Insomnia and Sleep Classifications

Insomnia Classifications

• Transient insomnia lasts less than one week
• Short-term insomnia lasts less than three months
• Chronic insomnia lasts more than three months

Exclusion Criteria for OTC Insomnia Medications

• Under 12 years old
• Over 65 years old
• Pregnant or breastfeeding
• Insomnia lasting more than 10 days

Stages of Sleep

• Stage 1: Transitional stage, occurs as the person falls asleep. Light sleep, about 50% of total sleep.
• Stage 2: Deeper sleep; sleepwalking, talking, nightmares, and bedwetting may occur.
• Stages 3 & 4: Neither light nor deep sleep. Skeletal muscle movement is inhibited. Not as much deep sleep as stage 2.
• REM Sleep: Rapid eye movement sleep. Eyes move rapidly side to side. High levels of brain activity, vivid dreams. Blood pressure, heart rate, temperature and metabolism increase. Repeats every 90-120 minutes.

Onset and Duration of Sleep Stages

• Onset of sleep is typically within seconds to minutes, lasting 5-10 minutes.
• Time spent in each stage varies. Stage 2 is most frequent while sleeping. REM periods increase in length as the cycle progresses, with the final REM stage lasting up to an hour.

Diseases and Medications Associated with Insomnia

• Allergies, asthma, COPD
• Alcohol abuse
• Anxiety, depression
• Arthritis, chronic pain
• Antidepressants (e.g., bupropion, fluoxetine, venlafaxine)
• Benign prostatic hyperplasia
• Antihypertensives (e.g., clonidine)
• Gastroesophageal reflux disease
• Amphetamines
• Heart failure
• Beta-adrenergic agonists (e.g., albuterol)
• Menopause
• Caffeine
• Obstructive sleep apnea
• Corticosteroids
• Pregnancy
• Decongestants
• Restless leg syndrome
• Diuretics (taken at bedtime)
• Shift-work sleep disorder

Pharmacologic Therapy for Insomnia

• Diphenhydramine: 25 or 50 mg, 30 minutes before bedtime.
• Melatonin: 2 to 10 mg, 30-60 minutes before bedtime.

Mechanism of Action of Diphenhydramine and Melatonin

• Diphenhydramine blocks histamine-1 receptors
• Melatonin regulates the sleep-wake rhythm by acting on melatonin receptors

Common Side Effects of Diphenhydramine and Melatonin

• Diphenhydramine: Dry mouth/throat, constipation, blurred vision, difficulty urinating, tinnitus.
• Melatonin: Dizziness, drowsiness, headache, nausea.

Non-Pharmacological Strategies for Insomnia

• Cognitive Behavioral Therapy (CBT-I): First-line treatment for insomnia. Addresses dysfunctional thoughts and behaviors.
• Sleep Hygiene: Establish regular sleep schedule, create a comfortable sleep environment, avoid caffeine and alcohol before bedtime, and limit daytime naps. Avoid screens before bed.

Therapeutic Considerations for Insomnia Medication

• Monitor patients for 3 nights of improved sleep.
• Stop medication for one night to assess effectiveness.
• Limit use to 7-10 consecutive nights.
• Doxylamine may be used but is not recommended for a lack of support for its efficacy in studies.
• Melatonin is relatively safe in adults (8mg daily up to 6 months, 10mg daily up to 2 months).
• Melatonin may be safe and possibly effective for insomnia, but clinical significance is sometimes limited.
• Consultation with a doctor is recommended when using medication for insomnia.

Insomnia Management Algorithm (Flow Chart)

• Initial Assessment: Confirm exclusion criteria and sleep problems, then assess for underlying issues like sleep hygiene.
• Difficulty falling asleep: Assess for other causes like stimulants, underlying conditions.
• Rested in the morning? If the patient feels rested and functional during the day, assess if stimulants are contributing to the issue.
• Problem related to stimulants / lifestyle? If identified as a factor, cessation/moderation should be suggested. If lifestyle or stress is the issue, then sleep hygiene and CBT-I should be encouraged.
• Insomnia resolved? If yes, the medication/treatment plan is effective. If not, consult a doctor, and continue to address underlying issues.

This quiz explores the various classifications of insomnia, including transient, short-term, and chronic types. Additionally, it covers the stages of sleep and the criteria for over-the-counter insomnia medications. Test your knowledge on sleep patterns and conditions affecting sleep quality.