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GoT of sleep disorder Tx
- promote restorative sleep
- minimize external (stress, noise) and internal (ie. pain, mood) factors
- reduce daytime impairment
- improve effectiveness of behavioral interventions
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Causes of insomnia
- primary: psychophysiological
- secondary: psychiatric, medications, substance abuse
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Classification of insomnia by duration
- 1. transient: 2-3days
- 2. short-term: <3weeks
- 3. long-term: >3weeks
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Drugs associated with insomnia
- 1. antidepressants: TCA, fluoxetine, SNRI, bupropion, MAOI
- 2. anti-hypertensives: BB, methyldopa
- 3. nicotine
- 4. sympathomimetic amines: caffeine, amphetamines, cocaine, sibutramine, decongestants
- 5. miscellaneous: CC, levothyroxine, PHT, levodopa, quinidine
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Non-pharm options for insomnia
- relaxation exercises
- stimulus control
- sleep restriction
- sleep diary
- aerobic exercise earlier in the day
- CBT
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Sleep hygiene
- regular sleep and waking schedule
- limit daily "in-bed" time
- avoid sleeping in/daytime naps
- avoid offending substances
- avoid evening stimulation/large meals
- 20min warm bath near bedtime
- use bedroom only for sleep and intimacy
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BDZ pharmacokinetics table
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BDZ doses for insomnia Tx
- 1. triazolam 0.125-0.25mg
- 2. oxazepam 15-30mg
- 3. temazepam 7.5-30mg
- 4. lorazepam 0.5-1mg
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Short-term problems with BDZ
- AEs
- carry-over effects (ie. effects lasting too long)
- cognition changes
- anterograde amnesia
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Long-term problems with BDZ
- tolerance
- deprendence
- rebound insomnia
- withdrawal s/s
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S/E of BDZs
- drowsiness
- fatigue
- decreased cognition
- anterograde amnesia
- incoordination
- respiratory depression
- paradoxical effects
- tolerance
- dependence
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Risk factors for BDZ withdrawal
- dose and potency
- duration of Tx (limit use to up to 4weeks)
- speed of withdrawal
- elimination t1/2
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BDZ withdrawal S/S
- confusion
- delirium
- ataxia
- irritability
- psychosis
- seizures
- depression
- anxiety
- insomnia
- fatigue
- blurred vision
- nausea
- hyperreflexia
- psychomotor agitation
- musculoskeletal aches
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Zopiclone doses for insomnia Tx
zopiclone 3.75-7.5mg
- *maximum 4 weeks
- t1/2= 6 hours
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Advantages of zopiclone (non-BDZ hypnotic) over BDZ
- less cortical effects
- less amnesia
- less rebound insomnia
- less tolerance and dependence
- less excitation in children
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S/E of zopiclone
- bitter, metallic taste
- dry mouth
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