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What to take for chronic insomnia, muffled hearing with ringing - Review

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Patient information: See related handout on insomnia, written by the authors of this article. Benzodiazepines may cause memory problems in the form of anterograde amnesia, independent of their effects on attention and alertness.
Chronic treatment with benzodiazepines has raised concerns about potential cognitive impairments.
The first and most important consideration in managing benzodiazepine-induced side effects is to establish a clear indication for their use.
If patients develop severe sedation or psychomotor impairment, dosages can be lowered to aim for minimal side effects while still maintaining efficacy.
Similar to the unsubstantiated fear of addiction to analgesic medications in patients with terminal illness,26 concerns of abuse and addiction have also been raised in chronic benzodiazepine treatment.27 Benzodiazepines are typically used in maintenance pharmacotherapy for patients with chronic anxiety, and long-term use may lead to a physiologic dependence as manifested by tolerance and withdrawal.
Several patient variables affect the severity of withdrawal symptoms and tolerability of discontinuation, and effective strategies for a planned medication discontinuation must address these patient variables.29,33 Patients who tend to have difficulty tolerating medication tapers include those with panic disorder, pre-existing history of alcohol or substance use, and higher levels of anxiety and depression prior to taper. Propranolol is not FDA-approved for anxiety, but it is commonly used off-label for the as-needed treatment of performance anxiety. Gabapentin is an anticonvulsant that is used off label for the treatment of social anxiety disorder.
Benzodiazepines are very good anxiolytics for the treatment of anxiety, but care must be taken to avoid adverse effects.
Though the above agents have led to better care for the mentally ill, they have a significant downside in causing adverse events which increase morbidity and, in some cases, mortality. Psychiatrists are consulted for patients with brain tumors typically after their diagnosis for adjustment, anxiety, mood disorders, or cognitive impairment. Acute subdural hematomas (SDH) accumulate rapidly following head injury; chronic hematomas can often (although not always) be traced back to a head injury. Psychiatric consultation should be obtained prior to surgery for treatment-resistant epilepsy in patients with psychosis, major mood disorders, severe personality disturbance, or nonadherence with anticonvulsant therapy.
Binge-eating disorder and night-eating syndrome are common in patients referred for bariatric surgery, with bulimia less so.
Approved by the Food and Drug Administration, mood stabilizers (lithium, valproic acid, carbamazepine, and lamotrigine) remain the first-line treatment for bipolar disorder.
Lithium has been used for >55 years and remains the first-line agent for the treatment of bipolar disorder.
Prior to starting lithium treatment, patients should be evaluated for renal, thyroid, and cardiac functions, as there are reports of acute changes in cardiac functioning. Nephrotoxicity4 with lithium can be divided into three categories, including nephrogenic diabetes insipidus, acute intoxication, and chronic renal disease. Multiple factors can lead to insomnia in hospitalized patients, including sleep disorders, psychological and physical factors, certain medical conditions, medications, environment, clinical activities, and poor sleep hygiene. A lack of diurnal light cycles also can contribute to insomnia, as can clinical activities performed at night. If a hospitalized patient complains of insomnia, the physician should obtain a thorough sleep history.
If insomnia is caused by a medical problem, treatment of the underlying condition should improve the patient's sleep.
Other nonpharmacologic therapies for insomnia in the hospital include white noise or music, back massage, and warm drinks.
Pharmacologic therapy should be considered if treatment of the underlying problem does not resolve the insomnia or if a hospitalized patient has failed or refused nonpharmacologic therapy. A prospective single-center study examined 100 hospitalized patients' preference for pharmacologic versus nonpharmacologic therapy for insomnia. Antidepressants, including trazodone, mirtazapine, and tricyclic antidepressants (TCAs), also have been used for insomnia (TABLE 1). For hospitalized patients, pharmacists can recommend appropriate hypnotics and dosages based on patients' renal and hepatic function and age. For patients who need a hypnotic after discharge, pharmacists should recommend that a short-term prescription (2-4 weeks) of the lowest effective dose be given.22 Patients should be advised to avoid alcohol with hypnotics.

Physicians may initiate treatment of insomnia at an initial visit; for patients with a clear acute stressor such as grief, no further evaluation may be indicated.
An approach to the evaluation and treatment of the patient with insomnia is shown in Figure 1. It is often unwanted in the treatment of anxiety, but even in cases where sedation is desired (eg, treatment of insomnia), residual daytime sedation can be problematic.
The length of benzodiazepine use was also quite variable (1–29 years) and the patient sample was heterogeneous, which included patients with anxiety, depression, and insomnia.
Once the patient reaches 50% of the baseline dose, that dosage should be maintained for over several months before proceeding with further taper.29 Regardless of the taper schedule, patients should be monitored closely and rates should be adjusted as tolerated. The most commonly experienced side effects include lightheadedness, dizziness, fatigue, and insomnia.55,56 gastrointestinal effects such as nausea and diarrhea are also common. The most common side effects of benzodiazepine are CNS effects such as sedation, problems with attention and memory, and psychomotor impairments (Table 3).4 Adverse effects can be minimized when benzodiazepines are used at the lowest effective dose for the shortest period of time, particularly in the elderly and patients with liver dysfunction. Levenson is professor in the Departments of Psychiatry, Medicine, and Surgery, chair of the Division of Consultation-Liaison Psychiatry, and vice chair for clinical affairs in the Department of Psychiatry at Virginia Commonwealth University School of Medicine in Richmond. Most studies and most reviews have concluded that no clear predictive relationships between psychopathology and bariatric surgical outcomes (especially sustained weight loss) have been established.10,11 While the existing literature about potential predictors of success after bariatric surgery is far from conclusive, it cannot be concluded that psychopathology will have no influence on postoperative adherence and outcomes for several reasons. Postsurgical eating disorders have rarely included new-onset anorexia nervosa.14 Such patients require special attention for appropriate diagnosis and treatment. Saxena is senior research associate of the Lithium Archive Project in the Department of Psychiatry at Columbia University College of Physicians and Surgeons and sub-investigator of the Foundation for Mood Disorders in New York City. The patient should be questioned about sleep patterns, sleep environment, and sleep hygiene at home to determine whether the insomnia is a new problem or a continuation or exacerbation of an existing problem. Data on the use of pharmacologic therapy for the treatment of insomnia in hospitalized patients are limited; most information is extrapolated from outpatient data. Forty patients developed insomnia while in the hospital; the other 60 had insomnia prior to admission.
They can also recommend that hypnotic orders be written at bedtime as needed or scheduled nightly while allowing for patient refusal of the medication. If alcohol is consumed, the hypnotic dose should be skipped.23 Patients should be told to take the hypnotic approximately 15 to 30 minutes before bedtime.
However, if insomnia is severe or long-lasting, a thorough evaluation to uncover coexisting medical, neurologic, or psychiatric illness is warranted. If a dose is missed, they should take the missed dose as soon as they remember unless it is close to the time of the next scheduled dose.
During the first 5–7 days of the switch (the length of time to achieve steady state for clonazepam), alprazolam can be taken as needed, up to the full dosage as before the switch, to cover residual anxiety. Lorazepam is an independent risk factor for transitioning to delirium in intensive care unit patients.
Benzodiazepine behavioral side effects: review and implications for individuals with mental retardation. Benzodiazepine use, cognitive impairment, and cognitive-behavioral therapy for anxiety disorders: issues in the treatment of a patient in need. The subsequent discovery of such agents as carbamazepine and valproate for treatment of bipolar disorder, selective serotonin reuptake inhibitors (SSRIs) and other atypical antipsychotics for depression, the second-generation antipsychotics (SGAs) for psychotic illness, and SSRIs and buspirone for anxiety has further led to improved treatment for debilitating psychiatric illness.
Chronic SDHs give rise to more gradually evolving symptoms and signs, including chronic headache, confusion, and dementia, and less commonly, depression or psychosis. Viewing oneself, especially with disfiguring facial burns, is in itself very traumatic for many patients.
The assessment practices of mental health professionals who evaluate bariatric surgery candidates vary widely as do the exclusion criteria for surgery.12,13 Studies have not been large enough to examine the effect of specific psychiatric disorders. Lithium has been in use for >50 years and is one of the most studied agents in psychiatry. Drug choices for insomnia in hospitalized patients include benzodiazepines (BZDs), BZD receptor agonists (BZD-RAs), melatonin RAs, antidepressants, and antihistamines (TABLE 1). If the patient's insomnia persists, nonpharmacologic treatment should be used, when possible, to minimize drug interactions and side effects.

Evidence-based recommendations for the assessment and management of sleep disorders in older persons. Insomnia among hospitalized elderly patients: prevalence, clinical characteristics and risk factors.
The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RTCs.
Hospitalized patients' preference in the treatment of insomnia: pharmacological versus non-pharmacological. Updating the Beers criteria for potentially inappropriate medication use in older adults: results of a US consensus panel of experts. A more comprehensive evaluation should be pursued with nonresponders or if a comorbid condition is present or suspected.The evaluation of chronic insomnia should involve a detailed history and examination to detect any coexisting medical or psychiatric illness and may include an interview with a partner or caregiver.
Regardless, physicians would need to take these potential cognitive effects into consideration when weighing the risks and benefits of long-term benzodiazepine use. Switching is most helpful with residual daytime sedation when benzodiazepines are taken as a hypnotic.5 In anxiety treatment, switching from a long-acting to a short-acting agent may be more tolerable, but the trade off is less anxiety coverage and possible discontinuation symptoms between doses. This issue of Primary Psychiatry gives a sense of how to evaluate and treat these adverse side effects to maximize outcome for the patient.
Rosse and colleagues also describe the advent of SSRIs and their side-effect advantage versus the older two groups, also noting the problems encountered with SSRIs, such as gastrointestinal and sexual side effects, problems with activation, and insomnia.
The author describes the utility of the non-benzodiazepine anxiolytic agents, including buspirone, propranolol, hydroxyzine, and gabapentin (which have limited indications for the treatment of anxiety), and their adverse events. Haloperidol is frequently added for psychotic symptoms during withdrawal or other causes of delirium but should not be used alone in alcoholic patients. Fieve is professor of clinical psychiatry at Columbia University College of Physicians and Surgeons, chief of psychiatric research in the Department of Lithium Studies at New York State Psychiatric Institute, and medical director of the Foundation for Mood Disorders in New York City. If side effects are not tolerable, lowering the dosage, switching agents, discontinuation of the medication, or considering alternative forms of treatment such as CBT may be helpful.
Burn patients with preexisting opioid dependence require higher doses of narcotics for pain; the burn unit is not the time nor the place to preach opioid abstinence.
Uniform guidelines for the psychosocial screening of bariatric surgery candidates are needed, but no consensus is likely to emerge until large long-term studies identify consistent psychosocial predictors of poor postoperative outcomes. The choice of drug depends on comorbid conditions, drug pharmacokinetics, and hospital formulary. Exercise improves sleep as effectively as benzodiazepines in some studies and, given its other health benefits, is recommended for patients with insomnia. Hospital pharmacists should expand their role to include providing recommendations to physicians and counseling to patients regarding pharmacologic and nonpharmacologic treatments for insomnia to help optimize patient care and reduce costs. Hypnotics generally should be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances. Family and psychotherapeutic therapy (cognitive-behavioral therapy, family therapy, and supportive psychotherapy) as well as psychoeducation for the patient and his or her significant others are also discussed.
Rather, patients should be evaluated regarding their capacity for informed consent and their ability to follow through and adhere with posthospital requirements (eg, initially liquid diets, small feedings, lifelong vitamin supplementation, and avoidance of high fat and high sugar foods). For example, clinicians should start 300 mg QD for day 1, 300 mg BID for day 2, and 300 mg TID for day 3.
If a planned discontinuation is expected, taper should be conducted very gradually and patients should be monitored closely for withdrawal symptoms. Through the institution of ongoing monitoring and early identification of side effects during the course of treatment for bipolar disorder, treatment can be managed and risks can be reduced.
Benzodiazepines are most useful for short-term treatment; however, long-term use may lead to adverse effects and withdrawal phenomena.

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Comments to “What to take for chronic insomnia”

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