Chapter 11 Sleep Disorders, ADHD PDF

11/15/2022 CHAPTER 11 Treatment of Sleep Disorders and Attention-Deficit Hyperactivity Disorder 2 Sleep Disorders and Medications Used to Treat Them (1 of 2) 1. Learn the terminology associated with sleep disorders and attention-deficit...

11/15/2022 CHAPTER 11 Treatment of Sleep Disorders and Attention-Deficit Hyperactivity Disorder 2 Sleep Disorders and Medications Used to Treat Them (1 of 2) 1. Learn the terminology associated with sleep disorders and attention-deficit hyperactivity disorder (ADHD). 2. Discuss the reasons why sleep is necessary. 3. Describe the phases of a normal sleep cycle. 4. Describe symptoms associated with sleep deprivation. 5. Describe the types of sleep disorders. 1  11/15/2022 3 Sleep Disorders and Medications Used to Treat Them (2 of 2) 6. Describe the function of neurotransmitters associated with symptoms of sleep. 7. Classify medications used in the treatment of sleep disorders. 8. Describe mechanism of action for each class of drugs used to treat sleep disorders. 9. Identify warning labels and precautionary messages associated with medications used to treat sleep disorders. 4 Key Terms Hypnotic Insomnia Melatonin Non-REM sleep Rapid eye movement (REM) sleep Rebound hypersomnia Sedative Stimulant 2  11/15/2022 5 Overview Sleep is a necessary biological function for the growth and maintenance of a healthy body. Sleep is needed for: A healthy functioning immune system A healthy functioning nervous system Emotional and social functioning Physical and mental agility Improved memory 6 The Sleep Cycle The sleep cycle is influenced by circadian rhythms. Circadian rhythms are biological changes that occur according to time cycles (sunlight is the primary external time cue for the pineal gland). The pineal gland controls the release of melatonin, a hormone that makes people feel drowsy in addition to regulating body temperature and hormone secretion. 3  11/15/2022 7 Five Stages of Sleep Stage 1: Easily awakened; sudden contractions of the limbs may occur Stage 2: Eye movements stop and brain activity decreases Stage 3 and Stage 4: Deep sleep and difficult to awaken; if awakened, the person feels disoriented Rapid eye movement (REM): Sleep cycle where dreaming occurs 8 Sufficient Sleep Varies… The amount of time a person needs to sleep ranges between 5 and 16 hours per day. Infants may sleep up to 16 hours per day. Teenagers require as much as 9 hours. Adults need as little as 5 to 8 hours. Elders often sleep for shorter time spans, sleep more lightly, and dream less than young adults. 4  11/15/2022 9 Sleep Deprivation Signs: Drowsy feeling during the day Falling asleep within 5 minutes of lying down Factors that contribute to sleep deficiency: Sleep apnea: breathing stops and starts; snoring and tiredness are symptoms Non-pharmacologic measure: CPAP – continuous positive airway pressure device Restless legs syndrome Caffeine consumption (eg. coffee, tea, cola) Prescription and nonprescription drugs Chronic illnesses (eg. gastroesophageal reflux disorder, angina, and chronic pain) 10 Sleep Disorders The most common sleep disorders are: Insomnia Restless legs syndrome: Ropinirole Pramipexole Sleep apnea Narcolepsy falling asleep suddenly and without warning 5  11/15/2022 11 Insomnia Insomnia is categorized according to the time period that symptoms persist: Transient insomnia lasts less than 7 days Short-term insomnia lasts up to 3 weeks Long-term insomnia lasts longer than 3 weeks 12 Treatment of Sleep Disorders Prescription drugs that are used to treat insomnia: Benzodiazepines Other sedative-hypnotics 6  11/15/2022 13 Benzodiazepines Used in the Treatment of Insomnia – “LAMS” & “PAMS” Common endings are “-epam” and “-olam.” Reduce neuronal excitability by opening calcium channels More desirable safety profile than barbiturates 14 Miscellaneous Drugs Used for Insomnia Zaleplon‡ and zolpidem (Sublinox®) are imidazopyridines (also called benzodiazepine receptor agonists). Eszopiclone◊ (Lunesta®) and zopiclone (Imovane®) are cyclopyrrolone derivatives. Diphenhydramine (Nytol®, Unisom®, Sleep-Eze®) and doxylamine (U.S.) are over-the-counter drugs (OTC) that are used for short-term relief of insomnia. ‡ not available in Canada ◊ now available in Canada 7  11/15/2022 15 MOA of Imidazopyridines and Cyclopyrrolone Derivatives Imidazopyridines and cyclopyrrolone derivatives act on benzodiazepine receptors subtype v-1. They modulate the GABAA receptor chloride channel to reduce neuronal excitability. 16 Imidazopyridines and Cyclopyrrolone Derivatives: Adverse Effects Sedation Dizziness Tolerance and dependence Photosensitivity (zaleplon only) Bitter or metallic taste (eszopiclone and zopiclone only) 8  11/15/2022 17 Herbal Treatments for Insomnia Herbal treatments include melatonin and valerian root. Melatonin is a hormone that is produced by the pineal gland; it is sensitive to light changes and tells the body it is time to sleep. The use of valerian root dates back more than 2000 years. 18 Nonpharmacological Treatment of Insomnia (1 of 2) Avoid stimulants close to bedtime (eg. colas, tea, chocolate, fortified water, Mountain Dew, OTC decongestants). Adopt a routine sleep schedule. Avoid daytime naps. Create a safe, comfortable sleeping environment, if possible. Eliminate noise, light (electronic displays) Reduce use of screen devices prior to bedtime. 9  11/15/2022 19 Nonpharmacological Treatment of Insomnia (2 of 2) Do not go to bed hungry, if possible. Exercise 20 to 30 minutes each day (5 to 6 hours before bedtime). Do not lie in bed awake. If you do not fall asleep, get up and engage in a nonstimulating activity such as reading. Try to go to sleep again in about 10 minutes. 20 Benzodiazepines: Warning Labels May cause drowsiness; may impair ability to drive Avoid alcohol May be habit forming 10  11/15/2022 21 Pharmacotherapy for Narcolepsy Stimulants used to treat narcolepsy Modafinil (Alertec®) is a nonamphetamine stimulant. MOA is not fully known, but it is believed to stimulate alpha1-adrenergic receptor sites. Modafinil is also prescribed for the treatment of sleep apnea. Amphetamine, methylphenidate 22 MOA of Drugs Used to Treat Narcolepsy The mechanism of action of modafinil and armodafinil‡ is not known, but they are believed to stimulate alpha1- adrenergic receptor sites. Amphetamine and methylphenidate are stimulants that are classified as sympathomimetic. ‡ not available in Canada 11  11/15/2022 23 Modafinil: Adverse Effects Stimulation Insomnia Tolerance and dependence 24 Modafinil: Warning Labels Avoid alcohol May decrease effect of oral contraceptives May be habit forming 12  11/15/2022 25 Attention-Deficit Hyperactivity Disorder and Medications Used to Treat It 10. Describe the etiology of ADHD. 11. Classify medications used in the treatment of ADHD. 12. Describe mechanism of action for each class of drugs used to treat ADHD. 13. Identify warning labels and precautionary messages associated with medications used to treat ADHD. 14. Identify significant drug look-alike/sound-alike issues. 26 Attention-Deficit/Hyperactivity Disorder (ADHD) Most commonly diagnosed childhood behavioural disorder. Symptoms include: Hyperactivity and restlessness Inability to sit still when required Impulsiveness Inattention and distractibility Forgetfulness Inability to complete tasks three subtypes of ADHD hyperactive-impulsive predominantly inattentive combined type 13  11/15/2022 27 Environmental and Nutritional Risk Factors for ADHD Genetic component Up to 25% of children with ADHD have a relative with it Cigarette smoke and alcohol during pregnancy High levels of lead-based paint Leaded gasoline (still used globally) Food additives and sugar may make ADHD worse. 28 Look-Alike/Sound-Alike Drugs Adderall® and Inderal® Ritalin®, Ritalin® SR 14  11/15/2022 29 Treatment of ADHD No cure for ADHD, only control symptoms Treatments of ADHD include pharmacotherapy and behavioural therapy. Drug treatment of ADHD is achieved with the administration of amphetamines and nonamphetamine stimulants. Amphetamines behave differently in people who have ADHD than they do in people without ADHD. Amphetamines decrease hyperactivity and improve focus. 30 Drugs Used in the Treatment of ADHD Adderall® (mixed salts of amphetamine) Dexedrine® (dextroamphetamine) Focalin®‡ (dexmethylphenidate) Biphentin®, Concerta®, Ritalin® (methylphenidate) Vyvanse® (lisdexamfetamine) Atomoxetine (Strattera®) is a nonamphetamine stimulant inhibits the reuptake of norepinephrine ‡ not available in Canada 15  11/15/2022 31 MOA Amphetamines have three mechanisms of action: Stimulate release of norepinephrine Block monoamine oxidase Stimulate release of dopamine Increased stimulation of adrenergic receptors by norepinephrine: Increases alertness and responsiveness Increases wakefulness Reduced awareness of fatigue *** not in textbook *** guanfacine (Intuniv XR®) is a non-stimulant that is used for ADHD It is a selective alpha2A-adrenergic receptor agonist Its mechanism of action in ADHD is unknown 32 Adverse Effects Decreased appetite Nausea Stomach ache Anxiety Irritability Insomnia Increased heart rate and palpitations Arrhythmia Dizziness Tremor Amphetamine syndrome (a drug-induced psychosis) 16  11/15/2022 Warning Labels Take with food May be habit-forming Swallow whole; do not crush or chew* (*sustained-release and extended-release) 33 17