What are the two phases of the sleep cycle?
Describe the NREM phase of sleep
- Stages 1-4
- Occurs <45 min after falling asleep
- Encompasses most of the time spent sleeping (~75%)
Which phase of sleep does dreaming occur?
T/F: REM first occurs 30-60 minutes after falling asleep, lasting 5-7 min initially and progressively becoming longer.
What tool is used to aid in sleep disorder diagnosis?
How often does the sleep cycle repeat?
Every 70-120 min
About how many cycles of sleep occur in one night?
How many hours of sleep does the average adult require?
How many hours of sleep does the typical American get?
What does sleep facilitate?
- Hormone release
- Memory consolidation
- Tissue repair
Primary sleep disorders include which two classes?
What is dysomnia?
Primary sleep disorder with abnormal amount, quality, or timing of sleep
What is parasomnia?
Primary sleep disorder with abnormal behavior/physiologic events
List some examples of dysomnias
- Obstructive sleep apnea
- Circadian rhythm disorders
T/F: Sleep walking, sleep terrors, and nightmares could all occur in an individual with a dysomnia disorder.
T/F: A minimum of 3 nights/wk for 3 months is required before someone can be diagnosed with a primary sleep disorder.
Which sleep disorder is the most common complaint in medical practice?
When does insomnia typically manifest?
In early/middle adulthood
Young adults typically have difficulty _______________ (falling asleep/staying asleep), while middle aged and elderly typically have difficulty _____________ (falling asleep/staying asleep.
Falling asleep; staying asleep
T/F: Insomnia affects men more than women
What percentage of the population does insomnia affect in a lifetime?
What percentage of insomnia occurs concurrently w/ a psychiatric disorder?
What are the characteristics of insomnia?
- Difficulty falling asleep
- Difficulty maintaining sleep
- Experiencing non-restorative sleep
- Causes significant stress/impairment in fxn
What are the classes of insomnia?
Which type of insomnia:
- Less than 1 week; self limiting
- Causes: acute life stress, medical illness, anxiety, poor sleep habits, travel
Which type of insomnia:
- 1-3 weeks
- Causes: more severe stressors
Which type of insomnia:
- >3 weeks / 1 month to years
- Causes: Medical problems, psychiatric disorders, substance abuse
Chronic insomnia is frequently comorbid w/ _________________
Psychiatric disorders / medical conditions
Complete diagnostic exam for insomnia includes:
- Lab tests
- Physical and mental status exam
- Medical history
What are the common etiologies for insomnia?
- Medical (i.e. heart failure, GERD)
- Pharmacologically induced (i.e. substance abuse)
Treatment of insomnia is based on ____________
Non-pharmacologic treatments for insomnia include:
- Good sleep hygiene
- Cgnitive behavioral therapies (Stimulus control)
List examples of stimulus control
- Est. regular sleep pattern
- Sleep only as much as necessary
- If unable to fall asleep (20-30 min), get up and perform relaxing activity until tired
- Avoid daytime napping
- Schedule "worry time" during day
- Avoid blue light (screentime) before bed
List examples of good sleep hygiene
- Exercise regularly, but not w/in 2-4 hrs of bedtime
- Make bedroom comfortable for sleeping (avoid temp extremes, noise, and light)
- Avoid caffeine, alcohol, or nicotine for at least 4-6 hrs before bed
- Avoid meals and large qty of liquid w/in 2 hrs before bed
- Engage in relaxing and enjoyable activities before bed
T/F: Pharmacologic treatment of insomnia is indicated for short-term and long-term insomnia.
Use of sedative hypnotics over how long is discouraged?
T/F: Clinicians should encourage hypnotic therapy using the lowest effective dose and shortest duration possible (but long term use is not contraindicated).
When can antihistamines be used for insomnia?
- Mild, transient and short-term insomnia
- Difficulty falling asleep
- Occasional use (after 2-3 nights, skip for 1 night)
List examples of antihistamines used for insomnia
What is the max duration of use of antihistamines for insomnia?
OTC agents that have "PM" in the name typically have what AI included?
What are common SE of antihistamines?
- Dry mouth and throat
- Blurred vision
- Urinary retention
- Hangover effect
How can anticholinergic toxicity manifest with antihistamines?
- Dilated pupils ("blind as a bat")
- Flushed skin ("red as a beet")
- hot and dry mucus membranes ("dry as a bone")
- elevated body temp ("hot as a hare")
- CNS manifestations ("mad as a hatter")
Antihistamines are contraindicated in what pts/diseases?
- Angle closure glaucoma
- Male pts of advanced age (BPH and difficulty urinating)
- CV disease (angina/rhythm disorders)
Describe complementary therapies for sleep
- Not well studied / regulated
- Melatonin, valerian, kava
- Inconsistency w/ purities and potency
- Only recommend after sleep hygiene initiated (and careful consideration)
Describe melatonin's place in therapy
- Short-term trtmt of delayed sleep phase syndrome
- Reduces sleep onset latency
- Sleep usually occurs w/in 30-45 min
What is the dose of melatonin?
0.3-5 mg (don't want to exceed 5 mg)
Valerian root MOA
Inhibits GABA/metabolites breakdown
Describe valerian root's place in therapy
- Reduces sleep latency and improves sleep quality
- continuous use for days-weeks for effect (takes 2-4 weeks for optimal effect)
- Withdrawal effect if used longterm
- Teratogenic and hepatotoxic
Valerian root dosage
- 300-600 mg (equivalent to 2-3 g dried root)
- Take 0.5 - 2 hrs before bed
T/F: Alcohol is a CNS stimulant and depressant that can reduce sleep latency and increase wakefulness after sleep onset, suppressing REM sleep.
Alcohol is not recommended as a sleep aid, as it can cause _____________
If use of OTC sleep aid is appropriate, what should you discuss with the pt?
- Dosage guidelines
- Duration of therapy
- Drug interactions
- Signs/symptoms that indicate they should SMA
- Discourage use of multiple products
- Seek med. evaluation if sleep not improved w/in 10 d
List classes of meds used for Rx therapy of insomnia
- BZD Receptor agonists (BZDRA; includes BZDs and nonBZDs)
- Melatonin Receptor agonists
- Orexin receptor agonists
Which class of Rx med is most commonly used to treat insomnia?
What BZDRA are newer agents that have sedative properties only and have less withdrawal, tolerance, and rebound insomnia?
NonBZD GABAa receptor agonists
BZDs decrease which phases/stages of sleep?
REM, stage 3 and 4
BZDs should be avoided in which pt pops?
- Untreated sleep apnea
- Hx of substance abuse
How long should BZDs be used for insomnia?
14-28 d; long-term efficacy not est.
What are dose dependent SE of BZDs?
- Daytime sedation (high doses / int. doses in elderly)
- Anterograde amnesia
- Rebound insomnia
Which nonBZD has a rapid onset with the shortest hal-life?
Which nonBZD is best used as a sleep aid for middle of the night awakenings?
What is the duration of Zolpidem?
How does the efficacy of zolpidem compare to BZDs?
- Decreases sleep latency
- Decreases nocturnal awakenings
- Increases total sleep time
- Less disruptive of sleep stages
What are some dose related SE of zolpidem?
- GI issues
- oral spray
T/F: Eszopiclone has a longer half life and can be taken for up to 8 mo.
Whichh nonBZD is a better option for sleep maintenance insomnia or early morning awakenings?
What is a viable option for pts w/ a history of substance abuse?
T/F: Ramelteon should be taken on an empty stomach and has no next-day somnolence / withdrawal effects
- CYP1A2 (major)
- CYP2C and CYP3A4 (minor)
Why would you need to increase the dose of Ramelteon for a smoker?
Smoking induces CYP1A2 = increased metabolism of the drug
T/F: Belsomra is a Scheudle V drug, but has no clear evidence of withdrawal effects.
AE of Ramelteon
- Unpleasant taste
- Dry mouth
Complex behaviors while asleep
List orexin receptor antagonists
- Suvorexant (Belsomra)
- Lemborexant (Dayvigo)
Dayvigo is contraindicated in:
- 5 mg immediately before bed, w/ at least 7 hrs of sleep
- May be delayed if after high fat/high calorie meal
- Sleep paralysis
- Hypnagogic/hypnopompic hallucinations
- Cataplexy-like symptoms
- Complex sleep behaviors
- Worsening depression/suicidal ideation
What can be used as an alternative for pts w/ non-restorative sleep who should not receive BZDs?
T/F: Antidepressants are useful for comorbid depression, pain, or those at risk of substance abuse bc the doses used as a sleep aid are effective at antidepressant doses.
List antidepressants that help induce sleep continuity and have significant daytime sedation and SE.
Which antidepressant causes daytime sedation and weight gain?
Which antidepressant is a beneficial 2nd line agent for transient/short-term insomnia?
- Carry over sedation
25-100 mg at bedtime
T/F: Trazadone has no risk of dependence/tolerance and may be used in combination in pts w/ SSRI / bupropion-induced insomnia.
What is the 1st line treatment for transient/short-term insomnia?
What is the 2nd line treatment for transient/short-term insomnia?
- Different BZDRA
What pharmacological agents are used to treat EDS in narcoleptic pts?
- Alternative: Sodium oxybate or selegiline
What pharmacological agents are used to treat sleep paralysis, cataplexy, and/or hypnagogic hallucinations in narcoleptic pts?
- Sodium oxybate
- Alt: Imipramine, protriptyline, selegiline
How would you treat jet lag?
- Short-acting BZDRA
How would you treat shift work circadian rhythm disorder?
- Naps and exposure to bright light at night and darkness during the day
- Modafinil and BZDRA for daytime sleep (if necessary)
What is the first line treatment for obstructive sleep apnea?
- Nasal CPAP
- Weight loss (if obese)
What is the second line treatment for obstructive sleep apnea?
What is the third line treatment for obstructive sleep apnea?
- Modafinil/armodafinil in select pts
- If that doesn't work/unable to tolerate, try alternative devices, surgery, etc.
What is selegiline effective for?
Hypersomnia and cataplexy
What should you be wary of if changing or discontinuing narcoleptic meds abruptly?
What are the most effective agents against cataplexy?
- TCAs (imipramine, nortriptyline, etc)
- Fluoxetine (same dosing as for depression)
Sunosi should be avoided _____ hours before planned bedtime
T/F: Sunosi is a C-IV medication
Which new EDS drug requires the dose to be slowly titrated over 3 weeks (17.8 mg to 35.6 mg daily)
Pitolsant hydrochloride (Wakix)