Sleep Disorders 06

Front 1

Which age groups are most affected by insomnia?

Back 1

Young adults and middled aged more than kids or adolescents

Front 2

Define Insomnia

Back 2

Difficulty falling asleep or staying asleep

Front 3

Describe which gender is more likely to be affected by insomnia

Back 3

Women!

Front 4

What do 40% of all insomnia patients also have?

Back 4

Some psychiatric illness.

Front 5

Define Sleep continuity

Back 5

Overall balance of sleep and wakefulness

Front 6

Define Sleep Latency

Back 6

"Amount of time required to fall asleep"

Front 7

Define Intermittent wakefulness

Back 7

Amount of awake time after initial sleep onset

Front 8

Define Sleep Efficiency

Back 8

The ratio of accrual time spent asleep to time spent in bed

Front 9

Dyssomnia

Back 9

Abnormalities in the amount, quality or timing of sleep

Front 10

Define Parasomnia

Back 10

Abnormal behavorial or physiological events occurring in association with sleep, specific sleep stages or sleep-wake transitions

Front 11

Normal duration of sleep

Back 11

7-8 hours

Front 12

Describe REM Sleep

Back 12

Rapid eye movement
a-Circulation to brain increases
b-Electrical and metabolic activity increases
c-Vivid dreams
d-Heart rate and respiratory rate fluctuate
e-Reduction in muscle tone

Front 13

Describe Non-REM sleep

Back 13

a- 4 stages (I-IV)
b- Low levels of metabolic and electrical activity
c- Dreams more purposeful and logical

Front 14

What part of the brain regulates circadian rhythm?

Back 14

Suprachiasmatic nucleus

Front 15

Melatonin is released from where and is responsible for what?

Back 15

It is released from the pineal gland and promotes sleep onset

Front 16

Many middle aged adults and elderly have both reduced quantity and quality of sleep due to declining levels of what?

Back 16

Melatonin

Front 17

What are some drugs that could cause sleep disorders?

Back 17

Anticonvulsants, Central Adrenergic blockers, diuretics, SSRIs, Corticosteroids and CNS stimulants

Front 18

Describe Primary Insomnia

Back 18

An endogenous disorder thought to be due to structural or neurochemical etiology that results in complaints for at least one month that impacts social, occupational or other components of living and other diseases are ruled out.

Front 19

Complications of Insomnia

Back 19

1.Increased mortality risk
2.Reduced work/school performance
3.Motor vehicle accidents
4.Psychological disturbances
5.Social problems

Front 20

Nightmare disorder, sleep terror disorder, sleepwalking are classified as what type of sleep disorders?

Back 20

Parasomnia

Front 21

Narcolepsy is classified as what type of sleep disorder?

Back 21

Dysomnia

Front 22

Describe Transient Insomnia

Back 22

Generally the result of an acute stressor and lasts 2-3 days

Front 23

Describe Short-term insomnia

Back 23

Lasts up to 3 weeks, may be associated with situational, personal or acute medical stress

Front 24

Describe Chronic Insomnia

Back 24

Symptoms persisting beyond 3 weeks that may be associated with a stressful situation, medical condition or a conditioned arousal response to sleep attempts

Front 25

Sleep disorder Treatment Goals

Back 25

1.Restore restful sleep
2.Enable functional daytime activity
3.Improve quality of life
4.Reduce morbidity/mortality

Front 26

Describe the place in therapy for NON-pharmacological therapy

Back 26

It should always precede or accompany pharmacological therapy

Front 27

Should Rx's be used in anticipation of difficulty sleeping?

Back 27

No, just when it occurs

Front 28

Describe the guidelines regarding sedative-hypnotics in those with transient insomnia

Back 28

They should be used very carefully as to avoid next day performance impairment

Front 29

Describe the guidelines regarding sedative-hypnotic use in those with short-term insomnia

Back 29

Use them intermittently, skip 1-2 nights of medications after 1-2 nights of sleep)

Front 30

Describe the overall treatment principles in terms of Chronic Insomnia

Back 30

1.Look for other causes!
2.Reinforce sleep hygiene
3.Limit use of sedatives to 1/3 nights to prevent tolerance and dependence

Front 31

If a patient has a long sleep latency, which type of agent should be used?

Back 31

A rapid onset agent

Front 32

If a patient has a problem with sleep maintenance, which type of agent should be used?

Back 32

One with a long duration

Front 33

Name the main Non-Pharm therapies

Back 33

1.Sleep hygiene
2.Stimulus control therapy
3.Sleep restriction
4.Relaxation tehrapy
5.Cognitive restructuring
6.Paradoxical intention

Front 34

Describe Sleep Hygiene

Back 34

1.Exercise 3-4x per week, but not within 3 hours of bedtime
2.Maintain a dark, quiet sleep environment
3.Avoid use of tobacco, alcohol or caffeine
4.Avoid large quantities of liquids near bedtime

Front 35

Describe Stimulus Control Therapy

Back 35

1.Regular wake/sleep times
2.Limit sleep to restful sleep
3.Only go to bed when sleepy
4.Use bed only for sleep and intimacy
5.No reading/watching TV in bed
6.If can not sleep, leave bed and engage in a restful activity
7.Avoid daytime naps (If unavoidable, nap before 3pm)

Front 36

Describe Sleep Restriction Non-Pharm therapy

Back 36

1.Total sleep time kept at a minimum of 5 hours
2.Goal is to reduce time spent awake in bed
3.As the time asleep to time in bed ratio (sleep efficiency ratio) reaches 85%, 15-20 min are added to time allowed in bed.

Front 37

Describe Relaxation therapy non-Pharm therapy

Back 37

1.coordinated by psychologist and lasts 6-8 weeks
2.Imagery training, meditation, progressive muscle relaxation

Front 38

Describe Cognitive restructuring

Back 38

Using a psychologist, thoughts that prohibit sleep (i.e. worry or perfectionism) are corrected

Front 39

Describe the Paradoxical intention sleep method

Back 39

Patients are instructed to try staying awake to avoid worrying about falling asleep.

Front 40

ADR of OTC Antihistamines

Back 40

1.Hangover effect - sedation the day after taking medication (MAY CAUSE FALLS IN ELDERLY)
2.Anticholinergic effects
3.Paradoxical stimulation in kids
4.Tolerance after 4 days of use

Front 41

Describe effectiveness of OTC Antihistamines

Back 41

Useful in mild, transient insomnia, but less than BZDs. Decreases sleep latency, reduces number of awakenings and increases total sleep

Front 42

Diphenhydramine DOSE

Back 42

50mg at HS

Front 43

Doxylamine DOSE

Back 43

25mg at HS

Front 44

Advantage of Doxylamine over Diphenhydramine

Back 44

Doxylamine has a shorter half life, therefore will have less of a hangover effect

Front 45

BZD MOA

Back 45

Binds to BZD-1 and BZD-2 receptors and enhances GABA actions.

Front 46

BZD ADRs

Back 46

1.Hangover effect
2.Anterograde amnesia
3.tolerance
4.Abuse
5.Respiratory depression
6.Prego Cat D or X
7.Reduce stage 3 and 4 sleepa nd REM sleep

Front 47

Describe aspects of the hangover effect often observed with BZD use

Back 47

Long acting BZDs such as Flurazepam and Quazepam are culprits due to accumulation of active metabolites.

Front 48

Which BZDs should be avoided in elderly and why?

Back 48

Long acting agents because of the risk of falls

Front 49

Which BZDs are the longest acting?

Back 49

Flurazepam and Quazepam

Front 50

In treating Insomnia with BZDs, why would a long acting BZD actually be preferred?

Back 50

If the patient has comcomitant anxiety, this can help maintain duration throughout the next day.

Front 51

Which BZD is especially bad with the anterograde amnesia?

Back 51

Triazolam, due to its rapid onset and short half-life

Front 52

Describe the tolerance ADR associated with BZDs

Back 52

Tolerance can develop within 1-2 weeks of continuous use of a short acting agent and 1-3 months for a longer acting agents

Front 53

Why should BZDs be used VERY carefully in those with sleep apnea?

Back 53

They are notorious for causing respiratory depression

Front 54

Are BZDs safe in breastfeeding women?

Back 54

No

Front 55

Regarding BZD Metabolism, which type of BZDs are preferred in those who are elderly or have hepatic dysfunction or are taking meds that alter CYP Fx?

Back 55

Those that are conjugated via glucuronidation

Front 56

BZD drug interactions

Back 56

1.Ethanol/Barbiturates - Additive sedation and respiratory depression.
2.Any meds that interact with 3A4 can alter BZDs if they also are metabolized by it.

Front 57

Describe BZD withdrawal symptoms

Back 57

Anxiety
Nausea
Vomiting
Tremors
Seizures
Rebound insomnia

Front 58

(Short/Long) acting BZDs are associated with more severe withdrawal symptoms.

Back 58

Short

Front 59

Describe the effectiveness of BZDs in treating insomnia

Back 59

-Decreased sleep latency
-Indicated for TRANSIENT/SHORT-TERM
-Shorter acting agents are preferred for sleep-onset problems and longer acting are used for maintenance

Front 60

Which types of insomnia are BZDs most effective for?

Back 60

Transient and Short-Term

Front 61

For the insomnia lecture, which two BZDs are Glucuronidated and not metabolized via CYP 3A4?

Back 61

Lorazepam and Temazepam

Front 62

Clonazepam Onset?

Back 62

Intermediate

Front 63

Clonazepam
Duration?

Back 63

Long

Front 64

Clonazepam
Metabolism

Back 64

CYP3A4

Front 65

Flurazepam - Onset

Back 65

Fast

Front 66

Flurazepam - Duration

Back 66

Long

Front 67

Flurazepam - Metabolism

Back 67

CYP3A4
Active metabolites

Front 68

Quazepam - Onset

Back 68

Fast

Front 69

Quazepam - Duration

Back 69

Long

Front 70

Quazepam - Metabolism

Back 70

CYP3A4
Active Metabolites

Front 71

Estazolam - Onset

Back 71

Intermediate

Front 72

Estazolam - Duration

Back 72

Intermediate

Front 73

Estazolam - Metabolism

Back 73

CYP 3A4

Front 74

Lorazepam - Onset

Back 74

Intermediate

Front 75

Lorazepam Duration

Back 75

Intermediate

Front 76

Lorazepam Metabolism

Back 76

Glucuronidation

Front 77

Temazepam - Onset

Back 77

Intermediate

Front 78

Temazepam - Duration

Back 78

Intermediate

Front 79

Temazepam - Metabolism

Back 79

Glucuronidation

Front 80

Triazolam - Onset

Back 80

Very Fast

Front 81

Triazolam - Duration

Back 81

Short acting

Front 82

Triazolam - Metabolism

Back 82

CYP3A4

Front 83

3 Long acting BZDs

Back 83

C - Clonazepam
F - Flurazepam
Q - Quazepam
Can't Flee Quickly

Front 84

2 Fast onset BZDs

Back 84

Flurazepam and Quazepam

Front 85

Fastest onset BZD

Back 85

Triazolam

Front 86

Short acting BZD

Back 86

Triazolam

Front 87

Zolpidem Dosing

Back 87

10mg QHS
Elderly/HepImp:5mg
20mg=More side effects

Front 88

Zolpidem CR Dosing

Back 88

12.5mg QHS
Elderly/HepImp:6.26mg

Front 89

Zolpidem MOA

Back 89

Selectively acts on BZD-1 with little anxiolytic, anticonvulsant or muscle relaxant activity

Front 90

Zolpidem MOA

Back 90

Minimal tolerance/rebound effects vs BZDs
Drowsiness, Amnesia, HA and GI complaints

Front 91

Describe the effectiveness of Zolpidem

Back 91

Comparable to BZDs for reducing SLEEP LATENCY (due to rapid onset) and increasing total sleep time and efficiency without messing up architexture

Front 92

Zaleplon Dose

Back 92

10mg QHS
5mg if elderly

Front 93

Zaleplon MOA

Back 93

Selective for BZD-1 receptor without anxiolytic, anticonvulsant or muscle relaxant properties

Front 94

Zaleplon ADR

Back 94

Dizziness, HA, Somnolence
NO SIGNIFICANT REPORTS OF HANGOVER, TOLERANCE OR WITHDRAWAL

Front 95

2 Major drug interations with Zoleplon

Back 95

Cimetidine Increase Zaleplon due to CYP3A4 inhibition, lower dose to 5mg
Rifampin can reduce zaleplon dose, consider alternative sleep aid

Front 96

Describe effectiveness of Zaleplon

Back 96

Has a short half life, so good for REDUCING SLEEP LATENCY, but NOT for reducing nocturnal awakenings or increasing total sleep time.
MAY BE USED IF PATIENT WAKES UP IN MIDDLE OF NIGHT AND 4 HOURS OF USEABLE TIME STILL OCCURS (NO HANGOVER EFFECT STILL!)

Front 97

Does Zaleplon or zolpidem modify the sleep architexture?

Back 97

No

Front 98

Eszopiclone (Lunesta) Dose

Back 98

2mg QHS
1mg in elderly
May increase to 3mg if persistant

Front 99

Eszopiclone MOA

Back 99

Selectively acts on BZD-1 with little anxiolytic, muscle relaxant or anticonvulsant properties

Front 100

Esczopiclone ADR

Back 100

HA, somnolence, unpleasant taste.
NO REPORTS OF TOLERANCE, WITHDRAWAL OR HANGOVER

Front 101

Eszopiclone Drug interactions

Back 101

CYP3A4 Inhibitors, start with 1mg if strong inhibitor is also being taken

Front 102

Examples of Strong CYP3A4 inhibitors

Back 102

Clarithromycin, Ketoconazole, Nefazodone

Front 103

Describe effectiveness of Eszopiclone

Back 103

REDUCES SLEEP LATENCY
IMPROVED MAINTENANCE WITH NO MODIFICAITON OF SLEEP ARCHITEXTURE

Front 104

OF BZD-1 selective agents, which has the shortest half life?

Back 104

Zaleplon (Sonata), thus is used to reduce sleep latency

Front 105

FDA Indication for Zaleplon

Back 105

Sleep initiation

Front 106

FDA Indication for Eszopiclone (Lunesta)

Back 106

Insomnia and Chronic Insomnia

Front 107

Zolpidem (BRAND)

Back 107

Ambien

Front 108

Zaleplon (BRAND)

Back 108

Sonata

Front 109

Eszopiclone (BRAND)

Back 109

Lunesta

Front 110

Ambien GEN

Back 110

Zolpidem

Front 111

Sonata GEN

Back 111

Zaleplon

Front 112

Lunesta GEN

Back 112

Eszopiclone

Front 113

Ramelteon (BRAND)

Back 113

Rozerem

Front 114

Rozerem GEN

Back 114

Ramelteon

Front 115

Ramelteon DOSE

Back 115

8mg QHS
Caution in hepaticImp
Do not use if severe hepatic

Front 116

Ramelteon MOA

Back 116

Agonist at MT-1 and MT-2 receptors and is for SLEEP INITIATION

Front 117

Ramelteon ADR

Back 117

Dizziness

Front 118

Ramelteon Drug Interaction

Back 118

Fluvoxamine - Can increase serum concentrations dramatically, thus don't use both

Front 119

Ramelteon Effectiveness

Back 119

Useful for patients with prolonged sleep latencies (Reduces by 10-15minutes).
Can be used for long term, not a controlled substance.
NO EVIDENCE OF WITHDRAWAL OR TOLERANCE
May have a role for substance abusers with insomnia

Front 120

Discuss use of Chloral Hydrate

Back 120

TRANSIENT

Front 121

Chloral hydrate DOSE

Back 121

500-1000mg PO or PR 15-30 minutes before bedtime

Front 122

Chloral Hydrate MOA

Back 122

Unknown depressant

Front 123

Chloral Hydrate ADR

Back 123

Where to begin...
Active metabolites can cause N/V/D, exacerbate respiratory and CV conditions.
MAY CAUSE HYPERBILIRUBINEMIA

Front 124

Describe effectiveness of Chloral Hydrate

Back 124

Rapid onset/Moderate duration.
Tolerance/Adverse effects limit use to 2-7 days.
Useful for Peds (10-40mg/kg)

Front 125

Barbiturate ADR

Back 125

Respiratory depression, CNS depression, bradycardia, hypotension

Front 126

Effectiveness of Barbiturates

Back 126

High risk of CNS/RESP depression vs. BZDS without advantage

Front 127

When are ADs warranted in the treatment of insomnia?

Back 127

Only when patients have depression, another indication or patient has insomnia and cannot take a BZD

Front 128

TCA MOA

Back 128

Blocks reuptake of NE and 5-HT

Front 129

TCA ADR

Back 129

Hangover
Falls inelderly
Anticholinergic
Cardiac conduction abnormalities

Front 130

Describe TCA Effectiveness

Back 130

Often used in non-depressed patients, but not well studied. Useful if patient has depression or neuropathic pain or co-moribidities

Front 131

Melatonin ADRs

Back 131

Vasoconstriction
Enhance immune function (No immunosuppressive co-therapy)
NO PREGO/Lactating

Front 132

What can cause Circadian Rhythm sleep disorders?

Back 132

1. Discrepancy is present between patients sleep-wake cycle and external demands for periods of sleep and wake or JET LAG or SHIFT WORK

Front 133

Describe Light therapy for Circadian disorders

Back 133

Bright light during the day, dark environment while sleeping

Front 134

Describe how to minimize jet lag symptoms

Back 134

1.If travel <7 days, then keep original time zone patterns.
2.If travel >7 days, attempt to alter sleep schedule gradually.

Front 135

Describe Pharm Tx for Circadian disorders

Back 135

1.Short acting BZDs
2.Zaleplon and zolpidem preferred
3.Ramelteon being studied
4.Melatonin is commonly used

Front 136

Define sleep apnea

Back 136

10 second cessation of airflow into the mouth or nose

Front 137

What agents should be avoided in patients with sleep apnea?

Back 137

CNS depressants (BZDs or Opioids), THEY ARE LETHAL

Front 138

What is Modafinil use for?

Back 138

Sleep apnea, helps those with daytime sleepiness despite CPAP.

Front 139

CPAP

Back 139

Continuous positive airway pressure is a standard treatment for patients with Obstructive sleap apnea

Front 140

Modafanil ADR

Back 140

HA, Nausea, Nervousness

Front 141

Hypnagogic

Back 141

At threshold of sleep

Front 142

Describe the Narcolepsy Tetrad

Back 142

1.Sleep attacks
2.Cataplexy
3.Hypnagogic hallucinations
4.Sleep paralysis

Front 143

Describe Cataplexy

Back 143

Sudden loss of muscle tone, can be precipitated by intense emotions, most narcolepsy patients have this

Front 144

Non-pharm Tx for Narcolepsy

Back 144

2 or more daytime naps for 15 minutes recommended

Front 145

Describe the Pharm Tx for EDS (Excessive daytime sleepiness) for narcolepsy patients

Back 145

Modafinil

Front 146

Does Modafinil help with cataplexy?

Back 146

Nope

Front 147

What are the most effective agents for the treatment of cataplexy?

Back 147

TCAs and Fluoxetine
OR
GHB

Front 148

Sodium Oxybate(GHB) MOA

Back 148

In terms of treating Cataplexy, its unknown. It binds to GABAb and specific receptors and does some stuff, who knows?

Front 149

ADR of Sodium Oxybate

Back 149

HA, Nausea, Dizzines

Front 150

Etiology of Restless Leg Syndrome

Back 150

Decreased D2 binding in the striatum of patients

Front 151

Describe RLS

Back 151

Abnormal feeling in the limbs (typically calfs) urging patients to keep legs moving. Sx are relieved by walking or moving legs

Front 152

Non-Rx Treatment of RLS

Back 152

Exercise, impove nutrition, sleep hygiene

Front 153

Rx therapy for RLS

Back 153

Mild: BZDs (Caution: Short-acting can cause wandering)
Opiates can work, tolerance though...
DA agonists (Must titrate)
Ropinirole
Pramipexole
Pergoloide

Front 154

What is one problem with using Dopamine agonists to treat RLS?

Back 154

May exacerbate insomnia