Week 6 - MH/Neuro/Insomnia Flashcards
Which medication has the strongest recommendation for use for insomnia: trazodone, melatonin, or diphendyramine? (for adults with insomnia)
Tricks! None of them – all of these have weak recommendations against their use.
None of the medications used to treat insomnia have strong evidence either FOR or AGAINST their use – all recommendations are weak either way. Weird huh.
In order for a medication for insomnia to be deemed useful for your patient, how many nights is an acceptable trial of efficacy?
Two nights.
What are some classes of prescription medications that can cause sleep disturbance?
SSRIs, SNRIs, bupropion, alpha blockers, beta blockers, diuretics, stimulants, acetycholinesterase inhibitors, dopamine receptor agonsits, systemic corticosteroids, varenicline.
What are some non-prescription medications and substances that can cause sleep disturbance?
ETOH, caffeine, cannabis (withdrawal), cocaine, decongestants, ephedrine, nicotine and nicotine replacement therapy, laxatives (eeeeee)
What is the maximum dose of zopiclone for adults, and for adults over the age of 65?
7.5 mg max for adults
5 mg for adults over 65 (also for those with renal/hepatic dysfunction or on a strong CYP3A4 inhibitor
What is the starting dose of zopiclone for adults?
3.75 mg
Why did Health Canada decrease max doses of z-drugs?
Because next-day impairment and decreased vehicle control was a thing. You should not drive for TWELVE HOURS after taking zopiclone or eszopiclone. Zolpidem is 8 hours (not sure if this one is available in Canada).
A study found impaired driving equivalent to 3-4 beer, 11 hours after taking 7.5 mg of zopiclone.
Studies have shown that the z-drugs include total sleep time per night by 2.5 hours.
True or false?
False!
30 minutes!
People tend to fall asleep approx 18 minutes faster than without the medication, and awake time after onset of sleep is approx 13 minutes.
Health Canada says the use of z-drugs for sleep disturbance should be limited to how long (duration)?
7-10 days.
Medications for insomnia can have crazy long half-lives, so the sedation effects can be felt the next day for many of them.
Matchy-match:
Zopiclone 12-20 hours
Diphenhydramine 30 hours
Lorazepam 4-11 hours
Amitriptyline 5-9 hours
Trazodone 30-40 hours
Clonazepam 3-9 hours
Zopiclone 4-11 hours
Diphenhydramine 3-9 hours
Lorazepam 12-20 hours
Amitriptyline 30 hours
Trazodone 5-9 hours
Clonazepam 30-40 hours
Diazepam is 24-100 hours, and doxepin is 31 hours! - you can see the cautions needed in the elderly peeps with anticholinergic effects and falls risks.
Doxepin is a TCA that has been rebranded as an insomnia medication that helps reduce waking time through the night by about 20 minutes. It does not help with time it takes to fall asleep.
It has been shown to help with sleep maintenance in older adults only.
What is the initial dose for older adults 65+?
How do meals affect this medication?
Initial recommended dose is 3 mg. Max dose 6 mg.
Onset of effect is delayed if taken within 3 hours of a meal.
To treat insomnia, trazadone is a safer choice than benzos, for older adults with falls risks. True or false?
False! Falls risk = falls risk.
Which classes of medications that are sometimes used to treat primary insomnia increases risk of mortality in older adults?
Atypical antipsychotics. The harms simply outweigh the benefits.
amitriptyline, mirtazapine, quetiapine, olanzapine, risperidone
When are atypical antipsychotics recommended?
To treat comorbid conditions, with caution after weighing risks and benefits.
Lemborexant is an orexin receptor agonist, marketed as Dayvigo. It has similar adverse events as others with some that are specific to this med. Can you name some?
Sleep paralysis
Cataplexy-like s/s (sudden leg weakness)
hallucinations
It has also shown risk of being misused as recreational.
In the PP, they discuss how ol’ Sue really liked this medication in her clinical practice. Jen the presenter said she hasn’t really used it because it is new to Canada (2023).
Important patient teaching if you prescribe lemborexant (Dayvigo)?
ETOH will DOUBLE the concentration of Dayvigo in your system. Abstain!
Guidelines across the world have strong recommendations for which treatment for insomnia?
CBTi - cognitive behavioural therapy for insomnia
Jen recommends free MH resources through Kelty’s Key website - they have CBT insomnia modules.
In terms of addressing medication overuse, Jen Carefoot gives us 4 components to include in your plan when tapering down insomnia medications. What are they?
- Plan a gradual dose reduction strategy with education.
- Identify alternative to managing the underlying health issue (that is causing the overuse). ie pain, mood
- Develop strategies to minimize withdrawal.
- Establish a schedule of follow-ups.
You should use a de-prescribing resource to help you taper down insomnia meds, true or false?
Of course! There is no “one best way” to do it. Call your pharmacist, use online tools, sites etc.
When counseling a patient about when to take zopiclone or eszopiclone, what should you tell them?
Take immediately before bed and only if you plan to get a full night’s sleep (8 hours).
What is normal pressure hydrocephalus (NPH)?
NPH = refers to a condition of pathologically enlarged ventricular size with normal opening pressures on lumbar puncture
a form of communicating hydrocephalus
distinguished from obstructive or noncommunicating hydrocephalus, in which there is a structural blockage of the cerebrospinal fluid (CSF) circulation within the ventricular system
What is the classic triad of symptoms in NPH? Are all o f these required for diagnosis?
dementia, gait disturbance, and urinary incontinence
**Patients need not have all three cardinal features, but gait must be the predominant problem
Is NPH a common cause of dementia?
No - rare condition compared with other causes of dementia in older adults
Who is more likely to get NPH?
Idiopathic NPH increases in prevalence with age and is most common in adults over the age of 60 years
Secondary NPH (those cases associated with an identified etiology) can occur in all age groups
M:F