1. What is Acute Insomnia? Characterized by: 1,2 –Sudden onset –Short course (duration ≤3 months) Patient may experience: –Difficulty initiating sleep –Sleep fragmentation –Increased duration of nocturnal awakenings –Short duration of sleep –Poor sleep quality 1.American Academy of Sleep Medicine. ICSD-2 – International Classification of Sleep Disorders, 2nd ed: Diagnostic and coding manual. 2005. 2.Alberta Medical Association. Toward Optimized Practice (TOP) Adult Insomnia: Diagnosis to Management Clinical Practice Guidelines. 2010.

2. Why Treat Insomnia? Early therapy can prevent the evolution of more complex sleep-related syndromes Recurrent, untreated insomnia may lead to more chronic, intractable insomnia Patient may develop psychophysiological (conditioned) insomnia over time; more difficult to resolve 1 Bidirectional link between insomnia and depression 2 1.Drake CL, Roth T. Sleep Med Clin. 2006;1:333-349. 2.Staner L. Sleep Med Rev. 2010;14:35-46.

3. Key Features to Assessment: 3 “P’s” Predisposing factors Precipitating factors Perpetuating factors

4. Predisposing Factors to Insomnia –.–. Static risk factorsPersonality characteristics Modifiable risk factors Age Sex Genetic predisposition Anxious predisposition Tendency to worry Circular thinking Generalized hyperarousal Life stress Poor sleep hygiene Shift work Medical comorbidities (eg, chronic pain) Psychiatric comorbidities (eg, anxiety, depression)

5. Precipitating Factors for Insomnia Most common is emotional distress -Bereavement -Relationship difficulties -Loss of work -Financial burdens -Particular stressors (school examinations, work projects, etc.) Changes in medication or dosing Onset of medical or psychiatric disorder or another primary sleep disorder

6. Perpetuating Factors for Insomnia Complex interaction between behavioural, emotional, and cognitive factors Behavioural issues are typically the easiest to address Cognitive and emotional elements may require specialized therapies and techniques

7. Management Strategies Primary goals –to improve sleep quality and quantity –to improve insomnia-related daytime impairments Reassess therapy every few weeks and/or monthly until insomnia appears stable or resolves Follow-up every 6 months thereafter to avoid relapse 1 If a single treatment is ineffective, try other options, a combination of therapies, 2 or test for comorbidities 1.Schutte-Rodin S et al. J Clin Sleep Med. 2008;4(5):487-504. 2.Zavesicka L et al. Neuro Endocrinol Lett. 2008;29(6):895-901.

8. Sleep Diary Important first step to determine management Engages patients in the treatment process Provides data on severity, regularity, and compounding influences Patient instructed to record sleep daily over 1–2 weeks Review diary entries on follow-up appointment

9. Overcoming Maladaptive Compensatory Behavioural Responses Insomnia PerpetuatingInsomnia Alleviating Earlier bedtimes and increased time in bed Reduce the time spent in bed to the ideal total sleep time Late rising times on days off work or school Implement regular rise times, even on weekends and days off Daytime nappingAvoid naps Increased daytime caffeine consumption Reduce caffeine intake, none after noon Increased evening alcohol consumption Avoid alcohol Reduction of social activitiesHave regular mealtimes Reduced exercise due to daytime tiredness Improve fitness with regular exercise

10. Benzodiazepines (BDZs) 1 Non-BDZ sedative-hypnotics 1 Flurazepam Nitrazepam Temazepam Triazolam Zopiclone Zolpidem Accompany with patient education treatment goals and expectations safety concerns potential adverse events and drug interactions other treatment modalities (cognitive and behavioural treatments) potential for dosage escalation rebound insomnia Pharmacotherapy 1.Health Canada. Authorized Sleep-Aid Medications in Canada.

11. Cautions Related to Medications Commonly Prescribed in the Acute Management of Insomnia CompoundReasons for Caution Antidepressants: mirtazapine, fluvoxamine, tricyclics Relative lack of evidence in insomnia Weight gain can be problematic with mirtazapine AmitriptylineRelative lack of evidence in insomnia Adverse effects; eg, dose-related weight gain Anticholinergic effects can be bothersome Antihistamines: chlorpheniramine Relative lack of evidence in insomnia Excessive risk of daytime sedation, psychomotor impairment, and anticholinergic effects Antipsychotics Conventional or first-generation (chlorpromazine, methotrimeprazine, loxapine) Atypical or second-generation (risperidone, olanzapine, quetiapine) Relative lack of evidence in insomnia Unacceptable risk of anticholinergic effects and neurological toxicity Relative lack of evidence in insomnia Unacceptable cost and risk of metabolic toxicity (eg, hypercholesterolemia, hyperglycemia, weight gain), psychotic behaviours BDZs Long-acting (diazepam, clonazepam, flurazepam, lorazepam, nitrazepam, alprazolam) Intermediate-acting (oxazepam) Ultra-short-acting (triazolam) Excessive risk of daytime sedation and psychomotor impairment (lorazepam has a long half-life, but a short duration of action due to rapid tissue redistribution) Very slow absorption: T max ~180 min Unacceptable risk of memory disturbances, rebound insomnia, and rebound anxiety

12. Short-term Therapies: Effective and Safe First- and Second-line Options First Line Zolpidem10 mgT max ~30+ minutes (1.4 hours) T 1⁄2 ~2-3 hrs (range 1.6-6.7 hours) Zopiclone5 mg, 7.5 mgT max ~30+ minutes (<2 hours) T 1⁄2 ~4-6 hours Temazepam15 mg, 30 mgT max ~ 2-3 hours T 1⁄2 ~ 8-10 hrs Second Line Trazodone*50-100 mgT max ~ 60+ minutes (delayed with food – T max up to 2.5 hours) T 1⁄2 ~ 8-10 hours *There is a moderate level of evidence and the extent of present use support the use of trazodone as a second-line agent

13. “Natural” Agents and Over-the-counter Products Used as Sleep Aids “Natural” products L-tryptophan500 – 2000 mg (most common dose is 1000 mg) Evidence supporting efficacy is variable and insufficient May be requested by individual patients looking for a “natural source” agent Melatonin0.3 – 6 mgThere is some support for sustained-release melatonin Valerian400 – 1000 mgSome similarities (though not identical) to BDZs in terms of mechanism of action Over-the-counter products Diphenhydramine25-50 mgPotential for serious anticholinergic side effects (especially in elderly) Residual daytime sleepiness Diminished cognitive function Dry mouth Blurred vision Constipation Urinary retention Not intended for long-term use and tolerance to sedative effects likely develops rapidly (~3 days) Dimenhydrinate is not approved in Canada as a sleep aid Dimenhydrinate25-50 mg Doxylamine25-50 mg