Insomnia

norepi,Ach,histamine,neuropeptides in the hypothalamus

Norepi

5 -HT

less delta sleep, REM, and total sleep time, More nocturnal awakenings, and total awake time at night

random eye movements, high muscle tone, low voltage EEG

Few eye movements, low muscle tone

Transition b/w wakefulness and sleep, lasts 30 seconds to 7 minutes, low voltage desynchronized EEG

low voltage EEG

high-amplitude, slow wave EEG; Delta sleep

Low-voltage, mixed-frequency EEG, Low muscle tone, REM's, autonomic fluctuations in heart rate and perspiration,dreaming in 80-90% of subjects

Primary, insomnia related to another mental disorder, and insomnia related to substance abuse

Dyssomias-nacrolepsy breathing-related sleep disorder, circadiam rhythm sleep disorder, jet lag, nightmare disorder, sleepwalking

duration of 2-3 days caused by acute situational or environmental stressors

lasting less than 3 weeks caused by personal ongoing stress

Lasting longer than 3 weeks, caused bby behavioral(poor sleep hygiene) medical causes, primary sleep disorder(sleep apnea, RLS)

-maintaining consistent bedtimes and awakenings
-not going to bed unless sleepy
-sleeping long enough to feel tired bu no longer
-optimize bedroom condition(light, temp, noise)
-developing consistent bedtime ritual to help unwind
-avoid going to be hungry or extremly full
-avoid reading, working, watching TV in bedroom
-avoid watching the alarm clock
-avoid naps during the day
-avoid caffiene and nicotine throughout the day
-avoid EtOH
-exercise regularly but not near bedtime hours
-if unable to fall asleep or if awaken and cannot fall back to sleep, do not stay in bed for more than 15-20min, get up and do something until sleepy again

For all types of insomnia when it is part of overall plan to deal with causes of insomnia and for defined periods of time, only to be an adjunctive tx

Barbiturates-no longer indicated
Chloral hydrate-limited use
BZD's
Zolpidem, zaleplon
Eszopiclone, ramelteon

Triazolam

Temazepam(Restoril), Estazolam(Prosom)

Flurazepam (Dalmane)
Quazepam (Doral)

well

Yes especially if they are used routinely

NO, they are typically effective for 2-4 weeks

-Can cause residual daytime sleepiness especially w/ longer acting agents(use lowest effective dose and chose a shorter acting agent)
-Can cause rebound insomnia(if the drug is used routinely and then is stopped so taper dosing)
-potential for antegrade amnesia
- habit forming potential (taper)

Worsening insomnia, photophobia, tinnitus, auditory and visual hypersensitivity, seizure

Taper the drug

-cause memory problems and increased risk of falls and dosage accumulation

a non-BZD sedative-hypnotic

binds to selective BZD receptors

Headache, dizziness, daytime somnolence,

Metabolism:Hepatic
Elimination: Renal, fecal

bupropion, venlafaxine and SSRIs(inc. risk of hallucinations)

obstructive sleep apnea

anticonvulsant activity, muscle-relaxant properties, tolerance and withdrawal, respiratory depressant effects

a non-BZD sedative-hypnotic

binds to selective BZD receptors

Dizziness, H/A, abnormal behavior

Absorption-rapid

Elimination: Renal, Fecal

1/2 life-1 hour

Pht, CBZ, phb

non-BZD sedative hypontic

can cause fewer AM effects even if give late compared to Zolpidem

GABA-a agonist; MOA relatively unknown

Rash, gynecomastia, N/V, xerostomia, confusion, H/A, somnolence, depression, hallucinations, anxiety, dysmenorrhea, CP

absorption-time to peak (1 hr)

Metabolism-hepatic

Elimination- Renal

1/2 life=6 hours

azoles, clarithromycin

chronic insomnia- it has AM effects if it is taken late

Melatonin agonist

Nausea, dizziness, fatigue, somnolence, depression

Absorption:time to peak -45 min
Distribution-highly protein bound
Metabolism-Hepatic
Elimination-renal, fecal

Fluvoxamine, azoles

for chronic insomnia, no data yet showing association with dependence of tolerance

Yes-they may be effective

most are both antihistaminergic and anticholinergic

typically have less efficacy then BZD's

The alter sleep patterns-which increase the incidence of daytime sedation

it can increase the risk of rebound tenderness

In the elderly it can worsen dimentia, and Alzheimer's

It should not be used with cholinesterase inhibitors

they may be effective if the dose is lower than for depression

its efficacy is not fully established

Insomnia due to SSRIs

it has no documented risk of dependence but does increase the risk of ADEs

There is little evidence to support long term use of them