Insomnia, Drowsiness, Fatigue

Insomnia

having trouble falling or staying asleep, walking up too early and not being able to return to sleep, or not feeling refreshed after sleeping

Wake Stage

alpha waves become more predominant than beta

Non-REM Sleep

-75% of sleep

-N1: alpha waves replaced by theta, muscle tone present and respiratory rate stable

-N2: sleep spindles and K complexes present, heart rate and body temp decrease

-N3: delta waves present, regrowth and repair of tissue, building of muscle and bone, and strengthening of immune system

REM Sleep

-beta waves present

- high brain metabolism and oxygen use

Sleep Stages

- whole cycle: 90-110 min per cycle

-have 4-6 cycles per night of sleep

Sleep Physiology Changes as Age Increases

-amount of sleep decreases through years

-never be assumed that older adults need less sleep: still recommended 7-9 hrs

-circadian rhythm change: mismatch in cortisol/melatonin secretion, hard time getting to/staying sleeping

Primary Insomnia

idiopathic, paradoxical, psychophysiological, inadequate sleep hygiene, acute stress, transient

Secondary Insomnia

true underlying cause: sleep disorder, SUD, mental health disorder, medical problem

Short Term Insomnia

persists less than 3 months

Long Term Insomnia

persists at least 3 months with symptoms occurring at least 3 times per week: in can be secondary to medical or psychiatric conditions, or to a substance use disorder

Medical Condition Causes

- nasal/sinus allergies

-gastrointestinal problems

-asthma

-chronic pain

-endocrine problems

-neurological conditions

-menopause

Medication Causes

-levodopa

-diuretics

-antidepressants

-beta blockers

-decongestants

-OCs

-thyroid preparations

-antihypertensives

-amphetamines

Lifestyle Changes

-smoking

-drinking alcohol

-caffeine

-lack of sleep routine/schedule

-environmental distractions

-screen time before bed

-late night food

-stress

-shift work

Presentation of Insomnia

-difficulty falling asleep

-anxiety and/or irritability

-waking up too early

-daytime sleepiness

-not feeling well-rested

-inability to focus

-difficulty recollecting memories

-lack of motivation

Exclusions for Insomnia

-<12 yo

-> 65 yo

-pregnancy/breastfeeding

-frequent nocturnal awakenings or early morning awakenings

-chronic insomnia (>3 months)

-sleep disorder secondary to psychiatric or general medical disorder

Goals of Insomnia Tx

-to improve the patients presenting sx, quality of life, and functioning

-general approach- short term, primary insomnia

-reestablish normal sleep cycle

Nonpharm Tx: Insomnia

-FIRST LINE

-sleep in cool/dark/quiet room

-go to bed and get up at same times

-putting away devices before bed

-decrease food/beverage before bed

-cognitive behavioral therapy

-regular weekly visits w/ clinician to change the way they sleep

-good sleep hygeine education

Pharm Tx : Insomnia

-diphenhydramine: only FDA option

-ethanol (alcohol): short term action

-doxylamine: not considered effective

Benadryl (diphenhydramine) Dose

25 mg (NTE) 50 mg

Onset of Action (Benadryl)

max sedation 1-3 hrs

Duration of Action (Benadryl)

4-6 hrs

Treatment Recommendations for Benadryl

take 30 min before bed, short term use only, as needed, over 7 days see doctor

Common side effects of Benadryl

DROWSINESS, anticolenergic effects

Complementary Therapy for Insomnia

The american academy of sleep medicine recommends that dietary supplements (melatonin) not be used to treat insomnia or any other sleep problem, unless approved by a healthcare provider:

-not enough info

-conflicting evidence

Children/Adolescents (Insomnia)

-Benadryl not recommended due to paradoxical excitation

-< 12: refer

-teens- ask about caffeine use, smoking, and alcohol

Pregnancy (insomnia)

-avoid Benadryl unless benefit> risk

-breastfeeding: refer

Older Adults (Insomnia)

-increased drowsiness

-increase fall risk

-BEERS: anticholinergic, Benadryl not recommended

-refer > 65 yo

Patient Counseling for Insomnia

-keep sleep diary

-counsel patients with self treatable symptoms that if symptoms worsen or do not improve after 7-10 days, they should contact there provider

-advise patients to utilize good sleep hygeine

-counsel patients on avalible OTC options

Drowsiness and Fatigue

the subjective experience of sleepiness which includes yawning, eye rubbing, a tendency to fall asleep, and decreased ability to focus and concentrate

Drowsiness/ Fatigue Presentation

self reported measures of sleepiness include the Stanford Sleepiness Scale and the Epworth Sleepiness Scale

Exclusions for Drowsiness and Fatigue

-< 12

-pregnancy

-breastfeeding

-cardiac conditions

-anxiety disorders

-medication induced drowsiness

-chronic fatigue (>6 mo)

Treatment Goal (Drowsy/Fatigue)

to identify and eliminate the underlying cause to improve mental alertness and productivity

Caffeine

-only FDA approved option

Caffeine Dose

200 mg every 3-4 hours as needed (NTE 200mg)

Peak Caffeine Concentration

30-60 min

Elimination Half Life for Caffeine

5 hrs (increases if preganate or have cirrhosis)

Caffeine Tx Rec

occasional use, short term

Common Side Effect of Caffeine

increased alertness/productivity

Children/Adolescents (caffeine)

-more susceptible to CNS/cardiac adverse effects of caffeine (due to low BW)

-not rec. < 12 yo

Pregnancy (caffeine)

-passes through placenta and breastmilk

-while preg: < 200 mg every 3-4 hrs, NTE 300 daily

-breastfeeding: minimal use, after feeding

Older Adults (caffeine)

greater possibility for DDI for those with polypharmacy

Patient Counseling for Drowsy/Fatigue

-focus on good sleep hygiene

-if caffeine product is indicated review: dosage, adverse effects, DDI

-symptoms of excessive caffeine ingestion: irritability, tremor, rapid pulse, dizziness, palpitations

-withdrawal: headache, anxiety

-successful outcome: increased productivity/alertness, peak performance

-when to seek medical eval: if experiencing things that indicate toxicity: increased HR/BP, headache, hand tremor, and anxiety, also after 7-10 days still feeling sxs