Insomia (Self Care).pdf

Insomnia, Drowsiness, and Fatigue Page 7: Insomnia Basics Insomnia: Falling asleep (sleep latency) Staying asleep (sleep maintenance) Not feeling refreshed after sleeping Impairment in daytime functioning is necessary for diagnosis ▪ The National Sleep Foundation recommends 7–9 hours of sleep nightl...

Insomnia, Drowsiness, and Fatigue Page 7: Insomnia Basics Insomnia: Falling asleep (sleep latency) Staying asleep (sleep maintenance) Not feeling refreshed after sleeping Impairment in daytime functioning is necessary for diagnosis ▪ The National Sleep Foundation recommends 7–9 hours of sleep nightly for adults ages 26–64 years, and 7–8 hours for adults 65 years and older ▪ Americans average per night but gets only 6.9 hrs! ▪ May be due to sleep apnea, narcolepsy, restless leg syndrome & others 1/3 of the US population suffers from insomnia nightly Left untreated can cause: Accidents, increased morbidity/mortality, depression, anxiety, substance abuse, etc Sleep Cycles: Stage 1: Transitional stage as you fall asleep; EEG resembles waking state more than sleep Stage 2: 50% of sleep time; light sleep Stage 3: Deep sleep (delta sleep); EEG shows delta waves which are slow frequency waves REM: Rapid eye movement sleep; Neither light nor deep; EEG shows high- frequency waves; Skeletal muscle is inhibited, eyes move rapidly; BP, HR, Temp, RR and metabolism are all ; Repeats every 70- 120 min Insomnia Classification-2 ways: Duration & Etiology Duration: Transient: Self-limiting Lasts less than 1 week Short Term: Lasts 1-3 weeks Chronic/ Long Term Often results from medical problems, psychiatric disorders or substance abuse, Lasts greater than 3 weeks Etiology: Primary: Sleep difficult lasts > 1 month and affects psychosocial functioning Not caused by another sleep disorder, general medical disorder, psychiatric disorder or medication- The primary issue needs to be addressed Secondary: An identifiable cause exists (disorder, medication, etc) Poor Sleep Latency (Falling Asleep): Often associated with acute life stresses, illnesses, anxiety and bad sleep hygiene Travel Hospitalization Anticipation of a stressful/important event Death of a loved one Recovery from surgery Divorce FINALS Unless managed, short term insomnia from the above may become chronic insomnia Medical Conditions associated with insomnia: General Medical Disorders: Sleep Disorders Arthritis: Psychological insomnia Benign Prostatic Hyperplasia (BPH): Restless Leg Syndrome (RLS) Chronic Pain Syndrome: Shift-work sleep disorder Diabetes: Sleep apnea Gastroesophageal Reflux Disease (GERD): Other Conditions Heart Failure: Menopause Peptic Ulcer Disease: Pregnancy Respiratory Disorders: Psychiatric Disorders Asthma: Anxiety Disorders Chronic Obstructive Pulmonary Disease (COPD): Depression Medications associated with worsening insomnia: Drugs That Can Cause Insomnia: Anorexiants (eg. phentermine) Beta-blockers (especially propranolol) Anabolic Steroids Caffeine Anticonvulsants Corticosteroids Antidepressants (eg. bupropion, fluoxetine, venlafaxine) Decongestants (eg. pseudoephedrine, phenylephrine) Antihypertensives (eg. methyldopa, clonidine) Diuretics (at bedtime) Antineoplastics Levodopa Amphetamines Nicotine Alcohol Oral Contraceptives Beta-Adrenergic Agonists (eg. albuterol) Thyroid Preparations Drugs that can cause Withdrawal Insomnia: Alcohol Amphetamines Antihistamines (1st generation) Barbiturates Benzodiazepines Chloral Hydrate Monoamine Oxidase Inhibitors Opiates Tricyclic Antidepressants IIIicit drugs (e.g cocaine, marijuana, phencyclidine) Page 14: Presentation of Insomnia Symptoms of insomnia: difficulty falling asleep, frequent awakenings, impaired daytime functioning Impact on quality of life and associated symptoms like fatigue and drowsiness Page 15: Exclusions for Self Care Less than 12 years of age Greater than 65 years of age Pregnancy Frequent nocturnal awakenings or early morning awakenings (may be associated with depression) Chronic insomnia more than 3 weeks (OTC options aren’t generally helpful) Sleep disturbances secondary to psychiatric or general medical disorders Page 16: Treatment Goals Goals of insomnia treatment: improve sleep duration and quality, reduce daytime fatigue, enhance daytime functioning, and minimize adverse effects Page 17: Patient Case #2 RF, a 39-year-old female with insomnia due to stress, hypertension, dyslipidemia, and allergic rhinitis Medications: Lisinopril/HCTZ, atorvastatin, loratadine Symptoms: difficulty sleeping, tiredness during the day Page 19: Treatment Algorithm Promoting restful and restorative sleep with a treatment algorithm Note The lecture covers the identification, causes, and treatment of insomnia, drowsiness, and fatigue. Patient cases illustrate insomnia scenarios in young adults and middle-aged individuals. Various factors like medical conditions, medications, and lifestyle contribute to sleep disturbances. Treatment goals aim to improve sleep quality, reduce daytime fatigue, and enhance overall functioning. Nonpharmacologic Treatment Recommended for transient and short-term insomnia o No underlying medical or psychiatric conditions causing insomnia Sleep Hygiene o Establish normal sleep cycle o Make bedroom comfortable for sleeping o Engage in relaxing activities before bed o Avoid caffeine, alcohol, and nicotine before bed o Exercise regularly but avoid late-night exercise o Avoid late-night heavy meals o Remove environmental distractions o Avoid daytime napping o Do not watch the clock Pharmacologic Treatment: Diphenhydramine MOA Competes with histamine for H1-receptor sites on effector cells in the GI tract,blood vessels, respiratory tract. o Anticholinergic and sedative effects Indication o Symptomatic management of transient and short-term sleep difficulty o Use of this should be limited Dosing o 50 mg at bedtime, some benefit from 25 mg o After 3 days take an “off” night to assess sleep o Tolerance develops in ~4 days o Use no more than 7-10 days consecutive nights Side Effects o Anticholinergic effects = dry mouth/ throat, constipation, urinary retention, blurred vision and tinnitus; anticholinergic toxicity may occur. o Drowsiness. o May interact with other drugs that can cause drowsiness Counseling Points o Avoid driving, operating machinery, cooking o Do not drink alcohol o Paradoxical excitation may occur Contraindications o Older men with BPH and trouble urinating, o Angle-closure glaucoma o Patients with decreased cognition/dementia o Patients with angina or arrhythmias o Diphenhydramine can be found in: ZzzQuil Unisom Tylenol PM Nighttime Sleep-Aid Advil PM Benadyrl Allergy Anticholinergic Side Effects Anticholinergics o Dry mouth, constipation, blurred vision Cholinergic Crisis o Symptoms like salivation, urination, defecation. o SLUD o Salivation o Lacrimation o Urination o Defecation o “Cant spit, Cant see, Cant pee, Cant shit” Pharmacologic Treatment: Doxylamine & Ethanol Doxylamine o Safety and efficacy not fully established o Commonly available in sleep aid products o Do not recommend - less efficacy data than diphenhydramine Ethanol o Initially improves sleep in patients who do not abuse alcohol o Used by patients to induce sleep o High doses: sleep disturbances occur in the second half of the night o Tolerance develops quickly and leads to using higher doses o Chronic uses causes disorganization of sleep, restless sleep, reduced sleep duration and rebound insomnia with discontinuation o Present in some OTC products (10%) The label indicates the alcohol content is 12% Pharmacologic Treatment-CAM Melatonin o Limited benefits, may be effective for some types of insomnia o Usual dose is 0.3- 5 mg at bedtime (30 minutes prior) BEST evidence seen in patients with neurological disorders, elderly, depression or jet lag Valerian (valeriana officinalis) o Limited benefit, continuous use needed for effects o Trials have used doses of 400- 900 mg o Continuous nightly use for days- weeks is needed for effects (not useful in acute insomnia) o Withdrawal can occur when large doses are taken for many years; discontinue slowly via taper Kava o Associated with severe hepatotoxicity o Do not recommend o Chamomile, ginseng, lavender, hops, lemon balm, passion flower o Inadequate evidence 5-Hydroxytrytophan (5-HTP) o Immediate precursor to serotonin o Efficacy is not established; May be linked to eosinophilia-myalgia syndrome (EMS) o Do not recommend o Special Populations Pregnancy o Benefit vs. risk, refer to medical provider Breastfeeding o Increased risk of CNS effects in infants o Drowsiness in infants with mothers ingesting sedating antihistamines Page 31: Special Populations Pregnancy: Benefit vs. risk -> refer to medical provider Diphenhydramine: pregnancy category B Breastfeeding: Increased risk of CNS effects in breastfed infants whose mothers ingest sedating antihistamines Use of low dose after last daytime feeding may lessen the effects Drowsiness can be seen in infants whose mothers ingest large doses of sedating antihistamines for sustained periods Children/ Adolescents: o o o o o Insomnia may be due to circadian rhythm disorder. Start with behavioral interventions/sleep hygiene first Avoid using diphenhydramine/doxylamine for children under 12. Diphenhydramine can cause paradoxical excitation in younger children. Avoid oral and topical diphenhydramine together in children (toxicity) Teenagers: o Inquire about caffeine/alcohol use. Older Adults: o o Beers criteria advises against anticholinergics. Diphenhydramine may lead to cognitive impairment/falls. Page 32: Patient Counseling Emphasize good sleep hygiene as a primary approach. Review dosage guidelines and therapy duration for pharmacologic options. Educate on adverse effects, drug interactions, and warnings. Inform about signs indicating the need for medical provider consultation. Discourage using multiple pharmacologic insomnia options. AASM weakly recommends against diphenhydramine for insomnia. Page 37: Drowsiness and Fatigue Basics Causes: inadequate sleep, caffeine Effects: Increases risk of workplace and transportation accidents, Increased accidents in drivers who report less than 7 hours of sleep per night. workplace accidents, mood/productivity issues. Caffeine: Caffeine is in multiple OTC drugs, Rx drugs, dietary supplements and beverages widely used stimulant, average intake 227 mg/day. Sleep and Wakefulness: Sleep and wakefulness is affected by: Homeostatic mechanisms Circadian rhythms Medications CNS depressants, benzodiazepines, hypnotics, antihistamines, antipsychotics, antidepressants, mood stabilizers, alcohol, anticonvulsants, opioids, dopamine agonists, antibiotics, antihypertensives Diseases: Depression, cancer, anemia, hypothyroidism, chronic pain, overexertion, imbalances in diet/ exercise Presentation of Drowsiness and Fatigue: Sleepiness Yawning Eye rubbing Tendency to fall asleep Decreased ability to focus and concentrate Page 40: Exclusions for Self Care Less than 12 years pregnancy Breastfeeding Heart disease Anxiety Medication-induced drowsiness. Chronic fatigue warrants referral to primary care provider. Page 41: Treatment Goals Identify and eliminate underlying causes of drowsiness. Enhance mental alertness and productivity. Sustain wakefulness. Page 46: Pharmacologic Treatment: Caffeine Caffeine cannot compensate for inadequate sleep!!! MOA: Increases levels of 3'5' cyclic AMP by inhibiting phosphodiesterase; CNS stimulant which increases medullary respiratory center sensitivity to carbon dioxide, stimulates centralinspiratory drive, and improves skeletal muscle contraction (diaphragmatic contractility); prevention of apnea may occur by competitive inhibition of adenosine Indication: Occasional use to restore mental alertness or wakefulness Low-moderate caffeine doses increase arousal, decrease fatigue and elevate mood; High doses are associated with anxiety, nausea and nervousness Dosing: 100- 200 mg every 3-4 hours as needed; rapid tolerance is seen Side Effects: Withdrawal may occur with abrupt discontinuation, symptoms include throbbing headache, fatigue, decreased alertness, drowsiness, depressed mood and irritability Aggravation of peptic ulcer disease (PUD), gastric reflux and esophagitis Increase in blood pressure and heart rate Increased risk of kidney stones in at risk patients Delayed sleep onset Drug Interactions: Cigarette smoking may increase the clearance of serum caffeine (1A2) by >50% ▪ What do you need to tell someone who is trying to quit smoking? Kinetics: Peak concentration in 30- 75 min ▪ Elimination half-life is 3- 6 hrs Contraindications Patients taking monoamine oxidase inhibitors (MAOIs) Patients with existing coronary artery disease (CAD) Uncontrolled hypertension Preexisting arrhythmias Additional Counseling: Caution use of dietary supplements and weight-loss supplements which often do not list caffeine amount Symptoms of excessive intake: Irritability, tremor, rapid pulse, dizziness and heart palpitations Page 49: Pharmacologic Treatment-CAM Ginseng: Boosts mental and physical energy. Strongest evidence for Chronic Fatigue Syndrome (not a self-care condition) Cola nut, guarana, yerba mate: Often found in caffeine-containing dietary supplements. Risks of additive adverse effects and toxicity. Page 50: Caffeine Content in Beverages and Dietary Supplements Coffee (8 oz): 108mg Espresso (2 oz): 100mg Brewed tea, USA (8 oz): 40mg Coca-Cola (12 oz): 34.5mg Monster Energy: 80mg Red Bull: 80mg Dexatrim Max: 200mg Metabofit Blend: 264mg Extreme Lean : Unknown Page 51: Caffeine Treatment Options NoDoz Maximum Strength and Vivarin contain 200mg of caffeine Anacin Caplets/ Tabs contain 32mg of caffeine Excedrin Migraine Geltabs/ Tablets/ Caplets contain 65mg of caffeine Midol Complete Caplets contain 60mg of caffeine Cafergot (Rx) contains 100mg of caffeine Fioricet (Rx) and Fiorinal (Rx) contain 40mg of caffeine Page 52: Special Populations Pregnancy: o Caffeine is pregnancy category B and crosses the placenta o Moderate consumption of ≤ 200mg/day is acceptable Breastfeeding: o Consume caffeine in small-moderate amounts after breastfeeding Children: o Maximum recommended intake is 2.5mg/kg/day o More susceptible to cardiovascular and CNS effects o Nonprescription caffeine products not for children less than 12 years Older adults: o o Prolonged elimination half-life of caffeine Exaggerated pharmacologic effect and sleep interference, avoid after dinner Page 53: Patient Counseling Practice good sleep hygiene Review dosage guidelines and adverse effects of caffeine products Educate on signs of caffeine withdrawal and inadequate sleep warning signs Warn about potentially life-threatening effects of excessive sleepiness Educate on signs indicating the need to see a healthcare provider Page 54: Patient Case #3 T.J., a 49-year-old man post-heart attack, feels tired during the day Takes Metoprolol, simvastatin, aspirin, and furosemide Wants to take NoDoz Maximum Strength in the afternoon Vital signs: BP 158/92; P 70; RR 20; T 37°C Page 55: Quiz Yourself Appropriate response to T.J.'s question on NoDoz: T.J. is not a candidate due to uncontrolled BP and recent heart attack Page 56: Quiz Yourself Medication most likely causing T.J.'s fatigue: Metoprolol succinate Page 57: Conclusions Identify causes of insomnia and drowsiness before treatment Emphasize sleep hygiene in counseling 1st generation antihistamines have anticholinergic side effects Caffeine therapy linked to various adverse reactions