Management of Sleep Disorders

Question 1

What are the types of insomnia

Answer 1

Sleep onset, sleep maintenance, early-morning awakening

Question 2

What is sleep load, why would someone be awake when the sleep load is high

Answer 2

Accumulation of adenosine that causes someone to be tired, circadian alerting signal is also high keeping them awake

Question 3

What is secreted remove the circadian alerting signal to keep the sleep load unopposed causing sleep

Answer 3

Melatonin

Question 4

What commorbidities are associated with sleep deprivation

Answer 4

Obesity, Diabetes, CVD

Question 5

What medications can keep patiens awake at night

Answer 5

Fluxetine and bupropion, stimulants, levothyroxine, caffeine, corticosteroids

Question 6

What is obstructive sleep apnea

Answer 6

Patients stop breathing during sleep not allowing for REM sleep (leads to impared daytime function)

Question 7

What drugs can make obstructive sleep apnea worse

Answer 7

alcohol, barbiturates, GABA mediated anxiolytics, BZD (reduce airway muscle tone)

Question 8

T/F: Restless leg syndrome can be treated with iron tablets and dopamine agonists

Answer 8

True

Question 9

What are behavioral strategies for treatment of insomnia

Answer 9

Cognitive therapy (challenge pt’s misconceptions), sleep restriction (limit time in bed), relaxation, stimulus control (relate bed strictly to sleep)

Question 10

T/F: Medications are the first line for insomnia

Answer 10

False: CBT is the first line for insomnia

Question 11

What antihistamines are used for insomnia, what is the consequence of using them

Answer 11

Diphenhydramine, high incidence of daytime sedation (avoid in elderly)

Question 12

What is the most common antidepressant that is used in insomnia do to being sedation, others

Answer 12

Trazodone/ amitriptyline, doxepin, mirtazapine

Question 13

When would doxepin be used for insomnia

Answer 13

Staying asleep (sleep maintenance)

Question 14

What are the side effects in trazodone

Answer 14

Orthostatic hypotension, significant daytime hangover, priapism

Question 15

What antipsychotics are used for insomnia

Answer 15

Quetiapine, Olanzapine

Question 16

T/F: It is fine to used OTCs/Antihistamines, antidepressants, antipsychotics as ways to aid in simomnia along with other first line options

Answer 16

False: CBT and FDA- approved benzodiazepine receptor agonists are the only options shown to have consistent efficacy in aiding sleep

Question 17

If sleep onset is the problem what type of medication should be used, sleep maintenance, excessive daytime sleepiness

Answer 17

Fast onset of action, longer duration of action, shorter duration of action

Question 18

What are the five BZDs approved for insomnia

Answer 18

Triazolam, Temazepam, estazolam, flurazepam, quazepam

Question 19

What is the rapid onset short acting BZD, when would it be used

Answer 19

Triazolam, initiating sleep

Question 20

What are the delayed onset intermediate acting BZDs (maintaing sleep)

Answer 20

Temazepam, estazolam

Question 21

What are the rapid onset, long acting BZDs (maintaing sleep)

Answer 21

Flurazepam, quazepam

Question 22

T/F: While BZDs increase the total duration of sleep the quality of sleep may be compromised due to effected REM sleep

Answer 22

True

Question 23

T/F: Using BZDs long enough can lead to tolerance to hypnotic effects

Answer 23

True

Question 24

What are sleep related problems with using BZDs and which type of BZDs are associated with them

Answer 24

Residual daytime sedation, flurazepam (L) and quazepam (L)/ rebound insomnia, traizolam (S)

Question 25

What class of medications bind to BZD receptors but have less complications than BZDs, how is the binding different

Answer 25

Z-hypnotics, Only bind to omega-1 for hypnotic effect but DO NOT bind omega-2 or omega-3

Question 26

T/F: Like BZDs z-hypnotics also cause anterograde amnesia, anticonvulsion, hangover effects, withdrawl, and addiction

Answer 26

False: Z-hypnotics have LESS side effects, NO anticonvulsant action, LESS hangover effects, Less tolerance and less dependecne than with BZDs

Question 27

What are the Z-hypnotics

Answer 27

Zolpidem, zaleplon, eszopiclone

Question 28

What is a key side effect of Z-hypnotics

Answer 28

Complex sleep related behaviors (sleep walking)

Question 29

Put the z-hypnotics in order from shortest half life to longest

Answer 29

Zaleplon (4 hours before waking), zolpidiem (at least 4 hours before waking), eszopicalone (sleep maintenance)

Question 30

What is the selective melatonin receptor agonist

Answer 30

Ramelton (binds M1, sleepiness, binds M2, circadian rhythm)

Question 31

When would ramelton be used in insomnia, when is full effect realized , when may this agent be preferred

Answer 31

Sleep onset, 3 weeks, patients with history of substance abuse

Question 32

What is the orexin receptor antagonist

Answer 32

Suvorexant

Question 33

What does oxerin do in the body, what disease state is seen due to orexin deficiency and should not use suvorexant

Answer 33

Alerting neurotransmitter that promotes wakefulness, Narcolepsy

Question 34

What are the first line drugs for insomnia

Answer 34

Z-hypnotics

Question 35

What drugs can be used indefinitely for insomnia

Answer 35

Eszopiclone, Zolpidem, Ramelteon