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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
Q

Non-pharms for insomnia?

A
  • 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
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26
Q

What is sleep latency?

A

How long it takes you to go from full wakefulness to fully asleep

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27
Q

How do relaxation techniques help ?

A

decrease sleep latency and increase sleep maintenance

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28
Q

When is relaxation techniques most likely helpful?

A

where insomnia is a result of hyperarousal

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29
Q

Use of relaxation techniques?

A
  • Progressive muscle relaxation
  • Biofeedback
  • Imagery training
30
Q

List 3 sleep hygiene recommendatiosn

A
  • Avoid caffeine, nicotine, and alcohol 4-6 hours before bedtime
  • Avoid daytime napping
  • Do something relaxating/enjoyable at bedtime (reading, yoga)
31
Q

Describe the principles of drug use

A

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
Q

List 2 OTC options for insomnia

A
  • 1st generation antihistamines

- natural products (melatonin, valerian)

33
Q

List 4 Rx options for insomnia

A
  • Antidepressants
  • Benzodiazepines
  • Zopiclone/Zolpidem
  • Miscellaneous
34
Q

List a 1st gen AH

*don’t need to know dosing

A

diphenhydramine

35
Q

Adverse effects of diphenhydramine?

A
  • tolerance
  • morning drowsiness
  • dizziness
  • grogginess
  • anticholinergic effects (dry mouth, dry eyes, urinary retention)
36
Q

Diphenhydramine:

onset

A

1-3 hours

37
Q

Diphenhydramine:

duration

A

3-6 hours

38
Q

Diphenhydramine:

Who is it CI in?

A
  • 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
Q

Diphenhydramine:

Recommended schedueling

A

no more than 4 nights/week and not to be used for greater than 7 consecutive days

40
Q

If using product > _____ = refer to physician

A

1 week

41
Q

List 2 natural products for insomnia

A
  • Melatonin (YAY)

- Valerian

42
Q

Describe Melatonin

A
  • Neurohormone synthesized from tryptophan
  • May increase total sleep time
  • May decrease sleep latency
43
Q

Melatonin:

Adverse effects

A
  • sleep disruption
  • fatigue
  • headache
  • dizziness
  • irritability
  • abdominal cramps
44
Q

Describe Valerian

A

-Purported to inhibit breakdown of GABA

AE: dizziness, nausea, headache and upset stomach

45
Q

OTC therapy monitoring points

A
  • 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
Q

What are some key counselling points?

A
  • 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
Q

Do you give the same dose of antidepressants for depression and insomnia?

A

No - for insomnia, we use lower doses

48
Q

List 2 antidepressants as options for insomnia treatment

A
  • Trazodone

- Tricyclic Antidepressants (Amitriptyline, Nortriptyline)

49
Q

Describe Trazodone

A

-Has sedation effect and improves sleep continuity
-Useful for antidepressant induced insomnia
-No issue with dependence
AE: dizziness, sedation, hypotension

50
Q

Describe Tricyclic antidepressants (Amitriptyline, Nortriptyline)

A

-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
Q

How do benzo’s help with insomnia?

A
  • 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
Q

AE of benzo’s?

A
  • daytime sedation
  • tolerance
  • withdrawls
  • falls
  • dizziness
  • motor vehicle accidents
53
Q

List some benzo’s that are good choices

A
  • temazepam (t1/2 = 11 hr)
  • lorazepam (t1/2 = 15 hr)
  • oxazepam (t1/2 = 8 hr)
54
Q

Benzos:

Side effects are ____ dependent

A

DOSE

55
Q

Benzos:

The ______ the half-life, the least amount of residual daytime sedation.

A

shorter

56
Q

Benzos:

Only meant for short term use, ideally no more than _____

A

2 weeks

57
Q

Benzos:

What should we emphasize?

A

PRN use rather than regular use

58
Q

Benzos:

Adverse effects?

A
  • drowsiness, dizziness, confusion
  • falls, vehicle accidents
  • CNS depression
  • rebound insomnia, withdrawal
59
Q

Benzos:

Must ______ them when discontinuing

A

taper

60
Q

Benzos:

When tapering, must also incorporate ?

A

behavioural therapies

61
Q

Benzos:

If used long term (> 3 weeks), how often should they be used?

A

only intermittently, no more than 3x per week

62
Q

Describe zopiclone

A
  • 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
Q

MOA of zopiclone

A
  • chemically unrelated to BZD

- acts selectively at BZD receptor (GABA) and has no anxiolytic, anticonvulsant or muscle relaxant properties

64
Q

Zopiclone:

Onset

A

15 mins

65
Q

Zopiclone:

AE

A
  • dizziness
  • metallic taste
  • headache
  • GI issues
66
Q

Zopiclone:

counselling points?

A
  • 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
Q

Describe Zolpidem (Sublinox)

A
  • New non-BZD hypnotic for insomnia
  • Onset = 15-30 mins
  • Duration = 7-8 hours
68
Q

Zolpidem (Sublinox):

AE?

A
  • daytime drowsiness
  • dizziness
  • amnesia
  • nausea
  • vomiting
  • headache
  • falls
69
Q

Is the goal to get patients to 8 hours/night?

A

No - it is to get them back to their normal restorative quality of sleep, also to improve continuity of sleep

70
Q

Do we use Chloral hydrate or L-tryptophan?

A

No - no real advantages

71
Q

What is sleep apnea?

A

Cessation of airflow lasting at least 10 seconds

72
Q

What drug is absolutely CI ins sleep apnea patients?

A

CNS depressants

Clinical 1 (Part B) (11 decks)

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