Self Care 2025: Insomnia, Drowsiness, and Fatigue

What is stage 1 of sleep?

Translational Sleep

The initiation of sleep

What is stage 2 of sleep?

Intermediate phase involving alpha rapid wave sleep (measured by an EEG)

What are stages 3 and 4 of sleep?

Deep sleep or delta sleep (slow-frequency waves on EEG)

What is stage 5 of sleep?

REM sleep, neither light/deep sleep,

Increase in dream activity (high frequency waves on EEG)

Insomnia

Difficulty falling or staying asleep consistently.

Some complaints of Insomnia

-Difficulty falling asleep

-Frequent awakenings

-Early morning awakenings

-Inability to fall back asleep

-Poor sleep quality

-Disturbed quality of sleep with unusual or troublesome dreams

Clinical Presentation of Insomnia

Actual duration of sleep may or may not differ from normal

-May report duration of sleep <7 hrs

-May report need >30 mins to fall asleep

What are some symptoms of Insomnia?

Fatigue, drowsiness, anxiety, irritability, depression, decreased concentration, and memory impairment

Treatment goals of Insomnia

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

Treatment Exclusions of Insomnia

-<12 yrs old

-65+ yrs old

-Pregnant or breastfeeding

-Frequent nocturnal awakenings or early morning awakenings

-Chronic insomnia (3+ months)

-Sleep disorder secondary to psychiatric or general medical disorders

Good Sleep Hygiene DOs

-Use bed for sleeping or intimacy only

-Establish a regular sleep pattern

-Make your bedroom a comfortable environment

-Engage in relaxing activities before bedtime

-If unable to sleep for 20 minutes, get out of bed and do something relaxing (don't continue to try and fall asleep)

-Exercise regularly but not within a few hours of bedtime

Good Sleep Hygiene DONTs (and Avoids)

-Avoid eating meals within 2 hours of bedtime (eat a light snack if hungry)

-Avoid napping or limit to 20-30 min

-Avoid using caffeine, alcohol, or nicotine for several hours before bed

-Avoid using electronic devices around bedtime

-Don't watch the clock

What are some OTC products for Insomnia?

-Benadryl Allergy (Diphenhydramine HCl 25mg)

-Advil PM (Ibuprofen 200mg, Diphenhydramine citrate 38mg)

-Unisom (Doxylamine Succinate 25mg)

-ZzzQuil (Diphenhydramine HCl 25mg)

Why might you use diphenhydramine?

Symptomatic management of transient and short-term sleep difficulties

Duration and Frequency of Diphenhydramine

-Take 30 mins before you want to sleep (establish a regular bedtime)

-After 3 night of improved sleep, skip taking for 1 night to see if insomnia is resolved

Side effects of Diphenhydramine

Morning grogginess, excessive sedation, dry mouth, blurred vision, constipation, and difficulty urinating.

Can I take diphenhydramine after I had a glass of wine?

No

Alcohol can increase the effects of the med on the CNS and disrupts the sleep cycle

Can I take diphenhydramine with my Zolpidem (Ambien)?

No

Don't combine with prescription sleep aids

Effects of using diphenhydramine long term.

Tolerance to sleep inducing effects, but not necessarily to its side effects.

100mg dose is not likely to be more efficacious

Diphenhydramine and ACE Inhibitors

Monitor blood pressure, may decrease effectiveness of medications

Diphenhydramine and Metoprolol

May increase serum concentrations (more likely in women)

Monitor or decrease dose as needed

Diphenhydramine and SSRIs

May increase side effects and psychomotor problems

Insomnia Supplements: Melatonin

-Main hormone that helps with the sleep cycle

-Concentration decreases with age

-Different forms available: ODT, patches, tabs IR or ER, gummies, sprays, sublingual forms

-ER may be more beneficial in elderly population

What happens when you take too much melatonin?

-Can possible mess with your circadian rhythm and cause you to have more problems falling asleep

-Some people can possibly build a tolerance (medication is metabolized through liver as a possible explanation)

Melatonin Drug Interactions

-Anticoagulant/Antiplatelet drugs (increase risk of bleeding)

-Anticonvulsants (reduce effectiveness of meds, kids with neurological impairment may be at increased risk of seizures)

-Antidiabetic Meds (can possibly improve, worsen, or not affect risk of hypoglycemia, avoid use to be safe)

Insomnia Supplements: Valerian Root

Not a lot of clinical data showing it helps with insomnia

Recommend other non-pharm methods

Insomnia Supplements: Camomile

Proposed to help induce sleep

Will need to use a more concentrated product than what is in the teat

Insomnia Supplements: Magnesium

Plasma magnesium levels are lower in sleep deprived people

More research needed, but modest positive results with improved sleep quality and anxiety across populations

Treatment Exclusion for Drowsiness and Fatigue

-<12 yrs old

-Pregnancy or breastfeeding

-Cardiac conditions

-Anxiety disorders

-Medication-induced drowsiness

-Chronic fatigue defined as 6+ months of fatigue

Most common cause of drowsiness and fatigue.

Inadequate sleep

Treatment goals for drowsiness and fatigue

Identify and eliminate underlying cause (thereby improving mental alertness and productivity)

What is the only FDA approved non-prescrition stimulation

Caffeine

Dose and frequency of Caffeine

200 mg every 3-4 hours as needed for adults

100-200 mg every 3-4 hours as needed for ages 12 and older

What happens when you consume too much caffeine?

Potential risks: decreased fine motor coordination, diaphoresis, nervousness, and nausea

More significant adverse effects: anxiety, irritability, insomnia, and tachycardia

Consuming caffeine while pregnant or breastfeeding

-Always talk to provider first!

-Doses less than 200mg Daily (~2 cups of coffee) has been shown to NOT increase risk of miscarriages or pre-term births

-Does cross the placenta

Side effects of caffeine in breastfeeding infant at higher doses (300mg)

-Nervousness

-Increased heart rate

-Sleeplessness

-Poor feeding

-Irritability

*Consume caffeine in small to moderate amounts after breastfeeding to minimize side effects

Drowsiness/Fatigue Supplements: Vitamin B12

One small study of Twice weekly IM B12 pointed to improvement in fatigue and general sense of well-being.

Drowsiness/Fatigue Supplements: Gingko Biloba

Only been evaluated in combo, effect on fatigue when used alone is unclear.

Drowsiness/Fatigue Supplements: Ashwagandha

-Adaptogen, Helps the body resist physiological and psychological stress.

-Small study indicated a significant decrease in chemo-related fatigue.

Drowsiness/Fatigue Supplements: Rhodiola

-Adaptogen, more data to support efficacy for fatigue compared to ashwagandha.

-Decreases fatigue, primarily in stressful situations.

-Use of up to 300mg BID for up to 12 weeks without adverse effects.

Drowsiness/Fatigue Supplements: Holy Basil

Adaptogen, less evidence of efficacy for drowsiness but some for improvement in stress levels.

Drowsiness/Fatigue Supplements: Panax Ginseng

-Adaptogenic properties

-Boost physical and mental energy and produce a sense of well-being.

Drowsiness/Fatigue Supplements: Taurine

-Present in normal diet (meat, seafood, and eggs).

-Lacking data for use for fatigue.