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Insomnia

Defined as: when someone has trouble falling asleep or staying asleep, wakes up
too early and cannot return to sleep, or does not feel refreshed after sleeping
Average adult requires 8 hr or more of sleep, but average is 6.9 hrs
Insomnia can be classified into:
o Transient self-limiting, lasting less than 1 week
o Short-term lasting 1-3 weeks
o Chronic/long-term insomnia lasts more than 3 weeks to years; often a
result of medical problem, psychiatric disorders or substance abuse
Often associated with acute life stresses or medical illness, anxiety, and poor
sleep habits
Sleep deprived patients are highly symptomatic and report symptoms of fatigue,
drowsiness, anxiety, irritability, depression, decreased concentration and
memory impairment

Treatment

Only for patients with transient or short-term insomnia, with no underlying


medical or psychiatric conditions that cause insomnia
If diphenhydramine is recommended it should be taken at bedtime only as
needed
o If continued insomnia after 14 days using diphenhydramine along with
good sleep hygiene refer to MD
Sleep hygiene measures are recommended in ALL patients with insomnia.
They should be recommended before trying pharmacotherapy.

Pharmacologic Therapy

Diphenhydramine is the only category I sleep aid listed by the FDA


Both diphenhydramine and doxylamine are members of the ethanolamine group
for antihistamines (do not have the same efficacy)
Diphenhydramine
o Significant drowsiness lasts from 3-6 hours after a single dose of
diphenhydramine 50 mg
o Next morning hangover reported after multiple nightly dosing for insomnia
o Primary indication: symptomatic management of transient and short-term
sleep difficulty, particularly in individuals who complain of occasional
problems falling asleep
o Usual optimal dose 50 mg, but some people benefit from 25 mg
o Intermittent use for 3 days with an off night to assess sleep quality
without medication is suggested to reduce tolerance to the hypnotic effect
o Should not be used for more than 14 consecutive nights (new textbook
says 10)
o Inhibitor of the CYP2D6 enzyme
o Anticholinergic toxicity can result in excessive antihistamine dosages
CNS: anxious, excited, delirious, hallucinations, stupor, coma,
seizures
Physical: pupil dilatation, flushed skin, hot & dry mucous
membranes
o In toxicity requires gastric lavage or activated charcoal

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Contraindicated in:
Male pts of advanced age with prostatic hyperplasia and difficulty
urinating
Angle closure glaucoma
Pts with CV disease
Pts with dementia
Pts should be cautioned to avoid tasks that require their full attention or
coordination until their response is known
They should avoid alcohol due to additive sedative effects
Some patients can develop paradoxical excitation especially children and
pts of older age
Avoid in geriatric patients due to cognitive impairment and falls
Category B for pregnancy, but refer to physician anyways
Do not recommend for children younger than 12
Establish regular bedtime and take 30-60 mins before going to bed. Max
dose is 50 mg each night.
After 2-3 nights of improved sleep, skip med for 1 night to see if the
insomnia is relieved

Other Therapies

Melatonin, 5-HTP, valerian, kava


o Dont even work why waste space

Non-pharmacologic

Use bed for sleeping or intimacy only


Establish a regular sleep pattern: go to bed and arise at about the same time
daily, even on the weekends
Make the bedroom comfortable for sleeping. Avoid temperature extremes, noise,
and light
Engage in relaxing activities before bedtime
Exercise regularly but not within 2-4 hours of bedtime
If hungry, have a light snack, but avoid eating meals within 2 hours before
bedtime
Avoid daytime napping
Avoid using caffeine, alcohol, or nicotine for at least 4-6 hours before bedtime
If unable to fall asleep, do not continue to try to sleep; rather, perform a relaxing
activity until you feel tired
Do not watch the clock at night
Avoid using electronic devices (particularly videos, television, and tablets) around
bedtime.

I have no idea where they got this shit:

Nodoz = Caffeine
Caffeine toxicity symptoms: tachycardia, tremors/jitteriness, anxiety, dizziness