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insomnia

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B. Wayne Blount, MD, MPH Professor, Emory S.O.M. * * * * * * * * * * * * * * * EXTRAS * Quiz Answer the questions below: hardly ever (1 point), sometimes (2), almost ... – PowerPoint PPT presentation

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Title: insomnia


1
insomnia
  • B. Wayne Blount, MD, MPH
  • Professor, Emory S.O.M.

2
OBJECTIVES
  • Define Classify Insomnia
  • State the incidence prevalence of Insomnia
  • List Common Symptoms of Insomnia
  • Explain how insomnia is Diagnosed
  • List pharmacologic non-pharmacologic treatment
    strategies for insomnia

3
ROADMAP
  • Definition
  • Epidemiology
  • Diagnosis
  • Treatment
  • Non-pharmacologic
  • Pharmacologic
  • Usual meds
  • Alternatives
  • Summary

4
Definitions
  • Sleep is a state of unconsciousness in which the
    brain is relatively more responsive to internal
    than to external stimuli
  • Mechanisms within the brainstem and hypothalamus
    regulate sleep through GABA and acetylcholine

5
Question 1
  • What is Philagrypnia?
  • Hint you have all experienced it.

6
Philagrypnia
  • Ability to stay alert with very little sleep

7
Purpose of Sleep
  • Speculative
  • NREM sleep may allow decrease in metabolic demand
    and allow replenishment of glycogen stores
  • Oscillating depolarization's and repolarizations
    consolidate and remove redundant or excess
    synapses

8
QUESTION 2
  • Sleep cycles are controlled by
  • A. The Pontine
  • B. The Hypothalamus
  • C. Ones sleep partner
  • D. The Caudate Nucleus
  • The Sandman
  • Hint All of you have one of these also

9
Circadian sleep rhythm
  • One of several intrinsic rhythms modulated by the
    hypothalamus
  • Without external stimulus, the suprachiasmatic
    nucleus sets the rhythm to approximately 25 hours
  • A nerve tract directly from the retina helps
    regulate us to 24 hours days.
  • Melatonin is a modulator of light entrainment and
    is secreted maximally by the pineal gland during
    the night

10
QUESTION 3
  • Which of the following is/are true about sleep
    requirements?
  • a. Average needed is 7 1/2 to 8 1/2hrs/night
  • b. Range (for adults) - 5-9 hrs/night
  • c. Steadily decreases from birth to old age
  • Elderly spend less time sleeping per night, and
    increase sleep latency with more frequent
    arousals
  • All of the above

11
Normal Sleep Physiology
  • Stages
  • 1 - light sleep, 5-10 of total sleep time,
    transition between awake and asleep
  • 2 - 40-50 of total sleep time
  • 3,4 - deep or delta wave sleep, occurs mostly
    early in the night
  • REM sleep, 20-25 of sleep
  • All 4 stages repeat in ultradian rhythm of about
    90 minutes

12
  • There are 4-5 cycles in a normal nights sleep
  • First REM- 10 minutes, but later REM periods may
    exceed 60 minutes

13
  • Insomnia
  • Difficulty initiating or maintaining sleep,
    Waking up too early, or sleep that is
    nonrestorative.
  • Patients subjective dissatisfaction with sleep
    quality or quantity

14
QUESTION 4
  • Traditionally there are how many types of
    Insomnia?
  • A. 1
  • B. 2
  • C. 3
  • D. 4

15
  • Transient Insomnia - Symptoms present for less
    than one week
  • Short Term Insomnia - Symptoms for 1-4 weeks
  • Chronic Insomnia - Symptoms present for more than
    one month

16
  • Initiation of Sleep Time to fall asleep
  • Standard - less than 30 minutes
  • Sleep Efficiency Time sleeping/ Time in bed
  • Standard - Greater than 85
  • May be caused by awakening frequently during the
    night with subsequent difficulty in re-initiating
    sleep, or awakening too early without being able
    to go back to sleep at all

17
Question Not to be answered on keypadsWhat do
you call a nun who sleep walks?
18
A Roamin Catholic
19
QUESTION 5
  • The consequences of Insomnia are all psychologic
    and financial.
  • A. True
  • B. False

20
Consequences
  • Mood Disturbance
  • Depression and/or Anxiety
  • Poor memory
  • Difficulty concentrating
  • Motor vehicle and other accidents
  • Higher Health care use
  • Impaired Work Performance

21
Physiologic Results
  • Elevated
  • Body temp
  • Resting Heart rate
  • Heart rate variability
  • Cortisol level
  • Beta wave activity

22
Medical Consequences
  • Exaccerbates
  • CV DZ
  • DM
  • GERD
  • Pain Syndromes
  • Parkinsons
  • COPD
  • Depression
  • PTSD
  • Substance Abuse

23
Scope of the Problem
  • 20 of population have insomnia
  • Only 5 tell their physician about it
  • Over 38 million prescriptions per year for
    sleeping pills
  • 39 of adults sleep less than 7 hours on
    weeknights
  • 54 of people over 55 report insomnia once a week
    or more

24
SOME FACTS ABOUT INSOMNIA
  • Average number of fatal crashes caused by drowsy
    driving each year 1,550
  • 39 of Health care workers have had a near miss
    accident at work because of fatigue
  • 19 of health workers report worsening a
    patients condition because of fatigue
  • 44 of law enforcement workers report having
    taken unnecessary risks while tired
  • 80 of US regional pilots report they sometimes
    nod off in the cockpit

25
QUESTION 6
  • The most important part of evaluating a patients
    insomnia is the history.
  • A. True
  • B. False

26
Evaluation
  • Patient Family History
  • Sleep Diary
  • Questionnaires
  • Looking for Obvious causes
  • P.E.

27
Sleep History
  • Timing of insomnia
  • Sleep schedule
  • Sleep environment
  • Sleep habits
  • Symptoms of other sleep disorders
  • Daytime effects
  • Medications, caffeine
  • Life stressors and worry over insomnia

28
Sleep Diary
  • Maintain for 2-4 weeks
  • Sleep and wake times
  • Awakenings
  • Daytime naps and activities
  • Correlation with bed partner

29
Causes of Insomnia
  • Stress/Situational
  • Fear
  • Anger
  • Depression
  • Medical
  • Behavioral factors
  • Life-style
  • Personality
  • Medicine

30
Medical Causes of Insomnia
  • Pain
  • GERD
  • BPH
  • OSA
  • RLS
  • Depression
  • Anxiety

31
Medications Causing Insomnia
  • Clonidine Bronchodilators
  • Beta Blockers Steroids
  • Theophyline
  • Certain Antidepressants
  • Protriptyline, Fluoxetine
  • Decongestants
  • Stimulants
  • Alcohol

32
Causes of Insomnia
  • Disruption of sleep patterns
  • shift working, children
  • Environmental factors
  • temperature, humidity, light
  • Inability to sleep
  • the mind might be overactive, running possible
    scenarios, problem solving, etc.

33
Causes of Insomnia
  • Daytime Naps
  • Environmental Noise
  • Bedroom Conditions
  • Poor Sleep Habits
  • Fatal Familial Insomnia genetic 28 families

34
QUESTION 7
  • The P.E. of the insomniac patient is
  • A. Focused
  • B. Similar to a complete physical
  • C. Doesnt need to be done

35
Physical Exam
  • Anatomic features of obstructive sleep apnea
  • Neurologic exam in case of restless leg or other
    neurologic syndrome

36
QUESTION 8
  • The laboratory work-up for insomnia needs to be
    extensive.
  • A. True
  • B. False

37
?Laboratory?
  • Multiple Sleep Latency Test (MSLT)
  • Polysomnography (PSG)
  • Usually not needed
  • Get when treatment
  • isnt working

38
Question 9
  • Which of the following treatments should be
    included in every insomniacs treatment plan?
  • A. Non-Pharmacologic
  • B. Pharmacologic
  • C. Both

39
Treatment Options
  • Cognitive Behavioral Therapy
  • Relaxation Therapy
  • Sleep Hygiene
  • Light Therapy
  • Pharmacologic
  • Non-Prescriptive
  • Prescriptive

40
  • Cognitive Behavioral Therapy
  • Cognitive Restructuring
  • Individual counselling- 6 sessions
  • Effective in 50 of patients

41
Relaxation Therapy
  • Recognize /control tension by systematically
    tensing and relaxing various muscle groups
  • Guided imagery and meditation
  • Biofeedback
  • Calming tapes
  • Effective in 50-70
  • More effective in non-elderly

42
Sleep Hygiene (Do in ALL patients)
  • Stimulus Control Avoid Alcohol
  • Sleep Restriction Caffeine
  • Temporally Correct exercise
  • Control Environmental Noise
  • A Regular Schedule Darker Room
  • Use bed only for S S Cooler Room
  • Avoid clock watching
  • Effective in 70-80

43
Stimulus Control Therapy
  • Reassociate the bed with sleepiness rather than
    wakefulness
  • No reading, TV, eating or working in bed
  • Lying down only when sleepy
  • If unable to sleep after 15-20 minutes, get out
    of bed and do something else
  • No Naps

44
Sleep-restriction Therapy
  • Eliminate excess time in bed awake
  • Purposefully limit sleep, which leads to more
    efficient and effective sleep habits.
  • Gradually allow more time in bed as insomnia
    resolves

45
AASM Practice Parameters
  • Psychologic and behavioral interventions are
    effective and recommended
  • Sleep 2006 291415

46
Pharmacologic Therapy
  • Non-prescription
  • Prescription

47
Non-prescription Therapy
  • Valerian - An herbal medication
  • Inhibits breakdown of GABA
  • May be safe and effective to decrease sleep
    latency. May work better if taken regularly at
    night rather than PRN.
  • Little evidence SOR I Bandolier
  • Main risk is uncontrolled manufacturing of herbal
    compounds

48
Melatonin
  • Not effective in treating most sleep disorders
  • Not effective in jet lag
  • Not effective in shift work insomnia
  • Is safe with short-term use
  • SOR B AHRQ
  • www.ahqr.gov/clinic/tp/melatntp.htm

49
Diphenhydramine hydrochloride
  • Main Ingredient in Tylenol PM, Sominex, Unisom,
    etc.
  • Antihistamine and anticholinergic agent
  • Non-specific and long lasting
  • Side effects, esp. in elderly

50
Prescription Drugs
  • Benzodiazepines
  • Benzodiazepine receptor agonists
  • Melatonin receptor agonists

51
Benzodiazepines
  • Most commonly used
  • If the problem is falling asleep, use medication
    with a rapid onset of action
  • Very short 1/2 life may be associated with
    increased risk of rebound anxiety
  • If the problem is staying asleep, a hypnotic with
    a longer ½ life may be more useful
  • Rebound insomnia if d/cd abruptly
  • SOR for elderly C Bandolier

52
Benzodiazepines
  • 7 approved in US
  • Increase stage 2 sleep decrease stages 1 4
  • Decreased Sleep latency by 4.2 minutes
  • Increased total sleep duration by 61.8 minutes
  • Side Effects
  • Daytime Drowsiness
  • Dizziness
  • Dependence

53
Benzodiazepine agonists
  • Eszopiclone Lunesta
  • 5-7 hr ½ life use for sleep maintenance
  • Zolpidem Ambien
  • 3 hrs Sleep latency
  • Zaleplon Sonata
  • 1 hr latency
  • No evidence that there is a difference in these
    meds

54
Eszopiclone (Lunesta)
  • New class of non-benzodiazepine
  • May affect GABA receptor
  • Rapid onset, 1/2 life 6 hrs
  • No tolerance or withdrawal after 6 months of
    treatment
  • 1,2,3 mg. dose
  • HA, taste somnolence

55
Zolpidem (Ambien)
  • Little effect on sleep stages
  • No tolerance out to 35 days of use
  • 10-20 mg
  • Elderly or liver dz 5 mg
  • ½ life 2.5 hrs
  • No active metabolites

56
Zaleplon (Sonata)
  • No rebound nor withdrawal
  • 10 mg or elderly 5 mg
  • ½ life 1 hr
  • Side effects HA, dizzy, somnolence

57
Concommitant Depression
  • Antidepressants with sedative properties
  • Trazodone (Desyrel)
  • Amitriptyline (Elavil)

58
Rozerem (ramelteon)
  • Unscheduled prescription drug
  • Acts on Melatonin receptors
  • Short ½ life 2-5 hrs.
  • Sleep Onset
  • Side Effects Increased Prolactin, dizzy
  • No activity on the following receptors
  • GABA, neuropeptides, cytokines,seratonin,
    dopamine, noradrenaline, acetylcholine, or opioid

59
Treatment Principles
  • Start with Non-Pharmacologic
  • Transient Insomnia
  • Usually does not require pharmacologic treatment
  • Short Term
  • If affecting QOL, consider Bz RAs
  • Chronic
  • Try Non-pharmacologic, then pharmacologic

60
Sedative-hypnotic Medication General rules
  • Symptomatic relief, not a cure
  • Combine with nonpharmacologic treatment
  • Smallest effective dose for the shortest possible
    time
  • Avoid alcohol
  • Pregnancy is a contraindication
  • Taper off to avoid rebound insomnia
  • Monitor for Side effects

61
When to Refer ?
  • Resistant to Treatment
  • Complex Co-morbidities
  • Sleeping while Driving

62
CODING
  • Insomnia 780.52
  • Adjustment 307.41
  • ETOH 291.82
  • Drug 292.85
  • Medical DZ 327.01
  • Mental 327.02
  • Nonorganic 307.41

63
ONE LAST, VERY EFFECTIVE TREATMENT OPTION
64
ONE LAST, VERY EFFECTIVE TREATMENT OPTION
  • Listen to this lecture

65
Summary
  • Common
  • Look for comorbidities
  • The Patient assessment
  • Treatment

66
  • EXTRAS

67
Quiz
  • Answer the questions below
  • hardly ever (1 point), sometimes (2), almost
    always (3)
  • After you have answered all of the
    questions, add up your points.
  • I sleep right through my alarm and then can
    barely roust myself from bed. (1) (2) (3)
  • I get annoyed by trivial matters because I am
    tired. (1) (2) (3)
  • I have a difficult time concentrating or find
    myself dozing off during the day. (1) (2) (3)
  • Fatigue causes me to turn down social engagements
    and other activities that I normally enjoy. (1)
    (2) (3)
  • I catch colds and the flu easily. (1) (2) (3)
  • I'm needlessly grumpy with my mate or family
    members because I'm tired. (1) (2) (3)
  • I need caffeine to stay alert during the day
    and/or alcohol to help me relax at night. (1) (2)
    (3)
  • I struggle to keep my eyes open when I drive at
    night. (1) (2) (3)
  • At bedtime, I am asleep five minutes after my
    head hits the pillow. (1) (2) (3)
  • I wake up during the night and find it difficult
    to fall back to sleep. (1) (2) (3)

68
  • to 15 YOU'RE A GOOD SLEEPER. Your dreams are
    sweet and long enough.
  • 16 to 24 YOUR SLEEP DEBT IS GROWING. Since you
    can't cram more hours into a day, try leaving a
    few things out Let your kids go to bed without a
    bath or permit yourself to serve a family meal
    that doesn't contain all the basic food groups.
    One activity to make more time for is exercise. A
    workout during the day--though not within three
    hours of bedtime, when it can wind you up--helps
    many folks sleep better. And regardless of the
    pace of your day, unwind before bedtime by
    reading, knitting, watching television, or doing
    whatever relaxes you. By the way, making love is
    believed by many researchers to be the best
    natural sedative of all.
  • 25-30 YOU'RE EXHAUSTED. Researchers suggest you
    force yourself to go to bed an hour or so earlier
    for at least ten days. Keep a diary noting how
    refreshed you feel and how "your ability to carry
    out difficult tasks improves during the
    experiment the extra Zs may be all you need. But
    if that doesn't do the trick, you may suffer from
    depression, insomnia, or sleep apnea, a condition
    that recent research found causes its typically
    unknowing sufferers (9 percent of women, 24
    percent of men) to stop breathing dozens of times
    a night for up to a minute at a stretch.

69
Acupuncture
  • Dont know
  • I SOR
  • Cochrane
  • www.cochrane.org/reviews/en/ab005472.html

70
Useful Websites
  • The sleep IQ test
  • http//www.sleepfoundation.org/nsaw/sleepiq99i.cfm
  • Sleep meditation quilt square A couple of
    simple things to remember and a cool site.
    http//www.irvingstudios.com/child_abuse_survivor_
    monument/Water_files/water14_help_with_sleep/help_
    with_sleep.html
  • Practice parameters for treating chronic primary
    insomnia in the elderly. Natl. Guideline
    Clearinghouse www.guidelines.gov
  • http//cks.library.nhs.uk/insomnia/view_whole_guid
    ance

71
Bibliography
  • Manifestations management of chronic insomnia
    in adults. NIH Consensus Stae-of-the-Science
    Statements, Vol 22, 2, June 13-15, 2005.
  • Silber MH. Chronic insomnia. NEJM.
    2005353803-10
  • Summers Mo, et al. Recent developments in the
    classification, evaluation treatment of
    insomnia. Chest. 2006 130 276-86
  • International Classification of Sleep Disorders
  • Diagnostic Coding Manual. Amer Acad
    Sleep Medicine, 2005.

72
Bibliography
  • Ozminkowski, RJ et al. The direct and indirect
    costs of untreated insomnia in adults in the US.
    Sleep. 200730263-73.
  • Candaras MM. Sleep Review 20067 38
  • Ramakrishnan K. Treatment options for insomnia.
    AFP 200776517-26, 527-8.

73
Benzodiazepines
  • Name ½ life Dose Metab?
  • Estazolam 12-15 1-2 No
  • Flurazepam 8 15-30 Yes
  • Quazepam 39 7.5-15 Yes
  • Temazepam 10-15 15-30 No
  • Triazolam 2 0.125-.25 No
  • Lorazepam
  • Clonazepam
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