Sleep Meds Final Flashcards
Sleep disorders are more common in?
Women and older patients
One theory on sleep disturbance is increased ______ activation (i.e. ____, ____, ____, ___)
physiological
- cardiac
- metabolic
- hormone
- EEG
Sleep disturbance may also arise from increased activation of the _____.
Hypothalamus
Risk factors for sleep disturbance include
Older age female previous insomnia FH insomnia -predisposed to waking easily
Psychiatric disorders associated with sleep disturbance
depression
anxiety
substance use disorder
PTSD
Pulmonary diseases linked to insomnia
chronic pain
CHF
Parkinson dz
HTN
Meds that can cause insomnia
CNS stimulants i.e. caffeine, cocaine, modafinil
- appetite supressants
- antidepressants (MAOIs, some SSRI esp. prozac/wellbutrin is a DNRI
- Glucocorticoids
- Beta blockers
- alcohol
- nicotine
What can beta blockers cause that can produce sleep disturbance?
Sleep-onset insomnia, vivid dreams and increased awakening
Two main types of insomnia?
Short term < 3 mos
Chronic >/= 3X/week and >/= 3 mos
Short term insomnia can also be termed…
Adjustment/acute insomnia
Clinically insomnia is classified as taking >/= ___ minutes to fall asleep or spend >/= ___ minutes awake during the night, or wake up >/= ___ minutes prior to desired time.
30, 30, 30
What is the first line therapy for insomnia?
CBT-I
What are the behavioral components of CBT-I?
- stable bedtime 7 days/wk
- only stay in bed while sleeping or sex
- get out of bed if not sleepy
How do you evaluate insomia?
- Detailed sleep hx & sleep diary
- Screening tools i.e. Pittsburg sleep quality index
- Sleep problem questionnaire
- Ddx
Tx for acute?
- Discuss the stressors
2. +/- short-term intermittent use of sedative (up to 4 wks)
List of benzos
Estazolam flurazepam lorazepam temazepam triazolam
List of non benzos
Zolpidem (Ambien)
Zaleplon (Sonata)
Eszopicline (Lunesta)
What is the cognitive aspect of CBT-I
treat:
- anxious thoughts about sleeplessness
- inappropriate expectations about hours of sleep
- misbeliefs about the effects of sleeplessness
- relaxation through mindfulness, progressive muscle relaxation and meditation
What is the concern with chronic use of sedatives for chronic insomnia?
- abnormal thinking
- behavioral changes
- CNS depression
- rx abuse
- increase sleep-related activities i.e. sleep driving or eating
Non controlled meds for insomnia?
Melatonin
Trazodone (off label antidepressant)
Doxepin (Silenor [TCA])
Suvorexant (Belsomra) >orexin receptor antagonist
What meds do you want to avoid for insomnia
Antipsychotics
Benadryl
Barbiturates
Alcohol
Sequelae of insomnia
Adverse cardiac outcomes from SNS activation i.e. HTN/MI
- Increased SI
- Self medication/substance abuse
Narcolepsy is daytime sleepiness with:
Cataplexy (type I with, type II without)
- Hypnagogic hallucinations
- sleep paralysis
- sleep attacks
When does narcolepsy usually begin?
Teens - early 20s
M=F
1 in 2000 people
Pathophysiology behind narcolepsy?
Loss of orexin-A & orexin-B
What the hell is orexin?
released during wakefulness and increase activity of brain regions that keep a person awake
Clinical features of narcolepsy
- fall asleep at inappropriate times without warning (sleep attack)
- sleepiness improves with nap
- usually feel rested in morning
- Epworth score >15
- sleep paralysis
- hypnagogic hallucinations
How to eval narcolepsy
- Sleep study (polysomnogram) showing spontaneous awakening, reduced sleep efficiency, increased light non-REM sleep
- Enters REM sleep quickly w/in 15 min (normal takes 80-100 min) - Multiple sleep latency test (falls asleep in < 8 min, normal is 10-15 min)
- naps often include REM sleep (>/= 2 naps with REM essential feature of narcolepsy)
Non-Rx tx of narcolepsy
1-2 20 min naps/day (around 1 pm best, can reduce sleepiness up to 3 hrs)
- maintain regular sleep schedule
- avoid alcohol/benzos/opiates
- psychosocial support
1st line rx for narcolepsy
Modafinil (Provigil)
-does not affect sleep
s/e: HA, nausea, dry mouth, anorexia, diarrhea
2nd line meds for narcolepsy include
Stimulants i.e. ritalin/concerta/amphetamines
- s/e: HTN, HA, sudden death, dependency
- Newly approved last 2019 solriamfetol
What is the narcolepsy medication that has to be taken QHS then 2.5-4 hrs later?
Sodium oxybate (liquid) show results in few days but up to >3 mos for full effect
- s/e: weight loss, dizzy, mood swings, worsening depression
- overdose potential with respiratory depression
What is the most common sleep-related breathing disorder?
OSA
Risk factors for OSA
getting old M>F Obesity Got a weird face or airway nasal congestion
What does OSA cause at a cellular level?
Gas exchange disturbances (hypercapnia and hypoxia)
Some maybe not so normal sxs of OSA
morning headaches
PE findings that might lead you to evaluate OSA
Obesity
Crowded airway (Malompati score)
Big ol’ neck
HTN
How to dx OSA
First-line is in lab sleep study or secondary home sleep apnea testing (HSAT)
Sleep study diagnostic criteria for positive OSA
Need an AHI (apnea hypopnea index) of 5 or more (AHI of 15 diagnostic on its own) per hour AND at least one of these (no shit criteria)
- sleepy, fatigue, insomnia
- wake up choking/gasping
- chronic snoring/apnea observed by partner
- HTN, mood disorder, cognitive dysfunction, CAD, CVA, CHF, AF, DM2
Complications of OSA besides the obvious
MVAs Metabolic syndrome DM2 Perioperative complications NAFLD 2-3 fold increase in all cause mortality
