Sleeping disorders

Question 1

What are the potential causes of insomnia?

Answer 1

• Situational
  
  • Work or financial stress
  • Major life events
  • Jet lag, shift work
• Medical
  
  • Cardiovascular (angina, CHF)
  • Chronic pain
  • Neurologic (Delirium, Parkinsons)
  • Endocrine (Hyperthyroidism, diabetes)
• Psychiatric
  
  • Depression
  • Anxiety disorders
  • Substance abus
• Drug Induced
  
  • Alcohol
  • Anticonvulsants
  • Diuretics
  • Selective serotonin reuptake inhibitors
  • Steroids
  • Stimulants

Question 2

Non pharm treatment for Insomnia?

Answer 2

• Establish a regular sleep schedule
• Avoid daytime naps
• Reserve the bed for sleep
• Dont try and force sleep
• Avoid exercise right before bed
• Create a comfortable sleep environment
• Avoid bright light during the night

Question 3

Pharmacologic treatment of Insomnia

Answer 3

• Antidepressants
• Antihistamines
• Benzos
• Non-benzos
• Suborexant
• Ramelteon
• Melatonin

Question 4

TCAs like amitriptyline and Doxepin?

Answer 4

• Avoid in elderly
• Anticholinergic SEs
• Daytime sedation
• Cardiac problems

Question 5

Trazodone?

Answer 5

• Often used in SSRI insomnia
• SE: Priapism
• Orthostasis
• Caution in elderly

Question 6

Mirtazepine

Answer 6

• Good for patients with depression
• Lower doses produce more sedation
• Daytime drowsiness, weight gain

Question 7

Antidepressants are beneficial for patients with insomnia that?

What are the disadvantages?

Answer 7

• Difficulty falling asleep
• Early morning awakening
• Depression
• Substance abuse
• Pain disorders (TCAs)

Disadvantages

• Anticholinergic SEs, Cardiac conduction prolongation (TCAs)
• Problematic in elderly
• Lacks studies demonstrating efficacy

Question 8

Advantages and disadvantages for Antihistamines treating insomnia?

Answer 8

• Help falling asleep and staying asleep
• There is a hangover effect and Anticholinergic effects, also tolerance, should be avoided in the elderly

Question 9

Benzos and Insomnia?

Answer 9

• Reduce latency of sleep
• Reduce number of awakenings
• Increase total sleep time
• Prolong Stage 1-2 decrease 3-4
• Dont decrease REM sleep

Question 10

What adverse effect od Hypnotics should be taken into account?

Answer 10

• Abnormal sleep behaviors
  
  • Sleep walking, eating, and driving

Its a warning on all prescription hypnotics, Sleep walking, driving, eating

Question 11

Counseling tips on benzos and non-benzos

Answer 11

• Avoid using longer than 3-4 weeks
• Take 30 minutes before bed
• Driving - Caution in next morning driving
• Additive to CNS effects with alcohol
• May cause psychological dependence
• Avoid activities needing psychomotor coordination
• Daytime drowsiness
• Rebound insomnia upon discontinuation

Question 12

Ramelteon

Answer 12

• Melatonin Receptor agonist
• Non-controlled substance for insomnia
• 30 minutes before bed
• onset is .3 hours
• Substrate for 1A2
• SE:
  
  • headache, somnolence, nausea, diarrhea, depression
  • Hormonal abnormalities decrease libido, galactorrhea, amenorrhea
• Takes a few days to take effect

Question 13

Suvorexant?

Answer 13

• Orexin receptor antagonist
• 30 minutes before bed
• Food delays onsely
• 3A4 inhibitors reduce dose to 5 mgs

Question 14

Suvorexant SEs?

Answer 14

• Abnormal sleep behaviors
• Worsenign depression or suicidal thinking
• Abnormal behaviors (aggression, hallucinations)
• Avoid in patients with norcolepsy - increase sleep paralysis and cataplexy
• Memory impairment

Question 15

What other prescription meds can be used for insomnia?

Answer 15

• Atypical antipsychotics (Quitiapine, Seroquel)
• Hydrocyzine

Question 16

Sleep apnea?

Answer 16

• Cessation to airflow at teh nose and mouth
• Obstructive - occlusion of the upper airways
• Miniarousal prevents patient from achieving sleep

Question 17

Obstructive sleep apnea treatment?

Answer 17

• Avoid CNS depressants
  
  • Alcohol, anxiolytics, hypnotics, narcotics, zolpidem,
  • Interfere with brain stimulate breathing
• Nonpharm
  
  • Weightloss, positional therapy
  • Surgery, CPAP

Question 18

Medication therapy for apnea?

Answer 18

• Modafinil (Provigil) - Sleepiness due to OSA
• Armodafinil

Question 19

Restless leg syndrome causes most common in?

Answer 19

• Caffeine, stress, alcohol, smoking, fatigue
• More common in elderly

Question 20

Norcolepsy symptoms

Answer 20

• Excessive daytime drowsiness
• Cataplexy
• Hynagagic hallucination
• Sleep paralysis

Question 21

Treatment of Narcoepsy?

Answer 21

• Excessive daytime sleepiness
  
  • Methylphenidate, dextromethamphetamine
  • Modafinil and Armodafinil
  • Sodium oxybate (can treat cataplexy)
• Adjunctive treatment for cataplexy
  
  • SSRI, SNRI (Fluoxetine, Venlafaxine)
  • TCAs (Nortriptyline, imipramine)
  • Selegiline

Question 22

Important questions to ask patient?

Answer 22

• Do you have difficulty falling asleep?
• Do you have difficulty staying asleep?
• Do you feel not rested despite sleeping enough?
• What medications are you taking?
• Do you dring caffeine or alcohol?
• What are your sleep habits?