Insomnia

Principals of good sleep hygiene
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Principals of good sleep hygiene
1. use bed for sleeping and intimacy only
2. establish a regular sleep pattern. go to bed and arise at about the same time daily, even on the weekends.
3. make bedroom comfortable for sleeping. avoid temperature extremes, noise and light.
4. engage in relaxing activities before bedtime
5. avoid use of electronic devices (particularly television and smart devices) around bedtime.
6. exercise regularly but not within a few hours of bedtime.
7. if hungry eat a light snack but avoid eating meals within 2 hours before bedtime
8. avoid daytime napping or limit naps to 20-30 minutes.
9. avoid using caffeine, alcohol, or nicotine for at least several hours before bedtime.
10. if unable to fall asleep after more than 20 minutes, do not continue to try to sleep; get out of bed and perform a relaxing activity until you feel tired.
11. do not watch the clock at night
***appropriate self care insomnia dose for diphenhydramine
take 25-50 mg once nightly for 3 days, then skip 1 day to see if working, use a second 3 day trial if needed.
when should a pt be referred to their medical provider after initiating self-care (non-pharm and OTC)
10 days after initiating self-care non-pharm and OTC
treatment for insomnia
1. All insomnia complaints can have non-pharm tx, specifically sleep hygiene
2. Short-term, primary insomnia, delayed sleep onset (self-care appropriate) pharmacologic tx, Diphenhydramine 25-50 mg every night for 3 nights, skip one day, use a second 3 day trial if needed.
3. If non-pharm/pharmacological tx doesnt work after 10 days of initiating self-care refer to PCP.
Diphenhydramine can cause anticholinergic effects (reason inappropriate for >65 years old)
1. hot as a hare
2. dry as a bone
3. blind as a bad
4. red as a beet
5. mad as a hatter
Image: Diphenhydramine can cause anticholinergic effects (reason inappropriate for >65 years old)
medical disorders assoc. with insomnia (memorize highlighted)
General medical disorders: Allergies, Arthritis, Benign prostatic hyperplasia, Chronic pain syndromes, Diabetes Mellitus, Gastroesophageal reflux disease, Heart Failure, Incontinence, Irritable bowel syndrome, Peptic ulcer disease.
Respiratory disorders: Asthma, Chronic obstructive pulmonary disease.
Psychiatric disorders: Anxiety disorders, Depression, Substance abuse disorders.
Sleep disorders: Restless legs syndrome, Obstructive sleep apnea, Psychophysiological insomnia, Shift-work sleep disorder.
Other conditions: Menopause, Pregnancy.
Who can we treat?
Primary insomnia, Short-term insomnia (<3months) with delayed sleep onset
Paradoxical insomnia
Paradoxical insomnia is a rare condition in which people misjudge how long it takes for them to fall asleep as well as how long they have actually slept. They may think they have only been asleep for a couple of hours, even if they have slept for seven or eight. People with this disorder are extremely aware of their surroundings while sleeping, suggesting that they may transition often between light, stage 1 sleep, and wakefulness.
Short-term insomnia
<3months, self-care is appropriate
Chronic insomnia
>3months, secondary to medical problems, psychiatric disorders, or a substance use disorder. Pathophysiology behind chronic insomnia is not going to be effectively treated by OTC meds.
Reason Diphenhydramine is recommended over DoxylamineSafety and efficacy of Doxylamine have not been fully established. It is used commonly for n/v in pregnant women so its not like we dont use it OTC. But for insomnia we have more data for Diphenhydramine.Diphenhydramine (Benadryl)1. H1 antagonist 2. Efficacy poor in chronic insomnia 3. Max sedation 1-3 hours after dose 4. Tolerance develops within days 5. Seek medical evaluation if use more than 10 consecutive nights. 6. 25-50 mg nightly for 3 nights, skip one, repeat 3 night trial if needed.AK, 78 yo male S: Difficulty sleeping C: "It takes me over an hour to fall asleep every night" H: States he has been suffering from sleep difficulty for "years" O: At lease a year ago. L: A: R: He reports drinking 2-3 whiskey drinks before bedtime to help him sleep. A: NKDA C: High cholesterol and hypertensionIs the patient appropriate for self-care? Why or why not? No because of his age (>65yo) No because he has chronic insomnia (>3months) No because he has significant sleep disturbance (takes >30 minutes to fall asleep) Provide any appropriate non-pharm recommendation(s) Non-pharm should ALWAYS be recommended if identified, sleep-hygiene opportunity would be to avoid alcohol several hours before bedtime. Provide tips on how to cut/decrease the alcohol intake. Provide any appropriate pharm recommendation(s) Not eligible for pharmacological tx due to exclusions Provide the patient with any appropriate counseling points Alcohol disrupts the sleep cycle. Patient can attempt to cut/decrease the amount of his alcohol intake for 10 days, if that does not help he needs to make an apt with PCP because none of the OTC meds available help him. When will you follow up with the patient / when should the patient seek medical evaluation? Patient can try the non-pharm recommendation to improve sleep hygiene and if he doesn't experience any relief after 10 days he should seek medical eval. Note regarding the lisinopril, the book lists some antihypertensive drugs as an exclusion but Lisinopril not an exclusion because it is an ACE inhib. and it is not listed in book.LG, 49 yo male S: Difficulty sleeping and asking about Unisom or ZZZ Simply Sleep C: Often wakes up 1-2 hours after falling asleep, has difficulty falling back asleep. H: Avoids caffeinated products before bedtime, avoid naps O: This has been happening for about a month L: A:"It is worse when I am feeling more anxious." R: Listens to a guided meditation tape before getting into bed M: Lisinopril (for hypertension) and venlafaxine (for anxiety) A: NKDA C: Hypertension, anxiety and restless legs syndrome (managed without medications)Is the patient appropriate for self-care? Why or why not? Secondary insomnia due to anxiety and restless legs syndrome Significant sleep disturbance - WASO (waking after sleep onset) Provide any appropriate non-pharm recommendation(s) Nothing can be identified to help in self-care non-pharm setting Provide any appropriate pharm recommendation(s) Not appropriate for pharmacological recommendations because of exclusions for self-care. Provide the patient with any appropriate counseling points. Venlafaxine is an SNIR which is a drug that can cause insomnia, refer to PCP to find a better tx option to treat underlying psychiatric disorder When will you follow up with the patient / when should the patient seek medical evaluation? Patient should refer to PCP right awayBM, 38 yo female S: Difficulty sleeping and would like your recommendation on melatonin use. C: She moved into a new apartment last week, having difficulty falling asleep in her new space. Runs 3-5 miles every morning. Drinks 1 cup coffee with breakfast, avoids caffeine the rest of the day. H: Has tried valerian in the past with little benefit, also watches TV in bed every night in an attempt to fall asleep. O: Last week L: A: R: Trying to watch TV at night, not sure this is helping M: Likes to avoid "drugs". A: NKDA C: No other medical conditionsIs the patient appropriate for self-care? Why or why not? Yes, no exclusions Provide any appropriate non-pharm recommendation(s) sleep hygiene recommendation = avoid using electronica devices (particularly television and smart devices) around bedtime. Provide any appropriate pharm recommendation(s) Diphenhydramine 25-50mg nightly for 3 nights, skip one night to see if insomnia is resolved, repeat 3-night trial if needed. Provide the patient with any appropriate counseling points. We prefer Diphenhydramine over Melatonin because there is more evidence behind its efficacy. Melatonin is a drug (anything that can effect the physiologic actions of the body is a drug) Establish a regular bedtime and take diphenhydramine 30 min before you want to go to sleep. Do not take more than 50 mg each night. Long periods of use can cause tolerance. Do not drink alcohol while using this medication. May cause anti-cholinergic effects. Do not use diphenhydramine in combination with prescription sleep aids. Consult health care provider before taking diphenhydramine with other medications. When will you follow up with the patient / when should the patient seek medical evaluation? Refer to PCP if there is no relief after 10 days of initiating self-care.JZ, 41 yo male S: Difficulty falling asleep, feeling tired all day C: "I am determined to fall asleep, I won't get out of bed once I've decided its time for sleep." Works a demanding job with varying hours, sometimes leaves the house at 5 am, sometimes not until 9 am. States that he aims for a healthy lifestyle, follows a healthy diet with lots of lean protein and vegetables. Runs nightly and then showers right before bedtime. Drinks 1-2 cups coffee every day with breakfast. H: Watches TV in bed in an effort to relax and fall asleep, it is not very effective. O: Its been really bothering me the past 2 months L: A: "Everything I try seems to make it worse!" R: Naps during the day if he is overly tired, but only in the early afternoon, sleeping no later than dinner time. M: Does not take any medications A: NKDA C: No medical conditionsIs the patient appropriate for self-care? Why or why not? Yes, no exclusions Provide any appropriate non-pharm recommendation(s) Sleep hygiene recommendation = if unable to fall asleep after more than 20 minutes, do not continue to try to sleep, get out of bed and perform a relaxing activity until you feel tired. Sleep hygiene recommendation #2 = exercise regularly but not within a few hours of bedtime. Sleep hygiene recommendation #3 = try to avoid daytime napping or limit to 20-30 minutes and avoid in later afternoons near bedtime. Provide any appropriate pharm recommendation(s) Diphenhydramine 25-50mg nightly for 3 nights, skip one night to see if insomnia is resolved, repeat 3-night trial if needed. Provide the patient with any appropriate counseling points Establish a regular bedtime and take diphenhydramine 30 min before you want to go to sleep. Do not take more than 50 mg each night. Long periods of use can cause tolerance. Do not drink alcohol while using this medication. May cause anti-cholinergic effects. Do not use diphenhydramine in combination with prescription sleep aids. Consult health care provider before taking diphenhydramine with other medications. When will you follow up with the patient / when should the patient seek medical evaluation? Refer to PCP if there is no relief after 10 days of initiating self-care.