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Flashcards in Insomnia Deck (108):

By definition, what is required for the diagnosis of insomnia?

  • Difficulty initiating sleep, maintaining sleep or early waking
  • Occurs despite opportunity for sleep
  • Impairs daytime function


What is the DSM-5 definition of an insomnia disorder? (TOP)

  • Dissatisfaction with sleep quality or quantity along with a complaint of difficulty initiating sleep (initial insomnia), maintaining sleep (middle insomnia) and/or waking up too early in the morning (late insomnia)


What 5 criteria are also required for the DSM-5 definition of an insomnia disorder? (TOP)

  • The sleep disturbance causes clinically significant distress or impairment in functioning
    • It occurs at least 3 nights per week
    • It is present for at least 3 months
    • It occurs despite adequate opportunity for sleep
    • It is not better explained by another sleep-wake disorder
    • It is not attributable to the physiological effect of a substance


What is the definition of acute/adjustment insomnia? (TOP/PBSG)

  • Sudden onset and a short course of insomnia, generally less than 3 months
    • <4 weeks according to PBSG


What is the definition of chronic insomnia? (TOP)

  • Lasting 3 months or longer for at least 3 nights each week


What is comorbid insomnia? (TOP)

  • Insomnia that occurs as a consequence of a medical or psychiatric condition


What are the 4 most common risk factors for insomnia? (TOP)

  • Age
    • Middle-aged adults 2x as likely to have insomnia compared to young adults
  • Female sex (1.2-1.5x more likely than males to seek help, 2x as likely to suffer from insomnia)
    • Highest among 1st degree relatives – especially mother-daughter
  • Comorbid medical or psychiatric conditions
  • Social (divorce/separation, unemployment, lower education)


What is the association between insomnia and depression? (NEJM)

  • 50% of those with insomnia have a psychiatric disorder (mood or anxiety)
  • Persistent insomnia doubles the risk of incident major depression (meta-analysis)


What is the definition of sleep-onset latency and what is considered normal? (DFCM Open)

  • Time it takes to fall asleep
  • Normal <30 minutes


What are 4 examples of circadian rhythm disorders?

  • Delayed Sleep Phase (physiological)
  • Advanced Sleep Phase (physiological)
  • Shift Work Sleep Disorder
  • Jet Lag


In whom is delayed sleep phase most commonly seen?

  • Teenagers
  • Problems falling asleep at an appropriate time, and thus waking as well
  • Worse with poor sleepy hygiene – video games, music, texting


In whom is advanced sleep phase most commonly seen?

  • Elderly
  • Falling asleep at a socially “early” time and associated with early rising



What are 3 management options for patients with Circadian rhythm disorders?

  • Behavioural strategies
  • Light therapy
  • Melatonin 0.3 – 5 mg taken 60 minutes before bedtime


What is the M:F ratio for OSA? (AFP)

  • M:F = 3:1


What are 8 risk factors for OSA? (AFP)

  • Age (40 to 70 years)
  • Commercial motor vehicle driver
  • Family history of OSA
  • Male sex
  • Obesity (BMI >35)
  • Postmenopausal woman not taking hormone therapy
  • Preoperative for bariatric surgery
  • Retrognathia  


What is the typical presentation (5) of patients with obstructive sleep apnea?

  • Loud snoring
  • Choking/gasping episodes during sleep
  • Daytime sleepiness
  • AM headaches
  • Large neck


What are 5 conditions associated with OSA? (AFP)

  • Hypertension
  • CAD
  • CHF – OR 2.4
  • Stroke
  • Atrial fibrillation (Cardiac arrhythmias) – OR 4
  • Diabetes
  • Depression – OR 2.6


What tool can be used to screen for OSA? (TOP)

  • STOPBANG Screening Questionnaire
    • Snoring
    • Tired
    • Observed
    • Pressure
    • BMI
    • Age <50
    • Neck size
    • Gender = Male


What “sign” is associated with OSA? (AFP)

  • “Elbow sign” – being elbowed by one’s bed partner due to snoring


In a patient suspected of having OSA, what management should be done?

  • Refer for sleep study
  • CPAP
  • Weight loss


What evidence is there for a benefit from CPAP with OSA (5)? (AFP)

  • Lowers BP
  • Lowers rates of arrhythmia
  • Lowers rates of stroke
  • Improves LVEF in patients with CHF
  • Reduces fatal and nonfatal cardiovascular events


What is an alternative treatment for OSA in patients who prefer it or cannot tolerated CPAP (e.g. discomfort, skin irritation, noise, claustrophobia)? (AFP)

  • Mandibular advancement device


Name 2 movement disorders of sleep.

  • Periodic Limb Movements in Sleep (PLMS)
  • Restless Leg Syndrome (RLS)


At what age does PLMS most commonly occur?

  • < 45 years (can occur at any age)


How does PLMS typically present?

  • Associated with brief arousals (most people don’t complain about sleep)
  • Only diagnosis when affecting daytime sleepiness)


How does RLS typically present and what aspect of sleep does it typically affect?

  • Delay in Sleep Initiation (prolonged Sleep Latency)
  • Uncomfortable sensation in the limbs that comes on at rest and is relieved by movement (such as walking)
  • Often co-exists with PLMS


What are 4 things that need to be ruled out in patients presenting with RLS?

  • Iron deficiency
  • Renal failure
  • Pregnancy
  • SSRI use


What are the two treatment classes for RLS?

  • Dopaminergic agents
    • Pramipexole (Mirapex)
    • Ropinirole (Requip)
  • Alpha-2-delta subunit calcium channel ligands
    • Gabapentin
    • Pregabalin


What notable adverse effect is associated with dopa agonists? (PBSG)

  • Impulsive behavior à gambling, shopping, eating, sex


What other adverse effects are associated with pramipexole and ropinirole? (AFP)

  • Pramipexole
    • Nausea
    • Somnolence
    • Nasopharyngitis
  • Ropinirole
    • Nausea and Vomiting
    • Headache
    • Dizziness
    • Somnolence


In a patient presenting with insomnia, what needs to be ruled out?

  • Primary Sleep Disorders (CAL)
    • Circadian rhythm
    • Sleep Apnea
    • Restless Legs


What 4 secondary causes of insomnia need to be ruled out?

  • MMMS
    • Mood
    • Medical
    • Medications
    • Substance Abuse


What are 5 red flags to be aware of in patients presenting with insomnia? (DFCM Open)

  • Depression
  • Bipolar
  • GAD or Panic Disorder
  • Excessive daytime sleepiness – unexpected or irresistible
  • Substance abuse


What are 5 medical disorders that need to be ruled out in a patient presenting with insomnia?

  • Chronic pain syndromes
  • Menopause
  • COPD/Asthma/CHF
  • BPH


What are 8 medications that should be asked about in patients presenting with insomnia?

  • Nicotine patches
  • Antidepressants
  • Corticosteroids
  • Stimulants – medical and recreational
  • Bronchodilators (beta-agonists)
  • Decongestants – Pseudoephedrine
  • Thyroid hormone (excessive)
  • SSRIs


What are 4 recreational drugs that should be asked about in patients presenting with insomnia?

  • Cigarettes
  • Coffee
  • Alcohol – promotes sleep onset, but shortens total sleep
  • Cocaine/Stimulants


In a patient presenting with acute insomnia, what should you assess for?

  • Trigger
    • If present, then identify and manage


What are 9 common triggers that can cause acute or adjustment insomnia? (TOP/PBSG)

  • Noise
  • Extreme temperature
  • Caring for a newborn
  • Jet lag
  • Daylight savings/time change
  • “Sunday night” insomnia
  • Death in family
  • Job loss
  • Relationship ends


What should you ask patients in regards to the quality of their sleep when presenting with insomnia? (PBSG)

  • Onset
  • Circumstances
  • Duration
  • Severity
  • Current sleep hygiene
  • Complaints from sleep partner
  • QOL (decline in work performance, difficulty concentrating, increased clumsiness or minor injury to self and/or others because of daytime symptoms)
  • OTC medications (melatonin, antihistamines for night-time)
  • Recent travel
  • Night-time or rotating shifts
  • Usage of screen devices


Why should patients be advised to avoid use of light emitting devices in the hour before bedtime? (PBSG)

  • Light suppressed the hormone melatonin, which promotes sleep, and negatively affects the timing of REM sleep
  • May result in sleep deficiency and disturb circadian rhythms


What symptoms should be asked about in patients presenting with insomnia? (PBSG)

  • Pain
  • Dyspnea
  • Nocturia
  • Cough
  • Nasal congestion
  • GERD
  • Menopause (e.g. vasomotor)
  • Anxiety
  • Stress
  • Depression


What can be used to determine the severity of the sleep disorder and to monitor the effect of treatment interventions? (TOP)

  • Insomnia Severity Index (ISI)


What investigations might you consider in a patient presenting with insomnia? (PBSG)

  • Ferritin
  • Magnesium
  • Renal function
  • B12 level
  • Nocturnal polysomnography (PSG) if suspecting sleep apnea, PLMS or sleep-state misperception


When would you consider treating acute insomnia? (TOP)

  • Substantial negative impact on daytime performance


How long should pharmacotherapy be given for acute insomnia? (TOP)

  • Short term (e.g. 2 weeks) with close follow-up


What is first-line therapy for the management of insomnia? (TOP/PBSG)

  • Non-pharmcologic therapies (i.e. CBT-I)


How can a patient evaluate their insomnia and monitor their progress?

  • Sleep diary


What are 8 suggestions that can be made for a patient to improve their sleep hygiene?

  • No PM coffee or tobacco
  • No alcohol within 6 hours of sleep
  • Exercise, but not within 3 hours of sleep
  • No late evening fluids
  • Minimize bright light before going to bed, including all technology
  • Stimulus control – quiet, dark, safe and comfortable room
  • Routine sleep and wake times
    • Don’t go to bed too early – go to bed when you are sleepy
    • Maintain a regular sleep schedule
  • Relaxation therapy – 1 hour before bed to unwind, stretch, yoga, abdominal breathing, etc.


What is the evidence supporting regular exercise to help with insomnia? (PBSG)

  • Total sleep time
  • Sleep efficiency
  • Sleep onset latency


Why is alcohol considered a stimulant in the management of insomnia? (PBSG)

  • Alcohol promotes sleep onset in the first half of the night
  • Moderate to high doses reduce total REM sleep % during the night


What effect does nicotine (and nicotine agonist products) have on sleep? (PBSG)

  • Longer sleep latency
  • Shorter overall sleep period
  • Higher REM activity


What are 4 components of CBT-I for insomnia? (TOP)

  • Sleep restriction therapy – build up the homeostatic sleep drive
  • Stimulus control therapy
  • Cognitive therapy
  • Relaxation techniques


What are the 5 steps of CBT-I for insomnia that should be discussed with patients? (PBSG)

  • Step 1 – discuss sleep hygiene and determine patient’s commitment to making necessary changes to improve sleep
  • Step 2 – recommend that patients keep a sleep diary
  • Step 3 – encourage patients to maintain a strict and constant routine of going to bed and getting up
  • Step 4 – strength appropriate thoughts about sleep
    • “Sleep needs to be allowed to occur, which ca be very difficult for people who are trying desperately to enter that state.”
    • Consider stimulus control to reduce those states of arousal, through strategies that include deep breathing and meditation
  • Step 5 – education about sleep restriction
    • May seem counterintuitive to patients who feel that extension (not restriction) of sleep time makes more sense
    • Important to avoid daytime napping


What is the evidence for the 5-component approach to CBT-I? (CMA POEM)

  • Meta-analysis (Ann Intern Med 2015)
    • Onset of sleep 19 minutes earlier
    • Minutes spent awake after first falling asleep 26 minutes shorter
    • NO change in overall sleep time


What is an effective behavioural method for patients to improve their sleep?

  • Sleep Restriction


How does sleep restriction help with insomnia? (TOP)

  • Helps build up the homeostatic sleep drive, and counters the unproductive strategy of going to bed early in an attempt to gain more sleep
  • Strengthens the circadian rhythm of sleep regulation


How is sleep restriction applied for patients with insomnia? (PBSG/TOP)

  • Have patients estimate actual time spent sleeping each night
  • Have patients choose a wake time each morning – advised patients not to vary the time, no matter the bedtime, even on weekends
  • Have patients deliberately delay bedtime to coincide actual time spent in bed with estimated time spent asleep (within 20-30 minutes)
    • Not to be less than 5 hours
  • Once sleep efficiency has improved to ~90%, can lengthen time in bed if needed based on tiredness


What is the NNT for sleep restriction based on a RCT? (CMA POEM)

  • NNT = 4 (Falloon et al Br J Gen Pract 2015)


Which online CBT-I program are evidence-based (RCT), effective and recommended for use with patients with insomnia? (TOP)

  • SHUTi
  • Sleepio


If considering pharmacotherapy for insomnia, how long should it be prescribed? (TOP)

  • < 7 nights (to break cycle) OR 3x/week if long-term
    • 3-5 doses per week ideal (TOP)


Should OTC agents be prescribed for insomnia? (TOP/PBSG)

  • No – potential harms from anticholinergic properties, rapid tolerance, cognitive impairment
  • Health Canada has diphenhydramine (Benadryl) listed for relieving occasional sleeplessness, for aid with falling asleep, and/or for occasional use when sleeplessness is caused by overwork, tiredness or fatigue


What potential AE are associated with diphenhydramine use? (PBSG)

  • Confusion
  • Urinary retention
  • Diminished cognitive function


What are four first-line pharmacotherapy options for insomnia and their hangover effect? (TOP)

  • Zopiclone (Imovane) 3.75 – 7.5 mg
    • Short half-life – low hangover effect
    • Metallic after-taste
    • 5 mg max dose for elderly, kidney/liver disease
    • Risk of physical tolerance and dependence
  • Zolpidem (Sublinox) 5 – 10 mg
    • Rapid onset of action
    • Risk of physical tolerance and dependence
  • Doxepin (Silenor) 3 – 6 mg
  • Temazepam (Restoril) 15 – 30 mg
    • Low to moderate hangover effect (intermediate half-life)
    • Risk of physical tolerance and dependence


Which benzodiazepine is the best to prescribed for insomnia and why? (PBSG)

  • Temazepam
    • Less rebound insomnia than other benzodiazepines such as lorazepam (which could result in significant anxiety and tension)


How do the half-lives of temazepam compare to diazepam, lorazepam and clonazepam? (NEJM)

  • Temazepam = 8-10 hours
  • Lorazepam = 8-12 hours
  • Diazepam = 44-48 hours
  • Clonazepam = 40 hours


How effective are benzodiazepines for patients with chronic insomnia without coexisting conditions? (NEJM)

  • Sleep Latency = -22 minutes
  • Time awake after sleep onset = -13 minutes
  • Total sleep time = +22 minutes


What adverse effects (8) are associated with benzodiazepines for insomnia? (NEJM)

  • Daytime sedation/drowsiness
  • Delirium
  • Ataxia
  • Anterograde memory disturbance
  • Complex sleep-related behaviors (e.g. sleepwalking and sleep-related eating)
  • MVAs
  • Falls and fractures in the elderly
  • Dementia


What is the NNT and NNH for benzodiazepines with insomnia? (CMAJ)

  • NNT = 13
  • NNH = 6


What is a potential strategy for tapering off of benzodiazepines? (PBSG)

  • Consider switching to a long-acting agent (e.g. diazepam)
  • Taper ~25% of the original dose every 2 weeks
  • Slow supervised schedule

Length of Use

Recommended Taper Length

< 6 to 8 weeks

Taper may not be required

8 weeks to 6 months

Slowly over 2-3 week periods

6 months to 1 year

Slowly over 4-8 weeks

> 1 year

Slowly over 2-4 months


What is the risk of tapering off of benzodiazepines when length of use has been longer than 8 weeks? (PBSG)

  • Rebound insomnia
  • Agitation
  • Seizures


For patients prescribed a Z-drug for insomnia, what is the minimum time that a patient should be in bed at night? (TOP)

  • At least 8 hours in bed


Which Z-drug has a lower chance of morning hang-over effect? (TOP)

  • Zolpidem


What is the half-life for the two Z-drugs used in insomnia? (PBSG/NEJM)

  • Zolpidem = 2.5-3 hours
  • Zopiclone = 6-9 hours


What is the evidence for Z-drugs in patients with insomnia? (TFP)

  • Help people fall asleep faster (~13-22 minutes)
  • Get ~5% more time sleeping while in bed


What are the potential risks of Z-drugs in patients with insomnia? (TFP/PBSG)

  • Headache, GI upset or dizziness (PBSG)
  • Increased risk of infections (NNH = 43, most mild – pharyngitis)
  • Moderate negative effects on verbal memory (zopiclone and zolpidem) and attention (zolpidem)


What other adverse effects are specific to zolpidem and not zopiclone? (PBSG)

  • Neuropsychiatric – hallucinations, amnesia, parasomnia, dementia


What was the safety review on zopiclone recently issued by Health Canada? (PBSG)

  • Next day impairment
    • Decreased ability to be alert within 12 hours of taking the medicine
    • Includes daytime sleepiness, impaired hand-eye coordination, decreased mental sharpness and related motor functions


What type of medication is doxepin? (TOP)

  • Tricyclic (H1 antagonist)


What is doxepin specifically indicated for with insomnia? (TOP)

  • Sleep maintenance and sleep duration
  • No effect on sleep onset


What are 3 advantages of doxepin in regards to the side effect profile? (TOP/PBSG)

  • Avoids next-day residual effects or termination effects
  • No fall risk or cognitive side effects
  • Minimal risk of physical tolerance/dependence


What is the concern with higher doses of doxepin (>10 mg) for insomnia? (TOP)

  • Traditional TCA side effect profile
    • Sedation
    • Fatigue
    • Weakness
    • Lethargy
    • Dry mouth
    • Constipation
    • Blurred vision
    • Headache


What dose of doxepin would you start patients on with insomnia? (PBSG)

  • 6 mg qhs for adults
  • 3 mg qhs for elderly (≥65 years)


What is a second-line pharmacotherapy option for insomnia and its hangover effect?

  • Trazodone (Desyrel) 25 – 100 mg
    • Low hangover effect (short half-life)
    • Minimal risk of tolerance/dependence


What are 3 potential adverse effects of trazodone for insomnia? (TOP)

  • Orthostatic hypotension
  • Rarely priapism and cardiac conduction issues


What is the new medication approved in 2014 by the FDA (not Canada yet) for insomnia? (NEJM)

  • Suvorexant (Orexin antagonist)
    • Major AE is morning sleepiness


What is the evidence for cannabinoids for treating insomnia? (PBSG)

  • Systematic review found no evidence that it improves insomnia
  • May interrupt normal sleep cycles


What is a nonprescription medication that can be given for insomnia and what dose? (TOP)

  • Melatonin 0.3 – 5 mg


At what doses of melatonin can there be a higher risk of daytime sleepiness? (TOP)

  • >4 mg


What possible adverse effects can occur with melatonin for insomnia? (TOP)

  • Dizziness
  • Headache
  • Nausea
  • Sleepiness


When should melatonin be taken for insomnia? (TOP)

  • Shift Circadian Rhythm à Lower dose 4-5 hours before bed
  • Hypnotic à 30 – 90 min before bed


For what circumstance did a Cochrane review find melatonin to be effective? (PBSG)

  • Preventing or decreasing jet lag when it involves crossing more than 5 time zones, particularly going west to east


What is the evidence for melatonin in patients with insomnia? (TFP)

  • Help people fall asleep faster (~10 minutes)
  • Spend more time asleep (~15 minutes)
    • ~18.2 minutes in jet lag/shift workers
  • Evidence generally poor and at high risk of bias


By how much do benzodiazepines, non-benzodiazepines, antidepressants and melatonin reduce sleep onset latency? (TFP)

  • Benzodiazepines = 10-20 minutes
  • Z-drugs = 13-17 minutes
  • Antidepressants = 7-12 minutes
  • Melatonin = 10 minutes


What can be prescribed for patients with both depression and insomnia? (TOP)

  • Mirtazapine


What can be prescribed for patients with pain related to fibromyalgia, neuropathic pain syndromes or restless leg syndrome (RLS) and insomnia? (TOP)

  • Gabapentin
  • Pregabalin


What can be prescribed for patients with resistant bipolar disorder or schizophrenia and insomnia? (TOP)

  • Chlorpromazine
  • Loxapine


What can be prescribed for patients with bipolar disorder, schizophrenia, resistant depression and anxiety and insomnia? (TOP)

  • Risperidone
  • Olanzapine
  • Quetiapine (Anxiety)


What should be done if there is no improvement in managing a patient’s insomnia after 12 weeks? (TOP)

  • Referral to sleep medicine
    • Literature states to refer if no improvement with CBT-I within 6 weeks


What is the preferred treatment option for chronic insomnia in the elderly? (TOP)

  • Non-pharmacological interventions


What is the first-line medication for chronic insomnia in the elderly? (TOP)

  • Doxepin (Silenor) – low-dose


What are two other medications that can be considered for chronic insomnia in the elderly? (TOP)

  • Melatonin
  • Short-acting GABA-A agonist (e.g. Sublinox)


What is the concern with long-term use of benzodiazepines for insomnia in elderly patinets? (PBSG)

  • Adverse cognitive effects
    • Memory impairment
    • Mental depression
    • Confusion
  • Difficult to reduce or withdraw


What can be done for pregnant women with insomnia concerned that their insomnia is negatively impacting their baby’s growth and development? (TOP)

  • CBT-I – reassure that no evidence that, in the absence of other medical or psychiatric factors, insomnia results in fetal damage
  • Normalize the sleep disturbance and minimize the anxiety for these women


Which benzodiazepine is recommended if being prescribed for insomnia in pregnant or breastfeeding women? (TOP)

  • Lorazepam


Why is lorazepam the recommended benzodiazepine for pregnant or breastfeeding women? (TOP)

  • Lacks active metabolites and is less likely to be associated with a withdrawal syndrome in the neonate
  • Low levels in breast milk and does not appear to cause any adverse effects in breastfed infants with usual maternal dosages


What 2 antidepressants are considered safe to be prescribed for insomnia in pregnancy? (TOP)

  • Nortriptyline
  • Trazodone (reduces sleep-onset latency)


What is the risk of using nortriptyline for insomnia in pregnancy? (TOP)

  • Neonatal (withdrawal) adaptation syndrome


Should melatonin be recommended for pregnant women with insomnia? (TOP)

  • No – limited data currently regarding clinical benefit or risk of adverse events