Insomnia notes (PHARM D)

Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep.
symptoms :
• People with insomnia have one or more of the following symptoms:
• Difficulty falling asleep.
• Waking up often during the night and having trouble going back to sleep.
• Waking up too early in the morning.
• Feeling tired upon waking.

1. Insomnia Presented by M. Tejashree Pharm D 4yr YR

2. DEFINATION : Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep . symptoms : • People with insomnia have one or more of the following symptoms: • Difficulty falling asleep. • Waking up often during the night and having trouble going back to sleep. • Waking up too early in the morning. • Feeling tired upon waking.

3. Acute insomnia : • A brief episode of difficulty sleeping. Acute insomnia is usually caused by a life event, such as a stressful change in a person's job, receiving bad news, or travel. Often acute insomnia resolves without any treatment. Chronic insomnia: • A long-term pattern of difficulty sleeping. Insomnia is usually considered chronic if a person has trouble falling asleep or staying asleep at least three nights per week for three months or longer. Some people with chronic insomnia have a long- standing history of difficulty sleeping. Chronic insomnia has many causes.

4. Onset insomnia : Difficulty falling asleep at the beginning of the night. Comorbid insomnia : • Insomnia that occurs with another condition. Psychiatric symptoms — such as anxiety and depression — are known to be associated with changes in sleep. Certain medical conditions can either cause insomnia or make a person uncomfortable at night (as in the case of arthritis or back pain, which may make it hard to sleep . Maintenance insomnia : • The inability to stay asleep. People with maintenance insomnia wake up during the night and have difficulty returning to sleep.

5. CAUSES Stress and anxiety • Some people develop insomnia after a stressful event, such as a bereavement, problems at work or financial difficulties. • The problem can continue long after the event has passed because they start to associate going to bed with being awake. This develops into an anxiety about sleep itself. • Having more general worries, for example about work, family or health, are also likely to keep you awake at night. These can cause your mind to start racing while you lie in bed, which can be made worse by also worrying about not being able to sleep. A poor sleep routine and sleeping environment • You may struggle to get a good night's sleep if you go to bed at inconsistent times, nap during the day, or don't 'wind down' before going to bed . • A poor sleeping environment can also contribute to insomnia, for instance an uncomfortable bed, or a bedroom that's too bright, noisy, hot or cold.

6. Lifestyle factors • Drinking alcohol before going to bed, and taking certain recreational drugs can affect your sleep, as can stimulants such as nicotine (found in cigarettes) and caffeine (found in tea, coffee and energy drinks). These should be avoided in the evenings . • Changes to your sleeping patterns can also contribute to insomnia, for example because of shiftwork or changing time zone after a long-haul flight (jet lag). Mental health conditions • Underlying mental health problems can often affect a person's sleeping patterns, including. • mood disorders –such as depression or bipolar disorder . • anxiety disorders –such as generalized anxiety, panic disorder or post-traumatic stress disorder . • psychotic disorders –such as schizophrenia.

7. Physical health conditions : • Insomnia can also be caused by underlying physical conditions, including : • heart conditions – such as angina or heart failure . • respiratory conditions –such as chronic obstructive pulmonary disease (COPD) or asthma. • neurological conditions –such as Alzheimer's disease or Parkinson's disease. • hormonal problems – such as an overactive thyroid . • joint or muscle problems – such as arthritis. • problems with the genital or urinary organs –such as urinary incontinence or an enlarged prostate . • sleep disorders – such as such as snoring and sleep apnea, restless legs syndrome, narcolepsy, night terrors and sleepwalking. • long-term pain

8. Medication: • Some prescriptions or over-the-counter medications can cause insomnia as a side effect. These include: • certain antidepressants . • epilepsy medicines. • medicines for high blood pressure –such as beta-blockers . • steroid medication. • non-steroidal anti-inflammatory drugs (NSAIDs). • stimulant medicines used to treat attention deficit hyperactivity disorder (ADHD) or narcolepsy . • some medicines used to treat asthma –such as salbutamol , salmeterol and theophylline .

9. Sleep maintenance problems Nonrestorative sleep Pathophysiology

10. Life stress Problem solving Rumination and worry Physiologic arousal Cognitive arousal Acute insomnia Chronic insomnia Sleep initiation problems Sleep maintenance problems Nonrestorative sleep Insomnia

11. Treatment Treat the underlying cause. In both primary insomnia (where no cause is identifi able)and insomnia due to other causes, management includes introducing good sleep hygiene and medications for short period, if required. Sleep hygiene Set a schedule: Go to bed at a set time each night and get up at the same time each morning . Avoid day time naps. Limit daily in bedtime to the usual amount present before the sleep disturbance . Avoid large meals near bedtime; eat at regular times daily. No stimulant medication or food beverages (caffeine, nicotine, alcohol, etc.) especially in the evenings.

12. Mild to moderate physical exercise in the morning. Relax before going to bed: a warm bath, reading, or another relaxing routine can make it easier to fall sleep. Avoid evening stimulation: substitute television by radio. Don’t lie in bed awake: If you can’t get to sleep, don’t just lie in bed. Do something else, like reading, watching television, or listening to music, until you feel tired. Practice evening relaxation routines, such as progressive muscular relaxation or meditation. Maintain comfortable sleeping conditions: avoid extreme temperatures.

13. Pharmacological Tab. Diazepam 5-10 mg or Tab. Lorazepam 1-2 mg, or Clonazepam 0.25-0.5 mg at bedtime . Or Tab . Zolpidem 5-10 mg at bedtime. Precautions Medication to be given ½-1 hour before the usual time of going to bed. Medications should be prescribed at the lower dose for a period of 5-7 days. Benzodiazepines have risk of abuse potential if taken for more than 4-5 weeks. Zolpidem has also dependence potential and, therefore, long-term use should be discouraged.

14. Patient education Stress on basic principles of sleep hygiene as above. Patient to avoid exceeding the prescribed dose and should not take medicines beyond the prescribed period. Sometimes these drugs can lead to sedation during daytime. In such case, reduce the dose to half and contact the doctor. Diazepam and nitrazepam carry risk of dependence.

15. Thank you