Sleep-Wake Disorders
MODULE 6: Sleep-Wake Disorders
Introduction
We will focus on the treatment of insomnia, hypersomnolence/narcolepsy, and restless legs syndrome (RLS) due to the lack of pharmacological treatment options for the other disorders in this chapter.
Insomnia is a frequently heard complaint throughout all areas of healthcare. The loss of sleep can significantly affect occupational, social, personal outcomes and overall quality of life. Before treating, however, a thorough evaluation is warranted as many factors can affect quality of sleep. Insomnia is frequently a symptom or manifestation of an underlying physical or psychological disorder. (Pharmacotherapy Principles and Practice, pg 734) Many medications, psychosocial stressors, and common behaviors can induce sleep disturbances as well. Ensuring that any underlying causes are being appropriately treated and encouraging nonpharmacological treatments should occur prior to starting pharmacological treatment for insomnia. Hypnotics are extremely effective in providing quick relief of insomnia but these medications should be used at the lowest required doses to reduce the risk of adverse effects and daytime impairments, as well as minimizing the risk of rebound insomnia and withdrawal symptoms when tapering off. (Gabbard pg 607)
RLS is another condition where a thorough evaluation is warranted. Symptoms consistent with RLS can be caused by many physical comorbidities and can be an adverse effect from common psychiatric medications, especially antipsychotics. Any comorbidities should be addressed and any potential offending medications should be discontinued or decreased prior to initiating treatment. Dopaminergic agents can induce or exacerbate psychotic symptoms, making the evaluation for physical or pharmacological explanations all the more important.
Narcolepsy, on the other hand, is an incurable neurological disorder that typically requires long term management. (Gabbard pg 616) Nonpharmacological interventions, like behavioral modifications, should be encouraged as they can enhance medication effectiveness. Although effective, stimulants should be used with caution in patients with comorbid psychiatric disorders as they can potentially exacerbate these illnesses.
Objectives
By the end of this module the student should be able to:
- Identify secondary causes of insomnia or RLS in a given case.
- Choose an appropriate first line pharmacological treatment for insomnia, narcolepsy, or RLS based on patient specific factors.
- Choose an appropriate modification to therapy in the event of nonadherence, partial response, nonresponse, or intolerability.
Read It
Required
Stahl’s Essential Psychopharmacology
- Chapter 11
Gabbard’s Treatments of Psychiatric Disorders
- Part VII: Sleep-Wake Disorders
- Chapter 36: Sleep-Wake Disorders; pg 603 – 619, 630 – 635
DynaMed summaries
This will provide a more detailed summary of pharmacological treatment guidelines and important information about medications (adverse effects, interactions, monitoring, etc.)
- Insomnia in Adults
- Narcolepsy
- Restless Legs Syndrome (RLS)
Highly Recommended
Pharmacotherapy Principles and Practice
- Chapter 41: Sleep Disorders
- This chapter is a nice introductory reading to the pharmacology and the treatment of the sleep disorders of focus in this module
Discuss It
| Module 6 | Discussions |
| Discussion | Group 1: KL is a 79 yo man requesting assistance for “something to help with sleep”. His past medical history is significant for coronary artery disease and s/p CABG, hyperlipidemia, hypertension, major depressive disorder, and benign prostatic hypertrophy. He is taking the following medications: Aspirin 81 mg daily, Lisinopril 20 mg daily, Metoprolol succinate 100 mg daily, Simvastatin 20 mg daily, fluoxetine 40 mg hs, and doxazosin 4 mg hs. He admits to drinking 2 alcoholic drinks/night and denies smoking. Include in your discussion:
The differences in initial, middle, and terminal insomnia and how would you best choose pharmacologic treatment for each one of these based on the half-lives of each hypnotic? Identify any secondary causes for insomnia. What treatment plan do you recommend for KL’s insomnia? (Be specific with your recommendations-which hypnotic and why) Group 2: Discuss the neurobiology of narcolepsy and then discuss the different pharmacological treatments including the MOA, efficacy, side effects and patient education that should be completed. Group 3: Discuss Restless Leg syndrome and Periodic Limb Syndrome. Include etiology and neurobiologic principles. Discuss treatments with emphasis on pharmacologic treatments. Don’t forget to include why and how these medications work to reduce symptoms by including the MOA, evidence for its use, and side effects along with patient education. Group 1: KL is a 79 yo man requesting assistance for “something to help with sleep”. His past medical history is significant for coronary artery disease and s/p CABG, hyperlipidemia, hypertension, major depressive disorder, and benign prostatic hypertrophy. He is taking the following medications: Aspirin 81 mg daily, Lisinopril 20 mg daily, Metoprolol succinate 100 mg daily, Simvastatin 20 mg daily, fluoxetine 40 mg hs, and doxazosin 4 mg hs. He admits to drinking 2 alcoholic drinks/night and denies smoking. Include in your discussion: The differences in initial, middle, and terminal insomnia and how would you best choose pharmacologic treatment for each one of these based on the half-lives of each hypnotic? Identify any secondary causes for insomnia. What treatment plan do you recommend for KL’s insomnia? (Be specific with your recommendations-which hypnotic and why) Group 2: Discuss the neurobiology of narcolepsy and then discuss the different pharmacological treatments including the MOA, efficacy, side effects and patient education that should be completed. Group 3: Discuss Restless Leg syndrome and Periodic Limb Syndrome. Include etiology and neurobiologic principles. Discuss treatments with emphasis on pharmacologic treatments. Don’t forget to include why and how these medications work to reduce symptoms by including the MOA, evidence for its use, and side effects along with patient education.
Responses must be a minimum of 275 words, scholarly written, APA formatted, and referenced. A minimum of 2 references are required (other than your text). Refer to the Grading Rubric for Online Discussion in the Course Resource section. |
