Insomnia treatment for stroke patients
The incidence of stroke in China in the 21st century ranks first in the world and is one time higher than that of the United States. The results of the 3rd National Cause of Death Survey in China show that stroke has risen to be the 1st cause of death in China. In addition to a high mortality rate, stroke is also characterized by a high disability rate and a high recurrence rate, and the quality of life of survivors is significantly reduced. Insomnia is the most common complaint of discomfort in stroke patients (57. 9% in China and 56. 7% abroad), much higher than the prevalence in the general population (9. 0% – 12. 9%). Insomnia has a significant impact on the prognosis of stroke patients, raising blood pressure, increasing stroke recurrence, causing psychological disorders, more severe cognitive impairment, aggravating somatic symptoms, affecting the recovery process, and schedule living ability. Treatment has not yet received sufficient attention, and most clinical management is still based on symptomatic treatment with sedative-hypnotic drugs.
Newly developed insomnia after stroke is defined as post-stroke insomnia. The main types of post-stroke insomnia are.
1. difficulty falling asleep (not falling asleep after 30 minutes of bed rest)
2. easy waking, frequent awakenings (>2 times/night)
3. early awakening, difficulty in falling back to sleep after waking, total sleep less than 6 hours, with dizziness and fatigue after waking, excessive daytime sleepiness, reversed sleep cycle, and/or with psychiatric symptoms. Depression: low mood
Causes of insomnia in stroke patients.
1. limb pain: limb exercise, the
2. sleep environment: unfamiliar environment, clinical patient snoring, etc.
3, therapeutic nursing operations: aspiration, infusion, turning, etc.
4, pathophysiological factors: increased nocturia, irritation of indwelling urinary catheters, abdominal distension, abdominal pain, nighttime hunger and drug factors, etc.
Characteristics of stroke patients with insomnia.
1. predominantly middle-aged and elderly.
2. many comorbidities, such as hypertension, diabetes mellitus, heart disease, chronic liver and kidney insufficiency, dysphagia, chronic bronchitis, etc.
3, combined with more medications.
Treatment: Need to strengthen psychological guidance and promote positive emotions. Create comfortable sleeping conditions and environment: defecate before bedtime, reduce nighttime operations. Correct functional exercise to prevent limb pain. Correct application of sleeping pills.
Medication: benzodiazepines: medium-acting: alprazolam, sulforaphane (t1/2 6 – 24 h). Long-acting: diazepam, nitrozepam, clonazepam, flurazepam (t1/2 26 — 49 h). Slow onset, with inhibition of whistling, next day dizziness, weakness. Shorten the slow wave sleep, long-term application can cause dizziness, muscle weakness, memory loss, easy addiction, withdrawal symptoms, overdose can cause coma and whistle inhibition. Non-benzodiazepines: zolpidem, zopiclone: fast onset, short half-life, does not affect sleep structure, less hangover symptoms in the next morning, drug dependence, less rebound from discontinuation, is the current first-line drugs. They are easily tolerated by elderly patients and are preferred for long-term insomnia after stroke. Melatonin and receptor agonists: ramelteon, agomelatine, etc. Involved in the regulation of the sleep-wake cycle and can improve symptoms caused by jet lag changes, delayed sleep phase syndrome and circadian rhythm disorder sleep disorders.
Drug selection: For those who have difficulty falling asleep: Sinequan or Zopiclone with short half-life, fast onset and small residual effect the next morning, 1 capsule/half capsule per night. Those who wake up early: long-acting sleeping pills, clonazepam, etc. Light sleepers, easy to wake up: medium-acting sleeping, drugs such as alprazolam and sulezapine. Those with combined depression: selective 5–hydroxytryptamine reuptake inhibitors, such as paroxetine, Zoloft, etc., are preferred. In the absence of depression: use Synthroid or Sulexpress while managing limb pain and improving sleep environment.
Mirtazapine: strongest action at 4 – 6 weeks. Anxiolytic through its antagonism of 5HT2 receptors, strongly induces sleep. The resulting quality of sleep is superior to that induced by other antidepressants. Adverse effects: appetite and weight gain, pronounced in the first 4 weeks, more in women than in men, gradually returning to normal after discontinuation of the drug. No effect on cardiovascular system. It is a first-line drug.
Remel: Melatonin receptor MTl and MT2 agonist, can shorten sleep latency, improve sleep efficiency, increase total sleep time, used for the treatment of insomnia with difficulty falling asleep as the main complaint and circadian rhythm disorder sleep disorder. No whistling inhibition and no withdrawal symptoms. Agomelatine: It is both a melatonin receptor agonist and a 5–hydroxytryptamine receptor antagonist with dual antidepressant and hypnotic effects, improving insomnia associated with depressive disorders and shortening sleep latency. Increases sleep continuity. Both can be used as alternative treatment for patients who cannot tolerate hypnotic drugs and for patients who have developed drug dependence.
Indications for medication change.
1. ineffectiveness of the recommended therapeutic dose.
2. development of tolerance.
3.Severe adverse reactions.
4.Interaction with drugs used to treat other diseases.
5, use for more than 6 months.
6, high-risk groups (patients with a history of addiction).
Treatment duration.
1.No clear regulations.
2.Adjustment of dose and maintenance duration according to the patient’s condition.
3, continuous treatment is an option for pharmacological interventions of less than 4 weeks
4.Drug interventions longer than 4 weeks need to be re-evaluated, and if necessary, the intervention program should be changed or intermittent treatment should be used when appropriate according to the patient’s sleep improvement status.
Discontinuation of treatment: When the patient feels that he/she is able to control his/her sleep, gradual discontinuation of medication can be considered.
Conclusion: The treatment of post-stroke insomnia has not been given enough attention; the assessment of efficacy is not yet uniform; individualized treatment is needed according to individual conditions.