CNS Lectures 20-21: Sleep Disorders & Treatment 1-2

REM Sleep

a period of desynchronized EEG activity during sleep, at which time dreaming, rapid eye movements, and muscular paralysis occur

also called paradoxical sleep

Non-REM sleep

synchronized EEG activity during deeper stages (3-4)

What is used to diagnose sleep disorders?

Sleep diary

Sleep pinventory

Blood tests

Sleep study

Primary insomnia

sleep that is distrupted for prolonged periods that is NOT attributable to psychological factors

Secondary Insomnia

sleep that is distrupted that IS attributable to a cause

What is the DSM-5 criteria for insomnia?

unsatisfying sleep quality or quantity for 3 nights per week for at LEAST 3 months

What are the different categories of insomnia?

Difficulty initiating sleep

Difficulty maintaining sleep

Early morning awakening

Poor/unrefreshing sleep

Which type of insomnia is common in depression?

early morning awakening

What are the treatment options for insomnia?

CBT-I

Pharmacotherapy

What is considered to be the standard of care for insomnia treatment?

Non-pharmacologic treatment

Treatments for insomnia should always include what as an adjunct?

sleep hygiene

Stimulus control therapy for insomnia

patient is trained to associate the bed with sleep and sex only

What are the non-pharmacological treatments for insomnia?

Counseling

Sleep hygiene

Stimulus control therapy

Sleep restriction therapy

What are the different elements of CBT-I?

Time spent in bed is restricted to the amount currently feasible and gradually increased

Behavioral components

Allowing sleep to happen

Exposure to bright light upon waking

What are some examples of good sleep habits?

Be consistent

Quiet, dark, relaxing environment

Remove electronic devices

Avoid large meals, caffeine, adnd alcohol before bed

Get exercise during the day

Sedation

decrased responsiveness

Sedatives

drugs that calm patients without inducing sleep

Hypnotic

drugs that induce and/or maintain sleep

What BZDs are used for sleep?

Triazolam

Estazolam

Flurazepam

Temazepam

Z-drugs

Zolpidem

Zaleplon

Eszopiclone

What is the first line treatment for insomnia?

behavioral therapies

What is the second line treatment for insomnia?

Pharmacologic treatment

True or false: SGAs can be used for treatment of insomnia.

False

Why should SGAs NOT generally be used for routine maintenance of insomnia?

ADRs

Other better options

Which BZDs are recommended for elderly or hepatic impairment?

Lorazepam

Oxazepam

Temazepam

Estazolam

Prosom

Flurazepam

Dalmane

Temazepam

Restoril

Triazolam

Halcion

Onset and duration of Estazolam

Onset: slow

Duration: Intermediate

Onset and duration of Flurazepam

Onset: Rapid

Duration: Long

Onset and duration of Temazepam

Onset: slow

Duration: Short to intermediate

Onset and duration of Triazolam

Onset: Intermediate

Duration: Short

Which BZDs used for sleep have a slow onset?

Temazepam

Estazolam

Which BZD used for sleep have a rapid onset?

Flurazepam

Which BZDs used for sleep have short durations?

Triazolam

Temazepam (or intermediate)

Which BZDs used for sleep have a long duration?

Flumazepam

What are the contraindications to BZDs?

Alcohol use

Sleep apnea

Hx of substance abuse

Pregnancy

What can occur if BZDs are used for a long period of time?

REM rebound

When should Z-drugs be taken?

taken right before bed only if 6-8 hours of sleep are dedicated

Can z-drugs be taken with food? Why?

NO! delays onset

ADRs of Z-drugs

next day impairment

Which Z-drug can have an unpleasant taste?

Eszopiclone (Lunesta)

If insomnia fails to remit after _________ days of treatment, re-evaluate.

7-10 days

What is the boxed warning for z-drugs?

Rare but serious injuries have happened

Sleepwalking, sleepdriving, and other activities while not being fully awake

Have resulted in deaths

Which formula of Zolpidem is for MONA?

Zolpidem SL (Intermezzo)

Which formula of Zolpidem is for sleep maintenance?

Zolpidem ER (Ambien CR)

What is unique about Zolpidem dosing?

Has male and female dosing

Suvorexant

Belsomra (C4)

How long can Belsomra be used for?

up to 1 year

What is Belsomra used for?

Sleep onset and maintenance insomnia

Ramelteon

Rozarem

Melatonin receptor agonist

Ramelteon

What are the benefits of Ramelteon?

Not controlled

No abuse potential

No withdrawal

Doxepin

Silenor

When is Doxepin used in insomnia?

patients with difficulty maintaining sleep

What are the contraindications of Doxepin use?

Untreated narrow angle glaucoma

MAOI use

BPH

What antihistamines can be used for insomnia?

Hydroxyzine

Which antidepressants be used for sleep?

Trazodone

Mirtazapine

Amitriptyline

If pharmacologic treatment is recommended for someone with insomnia, what do we start with?

Short or Intemediate BZDs

Z-drugs

Ramelteon

Which medicaitons used for sleep are on the Beer's criteria?

BZDs

Z-drugs

What are the sedating antidepressants?

Mirtazapine

Trazodone

Amitriptyline

Doxepin

Use of pharmacologic interventions for sleep should not be used longer than ________.

12 weeks

Which sleep medications can be used longer than 12 weeks?

Zolpidem ER

Lunesta

Belsomra

Ramelteon

Which medications can be used for sleep onset ONLY?

Ramelteon

Triazolam

Zaleplon

Zolpidem ER

Which medications can be uesd for ONLY sleep maintenance?

Doxepin

Belzomra

Which medications can be used for sleep onset and maintenance?

Zolpidem ER

Lunesta

Temazepam

What are the diagnostic criteria of narcolepsy?

recurring episodes of irresistible need to sleep at least 3 times a week for 3 months

Narcolepsy Tetrad

Cataplexy

Hallucination

Excessive daytime sleepiness

Sleep paralysis

What is the main treatment goal of narcolepsy?

Symptom management

Which medications are used for excessive daytime sleepiness in nercolepsy?

Modafinil

Armodafinil

Amphetamines

Sodium Oxybate

Which medications are used for cataplexy in narcolepsy?

Sodium Oxybate

TCAs

SSRIs (Fluoxetine)

SNRIs (Venlafaxine)

What are the symptoms of restless leg syndrome?

URGE

Urge to move

Rest induced

Gets better w/ activity

Evening and night worseining

What are the non-pharm treatment options for RLS?

Good sleep hygiene

Exercise

Cessation of smoking, alcohol, and caffeine

What are the first line pharmacologic options for RLS?

DA agonists (Ropinirole)

What are the second line pharmacologic options for RLS?

Gabapentin

What are the limitations of dopamine agonists?

Schizophrenia

Psychotic disorders

Impulse control disorders

Gambling problems

Hypersexuality

Compulsive behaviors

ADRs of Gabapentin

Somnolence

Sedation

Dizziness

Neurotoxicity

Dizziness

What medications should be avoided in OSA?

sedatives and hypnotics

What is the treatment for OSA?

CPAP or BiPAP

What is the treatment for central sleep apnea?

Reducing opioid medications

CPAP

When do sleep terrors occur?

stage 3-4 of non-REM sleep

What are some non-pharm options to treat nightmares?

Visualize an end to the nightmare

CBT

What medication is typically used off label for nightmares?

Prazosin

What is the important factor with sleep terrors?

there is NO recall of the nightmare

What is the treatment for night terrors?

no specific tx, just comfort the child and reassurance for the parents

What is the treatment for sleepwalking?

take them back to bed

What is REM behavioral disorder?

Occurs when people are able to act out their dreams

What is the treatment for REM behavioral disorder?

modifying the sleep environment

Can medications worsen or cure certain sleep disorders, such as sleep paralysis?

worsen

ADRs of Doxepin

Somnolence

Sedation

Nausea

URTIs

When should Ramelteon be taken?

30 mins before bed