Kembara Xtra - Medicine - Insomnia
Even with sufficient opportunity and conditions for sleep, trouble falling asleep or staying asleep, or nonrestorative sleep, results in at least one of the following daytime impairments: - Malaise or exhaustion - A decrease in memory, attention, or concentration - A decline in social or academic functioning - A change in mood or irritation - Daytime drowsiness - Loss of initiative, energy, or motivation - An increased risk of mistakes or accidents at work or while driving - Tension, headaches, or GI problems following a lack of sleep - Sleep-related anxieties or concerns Epidemiology Predominant sex: female > male (5:1) Predominant age: increases with age Chronic insomnia affects 10% of middle-aged individuals and one-third of people over 65. Insomnia (transient and chronic) affects 5–35% of the population and is associated with daytime impairment for 10%–15% of the population. Pathophysiology and Etiology Temporary/intermittent (less than 30 days) and brief (less than 3 months) - Usually brought on by a known stressor Shift work, enthusiasm, or mourning, as well as medical conditions Chronic insomnia, which lasts longer than three months, can result from high altitude but is typically not caused by a single factor. - Medical: GERD, sleep apnea, persistent discomfort, congestive heart failure, Parkinson's disease, Alzheimer's disease, chronic fatigue syndrome, and irritable bowel syndrome - Psychiatric: psychotic, anxious, and mood disorders - Idiopathic, psychophysiologic (heightened arousal and acquired sleep-preventing connections), paradoxical (misperception of the sleep state), primary sleep disorder - Circadian rhythm disorder: erratic behavior, jet lag, advanced or delayed sleep stage, shift work - Ambient: lights (LCD clocks), noises (snoring, home, traffic), and movements (spouse, small children, pets). Poor sleep hygiene and adjustment sleep disorders are behavioral issues. Antihypertensives, antidepressants, corticosteroids, levodopa-carbidopa, phenytoin, quinidine, theophylline, and thyroid hormones are among the medications that can be used to treat substance-induced psychosis. Age, female gender, medical comorbidities, unemployment, mental illness, impaired social interactions, lower socioeconomic position, shift work, separation from a spouse or partner, drug and alcohol misuse, and a personal or family history of sleeplessness are risk factors. Prevention Practice consistent sleep hygiene by: - Setting fixed wake-up and bedtimes (weekdays and weekends), regardless of the amount of sleep received; - Only going to bed when you're tired. Don't take naps. - Find a calm, dark, and cool place to sleep. - No activities or stimuli in the bedroom other than those related to sex or sleep. - Allow yourself 30 minutes to wind down before bed. If you can't fall asleep after 20 minutes, change places and do something quiet until you do. Do not consume caffeine after midnight.No alcohol after 4 o'clock.Predetermined mealtimes.Steer clear of drugs that disrupt sleep.Regular, moderate exercise (at least four hours before bed) Associated Conditions Addiction to drugs or alcohol, psychiatric problems, painful musculoskeletal ailments, obstructive sleep apnea and restless leg syndrome. Insomnia history - Duration, time of problem - Sleep latency, difficulty in maintaining sleep (repeated awakening), early morning awakening, non-restorative sleep, or patterns (weekday vs. weekend, with or without bed partner, home vs. away) Presenting History Daytime sleepiness and napping Unintended sleep episodes (e.g., dozing at a stoplight while driving, working) Sleep hygiene: bedtime and wake-up times; the physical environment of the sleeping area; including LED clocks, TVs, lights, and background noise - Activities: eating at night, working out, and having sex Caffeine, alcohol, herbal supplements, diet pills, illegal substances, prescription medications, and over-the-counter (OTC) sleep aids are all consumed. Signs or a history of significant psychological symptomatology such as depression, anxiety, obsessive-compulsive disorder, or another Restless leg syndrome and periodic limb movement disorder symptoms, heightened arousal symptoms, snoring and other sleep apnea symptoms, signs of drug or alcohol abuse in the past, current medication use, chronic medical conditions, sudden change in routine or stressors like travel or shift work, and a seven-day sleep diary. Clinical Assessment There is no connection between specific physical examination findings. Differential diagnosis includes: substance abuse; sleep disorders caused by medical or neurological conditions; sleep disorders of the breathing such as obstructive sleep apnea; CNS hypersomnias (such as narcolepsy); circadian rhythm sleep disturbances; sleep-related movement disorders (such as restless leg syndrome); and mood and anxiety disorders such as depression or anxiety. Laboratory Results In most cases, diagnostic testing is not necessary; however, if sleep apnea or periodic limb movement disorder are suspected, consider polysomnography. Initial examinations (lab, imaging) Routine laboratory testing is not advised; instead, testing based on a history and physical examination should be taken into consideration to assess for coexisting disorders. Other/Diagnostic Procedures Although not frequently recommended, polysomnography or multiple sleep latency testing may be taken into account if: the initial diagnosis is unclear; treatment approaches have failed. Management Short-term and transient insomnia may be treated with drugs; hypnotic sedatives are preferred. - Drinking alcohol while self-medicating can increase awakenings and sleep stage shifts. Chronic insomnia - Management of underlying condition (major depressive disorder, generalized anxiety disorder, medicine, pain, substance misuse) - Recommendation of appropriate sleep habits. - The first line of treatment for chronic insomnia is cognitive behavioral therapy. – As a long-term treatment, behavioral therapy may be more successful than medication in treating insomnia. - Ramelteon is the only agent with no history of abuse Medication: Nonbenzodiazepine hypnotics have addiction potential since they act on the benzodiazepine receptor, which makes them reserved for temporary and short-term insomnia caused by conditions including jet lag, stress reactions, and temporary medical conditions. Zaleplon (Sonata), 5–20 mg, 1–hour half-life Zolpidem (Ambien) is available in doses of 5 to 10 mg for males and 5 mg for females. Its half-life is 2.5 to 3.0 hours. Zolpidem (Ambien CR) is available in doses of 6.25 to 12.50 mg for males and 6.25 mg for females. Eszopiclone (Lunesta): 1–3 mg; 6–hour half-life Triazolam (Halcion) 0.25 mg; half-life 1.5 to 5.5 hours - Intermediate acting Benzodiazepine hypnotics Temazepam (Restoril), 7.5 to 30.0 mg, has an 8.8-hour half-life. Estazolam (Prosom), 1 to 2 mg, has a 10 to 24-hour half-life. Quazepam (Doral) 7.5 to 15.0 mg; half-life 39 hours (parent drug), 73 hours (active metabolite) Flurazepam (Dalmane) 15 to 30 mg; half-life 40 to 100 hours The following are some contraindications and precautions: - Long-term use is not recommended because to the potential for tolerance, dependence, impairment of daily attention and concentration, incoordination, and rebound insomnia. - Long-acting benzodiazepines should be avoided by the elderly, women who are pregnant or nursing, people who use drugs, and those who exhibit suicidal or parasuicidal behaviors. - They are also associated with a higher incidence of daytime drowsiness and motor impairment. Avoid in patients who have untreated chronic lung illness and obstructive sleep apnea. – There is insufficient proof to support the use of benzodiazepines in palliative care patients. – Sometimes nonbenzodiazepine receptor agonists can cause parasomnias, such as sleep feeding, sleep walking, and sleep driving. Ramelteon (Rozerem), an 8 mg tablet with a 1.0 to 2.6 hour half-life, is a melatonin receptor agonist. Effective for both short- and long-term use in adults to delay the beginning of sleep, without the potential for misuse; no comparative studies with older drugs have been carried out. Effects may not start for three weeks. Sedating antidepressants, such as Doxepin (Silenor), which has a 15-hour half-life and is the only antidepressant FDA-approved for treating insomnia. - Trazodone (Oleptro) 25–200 mg; 3–9 hour half-life Amitriptyline (Elavil) 25 to 100 mg; half-life 10 to 26 hours; and Mirtazapine (Remeron) 7.5 to 15.0 mg; half-life 20 to 40 hours Suvorexant (Belsomra), a 10–20 mg orexin receptor agonist with a 12-hour half-life. Because there is inadequate proof of their effectiveness and there are serious concerns about their hazards, sedating antihistamines are not advised and should only be used sparingly to treat insomnia. Antipsychotic usage is not supported by strong evidence. Only if the patient has a coexisting psychiatric condition that justifies their use should they be prescribed. Aspects of Geriatrics When administering benzodiazepines or other sedative hypnotics, take caution (risk of falls and confusion); if absolutely essential, utilize short-acting nonbenzodiazepine agonists at half the dosage or melatonin agonists for short-term treatment. Alternative Therapies Melatonin reduces sleep latency when taken 30 to 120 minutes before bedtime, but there is weak evidence that it is effective in treating insomnia, and long-term effects are unknown. Valerian has weak evidence that it is effective in treating insomnia, and its slow (2 to 3 week) onset of action disqualifies it from being used as an immediate treatment for insomnia. Acupuncture may help with sleep quality; antihistamines have insufficient evidence to support their use; cognitive-behavioral therapy, which includes relaxation techniques, is effective and preferred over medication as the first line of treatment for patients with chronic insomnia; there is no improvement in efficacy when medication is added; and mindfulness awareness techniques help with sleep quality and sleep-related daytime impairment for older adults. Follow-Up Daily exercise enhances sleep quality and may be more effective than prescription drugs.Avoid exercising four hours before going to bed.Patient observationRegularly reevaluate your pharmaceutical needs; stay away from standing prescriptions. Patient self-report (such as a sleep diary) should be used to assess treatment effectiveness because portable sleep monitors are frequently unreliable. Patients should be informed that both benzodiazepines and nonbenzodiazepine agonists (such as zolpidem, zaleplon, and eszopiclone) can lead to addiction. Studies indicate that having a hypnotic prescription is linked to a >3-fold increase in the risk of dying, even when just 18 tablets are administered annually. Diet Avoid large late-night snacks; reserve coffee for the morning only; and opt for small nibbles before bed.Avoid drinking alcohol six hours before sleeping. Prognosis Situational insomnia should pass with time, and the pillars of treatment include addressing the underlying cause and maintaining good sleep hygiene. Complications Temporary sleeplessness can develop into chronic insomnia. If untreated, chronic sleep apnea can cause pulmonary hypertension, hypertension, stroke, or heart ischemia. It can also cause daytime sleepiness and cognitive problems.
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