Treatment of Insomnia Flashcards
Elderly patients have:
More difficulty initiating sleep
Spend less time in delta sleep
Have increased awakenings
Medical Causes of Insomnia
Chronic pain COPD/ASthma Liver/renal failure DM Epilepsy HF Hyperthyroidism Hypoglycemia Sleep apnea/RLS CAD/angina
Psychiatric causes of insomnia
Anxiety Depression BD Alcohol or substance abuse Dementia
Medication/Substance Induced Insomnia
Alcohol Antidepressants BB and b-agonist Diuretics Nicotine/Caffiene Levodopa/carbidopa Thyroid hormons Steriods
DSM-5 Criteria for Insomnia
- A predominant complaint of sleep quantity or quality associated with one or more of the following symptoms:
1. Difficulty initiating sleep (induction insomnia)
2. Difficulty maintaining sleep (maintenance insomnia)
3. Early morning awakening with the inability to return to sleep - The disturbance causes significant distress or impairment of daily function
- The sleep difficulty occurs at least 3 nights per week
- The sleep difficulty is present for at least 3 months
- The sleep difficulty occurs despite adequate opportunity for sleep
- The insomnia does not occur exclusively during the course of another sleep-wake disorder
- The insomnia is not caused by a substance or medication
- Coexisting mental disorders and medical conditions are not causing the insomnia
- Specify if: episodic, persistent, recurrent
Define Episodic
Symptoms last at least 1 month but less than 3 months
Define Persistent
Insomnia last 3 months or longer
Define Recurrent
Two or more episodes within the space of 1 year
Complete evaluation of sleep problems includes
Obtaining a history and physical
Mental Health Evaluation
Keep a sleep diary and be consistent in documenting
What should be in a sleep diary?
Time to bed Time to fall asleep How many awakenings Time to awake Time to get out of bed How many naps and how long
Good Sleep Hygiene involves
- Regular time to wake and go to bed and keep this on off days
- Sleep only enough to feel rested
- Use bed for sleep or intimacy
- Go to bed only when sleepy
- Try to only worry during the day
- Avoid trying to force sleep
- Avoid computer or tablet for 30 minutes before bed
- Avoid daytime naps
- Exercise routinely
- Comfortable sleep environment
- D/c alcohol, caffeine, or nicotine
Avoid excessive fullness or hunger
Avoid lots of liquids in PM - Relax and enjoy before bed
Pharmacologic Treatment Pearls
Drug therapy should be short
Monitor effectiveness and reassess
Reduce or d/c that have insomnia as a side effect
First line Recommendation for Insomnia
Treat underlying medical condition
Try non-pharmacologicals
Second line Recommendations for Insomnia
D/c ASAP
BZD and Z-drugs are recommended unless CI
Choose based on what type of insomnia
If one doesn’t work, try another within these drug classes
Third line Recomendation for Insomnia
Ramelteon
Sedating antidepressants
Combination therapy as last line for Insomnia
BZD or Z drug + Sedating antidepressant
Ramelteon + Sedating antidepressant
BZD Drug Info
Controlled IV meds
Short-term only
Reduce latency to sleep and number of awakenings
Use lower dose in elderly
Triazolam (Halcion) Duration and Use
Short acting
Induction insomnia due to quick onset
Not M because of short duration
Temazepam (Restoril) Duration and Use
Intermediate acting
Both Induction and Maintenance
Flurazepam (Dalmane)
Long-acting- NOT recommended due to long half-life (daytime sedation/impairment)
Both induction and main.
Benzodiazepine SE
CNS depression Respiratory Depression Depression Confusion TOLERANCE
BZD Drug Interactions
Metabolized by 3A4
Avoid alcohol and CNS depressants
BZD CI/Precautions
Hepatic impairment
Sleep apnea
Pregnancy
Substance abuse
Non-BZD GABA Agonists- Drug Info
Z-drugs
Controlled- IV
No tolerance/withdrawals, minimal anxiolytic, muscle relaxants, and anticonvulsive effect
Lower does in women and elderly
Zolpidem IR/CR (Ambien) Onset, Duration, Use
Short term
Quick Onset
6-8 hour duration
Both induction and maint.
Zaleplon (Sonata) Onset, Duration, Use
Short term
Quick Onset
4 hour duration (take another dose at night)
Induction only
Eszopiclone (Lunesta) Onset, Duration, Use
Short/long term
Induction mainly but maint at high doses
Z drug Side Effects
CNS depression
Respiratory depression
Complex sleep related behaviors (sleep walking/eating/driving/sex)
Z drugs Interaction
CYP3A4
Avoid alcohol and other CNS depressants
Take on empty stomach***
Z drug CI/Precautions
Hepatic impairment
Sleep apnea
Pregnancy
Ramelteon (rozerem) MOA and drug info
Agonist of melatonin receptors
NOT controlled
Metabolized by CYP1A2
Ramelteon Onset, Counseling Points, SE, CI
Onset: 30 minutes but takes up to 3 weeks to see max benefits
Do not give with high fat meal and take 30 minutes before bedtime
Daytime sedation, headache, increased prolactin and decreased tesosterone
CI: pregnancy
Suvorexant (Belsomra) MOA and Drug info
Orexin receptor antagonists
Controlled IV
Metabolized by 3A4
Suvorexant Counseling point, AE, and CI
Take on an empty stomach and take 30 minutes before bed
CI: narcolepsy pts
AE: Daytime sedation, complex sleep related behaviors, sleep apralysis, cataplexy
Antidepressants Drugs, CI
TCA, mirtazapine, trazodone
Doxepin 3-6 mg = FDA approved
CI: Sleep apnea, incontinence, glaucoma
Antidepressant counseling points
Food will delay onset
Not to be taken within 3 hours of a meal
Anthistamines in Insomnia
Effective for episodic insomnia
SE: anticholinergic (dry mouth, incontinence, constipation, etc)
Melatonin in Insomnia
Useful in elderly and helps with jetlag
Use: REM sleep disorder
Not FDA approved
