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Self Care > Week 6: Insomnia and Nicotine > Flashcards

Week 6: Insomnia and Nicotine Flashcards

1
Q

What are the stages of sleep?

A

NREM
1. Falling asleep
2. Light sleep
3 and 4: Deep sleep
REM
5: Neither light nor deep, the body is more physiologically active

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2
Q

What is REM important for?

A

Regulation of mood and learning

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3
Q

How long is a NREM and REM sleep cycle?

A

90-120 minute
3-7 cycles
REM becomes longer and deep sleep becomes shorter

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4
Q

What is REM?

A

Dramatic physiological change from stage 4 NREM slow-wave sleep, to a state in which the brain becomes electrically and metabolically activated

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5
Q

What are the sleeping patterns of young adults?

A

Difficulty falling asleep

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6
Q

What are the sleeping patterns of middle age or older adults?

A

Staying asleep or decreased quantity

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7
Q

What is insomnia?

A
  1. Difficulty falling asleep
  2. Difficulty maintaining sleep
  3. Experiencing non-restorative sleep (not feeling rested)
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8
Q

What is primary insomnia?

A

Not caused by another sleep disorder, medical disorder, psychiatric disorder or mediation

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9
Q

What are examples of primary insomnia?

A

Inadequate sleep hygiene, travel, death of a loved one

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10
Q

What is secondary insomnia?

A

Caused by another sleep disorder, medical disorder, psychiatric disorder or medication

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11
Q

What are the duration classifications of insomnia?

A
  1. Short term: less than 3 months
  2. Chronic: greater than 3 months
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12
Q

What are the clinical presentation for insomnia?

A
  1. Difficulty falling asleep
  2. Short duration of sleep
    3/ Frequent awakenings
  3. Early morning awakenings
  4. Inability to fall back to sleep
  5. Impaired sleep quality due to dreams
  6. Impaired quality of life to sleep deprivation
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13
Q

How should we assess and monitor insomnia?

A
  1. Determine if any exclusions to self-treatment exist
  2. If in doubt, refer
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14
Q

What is the limit of self0treatment for insomnia?

A

10 days

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15
Q

What are the exclusions of insomnia?

A
  1. <12 YO
  2. > 65 YO
  3. Pregnant or breastfeeding
  4. Frequent nocturnal awakenings or early morning awakening
  5. Chronic Insomnia
  6. Secondary insomnia
  7. Significant sleep disturbance as defined by sleep-onset latency > 30 minutes
  8. wake after sleep onset (WASO) > 30 minutes
  9. sleep efficiency < 85%, and/or total sleep time < 6.5 hours
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16
Q

What should self-treatment insomnia be limited to?

A

Short term insomnia

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17
Q

What is the non pharm treatment for insomnia?

A
  1. Cognitive behavior therapy
  2. Good sleep hygiene
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18
Q

What is the pharm treatment for insomnia?

A
  1. Diphenhydramine
  2. Doxylamine
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19
Q

What is good sleep hygiene?

A
  1. Use bed for sleeping or intimacy only
  2. Establish regular patterns
  3. Avoid daytime naps
  4. Make bedroom comfortable
  5. Do something relaxing
  6. Avoid electronics
  7. Avoid large quantities of liquids
  8. Avoid large meals
  9. Limit alcohol and caffeine
  10. Exercise regularly
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20
Q

What is the MOA for diphenhydramine?

A

Ethanolamine antihistamine which block histamine 1 and muscarinic receptors

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21
Q

What is diphenhydramine used for?

A

Short term insomnia

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22
Q

What is the dose for diphenhydramine?

A

Take 30-60 minutes before bedtime
25-50 mg PO at bedtime

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23
Q

Is Diphenhydramine recommended for pediatrics?

A

Not for those under 12. Refer to behaviors interventions and good sleep hygiene instead

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24
Q

Is Diphenhydramine recommended for pregnancy?

A

Refer

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25
Q

Is Diphenhydramine recommended for lactation?

A

Refer

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26
Q

Is Diphenhydramine recommended for geriatric?

A

Refer to Beer’s list

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27
Q

What are the contraindications for diphenhydramine?

A
  1. BPH
  2. Narrow angle glaucoma
  3. CVD
  4. Dementia
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28
Q

What are the warnings of diphenhydramine?

A
  1. No alcohol
  2. No driving or operating heavy machinery
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29
Q

What are ADR of diphenhydramine?

A
  1. Paradoxical CNS stimulation
  2. Anticholineric effects
  3. Next morning hangover
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30
Q

What are the DDI of diphenhydramine?

A

Inhibits CYP2D6

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31
Q

What are complement therapies for insomnia?

A
  1. Melatonin
  2. Chamomile
  3. Valerian
  4. Kava
  5. Alcohol
  6. Mindfulness meditation
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32
Q

What are the available products for diphenhydramine?

A
  1. Capsules
  2. Gel caps
  3. Tablets
  4. Chewable
  5. Solutions
  6. Elixers
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33
Q

What is the etiology of drowsiness and fatigue?

A
  1. Inadequate sleep
    2/ Disease states
  2. Drug induced drowsiness and fatigue
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34
Q

What are the symptoms of drowsiness and fatigue?

A
  1. Yawning
  2. Eye rubbing
  3. Tendancy to fall asleep
  4. Decreased ability to focus and concentrate
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35
Q

How should we assess and monitor drowsiness and fatigue?

A
  1. Determine if any exclusions to self-treatment exist
  2. If in doubt, REFER
  3. Limit self-treatment to 10 days
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36
Q

What are the exclusions for drowsiness and fatigue self treatment?

A
  1. <12YO
  2. Pregnancy
  3. Breast feeding
  4. Heart disease
  5. Anxiety disorder
  6. Medication induced drowsiness
  7. Chronic fatigue defined as >6 months fatigue
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37
Q

What is the non pharm for drowsiness and fatigue?

A
  1. Identify and eliminate underlying cause
  2. Good sleep hygiene
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38
Q

What are the pharm for drowsiness and fatigue?

A

Caffeine

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39
Q

What is the MOA for caffeine?

A

Xanthine derivative which nonselective antagonizes A1 and A2 receptors of adenosine

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40
Q

What is the indication for caffeine?

A

Occasional use to help patients stay awake and improve mental alertness

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41
Q

What is the dose of caffeine?

A

100-200 mg Q3-4H, Max 600mg/24hr

42
Q

What should self treatment be limited for caffeine?

43
Q

What is the caffeine treatment for children?

A

Not recommended for under 12

44
Q

What is the caffeine treatment for pregnacy?

A

<200mg/day

45
Q

What is the caffeine treatment for lactation?

A

200-300mg/day
Intake caffeine after breast feeding to reduce infant exposure

46
Q

What is the caffeine treatment for geriatric?

A

<300mg/day
Clearance may be decreased

47
Q

What are the withdrawal symptoms of caffeine?

A
  1. Headache
  2. Fatigue
  3. Decreased concentration
  4. Irritability
48
Q

What are the precautions for caffeine?

A
  1. Patients taking MAOIs
  2. Coronary heart disease
  3. Uncontrolled hypertension
  4. Pre existing arrhthmias
49
Q

What are adverse effects?

A
  1. HA
  2. Tachycardia
  3. Increased BP
  4. ANxiety
  5. Insomnia
50
Q

What are the DDI for caffeine?

A
  1. Eliminated via CYP 1A2
  2. Theophylline
  3. Tobacco smoke
51
Q

What are the forms of tobacco?

A
  1. Cigarettes
  2. Smokeless tobacco (chewing tobacco, oral snuff)
  3. Pipes
    4 Cigars5.
  4. Clove cigarettes
  5. Bidis
  6. Hookah (water pipe smoking)
  7. Electronic cigarettes (“e-cigarettes”)*
52
Q

What are the physiological treatment of tobacco dependence?

A
  1. The addiction to nicotine is treated by medications for cessation
53
Q

What behavioral treatment of tobacco dependence?

A

The habit of using tobacco is treated by changing the problematic behavior

54
Q

What should an effective tobacco treatment address?

A

Should address both the physiological and behavioral aspects of dependence

55
Q

How do we address smoking behaviors?

A

Identify triggers as part of the quitting process

56
Q

What are nicotine withdrawal symptoms?

A
  1. Irritability
  2. Frustration
  3. Anger
  4. Anxiety
    5/ Difficulty concetrating
  5. Insomnia
  6. restlessness
57
Q

When would physiologic withdrawal symptoms set in?

A
  1. 1-2 days after stopping
  2. Peak in the first week
  3. Gradually decline over 2-4 weeks
58
Q

What are the DDI of smoking and caffeine?

A
  1. Smoke induce CYP1A2 enzymes that metabolizes caffeine
  2. Nicotine enhances caffeine levels (56%)
  3. Decrease caffeine intake by 50% when quitting, no caffiene in the evenings
59
Q

What is the DDI of using nicotine while taking hormonal contraceptives?

A

Increased risk of:
1. Stroke
2. MI
3. Thromboembolism
However, it doesn’t decrease the efficacy of hormonal contraceptives

60
Q

What are the non pharm methods of nicotine quitting?

A

Counseling and non-drugs

61
Q

What are the pharm methods of nicotine quitting?

A

FDA approved medications

62
Q

How do we help a patient to quit smoking?

A

Ask: about tobacco use
Advise: tobacco users to quit
Assess: Readiness to make a quit attempt
Assist: with the quit attempt
Arrange: follow-up care

63
Q

What are the stages of readiness to quit?

A
  1. Not ready to quit in the next month
  2. Ready to quit in next month
  3. Recent quitter, quit within past 6 months
    4: Former tobacco user, quit > 6 months ago
64
Q

Why do we assess a patients readiness to quit?

A

Enables clinicians to deliver relevant, appropriate counseling messages

65
Q

What is the cycle of quitting?

66
Q

What are the counseling strategies for someone not ready to quit?

A
  1. Relevance
  2. Risks
  3. Rewards
  4. Roadblocks
  5. Repetition
    Using tailored, motivational messages
67
Q

When do we refer someone with quitting?

A

Determine if any exclusions to self-treatment exist
If in doubt, REFER

68
Q

What is the plan if someone wants to quit?

A
  1. Set a quit date at least 2 days, no more than 2 weeks to allow time for patient to prepare
  2. Remove tobacco products from home
  3. Discuss plans with family and friends
  4. Identify triggers
  5. Follow up 1 week, 2 weeks, and 1 month, then prn
69
Q

What are the exclsuions for tobacco dependence self-treatment?

A
  1. Recent MI, Irregular heartbeat, severe angina
  2. HBP
  3. Pregnancy
  4. Breastfeeding
  5. <18YO
70
Q

What is Nicotine replacement therapy not recommended for?

A
  1. Pregnant smokers
  2. Smokeless tobacco users
  3. Individuals smoking fewer than 10 cigarettes per day
  4. Adolescents
71
Q

What are pharm therapy of NRT?

A
  1. Nicotine polacrilex gum
  2. Nicotine lozenge
  3. Nicotine transdermal patch
72
Q

What are examples of nicotine gum?

A

Nicorette and generic

73
Q

What are examples of nicotine lozenge?

A

Nicorette, Generic nicotine lozenge

74
Q

What are examples of nicotine patch?

A

NicoDerm, generic

75
Q

What is the rationale use for NRT?

A
  1. Reduce physical withdrawal from nicotine
  2. Eliminated the immediate, reinforcing of nicotine
  3. Allows patient to focus on behavioral and psychological aspects of tobacco cessation
76
Q

What do nicotine gum contain?

A

Resin complex

77
Q

What do nicotine gum contain?

A

Resin complex
1. Nicotine
2. Polacrilex

Sugar free gum base
Buffering agents to enhance buccal absoroption

Flavors: original, cinnamon, fruit, and mint

78
Q

What are the strengths of nicotine gum?

A

2mg or 4mg

79
Q

What is in a nicotine lozenge?

A
  1. Nicotine polacrilex formulation (25% more nicotine than gum)
  2. Contains buffering for enhance buccal absorption
    Flavors: mint and cherry
    Size: original and mini
80
Q

What are the strengths of nicotine lozenge?

A

2mg and 4mg

81
Q

How should we dose 2mg gum or lozenge?

A

If first cigarette of the day is smoked more than 30 minutes after waking

82
Q

How should we dose 4mg gum or lozenge?

A

If first cigarette of the day is smoked less than 30 minutes after waking

83
Q

What is the max amount of gum and lozenge?

A

gum: 24/day
Lozenge: 20/day

84
Q

What is the recommended schedule for gum and lozenge?

85
Q

What are the directions to use nicotine gum?

A
  1. Chew slowly
  2. Stop chewing at first sign of peppery taste or tingling sensation
  3. Park between cheek and gum
  4. Chew again when peppery taste or tingle fades
86
Q

What are the directions to use nicotine lozenge?

A
  1. Place in mouth and let it dissolve slowly
  2. Do not chew or swallow
  3. Roate to different areas of the mouth
  4. 20-30 minutes
87
Q

How should we educate a patient of a gum/lozenge?

A
  1. Use at least nine (9) pieces daily during the first 6 weeks
  2. Will not provide the same rapid satisfaction that smoking provides
  3. The effectiveness of the nicotine gum/lozenge may be reduced by coffee, juice, wine, and soft drinkgs
  4. Don’t eat or drink for 15 minutes before or while using
88
Q

What are the side effects of using gum and lozenges improperly?

A
  1. Lightheadeness (dizzy)
  2. Nausea and vomiting
  3. Hiccups
  4. Irritation of throat and mouth
89
Q

What are the adverse effects both gum and lozenge?

A
  1. Mouth and throat irritation
  2. Hiccupts
  3. GI complains
90
Q

What are the effects associated with nicotine gum?

A
  1. Jaw muscle ache
  2. May stick to dental work
91
Q

What are advantages of gum and lozenge?

A
  1. Oral substitute
  2. Delay weight gain
  3. Can be titrated
  4. Used with other agents
  5. Inexpensive
92
Q

What are the disadvantage of gum and lozenges?

A
  1. Frequent dosing
  2. GI adverse effects
93
Q

What are the disadvantages of nicotine gum specifically?

A
  1. Problem for people needing dental work
  2. Needs proper chewing technique
  3. Chewing might not be acceptable or desirable for some
94
Q

What are transdermal nicotine patches?

A
  1. 24 hr nicotine delivery
  2. Well absorbed in skin
  3. Avoids first pass
  4. Plasma nicotine levels are lower and fluctuate less than smoking
95
Q

How should we dose NicoDermCQ for a light smoker?

A

≤10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)

96
Q

How should we dose NicoDermCQ for a heavy smoker?

A

> 10 cigarettes/day
Step 1 (21 mg x 6 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)

97
Q

How should we dose Generic for a light smoker?

A

≤10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)

98
Q

How should we dose Generic for a heavy smoker?

A

> 10 cigarettes/day
Step 1 (21 mg x 4 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)

99
Q

What are the directions of transdermal nicotine patches?

A
  1. Choose area of skin on upper body or arm
  2. Skin needs to be clean, dry, hairless, and not irritated
  3. Apply patch to different area each day
  4. Do not use same area for at least 1 week
  5. Remove protective liner and apply adhesive side of patch to skin
  6. Peel off remaining protective covering
  7. Press firmly with palm of hand for 10 seconds
  8. Make sure patch sticks well to skin, especially around edges
  9. Wash hands: Nicotine on hands can get into eyes or nose and cause stinging or redness
  10. Do not leave patch on skin for more than 24 hours—doing so may lead to skin irritation
  11. Adhesive remaining on skin may be removed with rubbing alcohol or acetone
  12. Dispose of used patch by folding it onto itself, completely covering adhesive area
100
Q

How should we counsel a patient education on patch?

A
  1. Water will not harm the nicotine patch if it is applied correctly
  2. Don’t cut patches
  3. Keep new and used patches out of the reach of children and pets
  4. After patch removal, skin may appear red for 24 hours
  5. If skin stays red more than 4 days or if it swells or a rash appears, contact health care provider—do not apply new patch
101
Q

What is the local skin reactions of patches?

A
  1. Adhesive
  2. Up to 50% patients experience reaction
  3. Avoid patients with dermatologic conditions
102
Q

What are the clinical pearls of patches?

A
  1. NRT helps with withdrawl
  2. Combination therapy may be needed
  3. Treatment for longer that indicated on the package may be needed to prevent relapse
  4. Toxic effects may be seen when NRT is used incorrectly or excessively but more often patients do not use enough

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