Posted: April 30th, 2022

Unit 8 Medications for Sleep Disorders

Risks of Benzodiazepines for Sleep and Alternative Assessment Methods
Benzodiazepines are commonly prescribed medications for short-term treatment of insomnia and other sleep disorders due to their sedative and hypnotic properties. However, prolonged benzodiazepine use carries risks that are important to consider. Upon reviewing the current literature, this paper aims to discuss potential adverse effects of long-term benzodiazepine therapy and alternative assessment methods that may provide safer options in appropriate patients.
Risks of Prolonged Benzodiazepine Use
While benzodiazepines are effective for treating insomnia in the short-term, risks increase with prolonged, chronic usage. Tolerance can develop, requiring higher doses to achieve the same effect (Stahl, 2021). Physical dependence and withdrawal symptoms also become more likely if the medication is discontinued after long-term use (Ritvo et al., 2023). Abrupt cessation can cause rebound insomnia and other issues, highlighting the importance of slow tapering under medical supervision.
Additional risks include cognitive impairment that may persist even after stopping the medication. Next-day drowsiness from benzodiazepines increases falls and accident risk in older adults. Drug interactions are also a concern due to the sedative properties. Overall, the benefits must be weighed against these potential adverse effects, with non-drug and alternative therapies considered as first-line options for chronic insomnia where possible.
Alternative Assessment Methods
When discontinuing benzodiazepines or evaluating insomnia, alternative assessment methods may provide safer options compared to prolonged drug therapy alone. Actigraphy utilizes wrist-worn accelerometers to objectively record movements and disturbances during sleep (Naik et al., 2023). This data, combined with sleep logs or questionnaires, can help diagnose certain sleep disorders.
Home sleep apnea tests allow monitoring breathing and oxygen levels during sleep in a patient's own environment (Johns et al., 2022). This provides an alternative to in-lab polysomnography, offering increased accessibility and convenience. Both actigraphy and home sleep testing provide valuable insights to inform diagnosis and treatment planning for sleep issues.
In conclusion, while benzodiazepines have their place in short-term insomnia treatment, risks increase substantially with prolonged usage. Alternative assessment methods like actigraphy and home sleep apnea testing offer safer options to evaluate sleep problems when used appropriately in conjunction with clinical evaluation. A multifaceted treatment approach considering non-drug therapies, sleep hygiene, and lifestyle modifications alongside medical interventions provides the best strategy.

Unit 8 Medications for Sleep Disorders ---2 Peer Response 600w. due 10-25-23
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• There are multiple sleep disorders such as insomnia, sleep apnea, restless leg syndrome, hypersomnia, circadian rhythm disorders, and parasomnia which I think is “sleepwalking” or at least very similar to sleepwalking (Sleep Disorders, 2020).
Screening tools to diagnose sleep disorders can be just as gathering information from the patient, like history and physical. There are other screening tools such as actigraphy which is something like a watch the patient must wear and this tracks the movements the patient makes when sleeping and being awake (How is actigraphy used to evaluate sleep?, 2022)
Adding more we also have polysomnography also known as the “sleep study”, and this particular test records brain waves, oxygen level as well as heart rate (Polysomnography (Sleep Study) 2023). Epic (electronic health record) has something called the stop-bang questionnaire and it basically asks questions about snoring, blood pressure, and the size of the neck. There is also something called the Athens Insomnia Scale and Epworth Sleepiness Scale (Sleep disorders: Clinical tools, 2023).
Z-drugs such as zolpidem, zopiclone, and zaleplon are innovative hypnotics that aid with sleep, reduce sleep latency, and improve quality. These drugs are prescription dispensed only and they work by slowing the activity in the brain (Commissioner, 2023).
Benzodiazepines are medications such as lorazepam, diazepam, temazepam, alprazolam, and clonazepam among others that can have potential side effects such as respiratory depression, drowsiness, impaired judgment, nausea and vomiting, confusion, addiction, and even respiratory distress (Brandt & Leong, 2017).
References:
Brandt, J., & Leong, C. (2017). Benzodiazepines - statpearls - NCBI bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK470159/
Commissioner, O. of the. (2023). Taking z-drugs for insomnia? know the risks. U.S. Food and Drug Administration. https://www.fda.gov/consumers/consumer-updates/taking-z-drugs-insomnia-know-risks
How is actigraphy used to evaluate sleep?. Sleep Foundation. (2022, May 10). https://www.sleepfoundation.org/sleep-studies/actigraphy
Mayo Foundation for Medical Education and Research. (2023, February 17). Polysomnography (Sleep Study). Mayo Clinic. https://www.mayoclinic.org/tests-procedures/polysomnography/about/pac-20394877#:~:text=Polysomnography%2C%20known%20as%20a%20sleep,measures%20eye%20and%20leg%20movements.
Sleep disorders: Clinical tools. CAMH. (2023). https://www.camh.ca/en/professionals/treating-conditions-and-disorders/sleep-disorders/sleep-disorders---clinical-tools
U.S. National Library of Medicine. (2020, January 3). Sleep disorders. MedlinePlus. https://medlineplus.gov/sleepdisorders.html

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Week 8, Medications for Sleep Disorders
What screening tools can be used to affirm your initial diagnosis that a patient may meet the diagnostic criteria for a sleep disorder?
There are different tools for assessing sleep disorders. Among various rating scales, the Pittsburgh Sleep Quality Index (PSQI) was specifically designed to evaluate overall sleep quality and is among the recommended questionnaires for examining global sleep patterns and symptoms related to insomnia (Zitser et al., 2022). It is a self-report questioner and will assess the sleep quality over one month. Another useful scale is the Epworth Sleepiness Scale (ESS), which is a questionnaire designed to assess daytime sleepiness. A higher score on the ESS suggests the need for further evaluation for possible sleep disorders (Clinical application of headache impact test (HIT)-6 and Epworth Sleepiness Scale, 2023).
According to the literature, the gold standard for monitoring sleep and breathing is polysomnography (PSG). PSG observes various physiological factors during sleep, including brain activity, eye movement, heart rate, and muscle activity. It involves the use of special bands around the chest and abdomen, as well as sensors for temperature and airflow in the nose. PSG also utilizes a device to measure airflow and sensors for air pressure in the airway. However, it's important to note that these methods can be invasive and time-consuming to set up and understand (Naik et al., 2023). Home sleep apnea testing (HSAT) is a simplified version of PSG that can be conducted at home and offers several potential benefits compared to traditional PSG, such as increased accessibility, quicker treatment initiation, and cost savings (Johns et al., 2022).
Describe the pharmacological actions of non-z sleep medications?
Non-benzodiazepine (non-Z) sleep medications, such as zolpidem (Ambien), eszopiclone (Lunesta), and zaleplon (Sonata), function by enhancing the activity of the neurotransmitter known as gamma-aminobutyric acid (GABA) in the central nervous system. GABA is an inhibitory neurotransmitter that promotes relaxation and facilitates sleep. One key distinction between benzodiazepine medications and non-Z medications is their selectivity in targeting GABA receptors (Stahl, 2021).
Benzodiazepines act on various GABA receptor subunits (including alpha 1, alpha 2, alpha 3 and alpha 5 receptors) nonselectively. Benzodiazepines acting on alpha2 and alpha3 receptor subtypes have effects that reduce anxiety, promote muscle relaxation, and enhance the effects of alcohol. On the other hand, the alpha5 subtype, found in the hippocampus, may be implicated in cognitive processes. As a result, benzodiazepines are employed for the treatment of sleep disorders, seizure disorders, and anxiety disorders due to their broader spectrum of activity (Stahl, 2021).
In contrast, non-Z medications selectively target alpha 1 receptors, which are primarily associated with the sleep process. Therefore, non-Z medications are specifically designed to induce and improve sleep without affecting the full spectrum of GABA receptors. Another distinction to note is that benzodiazepines typically have longer half-lives, which means they remain in the body for a more extended period compared to non-Z medications. This difference in half-life can have implications for factors such as prolong sedation and potential for dependence or withdrawal when using these medications. Non- Z medications are usually used for short amount of time and do not cause dependence or withdrawal symptoms (Stahl, 2021).
What problems can occur when benzodiazepines are used to help with sleep?
Benzodiazepines are potent medications known for their effectiveness, but they come with a range of significant concerns and potential problems. They have sedative properties, leading to drowsiness and increased sleepiness in patients. Additionally, benzodiazepines exhibit a prolonged half-life, resulting in an extended duration of action within the body, which can impact a patient's overall quality of life. These medications have been associated with several adverse effects (Stahl, 2021).
Benzodiazepines can impair cognitive function, memory, and coordination, potentially leading to accidents and reduced overall performance. A major concern with benzodiazepines is the development of tolerance. Over time, patients may require higher doses to achieve the same therapeutic effect. This can lead to physical and psychological dependence, as patients become addicted to the sedative properties of the medication (Stahl, 2021).
Abruptly discontinuing benzodiazepines can result in unpleasant withdrawal symptoms, which can be challenging for patients. One study by Ritvo et al. (2023) revealed that over 40% of the respondents reported experiencing 17 or more symptoms persisting for at least one year after discontinuing their use of benzodiazepines. Common side effects associated with benzodiazepines include dizziness, drowsiness, and coordination problems, which can be especially problematic for individuals who need to remain alert and functional. It's essential to be mindful of potential drug interactions, as benzodiazepines can interact with other medications, potentially affecting their effectiveness or causing unexpected side effects (Stahl, 2021)
Given these concerns, it is advisable to use benzodiazepines cautiously and only for short durations. When discontinuing their use, a slow tapering approach is often recommended to minimize the risk of withdrawal symptoms. This ensures that the benefits of these medications are balanced against the potential risks and adverse effects they may cause.
References
Clinical application of headache impact test (HIT)-6 and Epworth Sleepiness Scale (ESS) for sleep apnea headache. (2023). Sleep Science and Practice, 7, 1-9. https://doi.org/10.1186/s41606-023-00084-2Links to an external site.
Johns, J. D., Armin, M., Alexandra, W., Jeffrey, K. H., Mikula, S. K., & Hoa, M. (2022). Reliability of home sleep apnea testing for diagnosing obstructive sleep apnea in patients with spontaneous cerebrospinal fluid leaks. Cureus, 14(10)
https://doi.org/10.7759/cureus.29854
Naik, G. R., Breen, P. P., Jayarathna, T., Tong, B. K., Eckert, D. J., & Gargiulo, G. D. (2023). Morphic sensors for respiratory parameters estimation: Validation against overnight polysomnography. Biosensors, 13(7), 703. https://doi.org/10.3390/bios13070703Links to an external site.
Ritvo, A. D., Foster, D. E., Huff, C., Reid Finlayson, ,A.J., Silvernail, B., & Martin, P. R. (2023). Long-term consequences of benzodiazepine-induced neurological dysfunction: A survey. PLoS One, 18(6) https://doi.org/10.1371/journal.pone.0285584
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical application (5th ed.).
Zitser, J., Allen, I. E., Falgàs, N., Le, M. M., Neylan, T. C., Kramer, J. H., & Walsh, C. M. (2022). Pittsburgh Sleep Quality Index (PSQI) responses are modulated by total sleep time and wake after sleep onset in healthy older adults. PLoS one, 17 (6) https://doi.org/10.1371/journal.pone.0270095