Insomnia
Causes of insomnia
drugs
life events
environment
illness
increased age
increased daytime napping
chronic: anxiety, depression
What is the sleep cycle? Stages
- NREM 1: transition between wakefulness and sleep, 10mins
- NREM 2: body temp drops, HR slows, brain produces sleep spindles, 20mins
- NREM 3: muscles relax, bp and breathing rate drops, deepest sleep
- REM sleep: brain becomes more active, body relaxed, immobolised, dreams occur,
eyes move rapidly
Why does older age cause more insomnia?
- Spend more time in NREM1 and NREM 2
o More easily woken as not as deep sleep
- Weakened bladder
- Pain and breathing waking you up
What controls the sleep cycle?
- Melatonin and adenosine
- Adenosine builds up across the day making us sleepy
- Melatonin builds up in the evening and helps us remain asleep
- Diminishes in the morning
What happens to melatonin in the elderly?
- Melatonin peaks earlier and diminishes sooner
Types of insomnia
Transient
- Jet lag
- Work shift
- Short term
- Sleep well usually
Acute
- A few weeks
- Bereavement
- Physical illness
Chronic
- Long term
- At least 3 days a week
- For 3 months
- Right environment to sleep but still cant
- Having adverse daily issues
When should you refer a patient with insomnia?
- Snoring heavily
- Restless legs
- Mental health associated
, - Under 16
Routine advice to treat insomnia
- Sleep diaries
- Increased daily exercise
- Stop naps
- Bedroom light and noise minimum
- Reduce alcohol, fluids, chocolate, smoking and caffeine at night
o Caffeine after midday
o Smoking 6 hours before bed
o Fluid and food 3 hours before bed
- Relaxation audio tools
- If you can’t sleep for 30 mins get up and do something else
- Keep pets outside the bedroom
- CBTi
- Sleepio app
Effect of alcohol on sleep cycle
- Disrupts circadian function
- Increased toilet use at night
- More time in NREM1 than NREM2
- Makes you snore disturbing sleep
Pharmacological treatment for insomnia
Severe acute insomnia
- BZDs and Z drugs
- No difference in terms of efficacy
- Shortest time [period
- Usually 2 weeks max 4
- Lowest effective dose
Find and treat underlying cause
Prescribing advice for insomnia
- Risks outweight beenfits
- Prescribe lowest acquisition cost
- Reduce dose slowly if patients have used hypnotics for prolonged period
- Additive sedative effects with alcohol and other sedating drugs e.g. clozapine
o So, inform patient
What are some short-acting agents for insomnia?
- Temazepam
- Zolpidem
- Works within an hour and lasts 2-3 hours
- Helps for those who have difficulty falling asleep
- Increased risk of tolerance
What are long-acting agents for insomnia?
- Nitrazepam and zopiclone
- Takes a couple of hours to work
- Lasts 5-6 hours
- Frequent early morning waking patients
- Mindful of next day sedation and loss of co-ordination
Causes of insomnia
drugs
life events
environment
illness
increased age
increased daytime napping
chronic: anxiety, depression
What is the sleep cycle? Stages
- NREM 1: transition between wakefulness and sleep, 10mins
- NREM 2: body temp drops, HR slows, brain produces sleep spindles, 20mins
- NREM 3: muscles relax, bp and breathing rate drops, deepest sleep
- REM sleep: brain becomes more active, body relaxed, immobolised, dreams occur,
eyes move rapidly
Why does older age cause more insomnia?
- Spend more time in NREM1 and NREM 2
o More easily woken as not as deep sleep
- Weakened bladder
- Pain and breathing waking you up
What controls the sleep cycle?
- Melatonin and adenosine
- Adenosine builds up across the day making us sleepy
- Melatonin builds up in the evening and helps us remain asleep
- Diminishes in the morning
What happens to melatonin in the elderly?
- Melatonin peaks earlier and diminishes sooner
Types of insomnia
Transient
- Jet lag
- Work shift
- Short term
- Sleep well usually
Acute
- A few weeks
- Bereavement
- Physical illness
Chronic
- Long term
- At least 3 days a week
- For 3 months
- Right environment to sleep but still cant
- Having adverse daily issues
When should you refer a patient with insomnia?
- Snoring heavily
- Restless legs
- Mental health associated
, - Under 16
Routine advice to treat insomnia
- Sleep diaries
- Increased daily exercise
- Stop naps
- Bedroom light and noise minimum
- Reduce alcohol, fluids, chocolate, smoking and caffeine at night
o Caffeine after midday
o Smoking 6 hours before bed
o Fluid and food 3 hours before bed
- Relaxation audio tools
- If you can’t sleep for 30 mins get up and do something else
- Keep pets outside the bedroom
- CBTi
- Sleepio app
Effect of alcohol on sleep cycle
- Disrupts circadian function
- Increased toilet use at night
- More time in NREM1 than NREM2
- Makes you snore disturbing sleep
Pharmacological treatment for insomnia
Severe acute insomnia
- BZDs and Z drugs
- No difference in terms of efficacy
- Shortest time [period
- Usually 2 weeks max 4
- Lowest effective dose
Find and treat underlying cause
Prescribing advice for insomnia
- Risks outweight beenfits
- Prescribe lowest acquisition cost
- Reduce dose slowly if patients have used hypnotics for prolonged period
- Additive sedative effects with alcohol and other sedating drugs e.g. clozapine
o So, inform patient
What are some short-acting agents for insomnia?
- Temazepam
- Zolpidem
- Works within an hour and lasts 2-3 hours
- Helps for those who have difficulty falling asleep
- Increased risk of tolerance
What are long-acting agents for insomnia?
- Nitrazepam and zopiclone
- Takes a couple of hours to work
- Lasts 5-6 hours
- Frequent early morning waking patients
- Mindful of next day sedation and loss of co-ordination
