Sleep disorders

Question 1

Insomnia treatment

Answer 1

Most anxiolytics (sedatives) will induce sleep when given at night and most Hypnotics will sedate when given during the day. Although prescribing of these drugs is widespread, but dependence + tolerance can occur. 
-	This may make withdrawal of the drug difficult after the patient has been taking the drug regularly for a few weeks. Hypnotics and Anxiolytics are therefore reserved for SHORT-COURSES.

Question 2

most commonly used Anxiolytics and Hypnotics.

Answer 2

Benzodiazepines are the most commonly used Anxiolytics and Hypnotics. They should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress.

Question 3

Benzodiazepine Withdrawal syndrome

Answer 3

Insomnia, anxiety, loss of appetite + body weight, tremor, perspiration, tinnitus and perceptual disturbance. The original symptoms may return and encourage further prescribing.
- This syndrome may occur at any time up to 3 weeks after stopping a long-acting benzodiazepine, but may occur within a day in the case of a short-acting one.

Question 4

Short-term users of Benzodiazepines

Answer 4

Short-term users of Benzodiazepines (2-4 weeks only) can usually taper off within 2-4 weeks. However, long-term users should be withdrawn over a much longer period (several months – 1 year or more):

Question 5

how to withdraw benzodiazepine

Answer 5

1. Transfer patient stepwise, one dose at a time over about a week to an equivalent daily dose of diazepam preferably taken at night.
2. Reduce diazepam dose usually by 1-2mg every 2-4 weeks (in patients taking high doses, initially it may be appropriate to reduce the dose by up to one-tenth every 1-2 weeks). If withdrawal symptoms occur, maintain this dose until symptoms lessen
3. Reduce diazepam dose further, if necessary in smaller steps (steps of 500mcg may be appropriate towards end of withdrawal) … then STOP COMPLETELY.

Question 6

1. Short-acting hypnotics

Answer 6

Short-acting hypnotics are suitable for patients with sleep-onset insomnia when sedation the following day is undesirable or for the elderly patients

Question 7

2. Long-acting hypnotics

Answer 7

Long-acting hypnotics are suitable for patients with poor sleep maintenance (e.g. early morning waking) that causes daytime effects, when an anxiolytic is needed in the day or when sedation the following day is acceptable.

Question 8

• Transient insomnia

Answer 8

• Transient insomnia may occur in those who normally sleep well and may be due to noise, shift work and jet lag. If a hypnotic is given, one that is rapidly eliminated should be given and only 1 or 2 doses should be given.

Question 9

Short-term insomnia

Answer 9

• Short-term insomnia is usually related to an emotional problem/serious medical illness. A short-acting hypnotic should be given for a maximum of 3 weeks (preferably 1 week). Intermittent use is desirable with omission of some doses

Question 10

Chronic insomnia

Answer 10

• Chronic insomnia is rarely benefitted by hypnotics and is commonly caused by anxiety, depression and abuse of drugs + alcohol. The underlying psychiatric complaint should be treated, adapting the drug regimen to alleviate insomnia e.g. giving Mirtazapine for depression at night will help aid sleep.

Question 11

Hypnotics should not be

Answer 11

Hypnotics should not be prescribed indiscriminately, and routine prescribing is undesirable. They should be reserved for short courses in the acutely distressed. Tolerance to their effects develops within 3-14 days of continuous use & long-term efficacy cannot be assured.

Question 12

A major drawback of long-term use is

Answer 12

• A major drawback of long-term use is that withdrawal can cause rebound insomnia + a withdrawal syndrome

Question 13

Where prolonged administration is unavoidable, hypnotics should be

Answer 13

• Where prolonged administration is unavoidable, hypnotics should be discontinued as soon as feasible and the patient warned that their sleep may be disturbed for a few days before normal rhythm is re-established. Broken sleep with vivid dreams may persist for several weeks.

Question 14

Some anxious dental patients may

Answer 14

benefit from the use of hypnotics during dental procedures such as Temazepam or Diazepam. Temazepam is preferred when it is important to minimise any residual effect the following day.

Question 15

 Benzodiazepines used as Hypnotics include

Answer 15

 Nitrazepam + Flurazepam which have prolonged action and may give rise to residual effects on the following day. Caution: Paradoxical effects
 Loprazolam, Lormetazepam and Temazepam act for a shorter time and they have little or no hangover effect. However, withdrawal phenomena are more common with short-acting benzodiazepines.
 If insomnia is associated with daytime anxiety, then the use of a long-acting benzodiazepine anxiolytic such as diazepam given as a single dose at night may effectively treat both symptoms

Question 16

Zaleplon, Zolpidem and Zopiclone (Z-drugs)

Answer 16

 These are non-benzodiazepine hypnotics, but they act at the benzodiazepine receptor.
 They are not licensed for long term use + have a short-duration of action.

Question 17

Benzodiazepines and the Z-drugs should be avoided

Answer 17

in the elderly, because the elderly are at a greater risk of becoming ataxic (loss of control of bodily movements) and confused, leading to falls + injury.

Question 18

may be a useful hypnotic for the elderly

Answer 18

Clomethiazole may be a useful hypnotic for the elderly because of its freedom from hangover but routine administration is undesirable, and dependence occurs.

Question 19

Poor hypnotic

Answer 19

Alcohol is a poor hypnotic because the diuretic action interferes with sleep during the latter part of the night. It also disturbs sleep patterns and so can worsen sleep disorders.

Question 20

Antihistamines

Answer 20

• Some Antihistamines such as Promethazine are available OTC to the public for occasional insomnia.
• Their prolonged duration of action often causes drowsiness the next day.
• Antihistamines are associated with headache, psychomotor impairment + antimuscarinic effects

Question 21

Melatonin

Answer 21

Licensed for short term treatment of insomnia in adults >55 years

Question 22

Benzodiazepine as Anxiolytics

Answer 22

• Should not be used a sole treatment for chronic anxiety + not appropriate for treating depression
• Lowest possible dose for the shortest possible time
• Diazepam, alprazolam, chlordiazepoxide and clobazam have sustained action
• Shorter-acting preferred in patients with hepatic impairment such as lorazepam and oxazepam but they carry a greater risk of withdrawal symptoms

Question 23

Barbiturates e.g. phenobarbital

Answer 23

• Intermediate-acting barbiturates should only be used for the treatment of severe intractable insomnia in patients already taking barbiturates, they should be avoided in the elderly.
• The use of phenobarbital as a sedative is unjustified, but it can be used in epilepsy.
• Intoxication is characterised by increased hostility and aggression.