapy during shift and light restriction after shift
- Modafinil (Provigil) and armodafinil (Nuvigil) approved for residual sleepiness
34
Non-24 Rhythm Disorder Treatment
- 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
Sleep Apnea Diagnosis
- 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
Primary Sleep Apnea Treatment Targets
- Eliminate or reduce apneic episodes
- Maintain blood oxygenation
- Improve sleep quality
- Reduce daytime fatigue and improve function
37
Secondary Sleep Apnea Treatment Targets
- Improve blood pressure control
- Decrease morbidity and mortality
- Enhance quality of life
38
Sleep Apnea Treatments
- 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
Nightmares
- 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
Prazosin
- 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
Prazosin Dosing
- 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
REM Sleep Behavior Disorder
- 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
REM Sleep Behavior Disorder
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
Substance-induced Sleep-Wake Disorder
- 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
Insomnia Take-Home Points
- Pharmacotherapy is never first-line
| - Benzos and BDRAs are bad
46
Sleep Phase Disorders Take-Home Points
- Behavioral modification
| - Melatonin
47
Sleep Apnea Take-Home Points
- CPAP
| - APAP
48
Nightmares Take-Home Points
-Prazosin
49
REM Sleep Behavior Disorder Take-Home Points
- Clonazepam
| - Melatonin
50
Substance-induced Disorder Take-Home Points
- Melatonin may help in some cases
| - Usually takes weeks to resolve once offending agent is removed
