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Flashcards in Sleeping disorders Deck (22):
1

What are the potential causes of insomnia?

  • Situational
    • Work or financial stress
    • Major life events
    • Jet lag, shift work
  • Medical 
    • Cardiovascular (angina, CHF)
    • Chronic pain
    • Neurologic (Delirium, Parkinsons)
    • Endocrine (Hyperthyroidism, diabetes)
  • Psychiatric
    • Depression
    • Anxiety disorders
    • Substance abus
  • Drug Induced
    • Alcohol
    • Anticonvulsants
    • Diuretics
    • Selective serotonin reuptake inhibitors
    • Steroids
    • Stimulants 

 

2

Non pharm treatment for Insomnia?

  • Establish a regular sleep schedule
  • Avoid daytime naps 
  • Reserve the bed for sleep
  • Dont try and force sleep 
  • Avoid exercise right before bed
  • Create a comfortable sleep environment 
  • Avoid bright light during the night 

 

3

Pharmacologic treatment of Insomnia

 

  • Antidepressants
  • Antihistamines
  • Benzos
  • Non-benzos
  • Suborexant
  • Ramelteon
  • Melatonin

 

4

TCAs like amitriptyline and Doxepin?

  • Avoid in elderly
  • Anticholinergic SEs
  • Daytime sedation
  • Cardiac problems

 

5

Trazodone?

  • Often used in SSRI insomnia
  • SE: Priapism
  • Orthostasis 
  • Caution in elderly 

 

6

Mirtazepine

  • Good for patients with depression
  • Lower doses produce more sedation
  • Daytime drowsiness, weight gain

 

7

Antidepressants are beneficial for patients with insomnia that?

What are the disadvantages?

  • Difficulty falling asleep
  • Early morning awakening
  • Depression
  • Substance abuse
  • Pain disorders (TCAs)

Disadvantages 

  • Anticholinergic SEs, Cardiac conduction prolongation (TCAs)
  • Problematic in elderly 
  • Lacks studies demonstrating efficacy 

8

Advantages and disadvantages for Antihistamines treating insomnia?

  • Help falling asleep and staying asleep
  • There is a hangover effect and Anticholinergic effects, also tolerance, should be avoided in the elderly 

9

Benzos and Insomnia?

  • Reduce latency of sleep
  • Reduce number of awakenings
  • Increase total sleep time
  • Prolong Stage 1-2 decrease 3-4 
  • Dont decrease REM sleep 

 

10

What adverse effect od Hypnotics should be taken into account?

  • Abnormal sleep behaviors 
    • Sleep walking, eating, and driving 

Its a warning on all prescription hypnotics, Sleep walking, driving, eating 

11

Counseling tips on benzos and non-benzos

 

 

  • Avoid using longer than 3-4 weeks
  • Take 30 minutes before bed
  • Driving - Caution in next morning driving
  • Additive to CNS effects with alcohol
  • May cause psychological dependence 
  • Avoid activities needing psychomotor coordination 
  • Daytime drowsiness
  • Rebound insomnia upon discontinuation 

12

Ramelteon

 

  • Melatonin Receptor agonist
  • Non-controlled substance for insomnia
  • 30 minutes before bed
  • onset is .3 hours 
  • Substrate for 1A2 
  • SE:
    • headache, somnolence, nausea, diarrhea, depression 
    • Hormonal abnormalities decrease libido, galactorrhea, amenorrhea
  • Takes a few days to take effect

13

Suvorexant?

  • Orexin receptor antagonist
  • 30 minutes before bed
  • Food delays onsely 
  • 3A4 inhibitors reduce dose to 5 mgs

14

Suvorexant SEs?

 

  • Abnormal sleep behaviors
  • Worsenign depression or suicidal thinking
  • Abnormal behaviors (aggression, hallucinations)
  • Avoid in patients with norcolepsy - increase sleep paralysis and cataplexy 
  • Memory impairment 

 

15

What other prescription meds can be used for insomnia?

 

  • Atypical antipsychotics (Quitiapine, Seroquel)
  • Hydrocyzine 

16

Sleep apnea?

  • Cessation to airflow at teh nose and mouth
  • Obstructive - occlusion of the upper airways 
  • Miniarousal prevents patient from achieving sleep 

 

17

Obstructive sleep apnea treatment?

 

  • Avoid CNS depressants
    • Alcohol, anxiolytics, hypnotics, narcotics, zolpidem, 
    • Interfere with brain stimulate breathing
  • Nonpharm
    • Weightloss, positional therapy
    • Surgery, CPAP

 

18

Medication therapy for apnea?

  • Modafinil (Provigil) - Sleepiness due to OSA
  • Armodafinil

 

19

Restless leg syndrome causes most common in?

  • Caffeine, stress, alcohol, smoking, fatigue
  • More common in elderly 

 

20

Norcolepsy symptoms

 

  • Excessive daytime drowsiness
  • Cataplexy
  • Hynagagic hallucination
  • Sleep paralysis

 

21

Treatment of Narcoepsy?

  • Excessive daytime sleepiness
    • Methylphenidate, dextromethamphetamine 
    • Modafinil and Armodafinil
    • Sodium oxybate (can treat cataplexy)
  • Adjunctive treatment for cataplexy
    • SSRI, SNRI (Fluoxetine, Venlafaxine)
    • TCAs (Nortriptyline, imipramine)
    • Selegiline 

22

Important questions to ask patient?

  • Do you have difficulty falling asleep?
  • Do you have difficulty staying asleep?
  • Do you feel not rested despite sleeping enough? 
  • What medications are you taking?
  • Do you dring caffeine or alcohol?
  • What are your sleep habits?