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| Insomia ~Physician's Guide |
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Chapter 6-Physician's Guide To The Management of HD
Sleep Disorders Sleep disturbance is a common problem in Huntington's disease, and can be due to a variety of causes. A complaint of sleeplessness may be due to a mood disorder, either depression, or, less commonly, mania. In these cases, treatment of the mood disorder should lead to a normalization of sleep. The clinician should conduct a careful interview and speak to the patient's family to rule out this possibility. Good sleep hygiene is also important. Patients who do not have enough to do, and whose days are insufficiently structured may develop a reversal of the sleep-wake cycle in which they nap most of the day, and are then awake at night. This pattern tends to reinforce itself and can be hard to interrupt. Helpful strategies include sleeping consistently in a room which is not used for wake-time activities, having a regular bedtime and waking time, and enrolling in a day program, which keeps the patient occupied and prevents daytime napping. In the later stages of illness, patients may have an increased need for rest and daytime napping may be entirely appropriate, as long as the patient is sleeping at night. Some patients will require pharmacologic treatment of their insomnia. We would caution against long-term use of benzodiazepine or barbiturate hypnotics because of the potential for tolerance, dependence, and delirium and usually prefer to use a small dose of a sedating antidepressant such as trazodone (Desyrel), beginning at 25-50mg and increasing to about 200mg as necessary. Sedating tricyclics such as doxepin (Sinequan) or amitriptyline (Elavil) can also be employed, but are highly dangerous in overdose. It is not entirely true that chorea ceases when patients are asleep. Sleep studies conducted in patients with refractory insomnia have suggested that some HD patients have restless sleep because of a large amount of involuntary movements at night. The patient himself will often be unaware of these nighttime movements, but they will often be reported by the spouse or caregiver. A small dose of fluphenazine, haloperidol (0.5-2mg) or clonazepam (0.5-lmg) at bedtime, may suppress the movements sufficiently to allow more restful sleep. Polysomnography or referral to a sleep disorder center may be helpful in these difficult cases. Painful leg cramping caused by dystonia and spasticity can also disrupt sleep. Treatment with a muscle relaxant, such as baclofen may relieve the problem. __________________________________________________________
Type in Insomnia
Drugs that cause Insomnia Alcohol Antihypertensives Antineoplastics Beta Blockers Caffeine Diuretics Levodopa Oral Contraceptives Phenytoin (Dilantin) Selective Serotonin Reuptake Inhibitors (SSRI) Protriptyline (Vivactil) Corticosteroids Stimulants Theophylline Thyroxine Medication Causes of Nightmares http://www.fpnotebook.com/PSY174.htm Nightmares due to Medications Altered CNS Neurotransmitters Antidepressant Medications Tricyclic Antidepressants Monoamine Oxidase Inhibitors Selective Serotonin Reuptake Inhibitors (SSRI) Centrally acting Antihypertensive Medications Beta Blockers Rauwolfia alkaloids Alpha Adrenergic Agonists Antiparkisonian Medications Levodopa Selegiline Chemical Dependency: Drug Withdrawal Alcohol Abuse with withdrawal Barbiturate Abuse with withdrawal Benzodiazepine Abuse with withdrawal Miscellaneous medications Flutamide Procarbazine Ketamine Short-acting Barbiturates __________________________________________________________
Although written for PD, helpful information
Difficulties with sleep are common in Parkinson's disease, and can be categorized into four types:
MEDICATIONS TO IMPROVE THE SLEEP CYCLE While disrupted sleep seems to be an integral part of living with Parkinson's disease, the conventional antiparkinson drugs are not usually helpful. In fact, Parkinson drugs may be the cause of sleep disturbance in some patients. For example, selegiline can cause insomnia, particularly if taken in the afternoon or evening. By contrast, some patients sleep better on a trial of controlled-release Sinemet or one of the dopamine agonist preparations dosed late in the day, due to the long duration of action of these compounds. These drugs are probably most beneficial in those instances when the patient complains of severe immobility or tremor preventing resumption of sleep in the middle of the night. No single drug has proven to be uniformly effective in restoring nighttime sleep in Parkinson patients. EXAMPLES OF DRUGS USED TO PROMOTE AND MAINTAIN SLEEP
Some of the older antidepressant drugs can also be used to promote sleep because of their sedative properties; for example, amitriptyline or nortriptyline 10 - 25 mg. can be taken at bedtime. Some patients are able to achieve a more stable sleep pattern by using diphenhydramine 25 - 50 mg. at bedtime. Available as Benadryl® and many generic brands, this medication is available over-the-counter, and may also help reduce tremor and drooling in some patients. Patients should check with their physicians before using over-the-counter medications such as Benadryl®. Benzodiazepines, discussed previously for treating anxiety, are also sometimes used as a sleep aid. These drugs can be helpful in falling asleep initially, but may wear off in 3-4 hours, thus providing no relief from early morning awakening. Also, tolerance to benzodiazepines develops with regular use over time, and dose increases have significant risks in the elderly, such as over-sedation, confusion, and balance impairment increasing the risk of falls.
Source: http://www.parkinson.org/med36.htm __________________________________________________________
Drug therapy, when combined with good sleep hygiene, may be helpful for the short-term management of insomnia.
Benzodiazepines are commonly used for the management of sleep disorders. Shorter-acting benzodiazepines are less likely than long-acting benzodiazepines to be associated with drowsiness or sluggishness the next morning.
Other drugs used in the short-term management of insomnia include a unique agent called Ambien(zolpidem), barbiturates, sedating antihistamines, and a new drug called Sonata. Drug classes used to treat Sleep Disorders |
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Difficulty maintaining nighttime sleep is probably the most common sleep complaint in PD. Normal sleep is organized into stages, and an individual usually cycles through the various stages of sleep in a set order and time pattern. In Parkinson's disease the normal sleep cycles are frequently interrupted. Patients typically complain of difficulties staying asleep despite having little trouble falling asleep initially. In fact, many people complain that they fall asleep "too early" (7-8 p.m.) and then awaken at 3-4 a.m., unable to resume sleep. In addition, many people with PD will awaken several times throughout the night, although they may have no recollection of these events. Spouses may be more aware of the disrupted sleep than the patient. This disruption of normal sleep patterns may contribute to the daytime sleepiness often reported by Parkinson patients.
Establishing good sleep hygiene habits can also help one get a good night's sleep. These include establishing a regular bedtime and getting up time, limiting daytime napping, and avoiding food, excessive fluid intake, and alcohol for several hours prior to bedtime.
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