1. What is the definition of insomnia?
    complaint of disturbed sleep in the presence of an adequate opportunity and circumstance for sleep
  2. What factors are associated with idiopathic (Primary) insomnia?
    • chronic stress
    • poor sleep hygiene
    • learned insomnia
  3. What factors contribute to comorbid (Secondary) insomnia?
    • dementia, depression, anxiety disorders
    • GERD
    • pain
    • asthma
    • substance abuse
    • restless leg syndrome
    • sleep apnea
    • circadian rhythm disorders
    • periodic limb movement disorder
    • stimulants
    • diuretics
    • caffeine
  4. What is chronic insomnia?
    at least 3 nights/wk for a month

    most often associated with comorbid disorders
  5. What is acute insomnia?
    • one night to a few weeks
    • most often associated with emotional or physical stressors (illness, jetlag)
  6. What are the 2 stages of sleep?
    REM and nonREM
  7. nonREM sleep is divided into what 4 stages?
    • light sleep
    • intermediate sleep
    • deep sleep (physical well-being)
    • deep sleep (physical well-being)
  8. What are the characteristics of REM sleep?
    • physiological changes occur (BP, HR, RR)
    • dreaming
    • necessary for learning and mood regulation
  9. How long does a sleep cycle last?
    1.5-2 hours
  10. How many times in a night does the sleep cycle repeat?
    4-5 times
  11. Which stages increase as the number of cycles increases?
    Stage 2 and REM
  12. Which part of the night contains the most stage 3 and stage 4 sleep?
    the first half
  13. What happens to the sleep cycle as people age?
    • stage 3 and stage 4 decrease
    • stage 1 increases
  14. How many people actually respond to non-pharmacological tx of insomnia?
  15. What is Cognitive-behavioral therapy (CBT)?
    • sleep hygiene education:
    • regular sleep schedule
    • exercise
    • avoid stimulants and caffeine before bed
    • ensure comfortable sleep environment
    • stimulus-control therapy:
    • associate bedroom w/sleep
    • only go to bed when tired
    • avoid napping
    • leave bedroom if unable to sleep within 15-20 minutes
    • return to bed only when tired
    • relaxation therapy:
    • meditation
    • sleep restriction:
    • temporarily induce sleep deprivation (not recommended)
    • yoga
  16. What drugs are used for insomnia?
    • estazolam
    • flurazepam
    • quazepam
    • temazepam
    • triazolam
    • eszopiclone
    • zaleplon
    • zolpidem
    • amitriptyline
    • doxepin
    • trazodone
    • ramelteon
    • diphenhydramine
    • doxylamine
    • melatonin
    • valerian
  17. Which BZDs (sedative hypnotics) are used for insomnia?
    • estazolam
    • flurazepam
    • quazepam
    • temazepam
    • triazolam
  18. What is the MOA of BZDs?
    bind to GABA receptor, increasing the activity of GABA when it binds to GABAA
  19. What part of insomnia do BZDs affect?
    • decrease sleep latency
    • increase total sleep time
  20. What are the side effects of BZDs?
    • daytime sedation/hangover
    • anterograde amnesia
    • pregnancy category X
    • complex sleep behaviors
  21. What DI do BZDs have?
    all except temazepam are metabolized by 3A4 which increases CNS depression when used with other CNS depressants including alcohol
  22. Which BZD has the longest half-life?
    • flurazepam
    • quazepam
  23. Which BZD has shortest half-life?
    triazolam (means more likely to have anterograde amnesia)
  24. Which BZD has no active metabolites?
    • estazolam
    • temazepam
  25. Who should not take BZDs?
    pts with COPD or sleep apnea d/t respiratory depressant effects
  26. Which BZDs should you recommend for insomnia?
    • temazepam for sure
    • maybe estazolam, but it's more expensive and has more DI
  27. What BZD-Receptor Agonists (BZD-RAs) are used for insomnia?
    • eszopiclone (Lunesta)
    • zaleplon (Sonata)
    • zolpidem (Ambien)
  28. What is the MOA of BZD-RAs?
    bind near the BZD receptor on GABA causing increased GABA activity
  29. What is the effect on sleep of BZD-RAs?
    • decreased sleep latency
    • increase total sleep time (not zaleplon)
  30. Which BZD-RA can have the dose repeated if planning on sleeping at least 4 more hours?
    zaleplon (Sonata)
  31. How is eszopiclone (Lunesta) dosed?
    • lower doses for sleep latency
    • higher doses to increase total sleep time
  32. What are the side effects of BZD-RAs?
    • HA
    • dizziness
    • bitter taste
    • pregnancey cat C (except zolpidem - class B)
    • complex sleep behaviors

    all are metabolized by 3A4, careful with CNS depressants
  33. Which BZD-RA has shortest half-life?
    zaleplon (Sonata)
  34. Which BZD-RA has an active metabolite?
    eszopiclone (Lunesta)
  35. Who should use caution in using BZD-RAs?
    • pts w/COPD or sleep apnea b/c of respiratory depressant effects
    • depression - risk of suicidality
  36. What is the MOA for ramelteon (Rozerem)?
    • Melatonin receptor agonism
    • M1 and M2 specific
  37. What effects are produced by melatonin receptors?
    • M1 - sedation
    • M2 - circadian rhythm
    • M3 - not for sleep
  38. What effect on sleep does ramelteon (Rozerem) have?
    • decrease sleep latency
    • possibly increase total sleep time
  39. What are the SE of ramelteon (Rozerem)?
    • HA
    • dizziness
    • fatigue
    • nausea
    • preg C
    • complex sleep behaviors

    • metabolized by 3A4, careful with CNS depressants
    • high-fat meals significantly increase levels
  40. What ADs are used for insomnia?
    • amitriptyline (Elavil)
    • doxepin (Sinequan)
    • trazadone (Desyrel)
  41. What is the MOA for ADs in insomnia?
    produce sedation by blocking histamine, ACh, NE, and 5-HT presynaptic receptors
  42. What effect do ADs have on sleep?
    • decrease sleep latency
    • increase total sleep time
  43. What are the SE of ADs?
    • TCAs - anticholinergic
    • trazadone (Desyrel) - HA, OH, lethargy
    • preg C and enter breastmilk
    • risk of suicidality
  44. What antihistamines are used for insomnia?
    • diphenhydramine (Benadryl, Nytol, Sominex)
    • doxylamine (Unisom)
  45. What is the MOA for antihistamines in insomnia?
    block H1 and muscarinic receptors in the brain resulting in sedation
  46. What effect do antihistamines have on sleep?
    • decrease sleep latency
    • increase total sleep time
  47. What are the SE of antihistamines?
    • anticholinergic
    • avoid in breastfeeding
  48. What is a major drawback to using antihistamines for insomnia?
    tolerance develops in a week = no chronic use
  49. What herbal products are used for insomnia?
    • melatonin
    • valerian
  50. When should you take melatonin?
    1h before desired sleep time
  51. What specific indications may melatonin be good for?
    • shift-workers
    • jet lag
    • blindness
    • ADHD
    • autism
    • low melatonin levels
  52. Which drugs should be recommended for acute insomnia?
    • BZD (temazepam)
    • BZD-RA (zolpidem IR)
  53. Which drugs should be recommended for chronic insomnia?
    • Approved:
    • zolpidem CR (Ambien)
    • eszopiclone (Lunesta)
    • ramelteon (Rozerem)
    • Consider:
    • trazodone (Desyrel)
    • zolpidem IR (Ambien)
    • temazepam
  54. Which drugs should be avoided in elderly w/insomnia?
    • short half-life BZD
    • TCAs
    • antihistamines

    • consider:
    • trazodone (Desyrel)
    • zolpidem IR (Ambien)
    • start at 1/2 dose
  55. What should be used in peds/adolescents with insomnia?
  56. What should be used in pregnant women with insomnia?
    • zolpidem (Ambien):
    • cat B
    • compatible with breastfeeding

    avoid BZDs
  57. What should be checked in pts with restless leg syndrome?
    ferritin levels
  58. What can be done about restless leg syndrome?
    • Intermittent sx:
    • levodopa/carbidopa (Sinemet) q HS prn
    • Daily sx:
    • pramipexole (Mirapex)
    • ropinirole (Requip)
    • 2h before bed
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