Insomnia, Drowsiness, Fatigue

Isnomnia

most common type of sleep disorder

transient insomnia

insomnia <1 week

- 30-35% of adults

short-term insomnia

insomnia that is 1-3 weeks

- 15-20% of adults

chronic insomnia

- clinical diagnosis often occurs if insomnia is experienced at least 3 times per week for 3 months

insomnia that occurs at least 3 times per week for > 3 weeks

- 10%

Alcohol

Amphetamines

Antihistamines

Barbiturates

Benzodiazepines

Illicit drugs: Cocaine, Marijuana, Phencyclidine

MOAIs

Opiates

TCAs

drugs that can cause withdrawal insomnia

1. children < 12

2. adults > 65

3. pregnant women

4. individuals with frequent nocturnal awakenings or early morning awakening

5. individuals with chronic insomnia

6. individuals whose sleep disturbance is secondary to psychiatric or general medical disorder

Exclusions for self-treatment of insomnia

1. Antihistamines

2. Diphenhydramine

3. Doxylamine

4. Combination products should only be used if all medication sin the product are needed

- pain symptoms: Tylenol PM, Advil PM

- cold/cough symptoms: Nyquil

Nonpharmacological methods should be instituted by all individuals experiencing insomnia. Pharmacotherapy can be instituted if lifestyle modifications are not enough. Nonprescription and herbal supplements not recommended for chronic use:

• Chamomile

• Kava Kava

• L-theanine

• Lavender (topical)

• Melatonin

• Peppermint (topical)

• Valerian Root

herbal supplements for insomnia

Nyquil Liquid

Use of alcohol to induce sleep is common; it should NOT be suggested as a sleep aid

- Initially improves sleep, but tolerance can develop quickly

- Heavy alcohol use can cause sleep disturbance

- Chronic alcohol use can cause rebound insomnia upon discontinuation

- Alcohol is present in some nonprescription products, such as _____

1. stress management and relaxation techniques

2. avoid caffeine, nicotine, and alcohol use close to bedtime (not within 4-6 hours)

3. limit fluid intake at night

4. avoid large meals close to bedtime (not within 2 hours before)

5. limit engagement in stimulating or stressful activities in the evening

6. establish good sleep hygiene practices

- have a consistent sleep schedule; go to bed and wake up at the same times

- avoid daytime naps and sleeping in

- limit time in bed to sleep and intimacy and avoid working or studying in bed

7. avoid the use of cellphones/computers at night

8. avoid watching the clock

- leave the bed an pursue a quiet activity if there's difficulty falling asleep

- frustration at not sleeping can perpetuate the problem; return to bed when drowsy

nonpharmacological treatment for insomnia

diphenhydramine (antihistamines)

Is effective in decreasing the time to fall asleep (sleep latency) - Improves the reported quality of sleep for individuals with occasional insomnia

- Not as effective as prescription sleep aids for chronic insomnia

Diphenhydramine HCl 50mg

what is Unisom® Sleep Gels Maximum Strength Capsules generic and strength?

Diphenhydramine HCl 25mg

what is the generic and strength of Sominex® Nighttime Sleep Aid Tabs?

Diphenhydramine HCl 25mg and 50mg/30mL

what is the generic and strength of ZzzQuil® liquid capsule/oral solution?

Diphenhydramine HCl 25mg

what is the generic and strength of Simply Sleep® Tablets?

Doxylamine succinate 25mg

what is the generic and strength of Unisom® Tablets?

Diphenhydramine citrate 38mg; ibuprofen 200mg

what is the generic and strength of Advil PM Caplets?

Diphenhydramine citrate 38.3mg; aspirin 500mg

what is the generic and strength of Bayer PM Extra Strength Caplets?

Diphenhydramine citrate 38mg; APAP 500mg

what is the generic and strength of Excedrin PM Geltabs/Caplets/Tabs?

Diphenhydramine HCl 25mg; APAP 500mg

what is the generic and strength of Tylenol PM Extra Strength Geltabs/Gelcaps/Caplets?

Doxylamine succinate 12.5mg; dextromethorphan 30mg/30mL

what is the generic and strength of NyQuil® Cough oral solution?

Doxylamine succinate 12.5mg; dextromethorphan 30mg; APAP 650mg/30mL

what is the generic and strength of NyQuil® Cold & Flu?

Precautions:

1. caution in elderly: cognitive impairment, fall risk, disease exacerbation (BPH, glaucoma)

2. anticholinergic toxicity: anxiety, excitement, tachycardia

3. Additive CNS depression may occur if used with sedative agents (antihistamines, melatonin, valerian root, etc)

SEs: sedation, anticholinergic action (dry mouth, constipation)

precautions and SEs of diphenhydramine

1. take 30-60 min prior to bedtime

2. usual dosing: 50 mg nightly MAX

3. do NOT use for more than 7-10 consecutive days

4. intermittent use for 3 days with an "off" night to assess sleep quality without medication

- may reduce tolerance

5. be aware of nonprescription and herbal medications that increase side effects (antihistamines, melatonin, valerian, etc)

counseling points for diphenhydramine when used for insomnia

B

Diphenhydramine is classifies as pregnancy risk category _____

A

Doxylamine/pyridoxine is classifies as pregnancy risk category ____

- used for n/v

true

T/F: Although Diphenhydramine may be used in pregnancy, an increased risk of CNS side effects can occur in breastfed neonates after maternal intake of a sedating antihistamine; therefore, Diphenhydramine should not be used by breastfeeding mothers.

12

Diphenhydramine and doxylamine are not indicated to treat insomnia in children younger than ___ years old.

paradoxical excitation

Diphenhydramine may cause _____ in young children

• Acupuncture

• Tai Chi

• Light Therapy

alternative therapies for insomnia (not pharmacological or herbal)

hepatotoxicity

Kava kava is banned in several countries due to _____.

- should not be recommended for treatment of insomnia

1. 0.3-5 mg 30-60 minutes prior to bedtime

2. minimal common AEs

3. rare AEs: tachycardia, irritability, worsening of depression

counseling points for melatonin

1. 400-900 mg administered 30-120 minutes prior to bedtime

2. BZD-like withdrawal symptoms may occur after cessation of contunous use; should be tapered to discontinue

3. chronic use linked to hepatotoxicity

counseling points for Valerian root for insomnia

Benzodiazepines

Hypnotics

Antihistamines

Alcohol

Anticonvulsants

Opioids

List the CNS depressants that commonly cause drowsiness and fatigue

• <12 years of age

• pregnant women

• Breastfeeding women

• Heart disease

• Anxiety disorders

• Medication-induced: refer to PCP for dose adjustment

• Chronic fatigue, despite adequate sleep: refer to PCP to rule out hypothyroidism, sleep apnea, other medical conditions

exclusions for self-treatment of drowsiness/fatigue

half

Chronic caffeine users who smoke should be advised to reduce their caffeine consumption by ____if they quit smoking.

Precautions:

1. caution in patient with certain medical conditions: GERD, HTN, anxiety

2. additive effects can occur when multiple sources of caffeine are used

- herbal supplements, energy drinks, coffee

SEs: elevated BP, insomnia, upset stomach (diarrhea), nervousness, tachycardia

precautions and SEs of caffeine use for drowsiness/fatigue

1. Caffeine is marketed for occasional use to help restore mental alertness or wakefulness

2. do not exceed the recommended dose of 100-200 mg every 3-4 hours PRN

3. withdrawal symptoms can occur 12-24 hours after abrupt cessation and last for 1-5 days

- headache, fatigue, decreased concentration, irritability

counseling points for use of caffeine for drowsiness/fatigue

B

**women who are pregnant or breast-feeding should not use caffeine

Caffeine is classified as FDA Pregnancy Risk Category ____ and freely crosses the placenta. Infants unable to metabolize caffeine or received large quantities with breast milk may have symptoms of nervousness, increased HR, sleeplessness, poor feeding, and irritability.

12

Children are more susceptible to the cardiovascular and CNS AEs of caffeine due to their lower body weight. Do not use caffeine in children younger than _____ years of age.

true; there is an increased susceptibility to an exaggerated pharmacological effect and interference with sleep

- should avoid dietary caffeine or as an ingredient in medications before dinner

T/F: The elimination half-life of caffeine is prolonged in older adults.

Ginseng

complementary therapy that is frequently used to boost physical and mental energy and sense of well being

1. 200 mg/day in divided doses

2. can lower blood glucose

3. increased bleeding risk with anticoagulants/antiplatelets

counseling points for Ginseng

Ginseng

Cola nut

Guarana

Yerba mate

list the complementary/alternative therapies for drowsiness/fatigue

caffeine

list the pharmacological therapy for drowsiness/fatigue