Sleep Disorders (Insomnia) Flashcards
What are immediate consequences of poor sleep?
- less occupational productivity
- less healthcare utilization
- lower QOL
- higher morbidity
- daytime sleepiness
In what population do we commonly see sleep disorders?
geriatric
When do we see sleep disorders occuring?
- difficulty falling asleep
- poor sleep quality
- frequent nighttime awakenings
- early arousal without the ability to fall back asleep
Why shouldn’t you self-treat a sleep disorder with alcohol?
Alcohol helps induce sleep, but reduces rapid eye movement (REM) sleep and suppresses breathing and can precipitate sleep apnea.
Definition of a short-term sleep disorder
less than 3 months
Definition of a chronic sleep disorder
3+ sx/wk for at least 3 months
risk factors
- female
- increased age
- medical or psychiatric comorbidities
- substance abuse
- emotional stress
- work-related conditions (unemployed, night shift, changing shifts)
- circadian rhythm disturbances
- low socioeconomic status
DSM V Criteria
difficulty initiating or maintaining sleep, waking too early, or non-restorative or poor quality sleep DESPITE good opportunity and circumstances
AND (at least one):
- fatigue or malaise
- attention, concentration, or memory impairment
- social or vocational dysfunction/ poor school performance
- mood disturbance, irritability
- daytime sleepiness
- motivation, energy or initiative reduction
- prone to errors/accidents at work/driving
- tension, headaches, GI sx (due to sleep loss)
- concerns/worries about sleep
What is primary insomnia?
tension and learned sleep-preventing associations
- vicious cycle: negative associations cause difficulty sleeping, which are then worsened by the patient’s concerns
(psychophysiologic insomnia)
What is secondary insomnia?
due to medical or psychiatric process
- treat the underlying condition here first!
What are the medical conditions that cause of secondary insomnia?
- CV
- Respiratory
- chronic pain
- endocrine disorders
- GI
- neurologic
- pregnancy
What are the psychiatric conditions that cause secondary insomnia?
- mood
- anxiety
- substance abuse
What prescription drugs cause secondary insomnia?
- anticonvulsants
- central adrenergic blockers (clonidine, B-blockers, ACEis, methyldopa, reserpine)
- diuretics
- SSRIs, Bupropion, MAOis, TCADs
Steroids - Stimulants
What illegal drugs cause secondary insomnia?
- cocaine
- methamphetamine
Is treatment really necessary?
YES if:
- impaired QOL
- impaired cognitive function
- incr. risk of: pain, depression, accidents, psych disorders
How do we determine and treat ST insomnia?
< 12 wks + trigger (no psych/med conditions untreated)
shortest acting med 3-4x weekly for 3-4 wks then taper off
How do we determine and treat chronic insomnia?
> 12 wks + (2 wks sleep diary OR insomnia questionnaire OR Epworth Sleepiness Scale)
Multi-modal Cognitive Behavioral Therapy (CBT)
- may combine with med in resistant cases
What is CBT?
work with professional to understand root of problems and create a plan to change thinking (recognize one’s distortions in thinking, and reevaluate realistically; develop a greater sense of confidence is one’s own abilities) and behavioral (Facing one’s fears instead of avoiding them; Learning to calm one’s mind and relax one’s body) patterns
COGNITIVE BASED THERAPY
What can we use as pharmacologic tx?
non-BZ hypnotic agents
- alcohol
- antihistamines
- antidepressants
- chloral hydrate
- eszopiclone
- melatonin
- OTC (diphenhydramine, doxylamine)
- Ramelteon
- Suvorexant
- Zolpidem
- Zaleplon
BZDs
What do we want to recommend for sleep onset +/- maintenance?
Eszopiclone or Suvorexant/Lemborexant (best options)
> Zolpidem
> BZDs (especially in older patients)
What do we want to use for sleep onset ONLY?
Ramelteon > zaleoplon > triazolam
What do we want to use for sleep maintenance?
Suvorexant/Lemborexant/doxepin - 3 mg/6mg doses
6 General Steps to selecting/recommending therapy
- Short-term vs chronic
- primary vs secondary
- Epworth Sleepiness scale (is therapy necessary?)
- Assess sleep hygiene
- Determine type of sleep disturbance
- Evaluate patient characteristics, conditions, PMH,
Which is more effective: CBT or pharmacologic therapy, for treating chronic insomnia?
CBT
(just as or more effective than pharm therapy)
- CBT + pharm agents may have additional benefits
- CBT can reduce medication need in patients on insomnia meds
Which is more effective BZDs or BZD agonists?
Trick question! –> no significant differences in efficacy
T/F: OTC agents, like diphenhydramine or doxylamine, should be used in treatment
FALSE
- OTC are not recommended by AASM
T/F: Orexin/hypocretin receptor antagonists and BZD-agonists have a better safety profile than BZDs
TRUE
