rxPassport Pharmacy Newsletter
 
October 2014
 
 
Can’t Sleep? Count Sheep: Summary, Assessment and Treatment of Insomnia
 
Patient Case
 
Patient Name: Bobby C, 57-year-old male financial advisor
 
You notice Bobby standing in the OTC sleep section. When you ask, he says that he is looking for the strongest product for sleep.
 
You gather the following information:
  • Sleeping restlessly for 4-5 hours of a night
  • Wakes up 2-3 times a night
  • He always had problems sleeping but it has been particularly bad for the last 6 weeks
  • He says has no energy for socializing and has trouble functioning all day.
  • Had severe insomnia in the past. His doctor prescribed him something but he refused to fill it.
  • He has tried diphenhydramine but found it unhelpful
  • He feels the lack of sleep is affecting his work and he is very worried that he may lose his job.
  •  
    Bobby grabs a vial of Melatonin nearby. He asks, “Will this work?”
    Insomnia - A Refresher
     
    Insomnia is mainly identified as a difficulty initiating or maintaining sleep, or poor quality of sleep.1
     
    Approximately 20% of Canadians seen by a physician report significant sleep disturbances.1,3 Statistics Canada reports that approximately 40% of adults experience at least 1 symptom of insomnia 3 times per week, with approximately 10-13% meeting criteria for insomnia.1,3
     
    Insomnia Risk Factors5
    MEDICATION LIFE EVENTS
     
  • Stimulants
  • Antiepileptics
  • Alcohol
  • Beta blockers
  • Antidepressants
  • Diuretics
  •  
  • Shift work, work-related stress
  • Death in family
  • Job loss
  • Divorce
  • Jet Lag
  • CERTAIN POPULATIONS MEDICAL CONDITIONS
     
  • Family history of insomnia
  • Increasing age
  • Female Sex
  •  
  • Psychiatric
  • Cardiovascular
  • Neurological
  • Genitourinary
  • Endocrine
  • Musculoskeletal
  • Menopause
  • Patient Assessment
     
    When assessing a patient presenting with insomnia, consider asking the following questions:5,8
     
    Information Gathering Questions4
    TOP 3
    • How long and how frequently have you been experiencing these symptoms?
    • Are you experiencing any other symptoms such as pain, depressed mood, marked decrease in interest or pleasure, restlessness, or anxiety?
    • Can you describe what you typically do prior to bedtime?
    ADDITIONAL 5
    • Do you smoke or use nicotine replacement therapy?
    • Are you travelling frequently or have shift work?
    • Are you fairly inactive or have excessive daytime napping?
    • Does your bed-partner have behaviors such as snoring or leg movement that disturb your sleep?
    • What do you eat and drink within 3 hours of bedtime?
     
     
    Red-Flags: After gathering information, the following are reasons to refer: 4
     
    - Age < 12
     
    - Duration > 3 weeks
     
    - No ascertainable cause for Insomnia
     
    - Undiagnosed medical conditions
     
    - Symptoms suggest anxiety or depression
    Treatment
     
    Non-Pharmacological Therapy
     
    Non-pharmacological treatment helps by modifying behavioral pattern.3,5 Encourage these options to insomnia patients.
     
    Sleep Hygiene Tips5,8
    1. Keep a regular sleep-wake schedule (7 days/week)
    2. Avoid sleeping in and daytime napping
    3. Ensure bedroom temperature is not too cold or hot.
    4. Ensure comfortable and clean pajamas and bed sheets.
    5. Get approximately 40 minutes of moderate activity/exercise a day.
    6. Avoid caffeine, nicotine, alcohol and other recreational drugs. Avoid smoking after 7 p.m.
    7. Plan a quiet period before lights out (e.g. warm bath).
    8. Avoid large meals late in the evening.
    9. Turn the clock face away and use the alarm.
    10. Keep the bedroom dark and soundproofed as much as possible. Consider ear plugs.
    11. Use the bedroom only for sleep and intimacy. Avoid reading or watching TV in bed.
    12. If you awaken during night and are wide awake, get up and leave the bedroom and do something quiet and return to bed when feeling drowsy.
     
    Psychological-behavioural techniques have demonstrated efficacy in clinical trials and can be customized to the patient by a therapist.
     
    Recommend a sleep diary, which can be used before, during, or after treatment.
     
    Pharmacological Options for Insomnia1-8 (Click tables to enlarge)
     
     
     
     
     
    Articles about L-tryptophan, Skullcap, Passion flower, and Chamomile circulate on the internet as remedies for insomnia. There is a limited evidence to support their use. Click here for more information.
    It’s important to identify the insomnia pattern (sleep onset, sleep maintenance, or combination) to provide targeted therapy. Sleep onset (commonly interchanged with sleep latency) is the transition from wake to sleep, which we aim for ≤ 30 minutes after lying in sleep position. Sleep maintenance is frequently waking during the night resulting in fragmented sleep. The goal is to achieve minimal to no awakenings with the duration of sleep fulfilling sleep needs.8
     
    Clinical Practice Tip: Ensure proper monitoring and follow-up with the patient (even with only sleep hygiene counselling).5
     
    Monitoring:
     
    1. Symptom(s)
    • Reduced Sleep Latency to ≤ 30 min
    • Reduced nocturnal awakenings frequency
    • Maintain/Increased duration of sleep between 5-7 hours/night
    • Improved subjective quality of sleep
    2. Side Effect(s)
    • Minimal to no morning drowsiness, grogginess, or dizziness
    Follow-Up with patient on days 3, 14, and every pharmacy visit. Follow up post-treatment to assess for rebound insomnia and other withdrawal symptoms.
     
    By: Vaneet Gill, PharmD Candidate
     
    With appreciation to Mike Boivin
    In this issue:
     
    Patient Case
     
    Insomnia Refresher
     
    Patient Assessment
     
    Treatment
     
    Pharmacological Therapy
     
    Resources
     
    References
     
     
    TEST YOURSELF
     
    Which of the following risk factor(s) apply to Bobby C?
     
     
    Age
     
     
    Age and work-related stress
     
     
    Age, work-related stress, and jet lag
     
     
    Age, work-related stress, loss of job, and jet lag
     
     
     
    Participate Now
    Resources
     
    1. Clinical Guidelines for the Evaluation and Management of Chronic Insomnia in Adults; Journal of Clinical Sleep Medicine View Resource
     
    2. Chronic Insomnia Overview: View Resource
     
    3. The diagnosis and management of insomnia in clinical practice: a practical evidence-based approach: View Resource
     
    4. Sleep Foundation: View Resource
     
    References
     
    1. Schutte-Rodin, S et al. “Clinical Guideline for Evaluation and Management of Chronic Insomnia in Adults.” J Clin Sleep Med 4.5 (2008): 487-504.
     
    2. Bryson, Michelle. “Insomnia: Focus on new dosing concerns in women.” Practical Pain Management. Web. 05 Oct. 2014.
     
    3. Rutter, P et al. Community Pharmacy: Symptoms, Diagnosis and Treatment. Australia: Elsevier, 2012. eBook.
     
    4. Buysse, D. “Chronic Insomnia.”Am J Psychiatry 165.6 (2008): 678-686
     
    5. Fleming, J. “Psychiatric Disorders: Insomnia.” Therapeutic Choices. Web, eResource. 05 Oct 2014.
     
    6. Greenblatt, DJ et al. “Zolpidem for insomnia.” Expert Opin Pharmacother 13.6 (2012): 879-893.
     
    7. Holbrook, AM et al. “Meta-analysis of benzodiazepine use in the treatment of insomnia.” Can Med Assoc J 162.2 (2000): 225-233
     
    8. Pagel, JF et al. “Medications for the Treatment of Sleep Disorders: An Overview.” Prim Care Companion J Clin Psychiatry 3.3(2001): 118-125.
     
     
       
     
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