Module 1.3 (Insomnia)

Question 1

What is insomnia?

Answer 1

Insomnia „

• The inability to initiate or maintain sleep, or lack of refreshing sleep „
• Associated with daytime symptoms:„

Fatigue, sleepiness, inattention, mood disturbance and impaired performance

Question 2

What are the two stages of sleep?

Answer 2

NREM „

• 75-80% total sleep time „
• N1-N3 (deep sleep) „

REM

Question 3

What are the four causes of insomnia?

Answer 3

• An insomnia disorder

> Adjustment sleep disorder –> acute emotional stressors

> Psychophysiologic insomnia –> Insomnia that persists beyond resolution of precipitating factors

• Inadequate sleep hygiene

1Caffeine/stimulant medication in afternoon/evening. Exercise or other stimulating activity (eg Netflix!) in the evening. Irregular sleep wake schedule

• Psychiatric disorder (esp depression, anxiety and substance-use disorder)
• Medical disorder (eg pulmonary, musculoskeletal, chronic pain)

Question 4

What are the AE of insomnia?

Answer 4

Decreased quality of life

• Fatigue, anxiety, depression, sick days, medical issues

Subjective decrease in cognitive function and performance „

Self medication „

Association with suicide „

Increased cardiovascular risk

Question 5

What can insomnia be a part of?

Answer 5

Insomnia can also be a part of some other disorders such as sleep apnoea and episodic movement disorders (eg restless legs syndrome)

secondary insomnia: depression, pain, substance use disorder

Question 6

What are the individual factors associated with an increased risk of insomnia?

Answer 6

• Older age „
• Female gender (esp peri- and post-menopausal) „
• Previous episode of insomnia „
• Family history „
• “light sleeper

Question 7

What are some psychiatric conidtions and medical conditions that can lead to chronic insomnia?

Answer 7

Question 8

What are medications and substances are risk factors and co-morbidities for insomnia?

Answer 8

• CNS stimulants – caffeine, methylphenidate, dexamphetamine, modafinil „
• Respiratory stimulants – theophylline „
• Appetite suppressants – phentermine „
• Antidepressants „

MAOI’s – insomnia in ~70% „ SSRI’s – insomnia in ~5-35% „ SNRI’s – insomnia in 4-18% „ Anticonvulsants – eg phenytoin

• Beta-blockers – sleep onset insomnia, increased awakenings and vivid dreams - eg propranolol and metoprolol (lipid soluble)
• Glucocorticoids – increased wakefulness (insomnia in 50- 70% on prednisolone)
• OCP
• Thyroid hormones
• Alcohol – misuse and withdrawal
• Tobacco and NRT
• OTC – eg pseudoephedrine
• „ Withdrawal of medication – sedatives, hypnotics, antidepressants, illicit drugs and glucocorticoids

Question 9

What are THREE components that are required for diagnosis?

Answer 9

1. Persistent sleep difficulty
2. Adequate sleep opportunity
3. 3Associated daytime dysfunction

Question 10

What are the THREE main components of of insomnia diganosis?

Answer 10

1. Persistent sleep difficulty

> Poor sleep quality or insufficient quantity due to difficulty initiating or maintaining sleep, or waking up too early

> May be variable

2. Adequate sleep opportunity
3. Associated daytime dysfunction

> Fatigue

> Poor concentration

> Social/vocational/educational dysfunction

> Mood disurbance

> Daytime sleepiness

> induced motivation/energy

> increased errors

> behavioural problems eg aggression

> on going worry about sleep

Question 11

What are the types of insomnia?

Answer 11

• Short-term

> Days to weeks (usually <1 mth, definitely <3months)

> In response to an identifiable stressor

• Chronic

> Sx >3x/week for >3 months

Question 12

What are the differential diagnosis for insomnia?

Answer 12

• Short sleep duration ƒ
• Chronic sleep insufficiency ƒ
• Delayed sleep-wake disorder ƒ
• Advanced sleep-wake disorder

Question 13

What are the evaluation tools for insomnia?

Answer 13

• Sleep history „
• Sleep diary „
• Self-report screening tools „
• Validated questionnaires „
• Consider contributing factors

Physical examination/laboratory test for comorbid conditions

• Screen for depression/anxiety
• Sleep apnoea/RLS –> Polysomnography „
• Caffeine/other medication

Question 14

Summary of insomnia

Answer 14

The inability to initiate or maintain sleep, or lack of refreshing sleep „

Associated with daytime symptoms

One of the most common presentations to a doctor

Most commonly caused by

• Insomnia disorder „
• Inadequate sleep hygiene „
• Psychiatric disorder „
• Medical disorder

Adverse outcoms of insomnia

• ​Decreased QOL, decrease in cognitive function, self medication, association wiith suicide and increased cardiovascular risk

Risk factors and co-morbidities – complex relationship with insomnia

• Psychiatric, medical and neurological conditions, other sleep disorders, medications and other substances, environmental factors

Diagnosis

1. Persistent sleep difficulty
2. Adequate sleep opportunity
3. Associated daytime dysfunction

> Short term vs chronic mania

Evaulation

• Sleep history
• Sleep diary
• Self-report screening tools
• Validated questionnaires
• Consider contributing factors

Question 15

What are the FOUR goals of treatment for insomnia?

Answer 15

Aim to improve sleep quality and quantity, and relieve insomnia-related daytime impairment

1. Management of underlying problems (e.g. GORD treat with PPI or comorbid depression treat with SSRI) –> address the underlying condition and you may assist the insomnia
2. Good sleep practices
3. Psychological and behavioural interventions
4. Pharmacological treatment

Question 16

For good sleep practices, what are examples of

A) sleep-wake activity regulation

B) sleep setting and influences

C) sleep-promoting adjuvants

Answer 16

A)

• go to bed same time each day
• arise at regular time
• avoid overlseeping

B)

• avoid heavy meals within 3 hours of bedtime
• seek exposure to bright light after rising
• avoid tobacco, especially in the evening
• avoid caffeine after midday

C)

• Have a light snack or a warm milk drink ebfore bed
• Have a warm bath before bed
• Ensure comofortable temperature for sleep and maximal darkness

Question 17

For psychological and behavioural interventions

A) What is it the msot effective treatment for?

B) What are the four types?

Answer 17

A)

• These are the most effective treatments for chronic insomnia

Psychological and behavioural interventions are effective treatments for insomnia. CBT and brief behavioural therapy are evidenced based treatments for chronic insomnia and first line

B)

• Relaxation therapies –> hypnosis, meditation, deep breathing, progressive muscle relaxation
• Cognitive therapy –> reassure people that those with insomnia get more sleep than they perceive
• Stimulus control –> learn to associate bedroom only with sleep
• Sleep restriction –> suitable for people who have difficulty staying asleep due to poor sleep drive

Question 18

What are the pharmacological treatment options for insomnia if the previous options were not effective?

Answer 18

Pharmacological treatment with a hypnotic drug (a benzodiazepine, zolpidem or zopiclone) or melatonin may be indicated for short-term management of acute insomnia, and for chronic insomnia where the above strategies are not effective.

• Temazepam before bedtime
• Zolpidem controlled release at bedtime
• Zolpidem immediate release at bedtime
• Zopiclone before bedtime OR melatonin prolonged release 2mg before bedtime

Question 19

What guides the decision to prescribe a hypnotic or melatonin?

Answer 19

• The cause of insomnia
• The level of distress caused by the lack of sleep
• The degree of impairment from the daytime sequelae of insomnia
• Likely benefits balanced against the possible harms of treatment

Question 20

What are potential problems of using benzodiazepines and zolpidem/zopiclone?

Answer 20

• Impaired daytime alertness „
• Tolerance and dependence with long-term use „
• Falls risk
• Sleep may not be “refreshing” „
• Watch for contraindications (eg OSA)

Question 21

Timeframe if treatment prescribed for benzodiazepines and zolpidem/zopiclone?

Answer 21

Shortest possible timeframe (preferably dosed intermittently and for <2weeks)

• Intermittent tx for long-standing treatment resistant insomnia may be considered
• A definite duration of use agreed with the patient at the outset

Question 22

When does rebound insomnia occur?

Answer 22

• Broken sleep with vivid dreams may occur when hypnotics ceased „
• May take days-weeks for sleep patterns to be re-established

> May be misinterpreted as needing more medication

Question 23

Outline why temazapem may be used and when it may not be appropriate for certain options

Answer 23

Why should be used

• Preferred option for insomnia (per eTG) „
• Rapid onset and short t ½ „
• May be used short term in the management of insomnia –> when starting SSRI

Why should not be used

• May still cause daytime drowsiness the next day –> avoid BZD with longer half life
• Benzodiazepines can cause cognitive dysfunction with longterm use which may not be fully reversible
• Elderly patients are at increased risk of over-sedation, ataxia, falls, memory impairment and respiratory depression

> use lowest dose for shortest possible time

> avoid longer acting agents

Question 24

Compare zolpidem and zopiclone with other BZDs

Answer 24

Similar hypnotic properties

• „ Minimal anxiolytic, muscle relaxant and anti-epileptic properties „
• Less morning sedation and less disruptive effect on sleep patterns? elderly still sedated in morning and women
• Dependence, tolerance, withdrawal and misuse can still occur
• black box warning - zolpidem –> see attached image

Both zolpidem and zopiclone are contraindicated with concomitant alcohol intake

Question 25

How to manage long-term hypnotic use?

Answer 25

* Patient may have unwittingly become dependant „ * Discuss and trial a cessation of long-term hypnotic where possible \> Regular contact between patient and Dr „ \> Tailored dose reduction „ \> Non-pharmacological treatments „ \> Lots of support and encouragement

Question 26

when can continued treatment of hypnotics be acceptable?

Answer 26

May be acceptable in rare situations * Detailed history shows no adverse effects „ * Patient is aware they may be dependent „ * Reduction program has been unsuccessful or is against patients wishes

Question 27

What are other options besides hypnotics mentioned previously?

Answer 27

**Melatonin „** * Reduces sleep-onset latency in \>55 years * Long term safety and efficacy not established **Suvorexant** * May be useful for sleep-maintenance insomnia * Uncertain benefit for sleep-onset insomnia **Other agents** * TCAs, sedating antihistamines, chloral hydrate, antipsychotics, mirtazapine \> not recommended, especially not in the elderly \> toxicity/risk of adverse effects \> DO NOT use antipyschotics for insomnia **Valerian** * Complementary medication for sleep

Question 28

What are the indications for melatonin? What are the practice points?

Answer 28

**Indication** * Short-term monotherapy in primary insomnia with poor sleep quality „ * Trials only included those \>55yrs„ No data in hepatic impairment **Practice points** * Limited evidence it may improve sleep quality * There do not appear to be any dependence or withdrawal effects, or rebound insomnia Melatonin is an endogenous hormone associated with the control of circadian rhythms and sleep regulation. Melatonin levels may be reduced in middle-aged and elderly patients with insomnia. Supplementation with melatonin has been shown to improve limited aspects of sleep in 30–50% of patients over 55 years of age

Question 29

For **suvorexant** A) MOA B) Indication C) AE D) Practice points

Answer 29

A) Orexin receptor antagonist B) Treatment of chronic insomnia * People with neruological or physcological issues excluded from trials C) * Common – somnolence, headache * Infrequent – abnormal dreams, sleep paralysis, hallucinations in sleep „ * Rare – sleepwalking, suicidal ideation D) * May be useful for sleep-maintenance insomnia * Avoid in combination with CYP3A4 inhibitors or inducers * Only take if intending to get a full nights rest (at least 7 hours) * May be drowsy the following day (don’t drive for at least 9 hours) „ * Assess response to treatment after 7–10 days; reassess after 3 months

Question 30

Why is there a concern with BZD use in the elderly?

Answer 30

* Elderly are the most at risk of harm from adverse effects \> Falls, cognitive impairment, incontinence, confusion, dependence

Question 31

How is insomnia in dementia presented? What treatment is recommended?

Answer 31

Often have marked sleep fragmentation * Dozing during day * Sundowning (agitated, wandering and wakeful early evening/night) **Non pharmacological interventions recommended**

Question 32

For Jet Lag: A) What happens? B) What is the treatment?

Answer 32

A) * Body clock out of sync with local time \> Worsens depending on how many time-zones crossed \> Worse in an easterly direction * Co-existing sleep loss due to flight times and environmental factors * Commonly affects travellers who cross several time-zones B) * Adjust to new time zone as quickly as possible --\> Exercise and early morning light * Melatonin – taken at target bedtime at destination decreases jet lag * Short-acting hypnotic (tamazepam) on flight and for 3 consecutive nights at bedtime \> increased DVT risk if taken on plane \> may be additive sedation if used with melatonin

Question 33

INSOMNIA SUMMARY

Answer 33

**4 STEPS** **1. Management of underlying problems** **2. Good sleep practices** * Sleep wake activity regulation * Sleep setting and influences * Sleep promoting adjuvants **3. Psychological and behavioural interventions** * Relaxation therapies * Cognitive therapy * Stimulus control * Sleep restriction **4. Pharmacological Treatment** * Hypnotics \> Benzodiazepines (temazepam) \> Zolpidem/zopiclone – BLACK BOX WARNING - potentially dangerous complex sleep-related behaviours \> Risk of dependence and tolerance * Melatonin – primary insomnia with poor sleep quality * Suvorexant – NEW MEDICATION – sleep paralysis, suicidal ideation. Sleep maintenance insomnia

Question 34

INSOMNIA SUMMARY PT 2

Answer 34

**Treatment considerations with hypnotics** * Impaired daytime alertness „ * Tolerance and dependence with long-term use „ * Rebound insomnia „ * Falls risk „ * Sleep may not be “refreshing” „ * Watch for contraindications \> use lowest possible dose for shortest possible duration **Management of jet leg** Adjust to new time zone asap * Melatonin * Short term hypnotic