Flashcards in Insomnia-Test 2 Deck (73):
What is insomnia?
Difficulty falling asleep
Difficulty staying asleep
Experiencing non--‐restorative sleep
What is the daily sleep requirement?
What is the sleep cycle?
4-5 cycles per night
What are the stages of non-REM “quiet sleep”?
Stage 1- light sleep
Stage 2 “true sleep”
Stage 3- deep sleep
Stage 4- Very deep sleep
What stage if sleep is REM?
Stage 5- dreams
What is REM?
“Hyperactive brain in paralyzed body”
What is the sleep cycle for children?
By age of 6, most children awake all day and sleep ~10h/night
What is the sleep cycle for adolescents?
Most teenagers need an hour more sleep than children; however most get an hour LESS
What is the sleep cycle for adults?
Between 20-30 years, amount of deep sleep drops and nighttime awakeness doubles
By age 40, later stages of sleep begin to diminish
What is the sleep cycle for elderly?
Deep sleep accounts for ~5% of sleep
Falling asleep takes longer
How long is acute insomnia?
Several days up to 4 weeks
What are common precipitating conditions for acute insomnia?
Unfamiliar / uncomfortable sleep
Caffeine, EtOH, nicotine, or ADR’s
Life stressors (moving, divorce, marriage, bereavement, holidays ect.)
What is chronic insomnia?
Greater than 4 weeks
What can cause chronic insomnia?
Physical/emotional illness, RLS, sleep apnea, meds, or ETOH
What are risk factors for chronic insomnia?
¨Women, elderly, stressful lives
¨Lower socioeconomic or educational background
¨Separated, widowed, unemployed
¨Previous episodes of insomnia
¨Psychiatric/ mental conditions
What is the DSM V criteria for diagnosing primary sleep disorders?
> 2 of the following for at least 1 month
Difficulty initiating sleep
Difficulty maintaining sleep
Poor sleep efficiency
Sleep disturbances on > 3 nights/week
Significant impairment in social, occupational, or other areas of functioning
What is rebound insomnia?
Insomnia that occurs following the d/c of sedatives
What drugs can cause rebound insomnia?
EtOH, antihistamines, BZD’s, older hypnotics (chloral hydrate)
--TCA’s, MAOI’s, SSRI’s
--Opiates, Marijuana, Cocaine
What is the pneumonic REST used for?
A screening questionnaire…. Restorative sleep, excessive daytime sleepiness or fatigue, snoring nightly, and total sleep time
What are non-pharm tx for insomnia?
1)Cognitive Therapy: Stimulus control, sleep hygiene, sleep restriction, CBT
2)Behavioral or Supportive therapy – relaxation techniques
4) sleep hygiene
5) stimulus control
What are components of sleep hygiene?
Avoid exercise to close to bed
Sleep in a comfortable environment
Avoid alcohol and stimulants
Avoid caffeine and nicotine for at least 6 hours prior to bedtime
Avoid going to bed excessively hungry
Spend time prior to bedtime relaxing
Establish a regular sleep schedule
What are components of stimulus control?
Go to bed only if you feel sleepy
Avoid activities in your bedroom that keep you awake, other than sex
Sleep only in your bedroom
Leave the bedroom when awake, return only when sleepy
Arise at the same time each morning regardless of amount of sleep obtained
Avoid daytime napping
What are pharm options for insomnia tx?
TCA’s, Trazadone, Mirtazapine
What are the indications for antihistamines?
Allergies, anxiety, and insomnia
What antihistamines can be used?
Diphenhydramine [Benadryl]: -25-50 mg qhsprn sleep
Hydroxyzine [Atarax): -25-50 mg qhs prn sleep
Doxylamine [Unisom]: -25-50mg qhs prn sleep
How long are antihistamines useful for in tx insomnia?
¨Effective for insomnia ~ 1 week, Limited due to ADR
What are the ADRs that limit usefulness of antihistamines?
Anticholinergic effects (problamatic esp. in elderly)
Dizziness, confusion, next day sedation
What can higher doses of antihistamines cause? Why?
Paradoxical excitation…. Higher doses do not increase sedation, just the side effects
What are the Z-hypotics?
Selective for BZ-1 receptor of GABAa receptor
¨Zolpidem (Ambien, Ambien CR)
What is zolpidem used for?
How long can zolpidem be used for?
What are the advantages of using zolpidem?
Minimal rebound insomnia
Little or no tolerance
Immediate-release and extended release formulas
What are the ADRs of zolpidem?
Agitation, HA, nightmares, dizziness, daytime drowsiness
How is zolpidem metabolized?
What drug shortens the half life of zolpidem?
What in zaleplon useful for?
Ideal agent for sleep latency
How is zaleplon metabolized?
Rapidly by CYP3A4
What are the ADRs of zaleplon?
HA, nausea, and dyspepsia
What is the first drug approved for long term use?
Eszopliclone … can be used for > 6 mo
What is eszopiclone used for?
Proven to help fall asleep quickly and maintain sleep throughout the night
What are the ADRs of eszopiclone?
anxiety, dry mouth, chest pain, HA, migraine, peripheral edema, somnolence, unpleasant taste
What are the advantages of using eszopiclone?
Low abuse potential
No tolerance for up to 12 months
Rarely associated with behavior changes (agitation, confusion, depression, suicidal thoughts, memory loss)
What is ramelteon?
Melatonin receptor agonist
More potent at MT1 and MT2 than MT3
When is ramelteon indicated?
for use in treatment of insomnia characterized by difficulty with sleep onset
Approved for chronic use
Not a controlled substance
What is the precaution associated with ramelteon?
Do not give with or shortly after a high fat meal
Caution Use with caution in patients with moderate hepatic impairment
Do not use with severe hepatic impairment
what are the ADRs of ramelteon?
Somnolence, fatigue, dizziness, nausea, myalgia
What benzos are used off label for insomnia?
Flurazepam, temazepam, and triazolma
What does flurazepam do?
Increases duration of sleep and reduced sleep-induction and number of awakenings
How long is flurazepam used for?
Effective up to 4 weeks
What does temazepam do?
Reduced number of awakenings
When is the peak sedative effect of temazepam?
2-3 hours after oral dose
What does triazolam do?
What do you need to watch for with triazolam?
Tolerance! It can develop within days and withdrawal will result in rebound insomnia
When are the 5HT2 blockers indicated for insomnia?
Best used to restore sleep in SSRI induced insomnia
What are the 5HT2 blockers?
Nefazodone, Mirtazapine, Trazodone
How do the 5HT2 blockers work?
Increase sleep continuity and time
What are the ADRs of the 5HT2 blockers?
Nausea, xerostomia, constipation, drowsiness, HA, rebound insomnia, priapism
Are TCA indicated for insomnia?
Not FDA indicated…. Only shown to be helpful in anxiety and depressive disorders
What 2 TCA are still sometimes used?
Doxepin and Amtriptyline
What are the ADRs with TCAs?
úIncrease with dosage; orthostatic hypotension, dizziness, sedation, xerostomia, blurred vision, constipation, urinary hesitancy
What is melatonin and how does it work?
Hormone released by pineal gland to regulate circadian rhythm
When is melatonin indicated?
Jet lag, shift work, elderly
What are the ADRs of melatonin?
Abdominal cramps, HA, irritability
What does valarian root do?
Increases GABA in synaptic cleft
When is valarian root indicated?
Mild hypnotic, improves sleep latency and quality of sleep
What is the ADR of valarian root?
What is sleep apnea?
Condition during sleep in which respiration ceases for relatively brief periods of time
What constitutes a potential diagnosis of sleep apnea?
> 2 or more of the following:
Choking or gasping sleep
Recurrent awakenings from sleep
Overnight monitoring demonstrating > 5 obstructed breathing events / hour during sleep
What are risk factors for sleep apnea?
Males, age, obesity, carniofacial abnormalities
What are non pharm tx for sleep apnea?
Weight loss, positional change, continuous positive airway pressure (CPAP)
What are the pharm tx for sleep apnea?
Modafinil (C-IV): Approved for treatment of residual daytime sleepiness despite traditional approaches
What is restless leg syndrome?
Creepy, crawly sensations in legs at rest, relieved by movement, Worse in evening or night
Aka: Periodic Limb Movement Disorder
Repetitive, rhythmic limb movements (legs) in series lasting minutes, with movements occurring every 20-40 sec