insomnia Flashcards

Question

How does sleep restriction work?

Answer 1

Restrict time in bed to improve sleep depth & consolidation Determine average time asleep based on baseline sleep diary Set time in bed = time asleep Consistent wake-up time No daytime naps If time asleep > 85% of time in bed then increase time in bed (15-20 minutes) If time asleep < 80% of time in bed then decrease time in bed (15-20 minutes) Time in bed increases continue as long as sleep efficiency > 85% until patient reports optimal daytime functioning

Answer 2

Strengthen bed & bedroom as sleep stimulus Use bed for sleep and sex only Go to bed only when sleepy Get out of bed when unable to sleep after approximately 15-20 minutes Wake up at a consistent time, including weekends Avoid daytime naps

Answer 3

Promote habits that help sleep; provide rationale for subsequent instructions. ``` Regularize sleep / wake schedule Avoid stimulants and stimulating behavior Establish relaxing bedtime routine Provide conducive sleep environment Limit daytime naps Reduce or eliminate alcohol and caffeine Obtain regular exercise Avoid clock watching ```

Answer 4

3% on MUCFI and 55% of MCUFI users take at least one other sedating medication and 10% take ≥ 3 High rates of MCUFI among elderly and individuals seeing mental health provider Most commonly prescribed Trazodone & Zolpidem

Answer 5

``` Acetylcholine Dopamine Glutamate Histamine Norepinephrine Orexin 1 and 2 Serotonin ```

Answer 6

``` Adenosine GABA Galanin Glycine Melatonin ```

Answer 7

onset 10-20 min half-life 1.0 dose 5-20 mg

Answer 8

onset 10-20 min half-life 1.5-2.4 dose 5-10 mg

Answer 9

onset 10-30 min half-life 3-4.5 dose 6.25-12.5 mg

Answer 10

onset 10 min half-life 5-7 dose 1-3 mg

Answer 11

onset 10-20 min half-life 1.5-5 dose 0.125-0.25 mg

Answer 12

onset 45-60 min half-life 1 8-20 dose 7.5-30 mg

Answer 13

onset 15-30 min half-life 36-120 dose 15-30 mg

Answer 14

onset 15-30 min half-life 15-120 dose 7.5-15 mg

Answer 15

``` Sleep continuity ↓ Sleep latency ↓Awakenings ↑ Sleep Duration ↓ Slow Wave Sleep (BZs only) ↓ REM (BZs only) ↑ Duration and number of sleep spindles ↓Periodic limb movements and associated arousals ```

Answer 16

``` Daytime Sedation Cognitive/motor impairment Anterograde amnesia Rebound insomnia upon discontinuation Parasomnia Tolerance/dependence/abuse/withdrawal (DEA schedule IV) ```

Answer 17

``` Associated with Longer total sleep time Fewer awakenings after sleep onset Shorter sleep latency Greater ease of falling asleep Better quality of sleep Increased sleep efficiency ```

Answer 18

1.3% or 3.1 million US adults use melatonin based on surveys from 2002-2012 per the National Health Statistics Reports, 2015 Melatonin use among adults in the US more than doubled between 2007 and 2012. Ramelteon, a melatonin receptor agonist, does not affect AHI or oxygenation in mild to moderate OSA

Answer 19

Suvorexant is a dual orexin receptor antagonist, the first in this new class of medications Half life 12 hours Recommended dosing: 10mg within 30 minutes before going to bed, in patients who plan to sleep continuously for at least 7 hours, with a maximum dose of 20mg Dose reduction should be considered in obese females, or patients taking moderate CYP3A4 inhibitors; excreted in feces and renally

Answer 20

Decrease REM and sometimes SWS

Answer 21

Increase sleep continuity

Answer 22

Increase sleep continuity

Answer 23

Mechanism of action H1 receptor antagonism Variable antagonism of cholinergic, serotonergic, adrenergic receptors ``` Adverse effects Sedation, grogginess Dry mouth Psychomotor impairment Delirium ```

Answer 24

Studies have shown that women on HRT seem to fall asleep faster, have longer periods of REM sleep, have fewer arousals, and sleep longer than those not on HRT. Taking HRT at bedtime seems to be the most helpful timing of drug.

Answer 25

blurred vision, excitability and cardiac arrhythmias.

Answer 26

The FDA has also warned that kava may be linked to serious liver damage and in addition should not be used by persons with cardiovascular disease.

Answer 27

Clomipramine, a tricyclic antidepressant, is one of the most potent REM suppressing drugs available. Other tricyclic drugs and SSRIs tend to cause a more modest suppression of REM sleep.

Answer 28

Trazodone and nefazodone have fewer effects on REM, and some reports have even shown an increase in REM sleep. In general, antidepressants have few effects on slow wave sleep. However, tertiary tricyclic antidepressants and trazodone have been found to increase slow wave sleep in some studies.

Answer 29

benzodiazepines may be of benefit in promoting sleep and improving tolerance of PAP. Non-benzodiazepine benzodiazepine receptor agonists such as zolpidem and eszopiclone do not affect obstructive sleep apnea AHI or SpO2. Multiple studies show improved adherence to PAP therapy when the patient is concurrently initiated on a Non-benzodiazepine benzodiazepine receptor agonists.

Answer 30

The most common side effects of zolpidem may include nausea, dizziness, malaise, nightmares, agitation, headaches.Do not see rebound insomnia between nights of treatment and drug-free nights. Zolpidem as-needed administration may allow patients to adapt treatment to their needs and to the evolution of their insomnia.

Answer 31

The effect of benzodiazepine receptor agonists versus placebo was measured as the effect size d, which is a standardized measure of the difference between active treatment and placebo. By convention, effect sizes below 0.5 are considered small, between 0.5 and 0.8 moderate, and above 0.8 large. On measures of self-reported sleep latency, total sleep time (TST), number of awakenings, and sleep quality, benzodiazepine receptor showed a consistently superior effects to placebo. The effect sizes were moderately large, demonstrating that these drugs are indeed efficacious for short-term treatment.

Answer 32

Sleep Restriction Therapy is designed to consolidate sleep by increasing sleep drive. The technique involves an initial reduction in the time spent in bed followed by a gradual extension of time in bed, The patient is initially prescribed a time-in-bed period that is roughly equal in length to the total amount of sleep reported on baseline sleep diaries. The actual placement of the sleep period should be determined based on the patient’s circadian rhythm preference and specific life constraints. The minimum time in bed recommended is 5 hours nightly. When sleep efficiency is at least 85% on average for approximately 1 week, the time in bed is increased by 15-20 minutes if the patient reports adverse daytime consequences. Increases in time spent in bed continue in 15-20 minute increments per week, as long as the sleep efficiency remains above 85% When sleep efficiency drops below 80%, time-in-bed is decreased by 15-20 minutes until sleep efficiency increases above 85%.

Answer 33

There is a 29% higher risk of cardiovascular disease in the insomnia group Insomnia or poor sleep was not associated with all cause mortality

Answer 34

Insula is a critical region for sleep maintenance Prefrontal cortex and default mode neck or may play crucial role and cognition dysfunction Increased Activity between right auditory language comprehension Center in executive control network leads to inability to disengage from external auditory stimulation and leads to hyperarousal

Answer 35

Compared to sleep diaries actigraphy Estimated a mean of 38 minutes more sleep in intervention studies and 35 minutes in non-intervention studies

Answer 36

Compared to PSG it estimates 10 extra minutes of sleep

Answer 37

Compared to PSG it estimates 8 less minutes of sleep Latency

Answer 38

Lunesta and 14 minute decrease in sleep latency with a moderate to large effect. Ramelteon had a 9 minute decrease in sleep latency with no improvement in sleep quality Temazepam had a 37 minute reduction in sleep latency with a small affect and sleep quality. Triazolam had a 9 minute reduction in sleep latency with a moderate improvement in sleep quality zaleplon and a 10 minute decrease in sleep latency with no improvement in sleep quality resulted in had a 5-12 minute decrease in sleep latency with a moderate sleep quality

Answer 39

In sleep maintenance Doxepin 26-32 minutes small to moderate Lunesta 2857 minutes moderate to large Restoril 99 minutes small suvorexant 10 minutes Zolpidem 29 minutes moderate

Answer 40

Sleep onset is ramelteon triazolam and zaleplon Sleep maintenance is doxepin and suverexant Both is Lunesta zolpidem and temazepam

Answer 41

67% of people using long-term hypnotic medications to help them sleep rated their sleep quality as improved and only 14% reported little or no improvement

Answer 42

Insomnia patients have substantially increased risk of future mood and psychiatric disorders higher health care use and costs elevated risk of falling reduced quality of life increased absenteeism and cognitive impairments

Answer 43

70% of insomniacs use for two weeks or less.

Answer 44

melatonin has a maximum concentration of about .5 hours and elimination half-life of one hour. It is effective for sleep onset. It may be associated with reversible inhibition of spermatogenesis and ovulation

Answer 45

Ramelteon is a half-life of 1 to 2.5 hours. Therapeutic dose of 8 mg is given 30 minutes before bedtime.

Answer 46

Doxepin is more effective in the last third of the night.

Answer 47

Trazodone t max of 1 to 2 hours and a half-life of 7 to 15 hours.

Answer 48

Gabapentin exerts its fact through binding to the alpha-2 Delta subunit of the N type voltage gated calcium channel. T max is 3.5 hours and half-life is 5 to 9 hours. Used in people with restless leg syndrome alcohol dependence and seizure disorder

Answer 49

Sodium oxybate has a Tmax of .5 to .8 and a half life of .3 - 1.2 hours. It is dose to bedtime and in the middle of the night is dosed in the range of 2.5 to 4.5 g. Side effects include Parasomnias celebration nausea and vomiting and amnesia. It should not be used in people with respiratory depression including those with sleep disordered breathing and COPD.

Answer 50

– Patients with recurrent episodes lasting several weeks at a time over several years, yet not meeting the 3-month duration criterion for any single episode may be diagnosed as chronic – Patients sleeping well with the use of a hypnotic medication who would meet the criteria without the medication - especially when voicing concerns about their inability to sleep without sleep medication

Answer 51

1. Fatigue/malaise 2. Attention, concentration, or memory impairment 3. Impaired social, family, occupational, or academic performance 4. Mood disturbance, irritability 5. Daytime sleepiness 6. Behavioral problems (e.g., hyperactivity, impulsivity, aggression) 7. Reduced motivation/energy/initiative 8. Proneness for errors/accidents 9. Concerns about or dissatisfaction with sleep

Answer 52

``` • Sleep hygiene recommendations • Psychotherapeutic techniques • Behavioral strategies • Cognitive behavioral therapy for insomnia (CBT-I) • Light/dark exposure • Schedule manipulations • Pharmacotherapeutic: – Substances – Medications ```

Answer 53

``` • Cognitive therapy strategies • Sleep restriction therapy • Stimulus control therapy • Relaxation therapy • Sleep hygiene education and rules • Paradoxical intention • Biofeedback • Multicomponent therapy without cognitive therapy ```

Answer 54

• Chronic insomnia patients often: – Assume daytime problems result from poor sleep – View transient sleep problems as chronic – Have unrealistic expectations about their sleep need – Exhibit cognitive errors: overgeneralization, rumination, and magnification – Have high anxiety associated with attempts to fall asleep

Answer 55

• Initial prescribed time in bed (TIB) determined by average sleep from 2-week sleep log – Awaken by alarm same time 7 days a week – Bedtime delayed for restricted schedule – No napping – (Do not limit TIB to less than 5 hours) • TIB bedtime adjustments are made each week – If sleep efficiency is 90% or greater, bedtime is adjusted 15 to 30 minutes earlier – If sleep efficiency is 85% or less, bedtime is adjusted 15 minutes later • Treatment course typically is 6 to 8 weeks

Answer 56

• Developed by Richard Bootzin (1970s) • Addresses the reinforced association between the bed, bedroom, and attempts to fall asleep in relation to excessive arousal, prolonged wakefulness, and frustration • Essentially, deconditions while some sleep deprivation promotes a reassociation of going to bed with successful sleep onset

Answer 57

``` Biphasic T½ – 3 to 6 hours – 5 to 9 hours Onset 30 – 120 minutes Receptor effects – 5-HT2A,2B receptor antagonist – 5-HT1A partial agonist – α1 -receptor antagonist – α2 -receptor antagonist – Histamine H1 antagonist – Serotonin reuptake inhibition Side effects – Dizziness– Sedation– Hypotension– Headache– Sweating– Arrhythmias– Priapism– Serotonin syndrome Active metabolite: mCPP ```

Answer 58

α Subtype % of CNS GABA A receptors Known Action Mediated α1 % of receptors 60 Sedation, amnesia, ataxia (!) α2 15 - % of receptors 20 Anxiolytic, myorelaxation α3 10 - 15 Myorelaxation (high doses), ataxia α4 % of receptors < 5 Insensitive to BZRAs α5 % of receptors < 5 Partial myorelaxation, ataxia α6 % of receptors < 5 Insensitive to BZRAs

Answer 59

Estazolam ProSom Dose 1, 2 half-life 10 to 24 Flurazepam Dalmane Dose 15, 30 half-life 2.3 (active metabolite: 48 - 160) Quazepam Doral Dose 7.5, half-life 15 39 (active metabolite 73) Temazepam Restoril Dose 7.5, 15, 22.5, 30 half-life 3.5 to 18.4 Triazolam Halcion Dose 0.125, 0.25 half-life 1.5 to 5.5

Answer 60

Eszopiclone Lunesta dose 1, 2, 3 half-life ~6 (~9 in elderly) Zaleplon Sonata dose 5, 10 half-life 1 Zolpidem Ambien dose 5, 10 half-life ~2.5

Answer 61

Zolpidem oral spray Zolpimist dose 5, 10 2.7 – half-life 3.0 Zolpidem sublingual Edluar dose 5, 10 half-life ~2.5 Zolpidem sublingual Intermezzo dose 1.75, 3.5 half-life ~2.5

Answer 62

Zolpidem ER Ambien dose CR 6.25, half-life 12.5 2.8 in males (longer in females)

Answer 63

• Rebound insomnia: Sleep is worsened relative to baseline for 1 to 2 nights after discontinuation. More likely with higher doses and short/intermediate half-life hypnotics • Recrudescence: Return of original insomnia symptoms • Withdrawal: New cluster of symptoms not present prior to treatment (e.g., anxiety, seizures)

Answer 64

FDA Recommends lower initial dose for men and women to be 1 mg at bedtime

Answer 65

* Residual effects * Dizziness * Headache * Somnolence * Blurred vision * Nausea/diarrhea * Fatigue * Ataxia * Anterograde amnesia * Somnambulism/complex sleep behaviors

Answer 66

``` • FDA approval: Indicated for the treatment of insomnia characterized by difficulty with sleep onset • No limitation on duration of use • Non-sedating • Single dose: 8 mg (Flat dose-response relationship) • Take about 30 minutes prior to bedtime • Avoid hazardous activities after dose • Elimination half-life 1 – 2.6 hours Adverse events – Somnolence (5%) – Dizziness (5%) – Fatigue (4%) Avoid with – Hepatic impairment (moderate to severe) – Fluvoxamine (Luvox) coadministration ```

Answer 67

``` Most common adverse events – Somnolence/sedation – Nausea – Upper respiratory tract infection Elimination half-life: 15.3 hours ```

Answer 68

USE: – 10 mg taken only once – Within 30 minutes of going to bed – At least 7 hours remaining before the planned time of awakening – Dose may be increased to a maximum of 20 mg – 5 mg is recommended for people talking a moderate CYP3A4 inhibitor – Time to effect may be delayed with food

Answer 69

Meeting sleep latencies on an SLT or higher are comparable to those of controls Increased 24-hour metabolic rate Increased global cerebral glucose metabolism awake and asleep on PET Increased beta and decreased data delta EEG activity during sleep Increased ACTH and cortisol secretion

Answer 70

``` • Less than 1 hour: – Ramelteon – Zaleplon • 2 to 6 hours: – Eszopiclone Triazolam – Zolpidem • 6 to 24 hours: – Doxepin (low-dose) – Estazolam – Temazepam – Suvorexant Greater than 40 hours: – Flurazepam – Quazepam ```

Answer 71

Cognitive therapy alone Sleep hygiene education alone Imagery training alone

Answer 72

``` Stimulus control therapy Relaxation training Sleep restriction Multicomponent therapy without cognitive therapy Paradoxical intention Biofeedback ```

Answer 73

Similar hypnotic action to benzodiazepines No muscle relaxant anticonvulsant or anxiolytic properties Not likely to cause rebound insomnia withdrawal symptoms or tolerance or to alter sleep architecture

Answer 74

Long and short sleep duration cause all cause mortality hypertension obesity and diabetes

Answer 75

Advanced phase sleep disorder

Answer 76

``` Evening light has a week therapeutic effect on advanced sleep disorder. 4000 lx for 2 hours Duration 12 days Increasing total sleep time Main phase delay is 2.4 hours ```

Answer 77

Contrary to widely held views, narcolepsy is not a rare disorder. Well designed studies have shown that the prevalence of narcolepsy with cataplexy in western European countries and North America approaches 0.05% (range 0.02% - 0.06%), or one case for every 2,000 people.1 This figure is not very different from that reported for multiple sclerosis (range 0.06% - 0.14%), another common neurological disorder.2 Some studies have shown that narcolepsy may be more frequent in Japan and rare in Israel.

Answer 78

Essential Excessive daytime sleepiness (EDS) Cataplexy Associated Hypnagogic hallucinations Sleep paralysis Disturbed nocturnal sleep

Answer 79

``` Sleep attacks on a background of chronic sleepiness or fatigue Frequent napping, usually refreshing Memory lapses and automatic behaviors Impaired attention / concentration Decreased work performance Increased drowsy driving crashes Visual disturbances ```

Answer 80

Insomnia is a common complaint in the population in general. Studies suggest that up to 30-40% of the population complain of difficulty falling or staying asleep, or non-restful sleep.

Answer 81

Insomnia that is also associated with daytime impairment or significant distress constitutes the general definition of insomnia as a disorder and is less common than the complaint of sleep disturbance alone (8-19%).

Answer 82

Insomnia is more likely to be reported by A meta-analysis found that women are almost 50% as likely to develop insomnia compared with men (relative risk 1.41). The difference in insomnia prevalence between men and women increases with age, and reaches greatest significance in the post-menopausal period.

Answer 83

Previous history of insomnia Increasing age Female sex Psychiatric symptoms and disorders Medical symptoms and disorders Stress Lower socioeconomic status Fewer years of education

Answer 84

Nocturia Gastroesophageal reflux Hormonal changes such as oxytocin release in late pregnancy Fetal movements & contractions Musculoskeletal pain Sleep disorders which develop during pregnancy (OSA and RLS)

Answer 85

Reproductive hormone levels Mood symptoms Vasomotor symptoms

Answer 86

Impact on pregnancy and post-partum course Association with pre-term birth Association with longer labor and cesarean deliveries Higher risk of incident and recurrent post-partum depression Deficits in post-partum neurobehavioral performance Increased pain in fibromyalgia

Answer 87

zaleplon, eszopliclone, zolpidem, ramelteon, gabapentin, doxepin and trazodone

Answer 88

Graduated extinction consisted of the parent putting the child to bed and ignoring the tantrum activity for increasingly longer amounts of time throughout the treatment.

insomnia Flashcards

(112 cards)