How to Manage Insomnia with and without medications Tatyana Gurvich, Pharm.D. USC School of Pharmacy UC Irvine SeniorHealth Center
Insomnia: How common is it? 26-50% of adult population complain of insomnia 50% of elderly patients living at home complain of insomnia 66% of institutionalized elderly complain of insomnia
Diagnostic criteria for insomnia: Difficulty initiating sleep Difficulty maintaining sleep Complaint of non-restorative sleep Associated daytime fatigue which leads to impairment of daily functioning
Diagnostic criteria for insomnia: cont Problems sleeping 3-7 times a week Waking up 3 or more times at night Taking 30min or more to fall asleep Feeling moderately or severely unrefreshed Complaint lasting at least one month
How much sleep does each person need every night? Does everyone need 8 hours of sleep per night? Do older adults need less sleep than an average younger adult? Everyone requires a different amount of sleep to function well during the day: 4-9 hrs.
Normal Stages of Sleep Stage I: Mental relaxation/eyes closing; 5-30min Stage II Disconnect from the outside world; can t hear noise; 50% of total sleep time Stage III-IV: Deep sleep: 15-20% III 20-50% delta waves/iv all delta waves REM sleep: dreaming
Stages of Sleep and Ageing Stage I: takes longer to fall asleep Stage II: Impaired. Easily awakened Stage III and IV: Shorter in older pts REM: Shorter in older pts.
Sleep and ageing Increased sleep latency More frequent awakenings Medical conditions which contribute to insomnia Pain Restless Leg Syndrome Sleep apnea Depression/Anxiety
NON-Drug Therapy is Effective Meta-analysis of 23 randomized trials of sleep hygiene education Increased sleep efficiency Improved sleep quality Decreased sleep latency Decreased wake up times
Principles of Good Sleep Hygiene Stick to a regular sleep schedule Exercise regularly EARLY during the day Schedule regular outdoor time Go to bed only when sleepy
Principles of Good Sleep Hygiene Put your worries away when you go to bed Do something relaxing Make sure your bedroom is quiet and comfortable
More Principles of Good Sleep Hygiene Avoid large meals before bedtime Eat a snack high in L-tryptophan or Melatonin before going to bed Foods rich in L-tryptophan Milk Turkey
Food Rich in Melatonin Oats Rice Sweet corn Cherries Banana Ginger Tomatoes Barley
Principles of Good sleep Hygiene No reading in bed No watching TV in bed Use the bedroom for sleep and sex only
Principles of Good Sleep Hygiene Don t toss and turn. If you can t fall asleep, get up and do something else. Return to bed only when sleepy. Remove clock from eyesight. Do not take long naps: Very disruptive to your circadian rhythm.
More about Good Sleep Hygiene Avoid alcohol, caffeine Review medications Anticonvulsants Diuretics Asthma medications Antidepressants Thyroid replacement Oral contraceptives Herbal supplements Antipsychotics Dementia medications Steroids Decongestants Appetite suppressants ADHD medications
Alcohol and Sleep Can be disruptive to sleep Having a night cap can help with falling asleep, but daily use will lead to disruptive, unpleasant sleep
Caffeine and Sleep Avoid caffeine containing foods Coffee Tea Soda Chocolate Energy drinks Vitamins Herbal products
Caffeine Content in Certain Products Coffee, brewed 8 oz. 133mg (range: 102-200 mg) (16 oz. = 266 mg) Starbucks Brewed Coffee (Grande) 16 oz.320 mg Tea, brewed 8 oz.53mg (range: 40-120) Starbucks Chai Tea Latte (Grande) 16 oz.100 mg Snapple, Lemon (and diet version) 16 oz.42 mg Diet Coke 12 oz.47mg (20 oz. 78mg) Pepsi 12 oz.38 mg (20 oz. 63 mg) Mountain Dew, regular or diet 12 oz.54 mg (20 oz. = 90 mg) Ben & Jerry's Coffee Heath Bar Crunch 8 oz. 84 mg Hot Cocoa 8 oz.9 mg (range: 3-13)
Beers Criteria Update on sedative-hypnotics AVOID anithistamines due to anticholinergic effects. Strength of recommendation: STRONG BZD: AVOID for treatment of insomnia, agitation or delirium. Strength of recommendation: STRONG NonBZD hypnotics: AVOID chronic use >90days
Over the Counter Medicines for Insomnia Diphenhydramine (Benadryl, Nytol, Sominex, Tylenol/Advil PM) Dose: 25-50 mg Onset of effect: 60-120 minutes Half life 2.4-9.3hrs Side effects: Dry mouth, Constipation, confusion, urinary retention, grogginess in the a.m. NOT RECOMMENDED IN THE ELDERLY
Over the Counter Medicines Doxylamine (Unisom) Dose 25 mg Onset of effect: 30 min minutes Half life 10 hrs Side effects: Dry mouth, Constipation, confusion, urinary retention, grogginess in the a.m. NOT RECOMMENDED IN THE ELDERLY
Herbal supplements used for insomnia Melatonin: Dose 2-5 mg. May be used for jetlag. Chamomile: Dose variable. Relaxing. Potential allergies. Valerian root: Dose variable. Similar in mechanism of action to BZD s
Prescription Medicines for Sleep Not a long term solution for insomnia Provide symptomatic relief only Can be effective long term only if NOT used every night Should only be used as a last resort
A meta analysis of risks and Benefits of insomnia medications 8 studies of 601 pts increase in sleep time was 25.2 min 8 studies of 524pts BZD vs placebo, increase in sleep time was 34.2 min 6 studies of 441 pts mean # of awakenings decreased by 0.63 6 studies of 296 pts BZD vs placebo mean # of awakenings decreased by 0.60
A meta analysis of risks and Benefits of BZD s and BZD-like drugs NNT to show improvement in sleep quality was 13 (1,072pts) NNT to cause harm was 6 (2,200pts) Drowsiness, fatigue, headache, nightmares, nausea, loss of balance, dizziness, falling, MVA, broken bones, mental alertness in the am
Bezodiazepines (BZD) Effective after a single dose Can be habit forming Tolerance develops with chronic use Can be used for other indications: Anxiety Muscle relaxation Seizures
BZD s effect on Sleep architecture Decrease sleep latency Increase Stage II sleep Decrease Delta wave sleep Decrease REM sleep
Benzodiazepines Restoril (temazepam) Dose: 7.5 30 mg Onset of effect: 45 120 minutes T1/2 3.5-18.4 hrs Duration of action 6-10 hrs Habit forming. Tolerance develops. Risk of falls, confusion.
Benzodiazepines Ativan (lorazepam) Dose: 0.25-4 mg Onset of effect: 20-30 minutes Half life 18hrs Habit forming. Tolerance develops. Risk of falls, confusion.
Benzodiazepines Halcion (tirazolam) Dose: 0.125-0.250 mg Onset of effect: 15-30 minutes Half life 1.5-5hrs Duration of action 2-5hrs Habit forming. Tolerance develops. Risk of falls, confusion.
Benzodiazepines Dalmane (flurazepam) Dose: 15 30 mg Onset of effect: 60 120 minutes Half life > 100 hrs Duration of action 10-20 hrs Habit forming. Tolerance develops. Risk of falls, confusion, grogginess. Hangover effect DO NOT USE IN THE ELDERLY
Benzodiazepine-like medications May be habit forming Tolerance can still develop if used nightly Shorter duration of action More expensive Effective for sleep only
Benzodiazepine-like medications Ambien/Ambien CR (zolpidem) Dose: 5-10mg regular/sublingual tab 6.25/12.5 CR formulation 1.75/3.5mg sublingual low dose Lunesta (eszopiclone) Dose: 1-3 mg Sonata (zalepon) Dose: 5-20 mg
Benzodiazepine-like medications Half life in hrs 1.5-4.5 hrs for zolpidem; 1.4-3.6hrs for Intermezzo 6hrs for Lunesta 1hr for Sonata
Benzodiazepine-like medications Duration of action: About 8hrs for most EXCEPT Intermezzo SL low dose: 4hrs Sonata 4hrs
FDA Zolpidem Safety communication 1/2013 Recommendation to lower dose Women 5mg/6.25mg Men consider prescribing lower doses Morning after impairment/difficulty driving/lack of mental alertness
Miscellaneous Agents Desyrel (Trazodone) Also used for depression May cause dizziness, priapism Dose may need to be increased to effect Not habit forming/no tolerance to dose Dose 25-150 mg Onset of effect: 30-60 minutes Duration of action 5-9hrs
Miscellaneous Agents Rozerem (Ramelteon) Not addicting Works like Melatonin Dose 8 mg Onset of effect 30 min Half life 1-2.6hr/2-5hrs metabolite Duration of action 8hrs
Miscellaneous Agents Remeron (Mirtazapine) Dose 7.5-15mg Onset of effect: unknown Half life20-40hrs Increases risk of RLS Used for depression induced insomnia
Miscellaneous Agents Doxepin (Silenor) Dose 3-6mg Half life 15hr/31hr for metabolite Duration of action 7-8hrs Does not improve sleep latency Sleep maintenance Increased by 52 min in week one and 63 min by week 4
What is the best way to handle insomnia? Limit daily caffeine Stay active Use some sleep hygiene techniques Medications should be used as a last resort! Remember, medications only work well if they are NOT used daily!
Wishing you a Good Night s Sleep