OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• sleep hygiene
• physiology of sleep
• fatigue
• managing jet lag and the body clock;
• Coping with shift work
• stress
• psychiatry and mental health
• sedatives, hypnotics and anxiolytics
• narcolepsy

• see physiology of sleep for details on control of sleep, sleep requirements, etc.
• consequences of acute sleep deprivation include:
  • impaired passive vigilance
  • impaired reaction time
  • impaired hand-eye coordination - ever tried playing a musical instrument or even golf after little sleep?
  • impaired clerical accuracy
  • impaired memory
  • impaired reasoning
  • increased sleepiness and micro-sleep events (eg. when driving a car)
  • increased risk of car accident and other accidents
• consequences of slow wave (delta wave) sleep deprivation include:
  • impaired cognitive performance
  • impaired immunity and ability to recuperate
• consequences of REM sleep deprivation include:
  • moodiness and risk of both depression and hypomanic states
  • hypersensitivity to stimuli (and perhaps lowering of the migrain threshold)
  • inability to consolidate complex learning
• consequences of long term sleep deprivation include:
  • decreased longevity in animal models
  • depression
  • burnout
  • divorce
  • substance abuse
  • chronic hypertension
  • metabolic syndrome, obesity and diabetes mellitus
  • increased cardiovascular mortality equivalent to more than 1 packet/day of cigarettes
  • infertility
  • injury risk
• sleep debt:
  • sleep latency can be measured
  • very poor correlation between self-reported sleepiness and objective measures of fatigue
  • alcohol intake causes sleep fragmentation and decreased REM sleep - hence one feels tired the next day
  • most sedative-hypnotics disrupt sleep architecture and are associated with impaired quality of sleep
  • caffeine:
    • 250mg improves psychomotor performance if sleep deprived but 500mg gives no further improvement but adds side effects
    • brewed coffee has ~135mg, while tea has 35-50mg.
    • benefit subject to tachyphylaxis
    • constant high doses may cause withdrawal headaches
    • adversely effects sleep latency and sleep quality
  • micro-awakenings decrease time in slow wave sleep and decrease time in REM sleep
  • a regular siesta may reduce coronary mortality by 37% ¹⁾
  • the only way to reverse the need for sleep is to sleep
• insomnia or difficulty in getting to sleep is a symptom and thus a cause should be sought

• emotional stress/anxiety - tends to cause trouble with falling asleep
• depression - tends to cause sleep which is interrupted by frequent awakenings

• bedroom too hot, too cold, too noisy (eg. crying baby, restless child, partner with snoring)
• bed cramped or uncomfortable

• obstructive sleep apnoea
• chronic airways limitation
• acute illness such as URTI, asthma, or pain
• restless legs syndrome

• delayed sleep phase disorder
  • the main cause in perhaps 15% of people with insomnia
  • hard to get to sleep before 2am and hard to wake up early
  • may respond to metatonon or agomelatine (Valdoxan), a new antidepressant which also acts on melatonin receptors to cause a phase advance.
• poor sleep hygiene
• lack of daytime exercise
• inadequate daytime exposure to light
• excessive time in bed
• shift work
• jet lag

• consider pt maintaining a sleep log to help ascertain extent & type of disturbance
• managing insomnia in older people:
  • discuss & agree on therapeutic objectives with the patient
  • assess the complaint - what is causing it?
  • treat or improve the underlying cause
  • educate the patient about good sleep habits - see behavioural Rx below
  • avoid use of hypnotic drugs whenever possible as adverse effects usually outweigh benefits except perhaps in short term usage, when prescriptions should be only for 2 weeks maximum
    • for every 13 patients aged over 60 years treated with hypnotics, it will improve sleep in 1 person but will cause an adverse effect (cognitive impairment, falls. fractures, motor vehicle accidents) in 2 people

• see sleep hygiene to ensure lifestyle maximises probability of quality sleep
• consider anxiety management & relaxation techniques if pts worried & anxious they will not be able to get to sleep
• consider cognitive behavioural therapy techniques
  • replace distorted beliefs and attitudes with positive ones
    • reassure that less than 8 hours sleep per night is not necessarily detrimental
• address learned association between going to bed and being unable to sleep
  • go to bed only when tired, and only use bed for sex or sleep
  • get out of bed if not asleep within a perceived 20 minutes - but DO NOT watch the clock
  • repeat each night until a stable sleep-wake schedule is established
  • restrict sleep time in bed to actual sleep duration (but at least 5 hours sleep) and have a set wake up time

• if hypnotics must be used, use them only 2-5 times per week and for less than 2 weeks duration
• see sedatives, hypnotics and anxiolytics
• benzodiazepines:
  • long half-life benzodiazepines (esp. in elderly) result in increased risk of:
    • confusion, drowsiness, memory loss, unsteadiness, falls (thus hip fractures) & incontinence
    • doubles risk of road traffic accidents in all age groups, but in addition, in persons over 65yrs, have an additional 50% risk if brief duration Rx or 30% risk if long term Rx.
    • most benzodiazepines lose their hypnotic efficacy after approx. 14 consecutive nights, even though people still keep taking them
    • quality of sleep is modified - less deep & relaxed sleep; tendency to fall asleep & awake earlier;
    • day-time: feelings of tiredness; lack of energy; mood disturbances;
• the 'Z drugs':
  • act on same receptor as benzodiazepines
  • said to have less adverse effects & less dependency than benzodiazepines, but these are still present
  • zolpidem has caused delirium, hallucinations, nightmares & hip fractures (2x risk of no Rx & more than Rx with benzo's, anti-psychotics or antidepressants)
  • zopiclone:
    • causes hangover effects & impairs psychomotor performance similar to temazepam & nitrazepam
    • has bitter taste
  • zaleplon:
    • short half-life, thus useful for sleep-onset insomnia
• valerian:
  • herbal extract with mild hypnotic activity, but limited studies as yet.
• melatonin:
  • a naturally occurring hormone secreted from pineal gland
  • widely used to regulate sleep-awake cycles in circadian-based disorders such as jet lag
  • adverse effects: enhanced immune functioning, vasoconstriction, exacerbation depression
• antidepressants:
  • should not be used to Rx insomnia unless concurrent depression
• antihistamines (H1):
  • should not be used as cause anticholinergic effects & confusion, esp. in children & elderly & tolerance develops quickly

• prolonged Rx with hypnotic medications for > 4 weeks increases risk of dependence
• this is particularly a problem with the elderly who are most at risk of adverse effects such as increased falls
• rebound insomnia may occur even with short term hypnotic use of less than 2 weeks and thus gradual dose reduction may be needed

• provision of a letter advising cessation combined with self-help advice doubles the chances of a patient wishing to cease Rx

• see NPS ²⁾

• discuss goals for stopping or reducing use
• agree on rate and duration of cessation
• outline the type, nature and expected duration of withdrawal symptoms
• advise on strategies to Mx withdrawal symptoms

• modify dose and/or frequency based on severity of withdrawal symptoms
• all time to stabilise between dosage reductions - at least a few days
• consider referral to a specialist if dose reduction proves too difficult
• example reduction of benzodiazepines:
  • reduce dose by 10-20% per week if it is within or slightly above the recommended dose
  • stabilise on an equivalent dose of diazepam (unless elderly) for a few days before dose reduction if patient was on a higher than recommended dose or finding it difficuklt to wean a short-acting agent.
  • if multiple benzodiazepines are used, the dose of each drug may be reduced one after the other

• weekly monitor effect of cessation on sleep patterns, mood, withdrawal symptoms and use of other substances (eg. alcohol, caffeine)
• encourage use of non-drug therapies
• suggest coping strategies

• engage family, carers, staff in residential facilities
• if unsuccessful, reassure that further attempts are worthwhile
• repeat STOP steps when patient willing to try again