INSOMNIA

Question 1

What are the symptoms of insomnia?

Answer 1

• Difficulty falling a sleep
• Frequent waking during the night
• Early morning waking
• Daytime sleepiness
• General loss of well-being due to a bad night’s sleep

Question 2

Causes

Answer 2

1. Primary insomnia
   - No identifiable cause
2. Secondary insomnia
   - Sleep apnoea
   - Circadian rhythm disorders
   - Stress/anxiety/depression
   - Meds

Question 3

Which medications can cause insomnia (as a side-effect)?

Answer 3

1. Anti-depressants
   - SSRIS, Venlafaxine, Bupropion, Duloxetine, MOAIS
2. Antiepileptics
   - Lamotrigine, Phenytoin
3. Antihypertensives
   - BB (e.g. Lipid soluble), CCBs
4. Hormones
   - CS, thyroid hormones
5. NSAIDs
6. Stimulants
7. Sympathomimetics
   - Salbutamol, salmeterol, theophylline, pseudoephedrine

Question 4

What are the different types of insomnia?

Answer 4

1. Transient - shift, jet lag
2. Acute - 1-4 weeks
3. Chronic - more than 4 weeks

Question 5

Management

Answer 5

1. Cause?
2. Good sleep hygiene
3. ONLY consider short-term hypnotic if symptoms are severe
4. Refer to psychological services e.g. CBT (if chronic insomnia)

Question 6

What constitutes
“good sleep hygiene”?

Answer 6

1. Fixed bedtime
2. Maintain a comfortable sleeping environment (e.g. not too cold or hot, noisy or bright)
3. AVOID napping during the day
4. AVOID caffeine, nicotine and alcohol within 6 hours of going bed
5. AVOID exercise within 4 hours of bedtime
6. AVOID eating a heavy meal at night
7. AVOID watching or checking the clock throughout the night
8. Only use the bedroom for sleep and sexual activity

Question 7

Drug treatment

Answer 7

Hypnotics:
- Benzodiazepines
OR
- Z-drugs (e.g. Zopiclone)

Question 8

When do you give pharmacological treatment for insomnia?

Answer 8

• ONLY if symptoms are severe and debilitating and interfere with normal daily living

Question 10

How long do you give pharmacological treatment for insomnia? And why?

Answer 10

• MAX 4 weeks(although you may not necessarily see this in practice!)
• Because there is a risk of dependence
• Rebound insomniaonce you try to stop (as withdrawal symptom), resulting in a vicious cycle of starting the drug again (relapse)

Question 11

If someone has transient insomnia, e.g. due to shift work or jet lag, can you give them medication?

Answer 11

• Yes
• BUT ONLY 1 or 2 doses

Question 12

Do patients with chronic insomnia benefit from hypnotics?

Answer 12

• Yes, but ONLY max 4 weeks
• The real cause of insomnia should be established in order to cure it in the long-term

Question 13

What are the common causes of chronic insomnia and what can be done to cure it?

Answer 13

Common causes:
- Psychiatric disorders
- Depression
Address underlying cause:
- depression = sedating antidepressant e.g. mirtazipine

Question 14

What are the other treatments for insomnia (apart from hypnotics)?

Answer 14

1. Melatonin
   - Helps to correct circadian rhythm
2. Sedating antihistamines
   - Chlorphenamine
   - Promethazine
   - Diphenydramine
3. Chlomethiazole
4. Herbal (very small evidence)
   - Valerian
   - Passion-flower
   - Jamaica dogwood

Question 15

What is the usual dose of Melatonin and who can take it?

Answer 15

• 2mg MR OD
• Adults 55 years old and over
• Children = specialist only
• NOTE: You will see doses higher than 2mg OD e.g. up to 10mg daily

Question 16

Is melatonin addictive?

Answer 16

Melatonin mimics natural melatonin and it is not addictive and well tolerated

Question 17

Who normally is indicated for Clomethiazole? And why?

Answer 17

• Elderly patients
• Because they don’t get a hangover effect the next day
• However, dependence/ tolerance can still occur, and respiratory depression in overdose