300104

Medications that Interfere with Sleep: An Overview

3 Contact Hours

Medications that Interfere with SleepAn Overview

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Care has been taken to confirm the accuracy of information presented in this course. The authors, editors, and the publisher, however, cannot accept any responsibility for errors or omissions or for the consequences from application of the information in this course and make no warranty, expressed or implied, with respect to its contents. The authors and the publisher have exerted every effort to ensure that drug selections and dosages set forth in this course are in accord with current recommendations and practice at time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package inserts of all drugs for any change in indications of dosage and for added warnings and precautions. This is particularly when the recommended agent is a new and/or infrequently employed drug.

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Medications that Interfere with SleepAn Overview

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Medications that Interfere with SleepAn Overview

Table of Contents
INTRODUCTION................................................................................................... 7 MEDICATIONS THAT CAUSE INSOMNIA ...................................................... 7

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ANTIDEPRESSANTS AND SLEEP ............................................................................... 7 ANTIHISTAMINES, DECONGESTANTS AND SLEEP .................................................... 8 THEOPHYLLINE ....................................................................................................... 8 WEIGHT LOSS MEDICATION AND SLEEP ................................................................. 8 SLEEPING PILLS AND INSOMNIA.............................................................................. 8 MEDICATIONS CAN DISRUPT YOUR SLEEP ................................................ 9 MEDICATION EFFECTS ON SLEEP............................................................... 11 COMMON POSSIBLE SIDE EFFECTS............................................................. 14 SLEEP AIDS IN MY PRACTICE......................................................................... 14 ASSOCIATIONS BETWEEN THE USE OF COMMON MEDICATIONS AND SLEEP ARCHITECTURE IN PATIENTS WITH UNTREATED OBSTRUCTIVE SLEEPAAPNEA ....................................................................... 15 ABSTRACT ............................................................................................................ 15 EFFECTS OF PARKINSONIAN MEDICATION ON SLEEP........................ 16 METHYLPHENIDATE VS. ATOMOXETINE ADHD MEDICATIONS: EFFECTS ON SLEEP ........................................................................................... 17 MEDICATIONS AND THEIR EFFECT ON SLEEP ARCHITECTURE..... 21 WHAT PROBING DEEP HAS EVER SOLVED THE MYSTERY OF SLEEP? ............................................................................................................................. 21 PAIN IS THE ROOT OF KNOWLEDGE ......................................................... 22 PEOPLE WHO SAY THEY SLEEP LIKE A BABY USUALLY DONT HAVE ONE.................................................................................................................... 23 PEOPLE WHO SNORE ALWAYS FALL ASLEEP FIRST............................. 23 THE BIG 3 CHALLENGES OF MODERN LIFE........................................... 24 HE SLEEPS WELL WHO IS NOT CONSCIOUS THAT HE SLEEPS ILL ..... 25 SLEEP IS THE GOLDEN CHAIN THAT TIES OUR HEALTH AND BODIES TOGETHER ....................................................................................................... 25 REFERENCES ......................................................................................................... 26 RITALIN HELPS....BUT WHAT ABOUT THE SIDE EFFECTS?................. 27 WHEN YOUR MEDICATION CAUSES SLEEP PROBLEMS ....................... 30 INSOMNIA............................................................................................................. 31 WHAT IS INSOMNIA? ............................................................................................ 31 TYPES OF INSOMNIA ............................................................................................. 31 OVERVIEW ............................................................................................................ 31 OUTLOOK ............................................................................................................. 32 LIFESTYLE CHANGES ............................................................................................ 32

Medications that Interfere with SleepAn Overview

COGNITIVE-BEHAVIORAL THERAPY ......................................................................33 MEDICINES ............................................................................................................33 EXAMINATION.....................................................................................................35

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Medications that Interfere with SleepAn Overview

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Medications that Interfere with SleepAn Overview

Medications that Interfere with SleepAn Overview #300104 3 CEUs

Learning Objectives
Identify the medications which can cause insomnia. Identify the various side effects that medications that impact sleep. Identify ways to minimize the negative impact medications can have on sleep.

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Introduction
Though medication and prescription drugs are designed to help with specific problems, they can often have negative side effects. Medicine can disrupt the normal balance of the body and lead to a disruption in sleep or insomnia. Even sleeping pills can have a negative impact on restful sleep.

Medications that Cause Insomnia

Many people have no idea that medication can alter and interfere with sleeping patterns. Those taking medicine for a particular purpose may attribute the sleep issues to the ailment, not the cure. However, many medicines can cause sleep problems. Here is a short list of some medicine types that can adversely affect sleep: antidepressants antihistamines decongestants sleeping pills Theophylline weight loss medication.

Antidepressants and Sleep

While some antidepressants, such as Prozac, are thought to help encourage better sleep, some have been linked to causing sleep problems. Some research has indicated that antidepressants can cause the onset of REM sleep disorder, which causes people to physically act out their dreams while fully asleep.

Medications that Interfere with SleepAn Overview Researchers seem to agree that for better or worse, antidepressants definitely have an affect on sleep. Be sure to discuss this with your physician prior to beginning any course of medication, or if you think your current medicine may be affecting how you sleep.

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Antihistamines, Decongestants and Sleep

Antihistamines and decongestants tend to have opposite effects on alertness. Antihistamines can cause a person to become drowsy, while decongestants can cause alertness and excitability. Taking an antihistamine during the day can cause sleepiness that interferes with later sleep. Decongestants, on the other hand, taken too close to bedtime can make it hard to fall asleep. If you are taking an overthe-counter remedy, be sure to read the possible side effects, and feel free to walk up to the pharmacist and ask his or her opinion on the subject. Theophylline Theophylline and other asthma and related medications have been studied recently in regard to their possible effect on sleep. While the medications help clear airways during waking hours, it seems to have other effects when the person is sleeping, including reducing time asleep and soundness of sleep. It is unclear whether this has a perceptible effect on waking function. However, if you are on asthma meds and notice a change in your sleep behavior, be sure to bring it up with your physician. Weight Loss Medication and Sleep Weight loss medication often contains some type of diuretic and/or stimulant (such as caffeine) to rev the body up and increase metabolism. Diuretics can cause people to awaken during the night to go to the bathroom, while stimulants can overexcite the mind and make it difficult to fall asleep. Sleeping Pills and Insomnia Ironically enough, sleep medications can often exacerbate the exact problem they are designed to help. Many sleep medicines override the bodys natural sleep mechanisms, making the body forget how to lull itself to sleep without assistance. This means that most sleeping pills should only be used for short durations as they have limited efficacy.

Medications that Interfere with SleepAn Overview

August 11, 2008 10:56 AM EDT by Julie K. Silver, M.D., Harvard Medical School

Medications can disrupt your sleep

When Ive had insomnia in the past, I usually know what is causing it, be it a particularly stressful week or a time change due to cross-country flight. But sometimes the cause of sleep troubles isnt so easy to pinpoint. According to the Special Health Report titled Improving Sleep: A guide to a good nights rest, you may need to look in your medicine cabinet to find the cause of your sleep woes. Heres what the report has to say on the subject: Often, medication rather than illness is the culprit behind sleep problems. A number of drugs steal sleep, while others may cause unwanted drowsiness. Your doctor may be able to suggest alternatives that do not disrupt sleep. Antidepressants. The selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine (Prozac), sertraline (Zoloft), and paroxetine (Paxil) disrupt sleep or produce daytime fatigue in about 10% to 20% of those who take them. Anti-arrhythmics. These drugs, used to treat heart rhythm problems, may cause daytime fatigue and nighttime sleep difficulties. Such medications include procainamide (Procanbid), quinidine (Cardioquin, others), and disopyramide (Norpace). Sedating antihistamines. These medications, commonly taken to relieve cold or allergy symptoms, also cause drowsiness in most people. They are also the active ingredients in most over-the-counter sleep aids and motion sickness pills (see Antihistamines). To find out if a medication might cause unwelcome drowsiness, check with a pharmacist. If you are taking a sedating antihistamine and are bothered by drowsiness, your physician may recommend a non-sedating alternative that does not readily enter the brain and affect wakefulness and sleep. Beta blockers. Beta blockers are used to treat high blood pressure, arrhythmias, and angina. These drugs can promote insomnia, awakenings in the night, and nightmares. Medications containing caffeine. Caffeine, found in some over-the-counter painkillers and appetite

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Medications that Interfere with SleepAn Overview suppressants, stimulates the nervous system and can induce insomnia. Caffeine makes people feel alert by blocking the action of adenosine, a substance that promotes drowsiness. Caffeines direct effects gradually diminish but may linger for six or seven hours or even longer in some people.

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Medications containing alcohol. Cough medicines often contain alcohol, which can suppress REM sleep and break up nighttime sleep. Clonidine. This medication, which acts on nerve cells that respond to the neurotransmitter norepinephrine, is used to treat hypertension and occasionally to curb nicotine craving in people who are quitting smoking. The drug can cause daytime drowsiness and fatigue; it also may interfere with REM sleep. Some people report no problems with clonidine, but others note restlessness, early morning awakening, and nightmares. Corticosteroids. Corticosteroids such as prednisone, used to suppress inflammation and asthma, often cause daytime jitters and nighttime insomnia. Diuretics. Diuretics, which rid the body of excess sodium and water, can interfere with sleep by inducing urination throughout the night. Potassium deficiency, a common side effect of some diuretics, can cause painful nocturnal cramping of calf muscles during sleep. Nicotine patches. Patches used to curb smoking deliver small doses of nicotine into the bloodstream around the clock. People who use them often suffer insomnia or experience disturbing dreams. Sympathomimetic stimulants. Sympathomimetic stimulants such as dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), and methylphenidate (Ritalin) are powerful central nervous system stimulants that enhance the effect of brain chemicals involved in wakefulness. People taking these agents have difficulty falling asleep; once asleep, they spend less time in REM sleep and non-REM deep sleep. When the drug is discontinued, extreme sleepiness and a craving for REM sleep may follow. Theophylline. This respiratory stimulant, used to treat asthma, is chemically related to caffeine. Many people who use it require doses that are high enough to disrupt sleep.

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Medications that Interfere with SleepAn Overview Thyroid hormone. Thyroid hormone taken to counteract the effects of an underactive gland may cause sleeping difficulties at higher doses.

Medication Effects on Sleep

Each person spends one third of his or her life asleep. It is not surprising that such a complex and pervasive cognitive state should be affected by drugs in many different ways. A philosophy that remains cogent for the CNS is that new research almost always shows this system to be more complex than previously thought. Only a few years ago, if patients complained of difficulty sleeping, they were given pills, often dangerous and addictive pills, to induce sleep no matter what the basis of the complaint might be. Sleeping pills may be safer now, and the understanding of the sleep state itself has increased rapidly. Diagnoses are still diffuse, however, and treatments are often poorly directed. Depression is the offspring of the phlegmatic disposition and the melancholia of another era. Clinically, diagnosis is based on a global assessment of symptoms. It is likely that a diagnosis of depression may include a spectrum of underlying diseases that cannot now be clinically differentiated. Medications have multiple effects on sleep and have many side effects. Progress has, however, been made beyond mothers little pills. Insomnia is no longer a diagnosis but a complaint to be addressed-a symptom of 1 of 60 potential sleep disorders. Each of these disorders has specific and appropriate treatments.

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Bipolar Medication Spotlight: Sleep Aids

BY CANDIDA FINK MD NOVEMBER 6, 2009

With this post, we continue our biweekly series on medications used to treat bipolar disorder and related symptoms. This week, we focus the spotlight on medications that can help you sleep. Before we crack open the medicine cabinet, Id like to say a few words about bipolar disorder and sleep. Sleep is a biggie. Too much could trigger or be symptomatic of depression. Too little could trigger or be symptomatic of a manic episode. At least one study shows that changes in sleep patterns can be an early predictor of a manic episode. Sleep plays a major role in mood disorders and recovery, so if youre having trouble sleeping, you and your doctor need to do something about it.

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Medications that Interfere with SleepAn Overview That something could consist of many strategies, ranging from very simple (such as going to bed the same time every night) to more involved medication, avoiding caffeine and other stimulants, maintaining a strict sleep schedule, and convincing other family members to stop banging around in the kitchen till two in the morning. In stubborn cases, you may benefit from a sleep study to identify factors that may be contributing to the sleep disturbances. Assuming your doctor and you decide that sleep medication is necessary, your doctor may prescribe one or both of the following: A mood stabilizer, atypical antipsychotic, anxiolytic (anti-anxiety agent), or other medication thats not primarily used for sleep but will hopefully help your sleep if it treats underlying mood or anxiety symptoms. Occasionally these medications are used just for the sedating side effects for sleep, but this is not so common. A bona-fide sleeping pill (sedative), which brings us to the main point of this post. A little-known fact is that the active ingredient in many over-the-counter sleeping pills is diphenhydramine the generic form of Benadryl!

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Prescription Sedatives
Several effective sleeping pills are available, which vary in terms of safety, side effects, and other considerations. The following list provides a quick rundown of some of the more common prescription sleep medications currently in use: Ambien (zolpidem): Ambien is available in two forms Ambien (and its generic), which help you fall asleep, and Ambien CR (no generic), approved to help you fall asleep fast and stay asleep. Ambien may not be safe for those who have a history of depression, liver or kidney disease, or respiratory conditions. Ambien may lose its effectiveness if taken longer than two weeks, while Ambien CR can be taken for a longer period of time. Ambien can trigger unusual side effects such as sleep walking, sleep eating, and even sleep driving. Ambien should not be mixed with alcohol the combination increases the risk of these types of side effects. For more about Ambien CR, visit http://www.ambiencr.com/. Lunesta (eszopiclone): Lunesta is approved to help you get to sleep and stay asleep, so you wake up feeling rested. It has a lowrisk for developing a dependency, so you can use it short- or long-term, and rebound insomnia (increasing severity of insomnia after stopping the medication) is rare. Lunesta may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; liver

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Medications that Interfere with SleepAn Overview disease; or are pregnant, planning to become pregnant, or breast feeding. Lunesta should not be combined with alcohol. For additional information, visit http://www.lunesta.com/. Sonata (zaleplon): Sonata is approved to help you get to sleep. Its particular niche is that it is short acting, so is less likely to produce a hangover effect in the morning. It is so short acting that you can take it a second time if you awaken in the middle of night. Sonata can be habit forming and may not be safe for those who have a history of depression, mental illness, or suicidal thoughts; a history of substance abuse or addiction; severe liver impairment; or are pregnant, planning to become pregnant, or breast feeding. Sonata should not be combined with alcohol. Rozerem (ramelteon): Rozerem works differently from other sleep medications and is designed to work in conjunction with your bodys internal clock. Its non-habit-forming, wont make you feel groggy the next day, and is safe to use with many prescribed medications. (Its not a controlled substance like most other prescription sleep medications.) Although Rozerem is generally considered safer and gentler than other prescription sleep medications, it may not be safe for those who have a history of kidney or respiratory problems, sleep apnea, or depression, or are pregnant or breast feeding. It may interact with alcohol, and high-fat meals may slow absorption of the drug. For more about Rozerem, visit http://www.rozerem.com. Some older sleep aids include Restoril (temazepam), Halcion (triazolam), and ProSom or Eurodin (estazolam). These are not used frequently anymore and have a history of being addicting and causing a number of side effects. Halcion has been withdrawn form the market in several countries. If your doctor recommends one of these medications, question the reasoning for using an older drug.

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Atypical Sleep Aids

Some medications that are not bona fide sedatives are often used for this purpose. Following are a few of the more common and effective medications in this group: Trazodone: This is an old fashioned antidepressant, rarely used for depression anymore, but, because it is so sedating, has become popular as a non-habit-forming sleep aid. Its use is limited to women for the most part though, because of a risk in priapism for men an erection that will not go away. This seems like it might be fun but it is actually a medical emergency.

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Medications that Interfere with SleepAn Overview Remeron: Another antidepressant used for sleep because it is so sedating, Remeron is pretty effective, but causes weight gain. Clonidine: This medication was primarily used for high blood pressure, but is quite sedating, is often used in children with ADHD, and is a good sleep aid thats not habit forming. It can sometimes cause a drop in blood pressure or rebound high blood pressure. In high doses, it can cause liver problems.

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What about melatonin? Melatonin is a natural hormone, released by the brain when it gets dark. It is available over the counter. It is an effective sleep aid and is well studied even in children. The safety profile is quite good. Doses range from 1-5 mg per night, and it comes in pills and spray forms.

Common Possible Side Effects

All medications have side effects. Prior to taking any prescription or over-the-counter sleep aid, consult your doctor let her know all the medications you are currently taking, including over-the-counter medications and all natural or herbal remedies. In addition, be aware that any sleep aid can cause drowsiness, so avoid driving or operating machinery while taking these medications, especially when you first start taking them and are unsure of the effect they may have on you. Additional side effects may include the following: Dizziness Allergic reaction, possibly severe Facial swelling Headache Prolonged drowsiness (especially the sleep aids designed to help you stay asleep) Sleep behaviors, such as sleep-driving and sleep-eating or a combination of the two, like if you sleep drive to McDonalds

Sleep Aids in My Practice

I recommend or provide sleep aids frequently, because sleep problems are so commonly associated with mood disorders and other psychiatric conditions. I encourage people to practice good sleep hygiene as a primary intervention: Regular bed time and wake up times No stimulants after 12 noon

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Medications that Interfere with SleepAn Overview No vigorous exercise in the evening Turn off screens and phones and work one hour before bedtime Try to keep the bed for only sleeping and sex no work or other activities No TV in the bedroom its bad for sleep

If we do need to use a sleep aid, I will often start with melatonin before proceeding to prescription interventions. We try hard to use medications for brief periods of time. Getting enough sleep is important in recovery from mood disorders, so treating aggressively is important. If you have bipolar and accompanying sleep-related issues, please share your experiences and insights and any helpful suggestions. This goes for you doctors and therapists out there, too!

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Smith, Simon S. and Dingwall, Kylie and Jorgensen, Greg and Douglas, James (2006) Journal of Clinical Sleep Medicine,

Associations Between the Use of Common Medications and Sleep Architecture in Patients with Untreated Obstructive SleepAapnea

Abstract
STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is often associated with other disorders, which are usually treated with medications. Little is known about the extent to which medications are used in the OSA population or the effects of common prescription medications on the sleep architecture of patients with OSA. The aim of this study was to describe the frequency of use of medications by patients with untreated OSA and to examine the potential associations between specific, frequently used medication types and indexes of sleep architecture assessed through laboratory-based polysomnography. DESIGN: This study used a retrospective design with analyses of archival clinical data. SETTING: Tertiary public sleep disorders center in Brisbane, Australia. Patients or Participants: Consecutive patients with a clinical diagnosis of OSA (N = 1779). INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of the patients with OSA, 77.1% were taking at least 1 medication; 12.4% were taking beta-adrenergic receptor-blocking agents and 20.8% were taking antidepressant or anxiolytic medications. Analyses of

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Medications that Interfere with SleepAn Overview covariance demonstrated reliable effects of medication use on sleep architecture, after accounting for age, sex, and body mass index variables. Both tricyclic and selective serotonin reuptake inhibitor antidepressant or anxiolytic medications were associated with a lower percentage of rapid eye movement sleep and lower sleep-efficiency values in patients with OSA, compared with those not taking any medications. The use of betaadrenergic receptor-blocking agents and aspirin had no consistent associations with the indexes of sleep architecture. CONCLUSIONS: Medication use was high within this sample of patients with OSA. Some common medications may be associated with differences in objective sleep quality in a large proportion of patients with OSA. The potential effects of classes of common medication on both the presentation and treatment of OSA need to be further assessed.

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D. Schfer1 and W. Greulich1 Institut fr Schlafphysiologie, Klinik fr Neurologie, Klinik Ambrock, Ambrocker Weg 60, 58091 Hagen, Germany, DE

Effects of Parkinsonian Medication on Sleep

Summary
Patients suffering from Parkinsons disease (PD) often report about sleep disorders and excessive daytime sleepiness. To some extent, motor disabilities or neural degeneration of sleep modulating structures may be responsible for these effects. Depressive disorders also contribute to the occurrence of insomnia and daytime sleepiness. Nevertheless, dopaminergic, anticholinergic, and other drugs used in PD have a great impact on sleep/wakefulness mechanisms. They may indirectly improve or worsen sleep by changing motor symptoms such as akinesia, hyperkinesia, or tremor. Although their is only little information on the complex regulation of vigilance, it is well known that monoaminergic and cholinergic drugs could influence it directly. Data from animal experiments and clinical experiences led to the hypothesis of a biphasic influence on sleep by dopaminergic substances: small doses of L-Dopa e. g. appear to improve sleep whilst higher doses led to insomnia. Different dopaminergic receptor types or changes in receptor sensitivity may explain these phenomena. Dopaminergic and anticholinergic drugs suppress REM sleep. Recently, initial data on sleep attacks after pramipexole or ropinirole treatment were published. Our preliminary results using 24 h polygraphic recordings showed excessive daytime sleepiness in patients taking ropinirole and L-Dopa which disappeared when changed to ropinirole monotherapy. Sleepiness did never appear as an irresistible attack. Current hypotheses on this topic are reviewed.

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Medications that Interfere with SleepAn Overview

Methylphenidate vs. Atomoxetine ADHD Medications: Effects on Sleep

Stimulants are often the primary source of medication for ADHD and related disorders. Medications such as methylphenidate (Ritalin, Concerta, Daytrana), Adderall, Vyvanse and the like are often the first line of defense and choice of prescription for ADHD for many practicing physicians. However, certain drawbacks exist to these medications. Perhaps the three most common concerns are cardiovascular effects, stimulant induced sleep difficulties, and appetite suppression and resulting weight loss. As a result, some parents and prescribing physicians choose a nonstimulant form of medication for treating ADHD such as Atomoxetine ( Strattera ). While some of the negative side effects mentioned above are less common for these non-stimulant options, the overall efficacy of reducing core ADHD symptoms is often less extensive than for the stimulant counterparts. In this post, we will investigate one of the problem areas of stimulant medication by examining a handful of studies comparing and contrasting the different effects of methylphenidate and atomoxetine on sleep patterns in ADHD individuals. Sleep patterns are often analyzed via reports (either the patients themselves, or parents if the patient is a child), actigraphy (less invasive) or polysomnography (more details and quantitative data).

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Methylphenidate
Adult ADHD studies on methylphenidate and sleep quality: While sleep difficulties are clearly evident in several studies, numerous others have actually shown overall positive effects of methylphenidate on sleep performance. For example, a study by Boonstra and colleagues on sleep activity patterns in adult ADHD showed that methylphenidate administration resulted in a delayed period of sleep onset. However, once subjects did fall asleep, the frequency of nighttime awakenings decreased significantly for the methylphenidate group (keep in mind that all of these individuals had ADHD), and that the overall duration of sleep for the night was less for the methylphenidate participants. These positive results were echoed in a study by Sobanski and coworkers, which found that methylphenidate administration improved efficiency and restorative quality in adults with ADHD compared to non-medicated individuals with the disorder. In other words, it appears that although methylphenidate can delay the onset of sleep, it appears to offer a

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Medications that Interfere with SleepAn Overview positive effect in promoting a deeper pattern of less-interrupted sleep in ADHD adults. ADHD, Methylphenidate and Sleep Quality in Children: One of the difficulties in assessing the effects of ADHD medications on sleep deficits in children is that it relies heavily on parental reports and observations. Unfortunately, the overall accuracy of these parental (as well as teacher ratings) has been called in to question by several recent findings. More info on this is given at the bottom of the post. Another key issue, is the relative lack of long-term controlled studies on methylphenidate in children due to a myriad of safety and practicality issues. As a result, obtaining clear-cut and accurate information on ADHD stimulant medications and sleep disorders in children is more tenuous than in the adult model, even though the overall number of studies on ADHD medication effectiveness is much higher in children. In other words, sleep disorders still hold a relatively remote corner amongst the sea of information on pediatric ADHD. Nevertheless, several studies on the matter have been done in the past few years. I will highlight some of them below: An investigation by OBrien and coworkers found a significant increase in sleep disturbances for ADHD children regardless of medication status. These findings suggest a neutral effect of stimulant medications such as methylphenidate for children with ADHD, but cite an often-overlooked characteristic: ADHD children typically exhibit more sleep difficulties than non-ADHD children. Therefore, some of the bad rap attributed to ADHD stimulant medications such as methylphenidate for inducing sleep disorders may simply be due to the nature of the individuals ADHD and not to the medication. This is an important observation to keep in mind, especially when investigating sleep medication studies. There is even some evidence that the assertion of methylphenidate administration later in the day (afternoon) may negatively impact sleep performance is less pronounced than popularly believed. Many physicians fear that a third daily dose of methylphenidate may cause sleep difficulties and omit the afternoon dosage. However, a study by Kent indicates that this may not be the case. Of course this is just one study, and should be regarded as such, but this may at least open the possibility that a number of these afternoon medication/sleep impairment fears may be less grounded than previously believed. Nevertheless, sleep disturbances are still a concern with ADHD medications such as methylphenidate, but, according to recent findings, the effects are relatively small.

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Medications that Interfere with SleepAn Overview

Do genetics play a role on sleep disorders and the ADHD medication response?

This is an intriguing question which needs to be investigated further. We have had several previous discussions on the COMT gene and its effects on ADHD. Now it appears that sleep disorders and potential medication response may actually be impacted by an individual variation in this hotbed region of the human genome. A study done by Gruber and coworkers suggests that ADHD children with the Val form of the COMT gene may be more prone to sleep difficulties while on methylphenidate compared to the Met form of the COMT gene (if you are unfamilar with this Val, Met and COMT terminology, a good explanation of these terms and how they relate to ADHD and ADHD medications can be found here ). ADHD, Sleep Quality and Strattera (Atomoxetine) in children: In contrast to methylphenidate, which seems to delay the onset of sleep, individuals on atomoxetine have a much smaller delay in sleep onset. These differences were highlighted in an article by Sangal and coworkers titled Effects of Atomoxetine and methylphenidate on sleep in children with ADHD. Other advantages of atomoxetine over methylphenidate include less irritability, less difficulty getting ready for bed, less difficulty waking up in the morning, and less of an appetite suppression. However, the postive effects of fewer nighttime awakenings seen in methylphenidate were not observed in atomoxetine. Methylphenidate vs. Atomoxetine: Comparative Effects on Sleep Here are some of the highlights obtained from the Sangal study. A number of parameters and categories were investigated, but I have only included ones which were either statistically significant or ones which I personally found to be noteworthy: Factor Sleep onset (minutes) Time to REM (minutes) % of Sleep time in REM # of awakenings Time to fall back asleep (minutes) Sleep onset (minutes) Total sleep time (minutes) # of sleep interruptions Total interrupted sleep time (minutes) No Meds 19 173 19 12 18 30 519 32 61 Atom MPH Method 19 209 18 8 15 42 504 30 62 36 170 21 5 7 69 483 27 55 Polysom Polysom Polysom Polysom Polysom Actigraphy Actigraphy Actigraphy Actigraphy

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Medications that Interfere with SleepAn Overview A comparison of differences between Atomoxetine (Atom) and Methylphenidate (MPH), as well as the effects of both medications compared to unmedicated ADHD individuals are shown above. Quantitative measurements were performed using both polysomnography (polysom) and actigraphy. Some key trends of note: A delayed onset of sleep was seen in Methylphenidate. However, REM sleep (an important factor in overall sleep quality) was reached faster with Methylphenidate and slower with Atomoxetine. Additionally, a slight increase in the percentage of sleep time spent in REM was seen with methylphenidate treatment. Fewer sleep disruptions (partial or full, as in awakenings) were seen with both medications, but the effects were even greater in the methylphenidate group. When a child did awaken during the sleep cycle, the children medicated with methylphenidate were able to fall back asleep much faster. Note this contrast to the increased time to fall asleep initially for the methylphenidate group. Overall, it appears that while methylphenidate does slow the onset of sleep initially at a significant level, it appears that once a child does fall asleep, the overall sleep quality is actually improved if the child is medicated with methylphenidate. This data runs against the grain as far as prescription medications for ADHD are concerned, in which nonstimulants such as Strattera (Atomoxetine) are often given in favor of stimulants such as methylphenidate if sleep disorders are a concern. This is likely due to the most obvious parameter (initial difficulty falling asleep), which favors Strattera, while the other parameters, which favor methylphenidate and are more numerous, are less intrinsically obvious. Why the pronounced difference between the two ADHD medications? While there is still a fair amount of debate surrounding the exact cause of different impacts of these ADHD medications on sleep, the different biological targets and modes of action may offer some clues. For example, while methylphenidate primarily targets the neuro-signaling agent dopamine in brain regions such as the striatum and nucleus accumbens, Strattera (atomoxetine) instead targets another neurotransmitter called norepinephrine. It appears that the different neurochemical targets and specific brain regions impacted by the two medications are responsible for the differences. For example, we have previously mentioned in another post on gene variations and attention control that the cingulate region of the brain, which essentially acts as the brains gear shifter, has a high density

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Medications that Interfere with SleepAn Overview of receptors for dopamine, the very chemical that methylphenidate targets. It is possible that changes in dopamine levels from methylphenidate may indirectly impact the gear shifting ability of the key brain region of the cingulate. We have previously discussed that an overactive cingulate region can lead to difficulties changing focus or transitioning between topics or activities, while an underactive cingulate can lead to difficulty maintaining focus on a particular thought or state. Putting this into context of our sleep and ADHD medication discussion, it is also worth noting that the Sangal paper mentioned that children who took the methylphenidate had a more difficult time getting up in the morning and settling down into a pre-bedtime routine than the Strattera group. In other words, it seems like the methylphenidate group had trouble with transitions. As a result, this blogger hypothesizes that the transitions may be caused, at least in part, by the increased activity of the cingulate region of the brain and its high density of dopamine targets, which see increased activities driven by a boost in free dopamine levels from the methylphenidate. In other words, I suggest the possibility that methylphenidate induces a state of the cingulate gear shifter becoming overactive and getting stuck in one routine (either the waking or sleeping state) and having trouble moving to another (getting out of bed or falling asleep). Further supporting this hypothesis is the data from the table above showing that the methylphenidate treatment group appears to be more inert (i.e. fewer sleep interruptions, and a quicker return to a previous sleeping state).

Notes

Thomas Bailey Aldrich Simone Weil Marianne J Davey MSc, Director, British Snoring & Sleep Apnoea Association

MEDICATIONS AND THEIR EFFECT ON SLEEP ARCHITECTURE

WHAT PROBING DEEP HAS EVER SOLVED THE MYSTERY OF SLEEP?

Sleep patterns vary from one individual to another, some need only 4-5 hours and others may need 10-12, but in general, adults sleep for about 7-8 hours per night. It is estimated that we spend around one third of our lives asleep and our day-to-day well-being is often measured by our perceived sleep quality. Approximately 35% of the population suffers from insomnia but only about 5% of them consultant their GP(12,16). Sleep is divided into two distinct states Rapid Eye Movement (REM) sleep and non-REM which is further divided into 4 stages: Stage 1

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Medications that Interfere with SleepAn Overview (drowsiness), Stage 2 (light sleep), and Stages Nr-3 (deep sleep). Deep sleep is often referred to as slow-wave sleep (SWS). These stages of sleep alternate in 70 - 90 minute cycles and in an average night, sleep will move through 4 to 5 cycles.

Notes

However, many individuals rarely obtain a good nights sleep. Sleep disturbances can be classified according their duration as either transient (<1 week), short-term (1-3 weeks) or chronic (months). Additionally they can be a primary disorder or occur secondary to other disorders. Here we will briefly examine the sleep disturbances caused by a range of prescription and over-the-counter (OTCs) medications and also discuss how some lifestyle choices can have a detrimental effect on our sleep.

PAIN IS THE ROOT OF KNOWLEDGE

Pain is probably the most frequent and disabling symptom in medicine. It causes sleep deprivation which can further worsen the severity of the pain. Studies have reported greater sleep disturbance among patients with acute or severe pain and can predict the level of sleep disturbance to the severity of pain. Analgesics used in the symptomatic treatment of pain can be broadly divided into 3 categories: opioids, nonopioids and adjuvant analgesics. Opioids include heroin, morphine, methadone and codeine. They are used as major analgesics and are known for their sedating effects but they also have a profound effect on sleep disturbance. Known disturbances include prolonged sleep latency (SL), decreased SWS and REM, and and an increase in arousals throughout the night. Opioids are also known to depress respiratory drive by decreasing the respiratory centres sensitivity to carbon dioxide. Kosinski in his study, evaluated the changes in pain and pain-related sleep disturbance with the use of Tramadol. Paradoxically, despite somnolence and insomnia being the most commonly cited adverse events, patients reported significant improvement in their pain-related sleep disturbance. Nonopioid analgesics are generally known as nonsteroidal antiinflammatory drugs (NSAIDs) that include paracetamol, aspirin and ibuprofen. In a study by Onen, paracetamol had a beneficial effect on sleep quality even in patients free of pain, whereas aspirin and ibuprofen had a negative effect (increased SL, increased awakenings, decreased

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Medications that Interfere with SleepAn Overview SWS). However, Genco in his study, treated healthy subjects with 400mg ibuprofen TID for 3 days, and reported no interference in sleep patterns. Adjuvant analgesics comprise those drugs that have a primary indication other than pain but are also known to be analgesic in some circumstances. These analgesics usually include antidepressants and anticonvulsants. Although antidepressants suppress REM sleep, induce more restless sleep, and sometimes worsen insomnia, according to Lam they objectively and subjectively improve quality of sleep in depressed individuals.

Notes

PEOPLE WHO SAY THEY SLEEP LIKE A BABY USUALLY DONT HAVE ONE

Benzodiazepines, are among the most commonly prescribed hypnotics. As well as affecting sleep architecture they can have an adverse effect on breathing during sleep. These medications are mild respiratory depressants and can increase the apnoea/hypopnoea index and decrease oxygen saturation. Browns study found the mean number of apneas increased from 5/hr on a control night to10/hr on the drug night with oxygen desaturation. This effect is more pronounced in those individuals who suffer from sleep disordered breathing (SDB). Antidepressants are prescribed for mood disorders but they are sometimes prescribed for use as hypnotics. In polysomnography (PSG) studies antidepressants were found to suppress REM sleep, increase awakenings and arousals and reduce total sleep time (TST). There is also the tendency to exacerbate periodic limb movements during sleep and restless leg syndrome. Symptoms of sleep abnormalities have been reported to occur in around 60-80% of depressed patients but there have been mixed reports on the use of antidepressants. In one study, improvements in both SL and TST were demonstrated. However, in Wilsons study, only an increase in REM onset latency was reported.

PEOPLE WHO SNORE ALWAYS FALL ASLEEP FIRST

The use of medications for the treatment of sleep disordered breathing is theoretically attractive. Compared with current treatments (Mandibular Advancement Therapy, CPAP), compliance would improve dramatically if patients simply had to take a daily pill. The use of ventilatory drive stimulants, central nervous system stimulants, antidepressants, serotonin reuptake inhibitors or antagonists, antihypertensive agents and even sedative hypnotics agents have been studied but no data has demonstrated that pharmacologic

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Medications that Interfere with SleepAn Overview agents improve upper airway muscle activity. Indeed studies have shown that sedatives have a deleterious effect on respiration during sleep, reduced genioglossal muscle tone with consequent worsening of Obstructive Sleep Apnea (OSA), increased apneas and increase in severity of nocturnal oxygen desaturation. Lu in his study, found some of the physicians (who did not usually treat patients with sleep disorders) prescribed sedatives to patients with undiagnosed OSA who presented with sleep related symptoms. Of the 50 physicians in the study, only one third of them screened their patients for OSA prior to prescribing sedatives.

Notes

THE BIG 3 CHALLENGES OF MODERN LIFE

Caffeine is without question the most commonly used stimulant worldwide, with an estimated mean consumption of 210-238 mg per person per day. PSG studies demonstrate the most prominent effects of caffeine to be prolonged SL, reduced sleep efficiency, reduced SWS and increased awakenings during sleep. Alcohol is the second most commonly used psychoactive substance used world-wide. An estimated 13% of people use alcohol as an aid to sleep. It is similar to sedative hypnotics and has significant effects on sleep. One study reported alcohol users to suffer decreased SL, suppressed REM sleep (dose-dependent) and increased excessive daytime sleepiness, significantly more than nonusers. The authors concluded that continued use of alcohol as a sleep aid exacerbates these disturbances. The effect of alcohol in alcoholics is different. SL and TST is decreased and their sleep is composed primarily of non-REM sleep. Even after more than two years of abstinence, recovering alcoholics show abnormal sleep patterns. Alcohol decreases muscle tone, particularly in the upper airway and leads to the development or worsening of snoring and OSA. It decreases the arousal response so that obstructive events become longer in duration. Nicotine affects sleep both during use and on withdrawal. PSG studies show that compared to nonsmokers, current smokers experience increased SL, less TST and lower sleep efficiency. Additionally, a drop in nicotine levels in the brain during sleep causes nicotine craving. This state of withdrawal modifies sleep continuity and subjective results showed smokers experience more difficulties with morning wakefulness and EDS than non-smokers. Cessation of smoking can reverse these conditions.

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Medications that Interfere with SleepAn Overview

HE SLEEPS WELL WHO IS NOT CONSCIOUS THAT HE SLEEPS ILL

Insomnia (specifically increased SL) is a common complaint of persons using illicit drugs, although withdrawal from the drug itself can also induce a variety of sleep problems. Increased TST and REM sleep occur during initial abstinence followed by persistent insomnia and REM disturbance for several weeks after. For some, sleep disturbance is so severe it can inhibit treatment success with consequent relapse to addiction. In asthma and allergic rhinitis inflammation increases at night often leading to disturbed sleep. The use of antihistamines and decongestants is common but the side effects of these medications can cause insomnia and subsequent daytime fatigue. Patients with Alzheimers disease (AD) commonly have poor sleep and a high incidence of SDB. Sleep disturbance in AD may be multifactorial and involve SDB and disrupted chronobiology often characterized by excessive daytime napping. In a study by Cooke(4), PSG results demonstrated that AD patients with SDB spent less of the night in REM sleep than those with no SDB, but there were no differences in other sleep stages. In a further study by Cooke, it was found that Acetylcholinesterase Inhibitors (AChEls) used in AD, changed sleep architecture significantly. There were changes to stages 1 & 2 sleep, but no changes to REM or SWS. A better understanding of the cause-and-effect relationship of AChEls is needed to further understand their effects on sleep architecture. Meanwhile treating these patients SDB may improve their daytime functioning.

Notes

SLEEP IS THE GOLDEN CHAIN THAT TIES OUR HEALTH AND BODIES TOGETHER
Although the effects of a drug are known, some medications may act differently in individuals who are more susceptible to sleep related problems. Screening patients for substance use/abuse, SDB and selfmedication with OTCs will provide useful information when patients present with sleeping difficulties. The Epworth Sleepiness Scale (ESS) is a simple and efficient test to determine the degree of daytime sleepiness. Patients with a high ESS and a BMI >25 are at risk of sleep disordered breathing.

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Medications that Interfere with SleepAn Overview

References
1. 2. Bliwise DL (2004) Sleep disorders in Alzheimers disease and other dementias. Clin Cornerstone 6 Suppl 1A S16-28 British Snoring & Sleep Apnoea Association (2007) Patient Information. www.britishsnoring.co.uk Brown D (2006) The effects of medication on sleep. Respiratory Care Clinics of North America 12 81-99 Cooke JR et al (2006) Acetylcholinesterase inhibitors and sleep architecture in patients with Alzheimers disease. Drugs & Aging 23 (6) 504-511 Cooke JR et al (2006) The effect of sleep disordered breathing on stages of sleep in patients with Alzheimers disease. Behav Sleep Med 4 (4) 219-27 DeMartinis NA & Winokur A (2007) Effects of psychiatric medications on sleep and sleep disorders. CNS & Neurological Dirsorders 6 17-29 Drapeau C et al (2006) Challenging sleep in aging: the effects of 200mg cafeine during the evening in young and middle-aged moderate caffeine consumers. Journal of Sleep Research 15 133-41 Gengo F (2006) Effects of Ibuprofen on sleep quality as measured using polysomnography and subjective measures in healthy adults. Clinical Therapeutics 28 (11) 1820-1826 Hudgel DW & Sitthep T (1998) Pharmacologic treatment of sleep disordered breathing. American Journal of Respiratory Care & Critical Care Medicine 158 (3) 691-699.

Notes

3. 4. 5. 6. 7.

8.

9.

10. Johnson EO et al (1998) Epidemiology of alcohol and medication as aids to sleep in early adulthood. Sleep 21 (2) 178-186 11. Kosinski M et al (2007) Pain relief and pain related sleep disturbance with extended release Tramadol in patients with osteoarthritis. Current Medical Research & Opinions 23 (7) 1615-1626 12. Lam R (2006) Sleep disturbances and depression: a challenge for antidepressants. Int Clin Psychopharmacol 21 (suppl 1) S25-S29 13. Lu B et al (2005) Sedating medications and undiagnosed OSA: Physician determinants and patient consequences. J Clin Sleep Med 1 (4) 367-371 14. Onen H et al (2005) How pain and analgesics disturb sleep. Clin J Pain 21 (5) 422431 15. Teplin D et al (2006) Screening for substance use patterns among patients referred for a variety of sleep complaints. The American Journal of Drug and Alcohol Abuse 32 111-120 16. Verster J et al (2004) Residual effects of sleep medication on driving ability. Sleep Medicine Reviews 8 309-325 17. Wilson S et al (2002) Effects of 5 weeks of administration of fluoxetine and dothiepin in normal volunteers on sleep, daytime sedation, psychomotor performance and mood. Journal of Psychopharmacology 16 (4) 321-331 18. Woods L & Craig T (2006) The importance of rhinitis on sleep, daytime somnolence, productivity and fatigue. Curr Opin Med 12 390-396

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19. Zhang L et al (2006) Cigarette smoking and nocturnal sleep architecture. Am J Epidemiol 164 529-537

Carol E. Watkins, M.D. Glenn Brynes, Ph.D., M.D.

Ritalin Helps....but what about the side effects?

The stimulants are often used to treat AD/HD and other conditions. The most common stimulants are methylphenidate (Ritalin, Concerta, Metadate-ER) and amphetamine (Dexedrine, Dexedrine Spansules, Adderall and Adderall XR.) We have been using these medications for years. Despite some dramatic media reports, the stimulants have a fairly good safety record. When a medication gives you a symptom that you did not want, we call that symptom a side effect. Many individuals take stimulants with few side effects. Others experience mild problems. Some are simply unable to tolerate stimulants. Often we can treat annoying side effects so the individual can continue to take the stimulant. Too many people stop their medication instead of working with their physician to find a way to decrease side effects. On the other hand, stimulants can have the potential for real side effects. This is why it is a good idea to keep in close contact with your doctor, especially during the early stages of treatment. Often we can treat side effects so you can continue to take your medication. Instead of stopping your medication, work with your physician to find a way to reduce side effects. Reduced appetite: This effect may be worse in the very young. It may improve after several weeks or months. If it continues to be problematic, one may reduce the dose; or time a short-acting stimulant to wear off before mealtimes. Some people find that methylphenidate compounds have slightly less appetite suppression than amphetamine compounds. In some cases we resign ourselves to a eating a large breakfast and supper followed by a very small lunch. A late evening snack can also help. Some non-stimulant AD/HD medications do not cause the same degree of appetite suppression. Rebound: Some people who take short acting methylphenidate or amphetamine experience irritability or depression for an hour as the stimulant wears off. Sometimes this is worse than the individuals behavior before the medication was started. One can avoid rebound by spacing the doses closer together, giving a smaller dose after the final larger dose, or by switching to a longer acting stimulant. Recently several new long-acting stimulant preparations have been released. Although the

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Medications that Interfere with SleepAn Overview long-acting compounds often have less rebound, it may still occur in susceptible individuals. Sometimes, we add a tiny dose of short-acting stimulant when the longer-acting stimulant wears off. Headache: If this does not improve with time, we may reduce the dose or switch to another stimulant. Sometimes caffeine restriction helps. However, if an individual with a heavy caffeine habit suddenly stops the caffeine he may get a caffeine withdrawal headache. If the caffeine cessation happens at the same time as the start of the stimulant, the caffeine withdrawal headache may be mistaken for a stimulant side effect. Jittery feeling: Eliminate caffeine or other stimulant-type medications. A small dose of a beta-blocker (a type of blood pressure medication) can block tremor or jitters. Make sure that the individual is eating regular meals. Gastrointestinal upset: Take the medication with meals or eat smaller, more frequent meals. Sleep difficulty: It is a good idea to take a sleep history before starting a stimulant medication. Sometimes the sleep problem is due to the AD/HD, not the medication. If the sleep problem is truly due to medication effect, we have several options. Sleep difficulty is more common when one is using a long-acting stimulant or if one is giving a short-acting stimulant in the evening. Now that there are more longacting stimulants on the market, one can often eliminate this problem by using one of the more intermediate-length stimulants. Clonidine or guanfacine may help decrease agitation and may also facilitate sleep. We also counsel the individual on establishing good sleep habits. Paradoxically, there are a few individuals who sleep better when they take a small dose of stimulant in the late evening. For these individuals, the stimulant helps slow racing thoughts and helps them lie still in their beds. Irritability: Sometimes irritability may be due to the AD/HD or another psychiatric disorder. If the irritability is truly due to the stimulant, one might reduce the stimulant dose, switch to a different stimulant, add an SSRI, (paroxetine, sertraline) an alpha agonist (clonidine/guanfacine) or use another class of medications to treat the AD/HD. Depression: This may occasionally be a delayed effect of stimulant medication. It may be more common with the long-acting stimulants. Screening for a history of depression, and treating co-existing depression can minimize this. If the depression truly is related to the medication, one may switch to another class of medications to treat the AD/HD. These

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Medications that Interfere with SleepAn Overview second-line medications would include the tricyclic antidepressants, bupropion (Wellbutrin) and atomoxetine (Strattera.) Anxiety: If an individual is anxious, the stimulants can exacerbate the symptoms. The treatment of this side effect is similar to that of depression. It may be best to treat a co-existing anxiety disorder before treating the AD/HD. Blood glucose changes: Individuals with diabetes mellitus or borderline glucose tolerance could potentially see a rise in blood sugar. On the other hand, if the stimulant cuts ones appetite, one may use less insulin. Individuals with diabetes can often take stimulants but may need closer monitoring of their diabetic control. Increased blood pressure: Stimulants may cause increases in blood pressure or pulse. This is usually not significant at normal doses in most people. However occasionally, the blood pressure effects can be significant. Individuals on very high doses of stimulants or individuals at risk for blood pressure problems should be monitored more closely. Some adults may opt to continue the stimulant and add a blood pressure medication. A small open study suggested that adults who were well controlled on their blood pressure medications could take amphetamine without significant increases in blood pressure. Individuals with blood pressure changes need to discuss the risks and benefits with their physicians. (1) Tics and stereotyped (repetitive) movements: In the past we rarely gave stimulants to individuals with tics because we believed that the stimulant would make the tics worse. Recent data seems to indicate that low to moderate doses of amphetamine or methylphenidate do not exacerbate tics. If an individual has tics, or develops them while on a stimulant, it should be discussed with the prescribing physician. The patient and physician should then carefully weigh the risks and potential benefits or medication treatment. Psychosis or paranoia: These are rare side effects. They may occur in an individual who is already predisposed to a bipolar disorder or another psychotic disorder. In a few cases, psychosis has occurred in individuals who have no previous history of bipolar disorder or psychosis. Psychosis may also occur when someone takes a stimulant overdose. It is important to screen for and treat certain other psychiatric disorders prior to starting a stimulant. If psychosis occurs while taking a stimulant, one should immediately stop the medication and call the prescribing doctor.

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Medications that Interfere with SleepAn Overview

by Aimee Amodio 24 FEB 2009

When Your Medication Causes Sleep Problems

Notes

When I was trying to clear up my clogged ear, I picked up a variety of decongestants to try. My family doctor suggested traditional Sudafed -made with pseudoephedrine, which can be hard to get in some areas. The Sudafed worked, but caused a different problem: I had trouble sleeping. Most nights, Id wake up every few hours -- instead of sleeping straight through like I normally do. The doc had warned me that the decongestant might cause problems sleeping, and suggested that I only take it in the mornings (instead of twice per day as indicated on the package). But I was in a hurry to get my ear cleared, so I took the Sudafed twice daily. Medications come with a laundry list of side effects, and sometimes the cure seems worse than the problem! Here are some tips that might help if your medications are wreaking havoc with your nights. If a prescription medication is the culprit: DONT just stop your medication cold turkey. Your doctor gave you that particular medication for a reason. Stopping it without a doctors approval may do you more harm than good. Talk to your doctor about your problem. There may be an alternate version of the same medication that comes with different side effects. There may be a different medication that treats the same problem without the insomnia. Ask about sleep aids. An over the counter or prescription sleep aid may help get you through the adjustment period for your medication. Just make sure your doctor or pharmacist approves your choice -- you dont want a medication that will interact negatively with your prescription. If an over the counter medication is the culprit: Talk to your pharmacist. They may be able to suggest an alternate medication that comes without the sleep problems. Take a look at natural sleep aids. That warm glass of milk grandma offered might do the trick. You might have some luck with a warm bath before bed, or some gentle aromatherapy (like lavender or chamomile) to help you relax. Sip chamomile or valerian tea. Try some relaxation. Reading an old favorite book, taking a bath before bed, or curling up with a cup of tea might help settle your mind and body at bedtime.

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Medications that Interfere with SleepAn Overview Try taking your medicine at a different time. Maybe right before bed isnt the best choice -- you might sleep better taking your medication in the afternoon or morning.

Insomnia
What Is Insomnia?
Insomnia is a condition in which you have trouble falling or staying asleep. Some people with insomnia may fall asleep easily but wake up too soon. Other people may have the opposite problem, or they have trouble with both falling asleep and staying asleep. The end result is poor-quality sleep that doesnt leave you feeling refreshed when you wake up.

Notes

Types of Insomnia
There are two types of insomnia. The most common type is called secondary insomnia. More than 8 out of 10 people with insomnia are believed to have secondary insomnia. Secondary means that the insomnia is a symptom or a side-effect of some other problem. Some of the problems that can cause secondary insomnia include: Certain illnesses, such as some heart and lung diseases Pain, anxiety, and depression Medicines that delay or disrupt sleep as a side-effect Caffeine, tobacco, alcohol, and other substances that affect sleep Another sleep disorder, such as restless leg syndrome: a poor sleep environment; or a change in sleep routine In contrast, primary insomnia is not a side-effect of medicines or another medical problem. It is its own disorder, and generally persists for least 1 month or longer.

Overview
Insomnia is a common health problem. It can cause excessive daytime sleepiness and a lack of energy. Long-term insomnia can cause you to feel depressed or irritable; have trouble paying attention, learning, and remembering; and not do your best on the job or at school. Insomnia also can limit the energy you have to spend with friends or family. Insomnia can be mild to severe depending on how often it occurs and for how long. Chronic insomnia means having symptoms at least 3 nights per week for more than a month. Insomnia that lasts for less time is known as short-term or acute insomnia.

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Medications that Interfere with SleepAn Overview

Outlook
Secondary insomnia often resolves or improves without treatment if you can eliminate its cause. This is especially true if the problem can be corrected soon after it starts. Better sleep habits and lifestyle changes often help relieve insomnia. You may need to see a doctor or sleep specialist to get the best relief for insomnia that is persistent or for which the cause of the sleep problem is unclear. How Is Insomnia Treated? Making lifestyle changes that make it easier to fall asleep and/or stay asleep can often relieve insomnia. For longer lasting insomnia, a type of counseling called cognitive-behavioral therapy can help relieve the anxiety linked to your sleep problem. Anxiety tends to prolong the insomnia. Several medicines also can help relieve insomnia and reestablish a regular sleep schedule.

Notes

Lifestyle Changes
To relieve insomnia, you should avoid substances that make it worse and have good bedtime habits that make it easier to fall asleep and stay asleep. Make sure your bedroom is a comfortable temperature, dark, and quiet enough for sleep. Avoid substances such as: Caffeine, tobacco, and other stimulants taken too close to bedtime (effects of caffeine can take as long as 8 hours to wear off). Certain over-the-counter and prescription medicines that can disrupt sleep (for example, some cold and allergy medicines). Alcohol. An alcoholic drink before bedtime may make it easier for you to fall asleep. But alcohol triggers sleep that tends to be lighter than normal and makes it more likely that you will wake up during the night. Good bedtime habits include: Following a routine that helps you wind down and relax before bed, such as reading a book, listening to soothing music, or taking a hot bath. Not exercising, eating heavy meals, or drinking a lot shortly before bedtime. Making your bedroom sleep-friendly. Avoid bright lighting and minimize possible sleep distractions, such as a TV, computer, or pet.

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Medications that Interfere with SleepAn Overview Going to sleep around the same time each night and waking up around the same time each morning, even on weekends. If possible, avoid night shifts or alternating schedules at work and other causes of irregular sleep schedules.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy for insomnia targets the thoughts and actions that can disrupt sleep. Besides encouraging good sleep habits, this type of therapy may use several methods to relieve sleep anxieties, including: Relaxation training and biofeedback at bedtime to reduce anxiety. These strategies help you better control your breathing, heart rate, muscles, and mood. Replacing worries about not being able to fall asleep with more positive thinking that links being in bed with being asleep. This method also teaches you what to do if youre unable to fall asleep within a reasonable period. Talking with a therapist individually or in group sessions to help you consider your thoughts and feelings about sleep. This method may encourage you to describe thoughts racing through your mind in terms of how they look, feel, and sound. The goal is for your mind to settle down and stop racing. Limiting the time you spend in bed while awake. This method involves setting a sleep schedule and, at first, limiting total time in bed to the typical short length of time youre usually asleep. At first, this schedule may make you even more tired because some of the allotted time in bed will be taken up by difficulty sleeping. The resulting fatigue (tiredness) is intended to help you get to sleep more quickly. Gradually, the length of time spent in bed is increased until you get a full night of sleep. For success with this type of therapy, you may need to see a therapist who is skilled in this approach weekly over 2 to 3 months. Cognitivebehavioral therapy is as effective as prescription medicine for many types of chronic insomnia. It also may provide better long-term relief than medicine alone.

Notes

Medicines
Several medicines cause sleepiness. Doctors sometimes prescribe sleepinducing medicine for 1 to 2 weeks to help establish a regular sleep schedule. Insomnia medicine helps you fall asleep, but can leave some people feeling unrefreshed or groggy in the morning. You may also be

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Medications that Interfere with SleepAn Overview groggy and should exercise caution if you must get up before getting a full nights sleep of 7 to 8 hours while taking these medicines. The Food and Drug Administration (FDA) hasnt approved all insomnia medicines for continuous, long-term use. Your doctor can help you understand the benefits and potential problems if medicines will be needed for long periods. Some people use natural remedies to treat their insomnia. These remedies include melatonin and L-tryptophan supplements and valerian teas or extracts. The FDA doesnt regulate these over-the-counter treatments. This means that their dose and purity can vary from product to product. Their safety and effectiveness is not well understood. Medicines also are available to treat symptoms of excessive sleepiness if your insomnia is the result of shift work or alternating work schedules. You should discuss your situation with your doctor to determine whether these medicines, together with improving sleep habits, can help you overcome insomnia.

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Medications that Interfere with SleepAn Overview

Examination
Select the best answer to each of the following items. Mark your responses on the Answer form. 1. Though medication and prescription drugs are designed to help with specific problems, they can often have negative side effects. Medicine can disrupt the normal balance of the body and lead to a disruption in sleep or insomnia. Even _______ can have a negative impact on restful sleep. a. aspirins b. sleeping pills c. vitamins d. All of the above 2. However, many medicines can cause sleep problems. A short list of some medicine types that can adversely affect sleep includes: a. antihistamines b. antidepressant c. decongestants d. All of the above 3. Some antidepressants, such as_______, are thought to help encourage better sleep, some have been linked to causing sleep problems. Some research has indicated that antidepressants can cause the onset of REM sleep disorder, which causes people to physically act out their dreams while fully asleep. a. Zinc b. Prozac c. Antihistamines d. None of the above 4. _______and other asthma and related medications have been studied recently in regard to their possible effect on sleep. While the medications help clear airways during waking hours, it seems to have other effects when the person is sleeping, including reducing time asleep and soundness of sleep. a. Prozac b. Corticosteroids c. Theophylline d. None of the above

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Medications that Interfere with SleepAn Overview 5. Weight loss medication often contains some type of diuretic and/or stimulant (such as caffeine) to rev the body up and increase metabolism. Diuretics can cause people to awaken during the night to go to the bathroom, while stimulants can overexcite the mind and make it difficult_______. a. to fall asleep b. enter REM sleep c. dream d. None of the above 6. Ironically enough, sleep medications can often exacerbate the exact problem they are designed to help. Many sleep medicines override the body's natural sleep mechanisms, making the body "forget" how to lull itself to sleep without assistance. This means that most sleeping pills should only be _______ as they have limited efficacy. a. used for short durations b. used when sleep is urgently c. rarely used d. None of the above 7. These drugs, used to treat heart rhythm problems, may cause daytime fatigue and nighttime sleep difficulties. Such medications include procainamide (Procanbid), quinidine (Cardioquin, others), and disopyramide (Norpace). a. True b. False 8. Beta blockers are used to treat high blood pressure, arrhythmias, and angina. These drugs can promote _______. a. insomnia b. awakenings in the night c. nightmares d. All of the above 9. Caffeine, found in some over-the-counter painkillers and appetite suppressants, stimulates the nervous system and can induce insomnia. Caffeine makes people feel alert by blocking the action of _______, a substance that promotes drowsiness. Caffeines direct effects gradually diminish but may linger for six or seven hours or even longer in some people. a. synapses b. adenosine c. adrenaline d. None of the above

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Medications that Interfere with SleepAn Overview 10. Corticosteroids such as prednisone, used to suppress _______, often cause daytime jitters and nighttime insomnia. a. inflammation b. asthma c. None of the above d. All of the above 11. Patches used to curb smoking deliver small doses of nicotine into the bloodstream around the clock. People who use them often _______. a. suffer insomnia b. experience disturbing dreams c. None of the above d. All of the above 12. Ambien may not be safe for those who have a history of depression, liver or kidney disease, or respiratory conditions. Ambien may lose its effectiveness if taken longer than. a. two weeks b. four weeks c. six weeks d. None of the above 13. Sonata is approved to help you get to sleep. Its particular niche is that it is short acting, so is less likely to produce a hangover effect in the morning. It is so short acting that you can take it a second time if you awaken in the middle of night. Sonata can be habit forming and may not be safe for those who have a history of _______, or a history of substance abuse or addiction; severe liver impairment; or are pregnant, planning to become pregnant, or breast feeding. a. depression b. mental illness c. suicidal thoughts d. All of the above 14. Clonidine: This medication was primarily used for high blood pressure, but is quite sedating, is often used in children with ADHD, and is a good sleep aid thats not habit forming. It can sometimes cause a drop in blood pressure or rebound high blood pressure. In high doses, it can cause liver problems. a. True b. False

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Medications that Interfere with SleepAn Overview 15. All medications have side effects. Prior to taking any prescription or over-the-counter sleep aid, consult your doctor let her know all the medications you are currently taking, including over-the-counter medications and all natural or herbal remedies. In addition, be aware that any sleep aid can cause drowsiness, so avoid driving or operating machinery while taking these medications, especially when you first start taking them and are unsure of the effect they may have on you. Additional side effects may include the following _______. a. Dizziness b. Prolonged drowsiness (especially the sleep aids designed to help you stay asle c. Facial swelling d. All of the above

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