On Call: Insomnia Insomnia DefinitionInsomnia – Difficulty Falling or Staying AsleepClassification:Acute Insomnia – Occurs for Less Than 3 MonthsOften Lasts Only a Few Days-Weeks in Response to an Acute StressorChronic Insomnia – Occurs ≥ 3 Times Per Week for ≥ 3 MonthsRisk FactorsElderlyFemale SexNeurologic Disorders:DementiaDeliriumStrokeTraumatic Brain InjuryDepression & AnxietyMedication:SteroidsAntidepressantsCNS Stimulants & DepressantsChronic PainCaffeineSubstance AbuseSleep ApneaCOPDHeart FailureDiabetesCancerComplicationsDeliriumFatigueAgitationDepression & AnxietyIncreased Risk of Cardiovascular EventsImpaired Immune Function Management General ApproachSupport Sleep Hygiene as AbleAvoid Aggravating Factor & StimulantsTreat Any Underling Psychologic or Physiologic Factors Causing Acute StressIndications for Pharmacologic Treatment:Severe Acute InsomniaAcute Insomnia Causing Substantial DistressConsider Cognitive Behavioral Therapy (CBT) as the First-Line Treatment for Chronic InsomniaSleep HygieneMaintain a Regular Sleep ScheduleMaintain a Regular Day-Night CycleKeep the Room Dark at NightKeep the Room Light During the DayAvoid Excessive Sleep During the DayAvoid Evening CaffeineAvoid Tobacco/SmokingAvoid Electronic Screens at Bedtime (Television/Laptop/Cellphone)Avoid “Watching the Clock”Avoid Excessive Noise or Frequent Nighttime “Checks” if Not NecessaryPharmacologic TherapyMelatoninGenerally the First-Line MedicationMinimal Side EffectsDose: 1-10 mg 30-60 Minutes Before BedtimeAntihistaminesAgents: Diphenhydramine (Benadryl) & Doxylamine (Unisom)Dose: 25 mg at BedtimeUp to 50 mg BenadrylIncreased Risk of Delirium – Avoid in the ElderlyTrazodoneMechanism: Serotonin Reuptake AntagonistDose: 50-100 mg at BedtimeRamelteon (Rozerem)Mechanism: Melatonin Receptor AgonistDose: 8 mg within 30 Minutes of BedtimeBenzodiazepine Receptor AgonistsAgents: Zolpidem (Ambien), Zaleplon (Sonata) & Eszopiclone (Lunesta)More Commonly Used in the Outpatient SettingIncreased Risk of Delirium – Avoid in the Elderly