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Clinical 1 (Part B) > 21 - Insomnia > Flashcards

21 - Insomnia Flashcards

1
Q

Describe the stages of NREM sleep (non rapid eye movement)

A

4 stages of NREM: each stage progressing to REM sleep. Skeletal muscle tone and eye movements are low

Stae 1: transition stage between wakefulness and sleep (about 0.5-7 min)

Stage 2: considered a “light” sleep. Intermediate sleep. Largest percentage of total sleep time (50% of the time)

Stage 3 and 4: Deep sleep (restorative sleep) - largely affects sleep quality. Also referred to as “delta” sleep

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2
Q

Describe REM sleep (rapid eye movement)

A
  • Increased brain activity, respiratory and heart rate, vivid dreams
  • Active inhibition of voluntary muscles so that you cannot “act out” your dreams
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3
Q

How long does a complete sleep cycle last for?

A

1.5-2 hours

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4
Q

How many times is a sleep cycle repeated each night?

A

4-5 times per night

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5
Q

With each cycle, time in ______ and ____ sleep will typically increase.

A

stage 2 and REM

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6
Q

____ patients = decreased REM, delta, and total sleep time

A

Elderly

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7
Q

Define insomnia

A

Subjective complaint of difficulty falling asleep, maintaining sleep, or not feeling rested despite a sufficient time and opportunity for sleep

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8
Q

Insomnia is usually accompanied by?

A 
Disturbances in daytime functioning:
-attention, concentration and memory impairment
-worries about sleep 
-irritability
-mood disturbance
-social dysfunction
etc.
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9
Q

List the diagnostic criteria for insomnia

A

Unsatisfactory sleep quantity or quality with:

  • difficulty falling asleep
  • difficulty staying asleep
  • waking up early and unable to fall back asleep

Results in dysfunction in social, occupational, educational, academic, behavioural or any other areas of life

Occurs > 3 nights/week and for > 3 months

Not related to another sleep-wake disorder

Not the result of a substance, mental disorder or medical condition

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10
Q

There are two potential explanations for insomnia:

Describe “Cognitive Model”

A
  • Stress induces worry, resulting in difficulty falling asleep
  • Over time, results in worry due to the lack of sleep and dysfunction that will occur
  • *stress
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11
Q

There are two potential explanations for insomnia:

Describe “Hyperarousal as a result of physiological factors”

A
  • Higher metabolic rate in patient’s with insomnia versus healthy individuals
  • Higher levels of: urinary and plasma cortisol, and adrenocorticotropic hormone in patients with insomnia
  • *hormones
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12
Q

What are the risk factors for insomnia?

A
  • higher rates for females
  • elderly
  • those with comorbid psychiatric or medical illness
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13
Q

Does alcohol help insomnia?

A

No. Alcohol does not help with sleep. Alcohol disrupts the sleep cycle. It may decrease your sleep latency but will cause you to wake up 2-4 hours later probably. It will decrease your total sleep duration.

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14
Q

Episodic insomnia

A

1-2 months

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15
Q

Persistent insomnia

A

> 3 months

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16
Q

Recurrent insomnia

A

2 or more episodes in a year

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17
Q

Common Etiologies:

Describe “Independent condition”

A

Situational - stress, conflict, environment

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18
Q

Common Etiologies:

Describe “Comorbid with another mental disorder”

A

Psychiatric - depression, anxiety, dementia, etc.

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19
Q

Common Etiologies:

Describe “Comorbid with another medical condition”

A
  • Medical - CVD (CHF), pain (osteoporosis, arthritis), respiratory (sleep apnea, COPD, AR), GI (GERD), neurological (MS, PD), BPH
  • Hormonal - pregnancy, menopause
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20
Q

Common Etiologies:

Describe “Comorbid with another sleep disorder”

A

Breathing-related sleep disorder, circadian rhythm disorders, parasomnias (sleep walking)

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21
Q

List a few drugs that can cause insomnia

A

-Antidepressants
-Anti-epileptics
-B blockers
-Diuretics
-CNS stimulants
etc.

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22
Q

Differential diagnosis for Insomnia

A
  • Situational/acute insomnia
  • Circadian rhythm sleep/wake disorders
  • Restless leg syndrome
  • Breathing related sleep disorders
  • Narcolepsy
  • Parasomnias
  • Substance/medication induced sleep disorder
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23
Q

Red flags/referrals for Insomnia

A
  • Symptoms associated with shift work
  • OTC ineffective after 3 evenings or required longer than consecutive > 7 days
  • Comorbid sleep disorders associated with insomnia (restless leg, breathing related sleep disorder symptoms, narcolepsy, parasomnias)
  • Drug induced
  • Comorbid with mental or medical conditions
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24
Q

Goals of therapy

A
  • Promote sound and satisfying sleep (quality, continuity and initiation)
  • Prevent dependence on drug therapy
  • Reinstate a normal sleep pattern without medication
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25
Non-pharms for insomnia?
- sleep hygiene (only use bed for sleep, avoid TV/screens before bed, exercise early in the day, avoid napping, always use an alarm) - stimulus control - relaxation techniques - cognitive-behavioral therapy - sleep restriction - paradoxical intention
26
What is sleep latency?
How long it takes you to go from full wakefulness to fully asleep
27
How do relaxation techniques help ?
decrease sleep latency and increase sleep maintenance
28
When is relaxation techniques most likely helpful?
where insomnia is a result of hyperarousal
29
Use of relaxation techniques?
- Progressive muscle relaxation - Biofeedback - Imagery training
30
List 3 sleep hygiene recommendatiosn
- Avoid caffeine, nicotine, and alcohol 4-6 hours before bedtime - Avoid daytime napping - Do something relaxating/enjoyable at bedtime (reading, yoga)
31
Describe the principles of drug use
1) Always use non-pharms first 2) OTC use: - for transient insomnia: 2-3 days - for short term or chronic: refer if OTC treatment needed for more than 7 consecutive nights and if ineffective after 3 evenings 3) Rx therapy: - use lowest dose possible, and only when required (no more than 4 nights/week) - sedatives can be habit forming expect 2-3 nights of poor sleep when stopped - Rx sedatives can all cause potential daytime drowsiness and confusion (should be used for no more than 2 weeks ideally
32
List 2 OTC options for insomnia
- 1st generation antihistamines | - natural products (melatonin, valerian)
33
List 4 Rx options for insomnia
- Antidepressants - Benzodiazepines - Zopiclone/Zolpidem - Miscellaneous
34
List a 1st gen AH | *don't need to know dosing
diphenhydramine
35
Adverse effects of diphenhydramine?
- tolerance - morning drowsiness - dizziness - grogginess - anticholinergic effects (dry mouth, dry eyes, urinary retention)
36
Diphenhydramine: | onset
1-3 hours
37
Diphenhydramine: | duration
3-6 hours
38
Diphenhydramine: | Who is it CI in?
- Asthma, chronic bronchitis, emphysema - Children under 2 yrs old - Enlarged prostate (BPH), cardiac disease, hyperthyroidism - Open angle and narrow angle glaucoma -Avoid in elderly > 65
39
Diphenhydramine: | Recommended schedueling
no more than 4 nights/week and not to be used for greater than 7 consecutive days
40
If using product > _____ = refer to physician
1 week
41
List 2 natural products for insomnia
- Melatonin (YAY) | - Valerian
42
Describe Melatonin
- Neurohormone synthesized from tryptophan - May increase total sleep time - May decrease sleep latency
43
Melatonin: | Adverse effects
- sleep disruption - fatigue - headache - dizziness - irritability - abdominal cramps
44
Describe Valerian
-Purported to inhibit breakdown of GABA AE: dizziness, nausea, headache and upset stomach
45
OTC therapy monitoring points
- Use a sleep diary to monitor sleep quality and quantity - If ineffective after 3 nights therapy and treatment still required refer to MD - Should see improvement in about 2-3 days - If requiring for more than 7 consecutive days, refer
46
What are some key counselling points?
- Talk about non-pharms - Do not use machinery while under the influence of sedating medication - Do not combine sedating drug therapy with alcohol - Discuss goals of therapy and management of side effects
47
Do you give the same dose of antidepressants for depression and insomnia?
No - for insomnia, we use lower doses
48
List 2 antidepressants as options for insomnia treatment
- Trazodone | - Tricyclic Antidepressants (Amitriptyline, Nortriptyline)
49
Describe Trazodone
-Has sedation effect and improves sleep continuity -Useful for antidepressant induced insomnia -No issue with dependence AE: dizziness, sedation, hypotension
50
Describe Tricyclic antidepressants (Amitriptyline, Nortriptyline)
-Helpful for sleep continuity -Useful in patients with comorbid conditions such as: chronic pain, depression, diabetic neuropathy AE: daytime sedation, anticholinergic effects, weight gain
51
How do benzo's help with insomnia?
- Reduce latency to sleep onset, number of awakenings and increasing total sleep time. - Decrease duration of stage 1 and 4 and increase stage 2 sleep.
52
AE of benzo's?
- daytime sedation - tolerance - withdrawls - falls - dizziness - motor vehicle accidents
53
List some benzo's that are good choices
- temazepam (t1/2 = 11 hr) - lorazepam (t1/2 = 15 hr) - oxazepam (t1/2 = 8 hr)
54
Benzos: | Side effects are ____ dependent
DOSE
55
Benzos: | The ______ the half-life, the least amount of residual daytime sedation.
shorter
56
Benzos: | Only meant for short term use, ideally no more than _____
2 weeks
57
Benzos: | What should we emphasize?
PRN use rather than regular use
58
Benzos: | Adverse effects?
- drowsiness, dizziness, confusion - falls, vehicle accidents - CNS depression - rebound insomnia, withdrawal
59
Benzos: | Must ______ them when discontinuing
taper
60
Benzos: | When tapering, must also incorporate ?
behavioural therapies
61
Benzos: | If used long term (> 3 weeks), how often should they be used?
only intermittently, no more than 3x per week
62
Describe zopiclone
- Less effect on sleep structure - Less effect on daytime performance due to short half-life - Less dependence or abuse than BZD, but can still occur - Appears to be absence of tolerance issues
63
MOA of zopiclone
- chemically unrelated to BZD | - acts selectively at BZD receptor (GABA) and has no anxiolytic, anticonvulsant or muscle relaxant properties
64
Zopiclone: | Onset
15 mins
65
Zopiclone: | AE
- dizziness - metallic taste - headache - GI issues
66
Zopiclone: | counselling points?
- counsel on the risk of impairment the following day - must allow at least 12 hours between dose and performing any duties requiring mental alertness (driving) - caution patients about alcohol use; rebound insomnia
67
Describe Zolpidem (Sublinox)
- New non-BZD hypnotic for insomnia - Onset = 15-30 mins - Duration = 7-8 hours
68
Zolpidem (Sublinox): | AE?
- daytime drowsiness - dizziness - amnesia - nausea - vomiting - headache - falls
69
Is the goal to get patients to 8 hours/night?
No - it is to get them back to their normal restorative quality of sleep, also to improve continuity of sleep
70
Do we use Chloral hydrate or L-tryptophan?
No - no real advantages
71
What is sleep apnea?
Cessation of airflow lasting at least 10 seconds
72
What drug is absolutely CI ins sleep apnea patients?
CNS depressants

Clinical 1 (Part B) (11 decks)

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