Phar 462 - Insomnia

Front 1

Why is Sleep a physiological necessity?

Back 1

Due to restorative and energy conservation

Front 2

What are the stages of Sleep?

Back 2

NREM:

Stage 1(Transition period),

Stage 2 (Most % of total sleep time),

Stage 3(Deep Sleep, Restorative)

REM: Dreams, Memory consolidation, life sustaining

Front 3

How does sleep change with age?

Back 3

i) Less Stage 3-4 NREM sleep

ii) More Stage 1 sleep

iii) Less Total Sleep Time

Front 4

What are the types of Insomnia?

Back 4

1) Difficulty falling asleep (long-sleep latency, delayed onset)

2) Difficulty staying asleep (excessive/prolonged awakenings)

3) Non-restorative sleep (non-refreshing)

Front 5

What is the clinical diagnosis/definition of Insomnia?

Back 5

i) Present despite adequate opportunity and circumstances to sleep

ii) Impaired daytime functioning or distress (fatigue, poor concentration & memory, irritability)

iii) ≥3 nights/week and duration longer than 4 weeks

Front 6

"Insomnia is objective NOT Subjective" True or False?]

Back 6

False; Insomnia is Subjective NOT Objective

Front 7

What Is the pathophysiology behind Insomnia?

Back 7

A disorder of hyperarousal

(worry and rumination, metabolic & hormonal)

Front 8

What are the risk factors of Insomnia?

Back 8

1) Chronic Stress

2) Poor sleep hygiene

3) Conditioned (learned Insomnia)

4) Older Age (due to medication conditions, age changes)

5) Gender (Female)

6) Separated/Divorced

7) Socioeconomic Status (unemployed/less education)

8) Medically ill (psychotic)

Front 9

"Men are more likely to experience Insomnia" True or False?

Back 9

False; Females are 1.2-1.5 times more then men

Front 10

What are the consequences of Insomnia?

Back 10

1) Health core utilization

2) Impaired cognition leads to poor job performance

3) Absenteeism (activity is reduced)

4) Traffic and workplace accidents

5) Risk factors for psychiatric disorders, Pain, Hypertension, Diabetes, Cardiac Events

Front 11

What are the main classifications of Insomnia?

Back 11

1) Primary - No identifiable medical cause

2) Secondary - Due to a comorbidity

Front 12

What are the types of Insomnia?

Back 12

i) Condition Insomnia

ii) Parasomnias

iii) Bed Partner Induced Insomnia

iv) Caretaker Insomnia

Front 13

What are examples of Primary Insomnia?

Back 13

1) Acute emotional or physical problems (Life Stress/Acute illness/hospitalization)

2) Situational (Jet Lag, Night Worker, Environmental Disturbances)

Front 14

What are the subsets of Secondary Insomnia?

Back 14

1) Psychiatric

2) Neurologic

3) Sleep Related Breathing Disorders

4) Medical Conditions

5) Primary Sleep Disorders

Front 15

What are examples of Psychiatric causes of Secondary Insomnias?

Back 15

(mood, anxiety, psychiatric disorders, eating disorders, substance related disorders)

Front 16

What are examples of Neurologic causes of Secondary Insomnias?

Back 16

(Dementia, Parkinson's Disease)

Front 17

What are examples of Sleep Related Breathing Disorder causes of Secondary Insomnia?

Back 17

(Sleep Apnea, Asthma, COPD)

Front 18

What are examples of Medical condition causes of Secondary Insomnia?

Back 18

(GERD, Chronic Pain, Hormonal Changes, Heart Disease, Hyperthyroidism, Diabetes, Obesity)

Front 19

What are examples of Primary Sleep Disorders that cause Secondary Insomnia?

Back 19

(Periodic limb movement disorder, RLS, Circadian Rhythm Disorder)

Front 20

What is Conditional Insomnia?

Back 20

An episode (single) of actute situational insomnia

Front 21

What are examples of Parasomnias?

Back 21

Sleepwalking, Sleep Tremors, Acting out of violent dreams, consumption of high calorie foods during partial nocturnal arousals

Front 22

"Parasomnias are more common in Women than in Men" True or False?

Back 22

TRUE

Front 23

What is Bed Partner Induced Insomnia?

Back 23

Due to snoring, body jerking, periodic ligaments or Parasomnias

Front 24

What is Caretaker Insomnia?

Back 24

Parents of Newborns and Adults who care for spouses/family members

Front 25

What is defined as Transient Insomnia?

Back 25

2-3 days

Front 26

What is defined as Acute Insomnia?

Back 26

<4 weeks

Front 27

What is defined as Chronic Insomnia?

Back 27

>4 weeks while >3 nights a week

Front 28

What are the red-flag signs of Insomnia?

Back 28

1) If non prescription sedatives are ineffective after 3 evenings

2) If non prescription sedatives are required for >14 consecutive days

3) Previous or current treatment with prescription sedatives

4) Chronic Insomnia

5) Secondary Insomnias (MDE, Generalized Anxiety/Panic Disorders, Excessive Daytime sleepiness of imminent risk to patient/society, Substance abuse)

Front 29

"Nonprescription sedatives work better in sedative naïve patients" True or False?

Back 29

TRUE

Front 30

What are the goals of therapy for Insomnia?

Back 30

1) Promote a sound and satisfying sleep

2) Reverse impact on daytime performance

3) Resolve the underlying cause

4) Establish a normal sleep pattern (without the need for medication)

5) Prevent transient insomnia progressing to chronic insomnia

6) Prevent medication dependence

Front 31

What are the non-pharmacological therapies used for Insomnia?

Back 31

1) Psychological & Behavioural Interventions

2) Sleep Hygiene Education

Front 32

What are the examples of Psychological & Behavioural Interventions for Insomnia?

Back 32

i) Stimulus control therapy

ii) Relaxation Training

iii) Cognitive Behavioural Therapy

iv) Sleep Restriction

Front 33

What is the goal of Stimulus Control Therapy?

Back 33

To reassociate bedroom with sleep & re-establish consistent sleep schedule

Front 34

What are the Stimulus control measures?

Back 34

1) Go to bed only when tired, wake up at same time

2 ) Avoid napping

3) Use the bedroom for only sex & sleep

4) Get out of bed if unable to sleep after 15-20mins

5) Go to another room and return when sleepy

6) Avoid mentally stimulating activities before bed

Front 35

When is Relaxation training helpful?

Back 35

Helpful when hyperarousal is the cause, should lead to mental relaxation

Front 36

What are the examples of Relaxation training?

Back 36

1) Progressive muscle relaxation

2) Meditation

3) Biofeedback

4) Imagery training

5) Controlled rhythmic breathing

Front 37

What are examples of Cognitive Behavioural Therapy?

Back 37

Address inappropriate beliefs and attitudes that worsens insomnia

e.g: i) unrealistic sleep expectations

ii) Misconceptions about cause of insomnia

iii) Amplifying the consequences

Front 38

What is the principle of Sleep Restriction?

Back 38

Induce sleep deprivation to improve sleep efficiency

Front 39

What is the definition of Sleep Efficacy?

Back 39

Sleep Efficacy =

Number(#) of hours slept/

Number(#) of hours spent in bed

Front 40

What is the goal of Sleep Restriction?

Back 40

To minimize wakefulness in bed by limiting total time in bed

(Goal is to have Sleep Efficiency >90%)

Front 41

What are examples of Sleep Hygiene education with reagrds to Personal Habits?

Back 41

1) Fix a bedtime and an awakening time

2) Avoid Caffeine 4-6hrs before bedtime and minimize total daily intake

3) Avoid Nicotine near bedtime and upon awakening at night

4) Avoid Alcohol 4-6 hrs before bedtime

5) Avoid heavy, spicy or sugary foods 4-6 hrs before bedtime

6) Exercise regularly BUT NOT before bed

Front 42

What are examples of Sleep Hygiene education with regards to Sleeping Environment?

Back 42

1) Use comfortable bedding

2) Find an optimal temperature setting

3) Keep the room well ventilated

4) Block out all distracting noise

5) Decrease light

6) Move the bedside clock out of sight

Front 43

What are examples of Sleep Hygiene education with regards to Getting ready for Bed?

Back 43

1) Try a light snack before bed such as warm milk and foods high in the amino acid Tryptophan (e.g. bananas, turkey)

2) Use relaxation techniques before bed

3) Don’t take your worries to bed

4) Establish a pre-sleep wind down

5) Get into your favourite sleeping position

Front 44

What are principles of Non-prescription therapy?

Back 44

i) Consider potential contraindications and adverse effects

ii) Use the lowest effective dose

iii) Use intermittent dosing (up to 4 times per week)

iv) Use short term, NO longer than 14 consecutive days

v) Discontinue medication gradually if used long term

Front 45

What is the MOA of Diphenhydramine and Doxylamine?

Back 45

Histamine (H1) Antagonists blocks the excitatory action of histamine in the CNS.

Causes drowsiness & Shortens latency to sleep onset.

Front 46

"Diphenhydramine and Doxylamine can reduce REM sleep and this could lead to ______"

Back 46

REM Rebound

Front 47

How quickly does Tolerance develop for Diphenhydramine and Doxylamine?

Back 47

Develops by 3rd/4th consecutive days of use

Front 48

What is the dose of Diphenhydramine used for Insomnia?

Back 48

12.5-50mg taken 30-60mins before bedtime (optimal dose = 50mg/day)

[Hypnotic effect <50mg, Flat dose response >50mg]

Front 49

What is the dose of Doxylamine used for Insomnia?

Back 49

25mg taken 30-60ms before bedtime

Front 50

What is the onset of action of Diphenhydramine for Insomnia?

Back 50

60-180 mins

Front 51

What is the onset of action of Doxylamine for Insomnia?

Back 51

60-120 mins

Front 52

What is the non-prescription drug of choice for Insomnia?

Back 52

Diphenhydramine (Benadryl, Sominex)

Front 53

What is the evidence of benefit of Diphenhydramine and Doxylamine for the treatment of Insomnia?

Back 53

i) Improved sleep parameters including sleep latency

ii) Most effective in naïve patients

iii) Dose Dependent Hypnotic effects

Front 54

Where is Melatonin is produced?

Back 54

In the pineal gland

Front 55

What is Melatonin?

Back 55

A neurohormone:

1) Shifts circadian pacemaker opposite from light

2) Production declines with age

3) Synthetic version preferred over bovine

Front 56

What is the MOA of Melatonin for the treatment of Insomnia?

Back 56

Unknown mechanism:

i) Correction of circadian dysregulation

ii) Decreased daytime alerting process of Suprachiasmatic nucelus

iii) Lowers core body temp

Front 57

What is the recommended dose of Melatonin for the treatment of Insomnia?

Back 57

Start at 3mg and take with food (Max=6mg/day)

Front 58

How should Melatonin be administered?

Back 58

Need to actually go to bed and lie down to experience hypnosis.

Front 59

What patients should try Melatonin?

Back 59

1) Used in patients with sleep latency and jet lag. Might help with total sleep duration.

2) Not effective in many patients but because of good safety profile

Front 60

What is the maximum duration of use for Melatonin?

Back 60

Do NOT use >4 weeks

Front 61

What patients should caution the use of Melatonin?

Back 61

Caution the use of Melatonin with Diabetes, Epilepticus or those with immune disease and warfarin patients.

Front 62

What patients should avoid the use of Melatonin?

Back 62

Avoid in lactating moms, pregnancy and depression/mood disorders.

Front 63

What is the evidence of benefit of Melatonin?

Back 63

1) 5.4mg decreased sleep onset; improved quality and depth of sleep and freshness on morning

2) Reduce sleep onset by 4min

3) Increased sleep efficiency by 2.2%

4) Increased total sleep duration by 12.8mins

Front 64

What is the MOA of Valerian for the treatment of Insomnia?

Back 64

Unknown mechanism (Long history of use in Europe)

Front 65

What is the recommended dose of Valerian for the treatment of Insomnia?

Back 65

400-900mg 30-60mins before bed.

[Doses in studies ranged from 225mg-1215mg]

Front 66

What is the evidence of benefit of Valerian for the treatment of Insomnia?

Back 66

1) Overall doubled sleep quality vs placebo

2) Many RCTs also reported NSS from placebo

3) Reduces in sleep latency from 14-18mins

4) Pharmacologically naïve patients may benefit from Valerian more

Front 67

What are the adverse effects of Diphenhydramine?

Back 67

1) Morning Drowsiness

2) Dizziness

3) Grogginess

4) Anticholinergic Side Effects

Front 68

What are anti-cholinergic side effects?

Back 68

Dry mouth, Memory deficits, Blurring visions, Urinary retention, Constipation

Front 69

What are the adverse effects of Doxylamine?

Back 69

1) Feeling tired in the morning

2) Feeling drugged

3) Hangover feeling in the morning

4) Anticholinergic side effects

Front 70

What are the contraindications of Diphenhydramine and Doxylamine?

Back 70

1) Glaucoma

2) Benign Prostatic Hyperplasia

3) Heart Disease

4) Constipation

5) Dry Mouth or Dry Eyes

6) Asthma

7) Avoid in Elderly (risk of falls, drug interactions, ADRs)

Front 71

What are the adverse effects of Melatonin?

Back 71

1) Drowsiness

2) Headaches

3) Dizziness

4) Irritability and Abdominal cramps

5) Decreased seizure threshold

6) Increased INR with Warfarin

7) Worsens Mood Disorder

8) Nightmares and Vivid dreams commonly reported

Front 72

What are the adverse effects of Valerian?

Back 72

1) Dizziness

2) Nausea

3) Headache

4) Upset Stomach

5) Hepatotoxcity

Front 73

What is the contraindication of Valerian?

Back 73

Pregnancy

Front 74

What are the efficacy monitoring parameters for Insomnia?

Back 74

1) Inability to fall asleep

2) Frequent nocturnal awakenings

3) Early morning awakenings

4) Reduced overall quality of sleep

Front 75

What are the therapeutic goals for Inability to fall asleep?

Back 75

Decrease in sleep latency <30mins

Front 76

What are the therapeutic goals for Frequent nocturnal awakenings?

Back 76

Decrease in or NO nocturnal awakenings

Front 77

What are the therapeutic goals for Early morning awakenings?

Back 77

Duration of Sleep between 5-7hours per night

Front 78

What are the therapeutic goals for Reduced overall quality of sleep?

Back 78

Improved subjective sleep quality with 3 nights of therapy

Front 79

How long should the Inability to fall asleep and frequent nocturnal awakenings be present while treated with therapy before referring to physician?

Back 79

>3 evenings

Front 80

How long should Early morning awakenings and reduced overall quality of sleep be present while treated with therapy before referring to physician?

Back 80

>14 consecutive days

Front 81

What is the therapeutic goals for morning, drowsiness, grogginess and/or dizziness?

Back 81

Minimal/Acceptable morning drowsiness, grogginess and/or dizziness throughout therapy

Front 82

What is the therapeutic goals for Constipation?

Back 82

Minimal constipation throughout therapy

Front 83

What is the therapeutic goals for Confusion?

Back 83

No confusion throughout therapy

Front 84

How frequently should the Morning/Drowsiness/Grogginess and/or Dizziness be monitored?

Back 84

Patient/Family member: Daily

Pharmacist: After 3-14 days of therapy or next pharmacy visit

Front 85

How frequently should Constipation be monitored?

Back 85

Patient: Every 3 days

Pharmacist: Within 1 week or next pharm visit

Front 86

How frequently should Confusion be monitored?

Back 86

Family: Daily

Pharmacist: Within 1 week of next pharm visit

Front 87

What is the recommended action for Morning, Drowsiness, Grogginess and/or Dizziness?

Back 87

Decrease the dose by 50% .

Then if still a problem after dosage adjustment and therapy still required to refer to a physician

Front 88

What is the recommended action for Constipation?

Back 88

1) Increase dietary fibre, water intake and exercise.

2) If still constipated recommended then recommend a laxative

Front 89

What is the recommended action for Confusion?

Back 89

Discontinue therapy immediately and refer to physican