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F1 Insomnia, Fatigue, and Drowsiness

Terms in this set (25)

What is sleep?
A physiologic state of relative unconsciousness, and inaction of the voluntary muscles, the need for which recurs periodically.
Stages of Sleep
Stage 1
- Occurs as the patient falls asleep
- Resembles waking state more than sleep
Stage 2
- 50% of sleep time
- Light sleep
Stage 3
- Deep sleep (delta sleep)
- Characterized by patterns of slow‐frequency waves
REM
Stage 4
- Rapid eye movement (REM): Neither light nor deep
- Changes in blood pressure and inhibited muscle movement
Comparisons of Sleep Cycles
Circadian rhythm promotes night time sleep under normal conditions
- circadian rhythm is strongly influenced by light exposure
- REM sleep encompasses 15-20% of total sleep
• associated with dreaming, changes in heart rate, bp, and respiration
- Non-REM Sleep is divided into 4 stages
- Episodes of REM sleep occur at approximately 90 minute cycles with the duration of each episode increasing through the night
Changes in Sleep Physiology with Age
- Elderly persons have more fragmented sleep, and a shorter duration of stage 3 and stage 4 sleep
- Increase in number of nighttime awakenings
- Less time spent in stage 4 and REM sleep
- Cannot assume older adults require less sleep
Insomnia Classifications
Transient
- Lasts < 1 week
- Travel, hopsitalization, stressful event anticipation

Short term
- Lasts 1-3 weeks
- Death of a loved one, recovery from surgery, divorce

Chronic
- Persists for >3 weeks to years
- Medical problems, psychiatric disorder, substance abuse
- Key complaint of patients with pain syndromes
Drugs Causing Insomnia
Alcohol
- can cause insomnia after acute use and as a withdrawal effect after chronic use
Anabolic steroids
antidepressants
anticonvulsants, antihypertensives
antineoplastics
amphetamines
anorexiants
beta-adrenergic agonists
beta-blockers
caffeine
corticosteroids
decongestants
- commonly associated with causing insomnia
diuretics
levodopa
nicotine
oral contraceptives
thyroid preparations
Clinical Presentation of Insomnia
- Patients may complain of:
• Difficulty falling asleep
• Frequent or early morning awakening
• Inability to fall back to sleep
• Disturbed sleep quality
- Symptoms:
• Fatigue, drowsiness, anxiety, irritability, depression, decreased concentration, and memory impairment
- Patients usually need more than 30 minutes to fall asleep
- Duration of sleep is usually less than 6‐7 hours nightly
• Duration of sleep may or may not be different
• National Sleep Foundation recommends an average sleep requirement of 8 hours for adults 18 years or older
Treatment of Insomnia
Treatment Goal
- Improve patient's symptoms, quality of life and
functioning

Transient and short term insomnia
- Re‐establishing normal sleep cycle
• Sleep hygiene
• With or without non‐prescription sleep aid
Nonpharmacological Therapy
Cognitive behavioral therapy
- First‐line for all patients
- Addresses dysfunctional behaviors and beliefs
- Behavioral interventions
• Sleep restriction
• Stimulus control
• Sleep hygiene
~ Should be tried before starting drug therapy
Sleep Hygiene
- Use bed for sleeping or intimacy only.
- Establish a regular sleep pattern. Go to bed and arise at about the same time daily, even on the weekends.
- Make the bedroom comfortable for sleeping. Avoid temperature extremes, noise, and light.
- Engage in relaxing activities before bedtime.
- Avoid using electronic devices (particularly videos,
television, and tablets) around bedtime.
- Exercise regularly but not within 2-4 hours of bedtime.
- If hungry eat a light snack, but avoid eating meals within 2
hours before bedtime.
- Avoid daytime napping.
- Avoid using caffeine, alcohol, or nicotine for at least 4-6 hours before bedtime.
- If unable to fall asleep, do not continue to try to sleep; get out of bed and perform a relaxing activity until you feel tired.
- Do not watch the clock at night.
Pharmacological Therapy
Diphenhydramine: the only sleep aid deemed to be safe and effective for self‐administration according to the FDA
Antihistamines
Ethanolamines
- Diphenhydramine
• 25‐50 mg nightly
• Intermittent use for 3 days with an "off" night
• Use no more than 7‐10 consecutive nights
- Doxylamine
• Safety and efficacy have not been fully established

Block histamine‐1 and muscarinic receptors

Poor efficacy in patients with chronic insomnia

Tolerance develops within days of repeated use
Antihistamines Adverse Effects
Anticholinergic side effects
- Dry mouth and throat
- Constipation
- Blued vision
- Urinary retention
- Tinnitus

Decrease cognition and increase confusion in dementia
- Avoid in patients with dementia
OTC Sleep Aid Products:
Single-Entity Antihistamine Products
Unisome SleepGels Capsules, liquid filled
- diphenhydramine 50mg

Sominex Nighttime Sleep-Aid Tablets
- diphenhydramine 25mg

ZzzQuil Nighttime Sleep-Aid Liquid
- diphenhydramine 50mg/300ml
OTC Sleep Aid Products:
Antihistamine/Analgesic Combination Products
Advil PM Caplets
- diphenhydramine citrate 38mg; ibuprofen 200mg

Excedrin PM Headache Caplets
- diphenhydramine citrate 38mg; acetaminophen 250mg; aspirin 250mg

Tylenol PM Extra Strength Caplets
- diphenhydramine 25mg; acetaminophen 500mg
Complementary Therapy
Melatonin
- Conflicting evidence of efficacy

Valerian root
- Limited benefit compared to placebo
- Continuous use for several days to weeks required
- Benzodiazepine‐like withdrawal and cardiac complications

Kava
- Associated with severe hepatotoxicity
- Do not recommend as a sleep aid
Melatonin
- Hormone produced by the pineal gland
- Regulates sleep and circadian rhythm
• Darkness induces the release
• Light suppresses the release
- Exogenous administration stimulates sleep regulation mechanism
- Variable evidence for occasional insomnia
- Due to minor adverse effects, may be an option on a trial basis
Key Points for Insomnia
- Refer patients with chronic insomnia or sleep disturbance caused by an underlying disorder
- Advise patients to contact their HCP if symptoms worsen or do not improve after 10 days
- Counsel patients with insomnia on nondrug measures such as good sleep hygiene
- Refer children younger than 12 years, pregnant women, and adults older than 65 years
- Advise patients about the different dosage forms of sleep aids so they can select best suited product
- Advise patients that diphenhydramine is the only antihistamine recommended as a sleep aid for occasional insomnia
- Counsel patients that nonprescription sleep aids can cause next‐day sedation
- Counsel patients on the adverse effects of diphenhydramine and other sleep aids, particularly drowsiness and the additive CNS depressant effects of alcohol and other sedating drugs
- Advise patients not to take other oral medications that contain diphenhydramine with a nonprescription sleep aid that also contains diphenhydramine
- Advise patients not to apply topical products that contain diphenhydramine if they are also taking a nonprescription sleep aid that contains diphenhydramine
Fatigue and Drowsiness
Most often caused by inadequate sleep
May also be caused by:
- CNS depressants
• Antihistamines, antipsychotics, anticonvulsants, and opioids
Dopamine agonists
- Antibiotics
- Antihypertensive agents
Insomnia Treatment
Goal
- Identify and eliminate underlying causes to improve mental alertness and productivity

Nonpharmacologic Therapy
- Good sleep hygiene

Pharmacologic Therapy
- Caffeine: only FDA approved nonprescription stimulant
• 100‐200 mg every 3‐4 hours PRN
Caffeine
Non‐selective adenosine antagonists
Effects on dopamine and acetylcholine
Low‐moderate doses (~250 mg)
- Increase arousal, decrease fatigue and elevate mood
- Transient increase in heart rate and blood pressure
Higher doses
- Anxiety, nausea, jitteriness, and nervousness
Limit intake to < 200 mg/day during pregnancy
Key Points for Drowsiness and Fatigue
- Caffeine appears to be safe and effective in low-moderate doses in the diet and for occasional use as a supplement
- Caffeine is most effective when taken intermittently at dosages of 100 or 200mg every 3-4 hours as needed
- Pregnant or nursing women, children younger than 12 years, patients with heart disease, and patients with anxiety disorders should avoid caffeine
- Adverse effects of caffeine are more likely to occur in occasional users and patients of advanced age
- Dietary supplements should not be used to increase energy or decrease fatigue
- Higher daily doses of caffeine can interact with some medications
Laura is a 35 y/o female presenting to the pharmacy. Reports having difficulty falling asleep for the past five days. Feels tired and unproductive during the day.Reports being promoted to a vice president position and experiencing stress due to new responsibilities and multiple deadlines. Reports drinking coffee in the evening to finish projects and watches Youtube
Videos for about half an hour before bed.

Allergies: NKDA
PMH: seasonal allergies
SH: smoking
Medications: Loratadine, Sudafed and Ibuprofen

Laura's insomnia is classified as:
a. intermittent
b. transient
c. short term
d. long term
B. transient
Laura is a 35 y/o female presenting to the pharmacy. Reports having difficulty falling asleep for the past five days. Feels tired and unproductive during the day.Reports being promoted to a vice president position and experiencing stress due to new responsibilities and multiple deadlines. Reports drinking coffee in the evening to finish projects and watches Youtube
Videos for about half an hour before bed.

Allergies: NKDA
PMH: seasonal allergies
SH: smoking
Medications: Loratadine, Sudafed and Ibuprofen

What are the appropriate counseling points for Laura regarding good sleep hygiene?

a. watching tv will help you fall asleep faster
b. drink a glass of wine an hour before bedtime
c. do not smoke or drink coffee 4-6 hours before bedtime
d. avoid using loratadine later during the day as it can cause insomnia
C. do not smoke or drink coffee 4-6 hours before bedtime
Laura is a 35 y/o female presenting to the pharmacy. Reports having difficulty falling asleep for the past five days. Feels tired and unproductive during the day.Reports being promoted to a vice president position and experiencing stress due to new responsibilities and multiple deadlines. Reports drinking coffee in the evening to finish projects and watches Youtube
Videos for about half an hour before bed.

Allergies: NKDA
PMH: seasonal allergies
SH: smoking
Medications: Loratadine, Sudafed and Ibuprofen

What would you recommend for Laura?
a. refer Laura to her PCP
b. recommend discontinuing Sudafed
c. recommend Melatonin 15mg nightly
d. recommend diphenhydramine nightly for 2-3 days
D. recommend diphenhydramine nightly for 2-3
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