Insomnia

Definition of insomnia

- When a person has trouble falling or staying asleep and does not feel refreshed after sleeping despite having the opportunity to sleep for an adequate amount of time in a sufficient environment

Definition of primary insomnia

Insomnia that is not caused by any underlying medical or psychiatric conditions

Causes of primary insomnia

Acute stressors such as medical illness, anxiety, travel hospitalization, divorce, or death of a loved one

Definition of paradoxical insomnia

- Presence of significant sleep symptoms even though objective measures of sleep indicate otherwise

Causes of paradoxical insomnia

Societal factors such as displacement, homelessness, racial discrimination, or unemployment

Definition of secondary insomnia

Insomnia that is caused by another sleep disorder, general medical or psychiatric conditions, substance use disorder, or other medications

Which medications can cause insomnia?

- Antidepressants

- Antihypertensive agents

- Sympathomimetic amines

Which substances can decrease REM sleep?

- Alcohol

- Barbiturates

- Benzos

Changes in sleep physiology with older adults

- Misalignment of melatonin and cortisol secretion can make falling asleep and sleep maintenance more difficult

- Amount of time spent in deep sleep decreases

Goals of sleep restriction method

- Reduce daytime drowsiness

- Improve sleep continuity

What do patients need to do in the sleep restriction method?

- Record the amount of time actually asleep every night

- Limit time in bed to just the time they are actually asleep

Physiological result of the sleep restriction method

Body adjusts to being in bed only when asleep and sleep drive increases

Effects of alcohol on the sleep cycle

- Decreases REM sleep

- Reduces overall sleep quality

Insomnia treatment goals

Improve the patient's presenting symptoms, quality of life, and functioning

Length of transient insomnia

Less than 1 week

Length of short term insomnia

Less than 3 months

Length of chronic insomnia

At least 3 months

Exclusion criteria for self-treatment of insomnia

- Younger than 12 or older than 65

- Pregnancy or breastfeeding

- Insomnia lasting more than 10 days

- Frequent nocturnal awakenings or early morning awakenings

- Chronic insomnia

- Secondary insomnia

Definition of Stage 1 sleep

- Transitional stage that occurs as a person falls asleep

Onset of stage 1 sleep

Seconds to minutes

Duration of stage 1 sleep

5-10 minutes

Definition of stage 2 sleep

Light sleep that constitutes about 50% of sleep time

Onset and duration of stage 2 sleep

Variable upon sleep cycle length

Definition of Stage 3 and 4 sleep

Deep sleep

What can occur during stage 3/4 sleep?

Sleepwalking, sleeptalking, nightmares, bedwetting

Duration of Stages 3/4 sleep

Remaining time not spent in stage 2

Definition of REM sleep

- Eyes move rapidly side to side

- Neither light nor deep sleep

- Inhibition of skeletal muscle movement

- BP, HR, temperature, respiration, and metabolism increased

- Vivid/intense dreams occur due to heightened cerebral activity

Onset of REM sleep

70-90 minutes

Duration of first REM period

10 minutes

Duration of final REM stage

1 hour

How often does a sleep cycle repeat?

90-120 minutes

Diseases/conditions associated with insomnia

- Allergies, asthma, COPD

- Depression/anxiety

- Arthritis, chronic pain

- BPH

- GERD

- Heart failure

- Menopause

- Obstructive sleep apnea

- Pregnancy

- Restless leg syndrome

- Shift-work sleep disorder

Drugs associated with insomnia

- Alcohol

- Antidepressants

- Antihypertensives

- Amphetamines

- Beta-adrenergic agonists

- Caffeine

- Corticosteroids

- Decongestants

- Diuretics at bedtime

- Nicotine

First-line nonpharmacologic strategy to address insomnia

- Cognitive behavioral therapy to address dysfunctional behaviors and beliefs

- Reinforce principles of good sleep hygeine

Diphenhydramine dosing for insomnia

25 or 50 mg 30 minutes before bedtime

Diphenhydramine MOA

Competitively blocks histamine H1 receptors

Common side effects of diphenhydramine

- Dry mouth and throat

- Constipation

- Blurred vision

- Difficulty urinating

- Tinnitus

When to skip a dose of diphenhydramine?

After 3 consecutive nights of improved sleep to assess if insomnia is relieved

How long should you use diphenhydramine for insomnia?

Up to 7-10 consecutive nights

Efficacy of doxylamine for insomnia

Few studies support it as a hypnotic so it is not recommended

Dosing of melatonin

2-10 mg 30-60 minutes before bedtime

Melatonin MOA

Regulates the sleep-wake rhythm through their actions on melatonin receptors

Common side effects of melatonin

Dizziness, drowsiness, headache, and nausea

Melatonin is likely safe at doses of ________ for up to _________

- 8 mg daily for up to 6 months

- 10 mg daily for up to 2 months

Melatonin is possibly safe at doses of _________ for up to _______

- 8 mg daily for more than 6 months

- 10 mg daily for more than 2 months

Effectiveness rating of melatonin for insomnia

Possibly effective