Insomnia

Elderly female with h/o HTN, heart failure, OSA, COPD, diabetic neuropathy, Parkinson disease, anxiety, depression, ADHD, PTSD, and chronic pain presents with poor sleep for greater than three months. Reports difficulty falling asleep and staying asleep resulting in daytime impairment. ROS positive for creeping, crawling, and itching sensation in legs that is most prominent in the evening and improves with movement. Employed as a night-shift worker. Endorses daily use of caffeine, alcohol, and tobacco. Prescribed medications include metoprolol, prednisone, escitalopram (SSRI), methylphenidate. Recently started OTC pseudoephedrine for nasal congestion. Masked facies, HTN, obesity, JVD, LE edema, end-expiratory wheeze, unilateral resting tremor, cogwheel rigidity, decreased sensation to monofilament, and shuffling gait on exam.

• Labs

  • Obtain CBC to evaluate for anemia

  • Consider CMP, HbA1c, BNP, urine drug screen

• Comorbid conditions

  • HTN: Optimize antihypertensive regimen

  • Heart failure with signs of fluid overload: Adjust diuretic regimen

  • Monofilament exam positive for diabetic neuropathy: Start amitriptyline 25 mg and increase to 50 mg after 1 week

  • Restless leg syndrome: Start pramipexole IR 0.125 mg 2 hours before bedtime and increase to 0.25 mg after 3 days

  • Anxiety/depression: Administer GAD-7 and PHQ-9 and treat accordingly

• Insomnia medications

  • Sleep onset

    • Melatonin 5 to 10 mg two hours before sleep

    • Ramelteon 8 mg one hour before sleep

  • Sleep maintenance: Doxepin 6 mg three hours before sleep (recommended for comorbid depression and geriatric patients)

  • Sleep onset and maintenance: Eszopiclone 1 mg before sleep for two weeks (MDD 3 mg qd)

• Consults

  • Suspicion for

    • Obstructive sleep apnea: Sleep study

    • Parkinsonism: Neurology

  • Refractory insomnia: Refer to sleep specialist

• Counseling

  • Pt advised to practice good sleep hygiene

    • Adopt a regular sleep schedule, sleep > 8 hours per night, and limit daytime naps to < 1 hour

    • Reduce caffeine, alcohol, tobacco, and other stimulant consumption

    • No exercise < 1 hour before bed

    • Eliminate excessive light and electronics in the bedroom

  • Pt advised to avoid OTC antihistamines

Notes

• Acute vs. Chronic

  • Acute insomnia lasts < 3 months and generally has an identifiable stressor

  • Chronic insomnia lasts > 3 months

    • May be related to sub-optimally treated, underlying medication condition

    • May require medical treatment

• Insomnia risk factors

  • Female sex

  • Night shift work

  • Medical conditions

    • Cardiovascular: HTN, heart failure

    • Respiratory: Obstructive sleep apnea (OSA)

    • Neurologic: Diabetic neuropathy, Parkinson disease (masked facies, unilateral resting tremor, cogwheel rigidity, shuffling gait)

    • Psychiatric (common): Anxiety, depression, PTSD, shift-work disorder

    • Other: Chronic pain, restless leg syndrome

  • Medications

    • OTC nasal decongestants, e.g. pseudoephedrine

    • Beta-blockers, e.g. metoprolol for heart failure

    • Glucocorticoids, e.g. prednisone for COPD

    • Antidepressants: SSRIs and SNRIs

    • Stimulants, e.g. methylphenidate

    • Vices: Caffeine, alcohol, tobacco

• Medications not recommended for insomnia

  • Do not use antihistamines, benzodiazepines, mirtazapine, trazodone

  • Anticonvulsants and antipsychotics may have limited use

Bipolar Disorder 

Diagnosis per DSM-5

• Bipolar I

  • At least one manic episode lasting ≥ 1 week required

  • Hypomanic and major depressive episodes commonly occur, but are not required for diagnosis

• Bipolar II

  • No history of manic episodes

  • At least one hypomanic episode lasting ≥ 4 days and one major depressive episode required

• Manic episode: Increased activity + abnormally elevated, expansive, or irritable mood + at least 3 of the following:

  • Distractibility

  • Indiscretion: Increased spending, sexual activity, substance use, etc.

  • Grandiosity

  • Flight of ideas

  • Activity increase

  • Sleep deficit

  • Talkativeness (pressured speech)

• Hypomanic episode: Diagnosis is similar to manic episode, but symptoms are less severe, i.e.

  • Self esteem is inflated, but not grandiosity does not occur. Social functioning may be improved.

  • More organized and often productive. For example, Ernest Hemingway produced most of his works during hypomanic episodes.

  • Risk-taking behavior is generally not illegally and does not produce long-lasting consequences.

  • Does not require hospitalization.

Treatment: Important to prevent kindling phenomenon (untreated mood transitions leading to rapid cycling) and suicide

• Lithium

  • Considerations

    • Contraindicated in pregnancy (Ebstein abnormality)

    • May adversely affect renal (irreversible) and thyroid function (reversible)

    • May produce arrhythmias (rare)

  • Initiating treatment

    • Stop all NSAIDs and diuretics

    • Obtain baseline BMP, TSH, T4, and EKG

    • Start 300 mg TID and obtain lithium level within 5 days of starting mediation; goal 1.0 +/- 0.2 mEq/L

  • Obtain BMP, TSH, T4 every 6 months for monitoring

• Valproic acid (anti-convulsant)

  • Especially effective for rapid cycling bipolar disorder

  • Potentially hepatotoxic: Obtain CMP prior to initiating therapy

  • Start 30 mg/kg/day and adjust every 3 days to achieve desired effect (maximum daily dose 60 mg/kg/day)

  • Obtain valproic acid level once symptoms controlled are controlled (goal 50-100 mcg/mL)

• Consider atypical antipsychotics, e.g. quetiapine that treat both mania and depressive symptoms

  • Start quetiapine (Seroquel) 100 mg BID

    • Increase quetiapine dose daily by 100 mg qhs until patient is taking 400 mg daily (i.e. 100 mg qAM, 300 mg qhs)

    • Once taking 400 mg daily, may increase by 25 mg/day to maximum daily dose of 800 mg

  • Obtain yearly lipid panel and HbA1c for monitoring

  • Although less common with atypical antipsychotics, monitor for neuroleptic malignant syndrome

Substance Abuse Disorders

Alcohol Use Disorder (DSM 5)

In the past year have you:

• Had times when you ended up drinking more, or longer, than you intended?

• More than once wanted to cut down or stop drinking, or tried to, but could not?

• Spent a lot of time drinking? Or being sick or getting over the aftereffects?

• Wanting a to drink so badly you could not think of anything else?

• Spent a lot of time drinking? Or being being sick or getting over other after effects?

• Found that drinking–or being sick from drinking–often interfered with in care of your home or family? Or caused job troubles? Or school problems?

• Continued to drink even though it was causing trouble with your family or friends?

• Given up or cut back on activities that were important or interesting to you in order to drink?

• More than once gotten into situations while or after drinking that increased your chances of getting her (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?

• Continued to drink even though it was making you feel depressed or anxious or adding to another health problem?

• Had to drink much more than you once did in order to get the effect you want? Or found that your usual number of drinks had much less effect than before?

• Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, racing heart, or seizure? Or sensed that things were not there?

Scoring

• Mild: The presence of 2-3 symptoms

• Moderate: The presence of 4-5 symptoms

• Severe: The presence of 6 or more symptoms

Early remission: Symptoms absent for at least 3 months, but less than 12 months.