Amber Lanae Smith, PharmD, MS, BCPS

PHA 4010 Principles Of Pharmacotherapy 1: Self-care And Alternative Health Care

Sleep, Insomnia, and Fatigue

Learning Objectives
1.
2.
3.
4.
5.

Describe the stages of sleep and basic structure of the sleep cycle
Differentiate between the various types of insomnia
List exclusions to self-treatment and know when to refer patients to a physician for further assessment
Recommend appropriate non-pharmacologic and pharmacologic treatment options
Counsel patients on the selection and proper use of OTC products used to improve sleep or reduce daytime
drowsiness & fatigue

Sleep & Sleep Cycle

1. Sleep is necessary for survival and good health
How Much Sleep is Really Needed?
Age
Sleep Needs
a. Individual requirements for sleep vary from
Newborns
(0-2
months)
12
18 hours
_______ hours every day
Infants (3-11 months)
14 15 hours
2. Sleep Cycle
Toddlers (1-3 years)
12 14 hours
a. 2 major stages: Non-rapid-eye-movement
Preschoolers (3-5 years)
11 13 hours
(NREM) and Rapid-eye-movement (REM)
School-age Children (5-10 years)
10 11 hours
Teens (10-17 years)
8.5 9.25 hours
b. NREM
Adults
1. 9 hours
i. Accounts for about _____ of total
sleep time
ii. Sleep progresses from Stage 1 to Stage 4

Stage 1
Polysomnography (sleep readings) shows a
reduction in activity between wakefulness
and stage 1 sleep
The eyes are closed
One can be awakened without difficulty-if
aroused from this stage of sleep, a person
may feel as if he or she has not slept
Stage 1 may last for 5-10min
May notice the feeling of falling during this
stage of sleep, which may cause a sudden
muscle contraction (called hypnic myoclonia).

Stage 2
This is a period of light sleep during
which polysomnographic readings
show intermittent peaks and valleys,
or positive and negative waves
These waves indicate spontaneous
periods of muscle tone mixed with
periods of muscle relaxation
The heart rate slows and the body
temperature decreases. At this point,
the body prepares to enter deep
sleep.

Stage 3-4
These are deep sleep
stages, with stage 4
being more intense than
Stage 3
Known as slow-wave, or
delta, sleep
If aroused from sleep
during these stages, a
person may feel
disoriented for a few
minutes.

c. REM
i. Neither light nor deep sleep
ii. High-frequency waves on EEG
a. Physiologic activity: eyes jerk rapidly; breathing rapid, irregular, shallow;
changes in BP, heart rate, body temp
d. People alternate between NREM & REM throughout the night
i. Sleep cycle repeats every ______ minutes; ____ cycles/night
ii. Cycle through the 3 stages of NREM, followed by a brief interval of REM sleep
1. NREM period becomes shorter and REM period becomes longer throughout the night
iii. Many people wake up during the night, briefly, but are typically unaware (stage W)
iv. Most vivid dreaming occurs during REM sleep; most talking during sleep, night terrors, and sleep
walking occur during stage 3 (NREM sleep)

Insomnia
1. Occurs when a person has trouble falling or staying asleep, wakes up too early and cannot return to sleep, or
does not feel refreshed after sleeping
a. 3rd most common patient complaint; 33% of Americans experience nightly
i. More common in patients w/ other medical conditions
ii. Adult Americans report treating with: Alcohol (11%); Non-prescription sleep aid (9%);
Prescription hypnotic medication (7%); Melatonin (2%)
b. $14 billion spent annually: > $325 million in OTC products
2. Classification
a. Transient Insomnia
i.
ii. Usually caused by acute life stress, excitement, disruption in the sleep environment
1. Travel, hospitalization, room too cold or too warm, anticipation of important/stressful
event: final exam in self-care course
b. Short-term Insomnia
i.
ii. Emotional or physical discomfort: recovery from surgery, short-term illness, or major life events:
Death of loved one, loss of job, divorce
iii. Can progress to chronic insomnia if underlying stressor/cause is not addressed
c. Chronic Insomnia
i.
1. Often the result of medical problems, psychiatric disorders, or substance abuse
d. May be further classified by CAUSE of insomnia:
i. Primary Chronic Insomnia
1. No clear identifiable cause (medical, psychiatric, etc.)
2. Lasts > 1 month
3. Affects psycho-social functioning
4. Usually requires referral to sleep specialist
ii. Secondary Chronic Insomnia
1. Ongoing
2. Identifiable cause can be found:
a. Medical Problems: sleep apnea, narcolepsy, nocturnal myoclonus, restless leg
b. Mental Disorders: psychiatric or neurological disorder
c. Substance Abuse: caffeine, nicotine, EtOH
d. Rx medications: antidepressants, anti-hypertensives
3. Clinical Presentation
Signs/Symptoms
Difficulty falling asleep
Frequent nighttime awakenings
Early morning awakening
Inability to fall back asleep
Troublesome dreams
Time to fall asleep: 30 minutes
Duration of sleep: < 6-7 hours
Impairment in daytime functioning

Clinical Assessment
Duration, onset, frequency
Characteristics
Sleep hygiene habits
Previous treatments
Family history of sleep disorders
Identify underlying causes
Bed partner sleep habits

Treatment Goals
Improve quality of sleep
Increase duration of sleep
Improve QOL & daytime functioning

Smith 2

Patient with complaint of insomnia

Exclusions for Self-Treatment

Frequent nocturnal awakenings or early
morning awakenings
Chronic insomnia (>3 weeks)
Sleep disturbances occurring nightly for
several days
Sleep disturbances secondary to
psychiatric or general medical disorders

Obtain medical/medication history. Determine

duration of problem. Assess sleep hygiene.

Yes

Contraindications to diphenhydramine or other

exclusions for self-treatment (see box)

Medical referral

No

No

Problem limited to difficulty falling asleep?

Yes

Yes

Patient feels rested in the morning & is

functional during the day?

Patient does not have insomnia. Sleep

hygiene measures to prevent development
of daytime dysfunction.

No

Problem related to use of stimulants (alcohol,

caffeine, nicotine)?

Yes

Cessation/moderation
of consumption &
avoidance of
stimulants in late
evening. Follow up in
10 days.

Insomnia resolved after

recommended treatment
period
Yes

No

Continue good sleep

hygiene measures

Problem related to lifestyle practices, poor

sleep habits, or stress?

Yes

No

Episodic insomnia

No

Appropriate sleep
hygiene measures +
diphenhydramine 2550 mg for 2-3 nights;
then skip a night to
reevaluate sleep
quality

Yes

Insomnia resolved?
No

Appropriate sleep
hygiene measures +
diphenhydramine 25-50
mg for additional 2-3
nights, not to exceed 14
days use of agent
Smith 3

1. Non-Pharmacological Treatment
Principles of Good Sleep Hygiene
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, eat 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

2. Pharmacological Treatment
a. Antihistamine Products: diphenhydramine and doxylamine
i. Ethanolamines that affect sleep through their affinity for blocking histamine and muscarinic
receptors
ii. Diphenhydramine
1. Indication: symptomatic management of transient and short-term sleep difficulty;
particularly in individuals who complain of occasional problems falling asleep
2. Dosing
a. 25-50 mg for 3 days with an off night suggested; Tolerance with repeated use
b. Should not be used for more than 14 consecutive nights
3. Side Effects: dry mouth, constipation, blurred vision, urinary retention, and tinnitus
4. Toxicity: anxiety, excitement, delirium, hallucinations, coma, or seizures
a. Physical signs: dilated pupils, flushed skin, hot and dry mucous membranes, and
elevated body temperature
5. Paradoxical effect: excitation (often occurs in children, elderly, or patients with mental
disorders)
6. Contraindications
a. Males with prostatic hyperplasia, close-angle glaucoma, cardiovascular disease
(angina or rhythm disturbance), dementia,
b. Elderly: Beers criteria recommend avoiding the use of anticholinergics in older
patients; risk of cognitive impairment and falls
b. Complementary Therapies
i. Melatonin
1. Dosing: 0.3-0.5 mg at bedtime
2. Side effects and drug interactions unknown
ii. Valerian
1. Prepared as teas or compounded into tablets and capsules; evidence shows no benefit
2. Dosing: optimum dose unknown, trials have used 400-900 mg
3. Continuous nightly use for several days or weeks is required for effect (not useful for
acute insomnia)
4. Patients can experience benzo-like withdrawal if used for several years-thus should be
tapered
Smith 4

Drowsiness and Fatigue

1. Typically results from acute or chronic sleep deprivation
a. Contributing factors: use of CNS depressants, dopamine agonists, and some anti-hypertensive agents;
consumption of excessive amounts of caffeine in medications or dietary sources
Clinical Presentation

Treatment Goals

2. Treatment Approach
a. Non-pharmacological Therapy: Good sleep hygiene
b. Pharmacological therapy:
i. Caffeine
1. Exerts its effects by increasing arousal, decreasing effects, and elevating mood;
secondary effects on other neurotransmitters may also increase alertness
a. Can cause moderate increases in blood pressure and relax the lower esophageal
sphincter (can aggravate the symptoms of peptic ulcer disease, gastric reflux, or
esophagitis)
2. 100-200 mg every 3-4 hours as needed, to a maximum of 600 mg/24 hours
a. 300 mg/24 hours: pregnant, breast-feeding, older patients, CVD
3. Side effects: increases in heart rate and blood pressure, headache, symptoms of anxiety
and insomnia, and increase in hand tremor
ii. Complementary Therapies
1. Ginseng
a. Dosing: 100-200 mg once or twice daily
b. Side effects: nausea, stomach upset, insomnia, headache, anxiety, tachycardia,
Stevens Johnsons syndrome
Source

Serving Size

Caffeine Content (mg)

Espresso
Coffee (regular)
Coffee (decaf)
Tea (Green)
Coke/Diet Coke
Mountain Dew
5-Hour Energy Drink
Red Bull/Monster Energy Drink
NoDoz
Excedrin
Dexatrim Max
Hydroxycut

1 oz
8 oz
8 oz
8 oz
12 oz
12 oz
2 oz
8.4 oz
1 tab
2 tabs
1 cap
2 caps

90
95-150
2-12
24-40
35-45
50-60
200
75-80
200
130
200
~200

3. Counseling Points

Smith 5