Insomnia

What are exclusions of self-treatment for insomnia?

- <12 yrs old - >65 yrs old -Pregnancy -Frequent nocturnal awakenings or early morning awakening -chronic insomnia -sleep disturbance secondary to psychiatric or general medical disorders

What drugs can produce withdrawal insomnia?

-Alcohol -Amphetamines -Benzodiazepines -Illicit Drugs -Monoamine oxidase inhibitors -Opiates -Tricyclic antidepressants

What are drugs that can cause insominia?

-Alcohol -Antidepressants -Amphetamines -Beta-adrenergic agonists -Caffeine -Corticosteroids -Decongestants -Diuretics -Nicotine

What are some adverse effects of Diphenhydramine?

-Anticholinergic effects (dry mouth and throat, blurred vision, urinary retention and constipation, especially in older patients) -cognitive impairment and falls in older patients -increased confusion -sedation

What are some important patient counseling points for diphenhydramine?

-Establish regular bedtime and take diphenhydramine 30-60 minutes before sleep, do not take more than 50mg each night -After 2-3 nights of improved sleep, skip med for one night to see if insomnia is relieved -Do not take med longer than 10 days longer use will cause tolerance to medication sleep-inducing effects but not necessarily to its side effects, and you may have underlying disorder that is causing insomnia -Note that med can cause morning grogginess or excessive sedation, dry mouth, blurred vision, constipation, difficulty urinating -Do not take med with alcohol, alcohol can increase effects of med in CNS, alcohol disrupts sleep cycle -do not take med w/ prescription sleep aids to improve sleep further

A patient approaches you, the pharmacist, and asks, "I have not had a full night of sleep in awhile. What can I take for insomnia?" What further information do you need to know before making an appropriate recommendation or referral?

-Meds they are on, new or old -What type of insomnia -Age -How long its been going on -If they tried anything already -recent social changes (job, other stressors)

What are some principles of good sleep hygiene?

-Use bed for sleeping or intimacy only -Establish a regular sleep pattern, go to bed and arise at same time daily even on weekends -make bedroom comfortable for sleeping, avoid temperatures extremes, noise, and light -engage in relaxing activities before bed -avoid using electronic devices around bedtime -exercise regularly but not within 2-4 hours of bed -if hungry, eat light snack, but avoid eating meals within 2 hours of bed -avoid daytime napping -avoid caffeine, alcohol, or nicotine, 4-6 before bed -do not continue to try to sleep if you cant, get out of bed and perform relaxing activity until tired -Do not watch the clock at night

A 26-year-old male patient complains of difficulty sleeping for the past 2 weeks. As a result, he feels tired and irritable during the day. He takes an hour-long nap in the afternoon 2-3 times per week. He tries to stay up until he is sleepy at night. He lies in bed and begins worrying about not being able to fall asleep. He watches the alarm clock, knowing that he has to get up in a few hours. When he cannot sleep, he usually turns on the television or plays games on the computer. He drinks 3-4 cups of coffee in the morning and 2 diet sodas throughout the day. He sleeps in on the weekends until about noon to "make up for lost sleep." Current medications: Allegra-D®(pseudoephedrine and fexofenadine) by mouth daily Social: Drinks 2-3 beers per night to help him to get to sleep; denies tobacco 1. What nonpharmacologic recommendations do you have for this patient?

-avoid day time naps -avoid drinking alcohol before bed -do not watch the clock at night -avoid using electronics at night -decrease caffeine consumption -sleep at the same time and wake up at the same time each day

1. Which of the following patients is an appropriate candidate for self-care of insomnia? Select all that apply. a. 39-year-old patient with difficulty falling asleep for the past 4 days b. 39-year-old patient with early morning awakening for the past 4 days c. 68-year-old patient with difficulty falling asleep for the past 4 days d. 68-year-old patient with early morning awakening for the past 4 days

A

Secondary insomnia is caused by

Another sleep disorder, general medical disorder, or a medication/substance -many medical disorders and psychiatric disorder are associated with chronic insomnia

what are pharmacologic therapy options for treating insomnia?

Antihistamines -Diphenhydramine and doxylamine available -Block histamine 1 and muscarinic receptors -Safety and efficacy of doxylamine not fully established (dont recommend doxylamine)

A 26-year-old male patient complains of difficulty sleeping for the past 2 weeks. As a result, he feels tired and irritable during the day. He takes an hour-long nap in the afternoon 2-3 times per week. He tries to stay up until he is sleepy at night. He lies in bed and begins worrying about not being able to fall asleep. He watches the alarm clock, knowing that he has to get up in a few hours. When he cannot sleep, he usually turns on the television or plays games on the computer. He drinks 3-4 cups of coffee in the morning and 2 diet sodas throughout the day. He sleeps in on the weekends until about noon to "make up for lost sleep." Current medications: Allegra-D®(pseudoephedrine and fexofenadine) by mouth daily Social: Drinks 2-3 beers per night to help him to get to sleep; denies tobacco Write a SMART goal for the treatment of insomnia in this patient

Effectiveness: -Alleviate the insomnia symptoms that patient is experiencing within two nights Safety: -Prevent adverse effects of therapy such as anticholinergic effects throughout duration of therapy Prevention of future occurrences: -Prevent any future insomnia throughout the patient's lifetime

What are the goals of therapy for treating insomnia?

For patients with transient or short-term insomnia but no underlying medical or psychiatric conditions and no medications or substances that exacerbate insonia, the goals of therapy are: -improve the duration and quality of sleep -reduce fatigue and drowsiness during the day -improve daytime functioning --minimize adverse effects of treatment

A 26-year-old male patient complains of difficulty sleeping for the past 2 weeks. As a result, he feels tired and irritable during the day. He takes an hour-long nap in the afternoon 2-3 times per week. He tries to stay up until he is sleepy at night. He lies in bed and begins worrying about not being able to fall asleep. He watches the alarm clock, knowing that he has to get up in a few hours. When he cannot sleep, he usually turns on the television or plays games on the computer. He drinks 3-4 cups of coffee in the morning and 2 diet sodas throughout the day. He sleeps in on the weekends until about noon to "make up for lost sleep." Current medications: Allegra-D®(pseudoephedrine and fexofenadine) by mouth daily Social: Drinks 2-3 beers per night to help him to get to sleep; denies tobacco What monitoring parameters do you have for this pharmacologic recommendation?

If insomnia persists after 10 days, refer pt to PCP Monitor overall duration of sleep Can recommend having patient download a sleep app to measure sleep, night camera to monitor their physical movements ***BE SPECIFIC*** what we are monitoring for and how we are monitoring it Self-monitor for adverse effects, say maybe every 8 hours or so, look for morning drowsiness and anticholinergics

Describe REM sleep

Increased blood pressure, heart rate, temperature, respiration, and metabolism

What is insomnia?

Occurs when a person has trouble with -falling or staying asleep -wakes up too early and cannot return to sleep -does not feel refreshed after sleeping

A 26-year-old male patient complains of difficulty sleeping for the past 2 weeks. As a result, he feels tired and irritable during the day. He takes an hour-long nap in the afternoon 2-3 times per week. He tries to stay up until he is sleepy at night. He lies in bed and begins worrying about not being able to fall asleep. He watches the alarm clock, knowing that he has to get up in a few hours. When he cannot sleep, he usually turns on the television or plays games on the computer. He drinks 3-4 cups of coffee in the morning and 2 diet sodas throughout the day. He sleeps in on the weekends until about noon to "make up for lost sleep." Current medications: Allegra-D®(pseudoephedrine and fexofenadine) by mouth daily Social: Drinks 2-3 beers per night to help him to get to sleep; denies tobacco What pharmacologic recommendation do you suggest to reach the SMART goal you established for this patient?

See pharmacologic treatment options, only one possible recommendation of diphenhydramine

What are nonpharmacologic therapy options while treating insomnia?

Sleep hygiene measures are recommended for all patients with insomnia -for many patients, these measures alone will resolve insomnia patients should be encouraged to try one or two measures at a time!

What are the different stages that sleep can be categorized into?

Stage 1 -transitional stage, occurring as patient is falling asleep Stage 2 -light sleep, constitutes 50% of sleep and is light sleep Stage 3 and 4 -collectively known as deep sleep or delta sleep Rapid Eye Movement -neither light or deep sleep

Insomnia can be classified as

Transient -lasting less than 1 week Short-term Lasts 1-3 weeks Chronic -lasts more than 3 weeks

What is Diphenhydramine and what is its normal dosing?

Used for symptomatic management of transient and short-term insomnia, particularly in patients who complain of occasional difficulty falling asleep Dose: 50 mg by mouth at bedtime -some individuals benefit from 25 mg -do not use for more than 10 consecutive nights -tolerance to the sedative effect of diphenhydramine occurs quick (recommend 3 nights followed by an off night to reduce tolerance to hypnotic effect)

People with insomnia are more likely to report being unable to

Work efficiently, exercise, eat healthfully, and engage in leisure activities because they are too sleepy