Name, Sign, Reg #.
Pro: does not accumulate, free of cognitive effects, minimal additive effects with low dose alcohol. Less addictive than BZD.
Con: bitter/metallic taste, may cause rebound insomnia and daytime anxiety on withdrawal. Habit forming in some- does have street value.
Lowest effective dose, ideal prn (<4X/week), Ideal short term treatment (2-4 weeks) depending on presentation. Need for tapering if longer term dosing (cut dose 25% per week), Consider WHEN to dose based on patient presentation (wakes late in the night, early in the night, etc.) mixed with ONSET of medication. Such as, for slower onset: take dose 1 hour before bed time, crawl into bed 30 min before “sleep” time. Patient plays active role in treatment.
(10 marks- add more that are case specific in exam)
Doctor questions re: meds that can cause insomnia (see below), lights, sleep hygiene, stress, pain, etc.
Emergance of a mood disorder
All follow-up visits, even into the following year
Protracted insomnia can be prodrome for mood disorder. Doctor monitors.
After 2 weeks if no improvement, re-evaluate compliance with sleep hygiene and psychological and medical status, then another 2 week course of hypnotic. If poor response then, refer for 2nd opinion from sleep specialist, neurologist, psychologist, etc. Withdraw at low stress time and shorten sleep by 20 min 2 nights before.
Non-pharm options: proper sleep hygiene (same wake/sleep time, calm down time before bed, no lights, etc.), relaxation/breathing exercises and tapes, stimulus control, sleep restriction, sleep diary, exercise earlier in the day (45 min with sweating), CBT for insomnia.