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121 Cards in this Set
- Front
- Back
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what is the basic definition of insomnia
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difficulty falling or staying asleep
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is insomnia more prevelant among women or men? young or old?
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women
elderly |
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prevelance of co-morbidity w/ insomnia?
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40% of pts w/ insom have concurrent psych illness
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what is the definition of sleep latency?
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amount of time required to fall asleep
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what is the definition of sleep efficiency?
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the ratio of accrual time spent asleep to time spent in bed
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what is the definition of sleep architecture?
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the amount and distribution of specific sleep stages
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what physiological changes do we under go during REM sleep?
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rapid eye movement sleep:
increased circulation to brain electrical and metabolic activity increases vivid dreams HR and RR fluctuate reduction in muscle tone |
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describe non-REM sleep
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4 stages (I-IV)
low levels of metabolic and electrical activity dreams more purposeful and logical |
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describes circadian rhythm
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regulated by the suprachiasmatic nucleus of brain
pineal gland releases melatonin, promotes sleep onset |
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what is the function of endogenous melatonin?
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release from the pineal gland, belived to promote sleep onset
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describe common etiologies of sleep disorder
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situational, medical, psychiatric, pharmacologically induced
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what are the DSM IV-TR criterea for primary insomnia?
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difficulty initiating/maintaining sleep or non-restorative sleep for at least 1 month
causes distress or impairment does not occur exclusively during course of other sleep disorder or another mental disorder disturbance is not due to substance/general medical condition |
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what complications are associated w/ insomnia?
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increased mortality
reduced work/school performance MVAs psych disturbances (anxiety) social problems |
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describe some diagnostic measures for insomnia
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evaluation through sleep history interview w/ psych and physical evals
when more in depth investigation is needed: polysomnography (differentiates sleep disorders) Multiple sleep latency test (MLST) measures daytime sleepiness Maintenance of wakefulness test (MWT) |
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differentiate between the temporal classifications of insomnia
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transient: due to acute stressor - 2-3 days
short term: lasts up to 3 weeks, may be due to situational, personal or acute medical stress chronic: sx for >3 weeks, may be associated w/ prolonged stressful situation, medical condition, or a conditioned arousal response to sleep attemps |
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describe the clinical presentation of insomnia
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difficulty falling asleep, maintaining sleep
early morning awakening daytime fatigue/inattention daytime naps impaired social inx easily aroused from sleep hallucinations |
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what are the treatment goals for insomnia?
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restore restful sleep, enable functional daytime activity, improve QOL, reduce morbidity and mortality
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describe the treatment principles associated w/ the treatment of insomnia
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pharmacotherapy should be preceded/accompanied by non-pharm
pharm agents used when difficulties encountered, not in anticipation of difficulties |
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what is the standard first line tx for insomnia?
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there is no standard, it is pt specific
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how is transient insomnia treated?
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sleep hygiene
careful use of sed-hyps (if next day perform is causing significant impairment) |
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how is short term insomnia treated?
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sleep hygiene
intermittent use of sed-hyps (skip 1-2 nights of use after 1-2 nights of good sleep) |
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how is chronic insomnia treated?
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careful re-assessment of other etiologies
reinforce sleep hygiene limit use of sed-hyps to one out of 3 nights to prevent tolerance/dependence |
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what is the significance of sleep cyles with regards to treatment of insomnia?
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if pt has trouble falling asleep, choose an agent w/ rapid onset
if pt cant stay asleep, choose agent w/ longer duration |
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what are the six methods of cognitive behavioral therapy?
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sleep hygiene, stimulus control therapy, sleep restriction, relaxation therapy, cognitive restructuring, paradoxical intention
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describe sleep hygiene
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exercise 3/4 days/week (not w/ in 3 hours of bedtime)
maintain dark, quiet sleep environment limit/avoid use of tobacco, EtOH and caffeine avoid large quantities of liquids near bedtime |
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describe stimulus control therapy
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regual wake/sleep times
limit sleep to restful sleep only go to bed when sleepy use bed only for sleep and intimacy no reading/watching TV in bed if cant sleep, leave bed and engage in restful activity avoid daytime naps (if unavoidable, nap<3pm) |
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describe sleep restriction
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total sleep time kept to mimimum of 5 hours.
goal = reduce time awake in bed as time asleep:time in bed reaches 85%, 15-20 minutes added to time allowed in bed |
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describe relaxation therapy
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coordinated by psychologist and lasts 6-8 weeks
imagery training, meditation, progressive muscle relaxation |
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describe cognitive restructuring
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psychologist attempts to correct thoughts (worry or perfectionism) that inhibit sleep
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describe paradoxical intention
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pts are intructed to try staying awake to avoid worrying about falling asleep
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describe the MOA of antihistamines
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H-1 recpt antagonists
1st gen have low selectivity for central/peripheral receptors; causes drowsiness |
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what is hydroxyzine used for?
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antihistamine typically used for peri-operative sedation, occasionally used for insomnia
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describe the use of second generation antihistamines in insomnia (loratadine)
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have greater selectivity for peripheral receptors so cause less drowsiness; not recommended for insomnia
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name two antihistamines used for insomnia
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diphenhydramine and doxylamine
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what ADRs are associated w/ antihistamine use?
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"hangover" - sedation the day after taking the med, may cause falls in elderly
antichol effects:dry mouth, eyes, urinary retention, constipation (cognition problems in elderly) paradoxical CNS stim in young children & elderly tolerance after 4 days of use, regular use should be avoided |
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describe the effectiveness of antihistamines in treating insomnia
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useful in mild, transient insom, less effective than BZDs; decreases sleep latency and number of awakenings; increases total sleep
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what is the typical dose of diphenhydramine used to tx insomnia?
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50 mgs po hs
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what is the MOA of BZDs?
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bind the BZD-1 and 2 receptors (alpha1-GABA-A and alpha2-GABA-A) in brain and periphery, enhancing GABA transmission
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what are the ADRs associated w/ BZD use for insomnia?
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hangover effect w/ long-acting BZDs (flurazepam and quazepam)from accum of metabs
long acting agents may cause falls in elderly anterograde amnesia (especially w/ triazolam) tolerance after 1-2 weeks of use of SA agents (1-3 monts for LA agents) abuse potential (avoid in pts w/ h/o sub abuse) respiratory depression reduces stage 3 and 4 sleep and REM sleep |
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when should long acting BZDs be used for insomnia?
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if pt has concomitant anxiety, want to maintain duration throughout the next day
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describe the relationship between lipophilicity and onset of action for BZDs
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more lipophilic = faster onset
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what pts will experience accumulation of BZDs due to decreased metab by CYP 450?
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elderly
pts w/ hepatic dysfx pts who are taking medications that alter enzyme availability; better options are LOT - conjugated instead of metabolized |
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what drugs, when used w/ BZDs can cause additive sedation and respiratory depresssion?
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EtOH and barbiturates
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why and how should BZDs be tapered?
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attempt to avoid rebound insomnia/withdrawl sx (anxiety, N/V, tremors, seizures)
SA BZDs = more severe w/drawl tapering: reduce dose 10-25% q1-2 weeks (plan should be individualized) if w/drawl experience, temp increase dose and start less aggressive taper |
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describe the effectiveness of BZDs in treating insomnia
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decrease sleep latency and increase total sleep time
indicated for transient and short term insomnia SA = sleep onset probs LA = sleep maintainence probs |
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what dose of flurazepam is used to treat insomnia?
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15-30 mg
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what dose of triazolam is used to treat insomnia?
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0.125-0.25 mg
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describe the MOA of BZD-1 selective agents
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selectively acts on BZD-1 receptor w/ little anxiolytic, anticonvulast or muscle relaxant activity
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what dose of zolpidem is used to treat insomnia?
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zolpidem 10mg hs
zolpidem CR 12.5 mg hs use 1/2 doses in elderly and hep impairment |
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what ADRs are associated w/ zolpidem (ambien)
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minimal tolerance/rebound effects compared to BZDs
drowsiness, amnesia, HA and GI complaints |
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descibe the efficacy of zolpidem in treating insomnia
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comparable to BZDs for reducing sleep latency, increasing total sleep time and efficiency, however, does not disturb sleep architecture
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what are the ADRs associated w/ zaleplon (Sonata)
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dizziness, HA, somnolence
no significant reports of tolerance, w/drawl or hangover |
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what drug inx are associated w/ zaleplon?
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concurrnet cimetidine use increases levels, use lower dose zaleplon
rifampin will decrease levels, consider alternative insom tx |
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describe the efficacy of zaleplon in treating insomnia
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short t1/2 and fast onset - good for reducing sleep latency, NOT for decreasing nocturnal awakenings or increasing total sleep time
may be used mid night if pt can still get 4 hours of sleep does not disturb sleep architecture |
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what dose of eszopiclone is used to treat insomnia?
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1-3 mgs hs
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what are the ADRs associated w/ eszopiclone (Lunesta)
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HA, somnolence, unpleasant taste
no signif reports of tolerance, w/drawl, hangover |
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what drug inx are associated w/ eszopiclone?
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3A4 inhibs - start w/ 1 mg
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describe the efficacy of eszopiclone in treating insomnia
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reduction in sleep latency and improved sleep maint while not disturbing sleep architecture
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which BZD-1 selctive agent is approved for long term use?
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eszopiclone
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what type of agent is ramelteon? (Rozerem)
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melatonergic
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what warnings are associated w/ rozerem?
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caution use in pts w/ hep insufficiency
do not use in pts w/ severe hep insufficiency |
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what is Rozerem's MOA?
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agonist at MT1 and 2 receptors, useful for sleep initiation
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Rozerem's ADRs?
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dizziness
no evidence of w/drawl/tolerance |
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what drug inx are associated w/ Rozerem?
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use w/ fluvox increases serum conc - do not use
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describe the effectiveness of rozerem
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useful for pts w/ prolonged sleep latency; can be used long term, not controlled substance
role for substance abusers? |
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what routes of administration are available for chloral hydrate?
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PO or PR
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what is MOA of chloral hydrate?
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unknown - CNS depressant
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what ADRs are associated w/ chloral hydrate?
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metabs can cause NVD and exacerbation of respiratory and cardiovasc conditions
may cause hyperbilirubinemia |
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chloral hydrate is used for
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transient insomnia
tx peds (low dose) |
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describe the effectiveness of chloral hydrate
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rapid onset, moderate DOA are useful
tolerance and ADRS limit duration to 2-7 days |
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what is the MOA of barbiturates?
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bind GABA channel and facilitate GABA transmission - results in reduction in cerebral cortex activity, muscle activity, cerebellar activity and sedation/sleep
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what ADRs are associated w/ barbiturates?
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respiratory depression, CNS depression, bradycardia, hypotension
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describe the effectiveness of barbiturates in treating insomnia
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higher risk of CNS/respiratory depression compared to BZDs w/o significant advantages
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when are ADs indicated for treating insomnia?
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not recommended unless pts have depression or another indication (not insom) for ADs
pts who have insomnia and cant take BZDs |
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what is the moa of TCAs?
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inhibit the reuptake of NE, and 5HT
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what are the ADRs associated w/ TCAs
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hangover effects
falls in elderly antichol effects cardiac conduction abnormalities (dangerous for pts w/ h/o suicide) |
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describe the effectiveness of TCAs in treating insomnia
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not well studied in non-depressed pts; probably useful for pts w/ depression or neuropathic pain as co-morbities
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describe the MOA of trazadone
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SSRI w/ mixed agonist antag effects at serotonergic rcpts
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what ADRs are associated w/ trazadone?
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Serotonin syndrome (if combined w/ other ser agent)
orthostasis from alph block priapism |
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describe the effectiveness of trazadone in treating insomnia
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increase total sleep time in pts w/ depression. little data for pts w/o depression.
low abuse potential |
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can mirtazapine be used to tx insom?
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yes
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which SSRI can treat insomnia?
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paroxetine (paxil)
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when are APs indicated for insomnia?
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not recommended unless pt has psychosis, mood disorders or other indication (not insom) for AP
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which APs can be used to treat insomnia?
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quetiapine
olanzapine |
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what non standard remedies are used to treat insomnia?
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EtOH
melatonin valerian root |
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describe the use of EtOH for insomnia
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decreases sleep latency, results in fragmented, unfruitful sleep
dangerous when combined w/ other CNS depressants |
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describe the MOA for melatonin
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supplemnts the bodies natural melatonin (release from pineal, initiates sleep)
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what ADRs are associated w/ Melatonin?
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vasoconstriction
enhanced immune fx (not good for pts on immunosupp) not recommended for preg/lact females |
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describe the effectiveness of melatonin for insomnia
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not evaluated by FDA
sold as supplement most often used for children or for jet lag |
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describe the MOA of valerian root
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unknown; inhibits GABA breakdown?
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what ADRs are associated w/ valerian root?
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HA, cardiac disturbance, uterine contractions, possible hepatotox
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describe the effectiveness of valerian root for insomnia
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not evaluated by the FDA
sold as a supplement |
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describe monitoring for the treatment of insomnia
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sleep diary (time in bed, sleep onset, time of awakening, activites near bedtime, sedative use, next day fx)
sleep studies (PSG, MSLT, MWT) sleep questionnaires |
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describe some common etiologies for circadian rhythm disorders
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caused when discrepancy is present between pts sleep/awake cycle and external demands for periods of wake and sleep
jet lag shift work |
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describe non-pharm tx for circadian disorders
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bright light therapy - exposure to bright light for 30 to 60 min when waking and dark when sleeping
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how can jet lag sx be minimized?
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if travel <7 days, keep sleep patterns from original time zone
if travel >7 days, alter sleep schedule gradually (1-2 hours/day) before leaving |
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describe some pharm options for tx of circ rhyth d/os
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short acting BZDs
zaleplon and zolpidem (lack of hangover-preferred) ramelteon? also herbal - melatonin |
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herbal remedy for cird rhyth d/o?
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melatonin
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define sleep apnea
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10 second cessation of airflow into the mouth or nose; high morbidity and mortality risk
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what causes OSA
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intermittent upper airway obstruction
obesity, enlarged tonsils, polyps |
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OSA is characterized by....
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heavy snoring and gasping
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OSA may result in....
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arrhythmias, HTN, cor pulmonale, sudden death
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describe non-pharm tx for OSA
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continuous positive airway pressure (CPAP)
wt loss, remove underlying obstruction avoid EtOH, anxiolytics, narcotics, CNS depressants external nasal strips? |
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what pharm tx can be lethal to OSA pts?
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CNS depressants (opioids, BZDs)
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what can be used to treat daytime sleepiness in OSA pts?
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modafinil (Provigil)
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what is modafanils MOA?
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CNS stimulant, lack ADRs of traditional stims (tachycard, HTN)
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what ADRs are associated w/ modafinil?
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HA, Nausea, nervousness
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describe the effectiveness of modafinil
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improvement in mean wakefulness and clinical status for OSA
improvement in EDS but not cataplexy in narc |
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what is the narcolepsy tetrad?
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sleep attacks
cataplexy hypnagogic hallucinations sleep paralysis |
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what other sx besides tetrad do narcoleptics experience
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nighttime sleep disturbances
EDS |
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what is non-pharm recommendation for narcolepsy?
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2+ daytime naps lasting 15 minutes
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pharm tx of narcolepsy?
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modafanil (CNS stim)
other stims can be used but more tolerance and abuse potential; does not treat cataplexy for cataplexy: TCAs, fluoxetine (most effective) sodium oxybate (GHB) |
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what agents can be used to treat cataplexy?
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TCAs and fluoxetine
GHB (Xyrem) |
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describe GHBs MOA
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binds GABAb and sodium oxybate receptors?
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what ADRs associated w/ GHB?
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HA, nausea, dizziness
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describe the effectiveness of GHB (sodium oxybate)
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improves sleep architecture while reducing EDS, sleep paralysis, cataplexy, hyp halluc
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how is Xyrem available?
why is it only available this way? |
Xyrem success program
hight potential for abuse 2nd line even though better than TCAs and fluox |
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describe the etiology of restless leg syndrome (RLS)
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associated w/ uremia, anemia, pregnancy, caffeine, stress, fatigue
decreased D2 recpt binding in striatum of pts w/ RLS |
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describe the sx of RLS
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abnormal feelings in limbs, urging pts to keep legs moving
sx relieved by walking/moving |
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describe non-pharm tx for RLS
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exercise
improve nutrition sleep hygiene |
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describe pharm tx for RLS
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mild: BZDs (short acting = nocturnal wandering)
opiates (concern w/ tolerance) DA agonists (tirate slowly to avoid nausea) ropinirole (requip) pramipexole (mirapex) pergolide (permax) DA ags may exacerbate insom anticonvulsants gabapentin |
