Insomnia LIVE SESSIOn - Crouse

Insomnia main take home points

• Non-pharm treatments are first line for insomnia

• Insomnia is often caused by concomitant psychiatric disorders, stressors, alcohol, caffeine or nicotine use

• Evaluate risk vs benefit of hypnotic —- use lowest dose possible with shortest duration

• Limited Options in the elderly

What does the ACP recommend in treatment of insomnia AFTER CBT-I?

clinicians uses shared decision making for whether to add Pharmacological therapy IF CBT-I was unsuccessful

• so MEDS 2nd LINE!!!!

  • or in conjunction (IF you follow the new guidelines)

20 year old college student comes to the counter with bottle of Unisom and melatonin which would help for insomnia — what do you want to ask them?

• Are you having trouble falling asleep ?

• Are you having trouble staying asleep?

• How long are you sleeping?

• Do you go straight to sleep? or do you lie in bed waiting?

• What have you tried?

• How long have you been experiencing these symptoms?

• What substances (caffeine, nicotine, etc) are you using?

• Rested? Or feeling fatigued?

DSM-5 criteria for Insomnia disorder

• Sleep complaints at least 3 nights per week for 3 months

• Social, occupational, academic, education impairment or distress

• Occurs even with ample opportunity to sleep

• NOT associated with another sleep-wake disorder, AE’s of a substance., or coexisting psych illness

Sleep Hygiene 101

• NO TV in bed

• No phone immediately in bed

• Read book is GOOD

• No ALCOHOL

• DONT eat large meal

• Drink chamomile tea is GOOD

• Exercise in the MORNING

• comfortable environment

• Limit lights and elctronics

• Relaxing before bedtime

• Exercise but not close to bedtime

Substances that affect sleep

• Caffeine - lack of sleep/falling asleep

• Alcohol - POOR Quality sleep

• Nicotine - lack of sleep/falling asleep

• Cannabis - POOR Quality sleep

What’s in Sleep3?

• Melatonin

• Valerian (not recommended )

• Chamomile

• Kava Kava (not recommended)

• L-Theanine

When should you take melatonin?

Suggested to take 6 hours before bed (circadian rhythm issues) OR 30 min before bedtime (for trouble falling asleep), OR 2 hours prior to bedtime

Max dose of melatonin per day?

10mg!!!! - Really only for autism or ADHD

• Recommend no more than 6mg really for regular adults

Which disorders can mask as insomnia or have insomnia as a symptom?

• GAD

• Depression

• PTSD

• Bipolar DO

Schizophrenia does NOT have insomnia as symptom

When should you evaluate for a co-morbid diagnosis instead of an insomnia diagnosis?

Reevaluate if insomnia persists after 7-10 days of treatment

What is the screening tool for OSA?

STOP-Bang test

In someone GERIATRIC, what insomnia medications would generally be avoided because fall risk ? (from the BEERs criteria)

Benadryl

BZDs

Non-BZD (Z-drugs)

TCA’s

Alternative drugs for sleep in older adults

• Doxepin (lower dose?)

• Off label Trazadone

  • monitor hypotension

• Ramelteon 8mg

• Suvorexant

• Lemobrexant

• OTC melatonin a few hours before bedtime?

Counseling points for Z drugs

• can cause CNS depression

• Respiratory depression

• Next day sedation

  • next-day driving impairment

• Complex sleep-related behaviors

• Depression

  • Worsening or SI

Z drugs counseling/proper administration

• Do not double doses

• Do NOT mix with alcohol or other CNS depressants

• Take Immediately before bedtime

• Possible Sex differences

  • Women may need less; even men taking 20 mg of Zolpidem had next day impairment

• Need appropriate amount of time before initiating activities requiring mental alertness

Triazolam and Flurazepam AE’s

Anterograde amnesia, rebound insomnia (effects may continue 2 nights after DC)

Eszopiclone AE

unpleasant taste

Zolpidem AE’s and counseling points

Falls with injury risk

• Take on empty stomach

• Time left in bed (4 hours)

Ramelteon AE’s

Hyperprolactinemia (Amenorrhea, galactorrhea), reduced testosterone, taste perversion

• Take 30 minutes prior to bedtime // do not take after hight fat meal

Doxepin counseling points

Do not take within 3 hours of meal

Trazadone AE’s

Dizziness, hypotension orthostatic, Priapism

Suvorexant and Lumborexant AE’s

Sleep paralysis, hallucinations, cataplexy (suvorexant)