sleep wake disorders

insomnia symptoms

difficulty falling asleep (sleep onset)

difficulty staying asleep (maintenance)

poor sleep quality, excessive daytime sleepiness, fatigue, memory impairment

insomnia dsm5

unsatisfactory sleep quality/quality, plus:

• difficulty initiating

• difficulty maintaining

• early awakening

causes distress or impairment

more than 3 times per week for more than 3 months

insomnia predisposing factors

medical or psych comorbidities

• allergies, asthma/COPD, pain, diabetes, GERD, heart failure, IBS, pregnancy, menopause

• MDD, anxiety, bipolar, substance use

genetics, female, personality (worrier)

meds causing insomnia

caffeine, amphetamines, bupropion, SSRI/SNRIs, nicotine, alc, albuterol, decongestants, levothyroxine

insomnia precipitating factors

situational stress, inappropriate environment

insomnia perpetuating factors

poor sleep hygiene, maladaptive coping (using phone)

insomnia non pharm

CBT for insomnia, very effective

(includes sleep hygiene education, stimulus control, sleep restriction, cognitive therapy, relaxation training)

when to use pharmacological agents for insomnia

only recommended for short term use, 4-5 weeks if CBT-I is unavailable or ineffective

options = benzos, z drugs, orexin antagonists, doxepin, ramelteon

off label for insomnia

trazodone, hydroxyzine, mirtazapine, quetiapine, olanzapine, clozapine, melatonin (otc)

benzo mechanism

allosteric GABA_A agonist

decrease sleep latency, increase total sleep, increase stage 2 non REM

but decreases REM

benzo considerations

C4 – risk of tolerance, abrupt d/c can cause rebound insomnia and withdrawal

can worsen depression, suicidal ideation

risk of resp dep when combined w alc, opi, other cns dep

BEERS → no in elderly

benzos for insomnia

• triazolam, temazepam, estazolam, flurazepam, quazepam

• quick onset (sleep latency) = triazolam, temazepam

• very long duration = flurazepam, quazepam (ade → hangover, sleepy next day)

zaleplon, zolpidem, eszopiclone mechanism

selectively bind alpha 1 subunit on GABA_A

z drug considerations

C4 but less risk of tolerance, rebound insomnia, withdrawal

ade = complex sleep behavior (sleep walking, eating, driving)

—orexant, DORA mechanism

orexin (1 and 2) antagonists

increase stage 2 non REM and increase REM sleep

DORA considerations

C4 but lower risk of dependence, withdrawal

ade = narc like symptoms, daytime sleepiness, do NOT drive

doxepin for insomnia

(3 mg or 6 mg)

mechanism = pure H1 antagonist

ade = next day somnolence

ramelteon for insomnia

mechanism = melatonin (MT1 and 2) agonist

effects = regulate circadian rhythm and sleep onset

ade = headache, dizziness

sleep onset insomnia treatments

triazolam, temazepam, all z, ramelteon

sleep maintenance insomnia treatments

temazepam, zolpidem, esz, doxepin, suvorexant

insomnia treatment for elderly

melatonin, ramelteon, doxepin, mirtazapine, trazodone (NO benzos or z drugs)

narcolepsy

abnormal transitions into REM sleep associated with excessive daytime sleepiness (EDS)

caused by low levels of orexin 

increased risk → HLA DQB1*0602 gene (H1N1 flu vacc)

narcolepsy symptoms

EDS, cataplexy, hallucinations, sleep paralysis

cataplexy

sudden muscle weakness → body goes into REM (can be triggered by during happy emotions)

hypnagogic

hallucinations when falling asleep

hypnopompic

hallucinations when waking up

narcolepsy type 1

narcolepsy + cataplexy (EDS, orexin/hypocretin def)

narcolepsy type 2

narcolepsy without cataplexy (just EDS)

narcolepsy rating scale

epworth sleepiness scale (likelihood to fall asleep)

> 10

narcolepsy non pharm

daily scheduled naps, strict sleep routine,

daily exercise, avoid alc and caffeine, avoid cataplexy triggers,

reduce carbs and sedentary activity after eating

cataplexy treatment

sodium oxybate, pitolisant

narc EDS treatment

modafinil/armodafinil, solriamfetol, pitolisant, sodium oxybate

sodium oxybate mechanism

GABA_B agonist, effective against all 4 narc symptoms

increase stage 3 non REM, but decreases REM

take at bedtime and 4-5 hours later (set alarm) SKIP DOSE if drank alc

sodium oxybate considerations

C3, REMS program

HIGH SODIUM CONTENT — avoid in htn, hf, renal disease

other formulations = lower sodium, extended release taken once

pitolisant

H3 inverse agonist → increases histamine

cataplexy treatment

pitolisant considerations

ade = QT prolong, insomnia, anxiety

contraindicated in severe hepatic impairment

many DDIs (birth control)

modafinil

C4, dopamine reuptake inhibitor; increase dopamine

ade = SJS, avoid in hx ventricular or valve problems

many DDIs (birth control)

armodafinil

R enan, longer half life, more potency, same efficacy

dopamine reuptake inhibitor (C4)

solriamfetol

dopamine and norepi reuptake inhibitor; increase dopamine

ade = headache, naus, insomnia, anxiety, htn, tachycardia (avoid in CVD)

C4, very expensive

obstructive sleep apnea

airway blockage that disrupts breathing during sleep (very common)

sleep apnea risk factors

excess weight, tonsil obstruction, large neck circumference

above 40, male, preg or menopause, pcos

hypothyroid, cushing, smoker, opioid use

sleep apnea dsm5

• sleep study showing 5+ apnea episodes per hour (AHI)

• disturbances in breathing during sleep (snoring, gasping)

• fatigue, daytime sleepiness

sleep apnea symptoms

EDS, snoring, gasping, poor quality sleep

worsening of diabetes, CVD, CKD, stroke risk

sleep apnea non pharm

CPAP machine (very effective)

sleep apnea treatments

improving airway obstruction → tirzepatide

improving EDS → modafinil, solriamfetol

tirzepatide

GLP 1/GIP agonist

OSA and obesity combined with calorie deficit and increased activity

circadian rhythm disorders

 when circadian rhythm does not align with individual’s sleep-wake cycle

→ difficulty falling asleep and maintaining sleep, unable to fall back asleep, poor sleep quality

types of circadian rhythm disorders

delayed sleep-wake phase disorder, advanced sleep-wake phase disorder

jet lag disorder, shift work sleep disorder

irregular sleep-wake rhythm disorder, non 24 hour sleep-wake phase disorder

circadian disorder general treatments

improve sleep hygiene, light therapy, melatonin

(delayed, advanced, jet lag and irregular rhythm)

shift work disorder treatments

modafinil, armodafinil

non 24 hour treatments

melatonin, tasimelteon (melatonin agonist)

restless leg syndrome

urge to move legs, worse at rest or at night

twice a week for 3 months

causing significant impairment or distress

RLS causes

idiopathic, low iron (ferritin in brain), dopamine dysfunction

parkinson’s, pregnancy, anemia, ESRD

medication induced RLS

quetiapine, olanzapine, clozapine, SSRIs, mirtazapine, opioid withdrawals

RLS treatment

non pharm = pressure bands

- gabapentin enacarbil (5 pm w meals)

- dopamine agonists (not preferred)

• ropinirole, pramipexole, rotigotine patch

RLS iron

replenish iron if lower than 75

IV ferric carboxymaltose (preferred), oral if lower than 50

pramipexole, ropinirole, rotigotine

dopamine agonists

augmentation — worsening of RLS caused by long term use

ade = compulsive behaviors