Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key


Play button


Play button




Click to flip

121 Cards in this Set

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