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Insomnia

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Sleep is a state of unconsciousness in which the brain is relatively more ... Characterized by muscle atonia, cortical activation, low voltage ... – PowerPoint PPT presentation

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Title: Insomnia


1
Insomnia
  • David A. Garfunkel, M.D.
  • August 31, 2005

2
  • Irrelevant Fact
  • Sleep Physiology
  • Joke
  • Scope of the Problem
  • Diagnosis
  • Commercial Break
  • Non-Pharmacologic Treatment
  • Pharmacologic Treatment

3
Who was the 2004 U.S. Open Tennis Womans Winner?
4
Svetlana Kuznetsova
5
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

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 and remove redundant or excess
    synapses

8
REM sleep
  • Generated by mesencephalic and pontine
    cholinergic neurons
  • Characterized by muscle atonia, cortical
    activation, low voltage desynchronization of the
    EEG, and rapid eye movements

9
  • REM sleep has both tonic and phasic qualities
  • Other features include periodic skeletal muscle
    twitches, increased heart rate variability and
    increased respiratory rate

10
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

11
  • Insomnia is defined as difficulty with the
    initiation, maintenance, duration, or quality of
    sleep that results in the impairment of daytime
    functioning, despite adequate opportunity and
    circumstances for sleep.
  • Patients subjective dissatisfaction with the
    sleep quality and quantity

12
  • 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

13
Poor Sleep Maintenance
  • Waking after sleep has been initiated, but before
    desired waking time

14
  • 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

15
  • Some patients may not meet any of the above
    conditions, but awake feeling poorly rested.

16
Sleep Requirements
  • Average - 7 1/2 to 8 1/2hrs/night
  • Range (for adults) - 5-9 hrs/night
  • Steadily decreases from birth to old age
  • newborns sleep 14-16 hours/24 hours
  • Elderly spend less time sleeping per night, but
    increase in sleep latency and more frequent
    arousals make their requirement in bed longer.

17
What do you call a nun who sleep walks?
18
A Roamin Catholic
19
Scope of the Problem
  • 2003 Sleep in America poll, which included 1,506
    adults ages 55 to 84 from various parts of the
    United States, found a prevalence of insomnia in
    48 percent.

20
Scope of the Problem
  • 1997 survey of almost 2000 HMO patients showed
    that 10 had current major insomnia as defined as
    taking more than 2 hours to fall asleep each
    night.
  • Only 5 spoke to their physician about it
  • Over 38 million prescriptions per year for
    sleeping pills

21
Consequences
  • Mood Disturbance
  • Depression and/or Anxiety
  • Poor memory
  • Difficulty concentrating
  • Motor vehicle and other accidents

22
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

23
  • There are 4-5 cycles in a normal nights sleep
  • First REM- 10 minutes, but later REM periods may
    exceed 60 minutes

24
Diagnosis- other sleep disorders
  • Hypersomnia - Excessive sleepiness, despite up to
    12 hrs./night of sleep
  • Gradual onset
  • Usually appears before age 25
  • Recurrent hypersomnia - Kleine Levin Syndrome
  • May be due to depression

25
Narcolepsy
  • Immune mediated destruction of hypocretin
    secreting neurons in the pineal gland
  • Not related to melatonin
  • Inherited on multiple genes, dominant with
    incomplete penetrance
  • CSF levels of hypocretin is low and is a useful
    test

26
  • The normal physiologic components of REM sleep,
    dreaming and muscle tone are separated and can
    occur while the patient is awake, resulting in
    half sleep dreams, cataplexy and sleep paralysis

27
  • Characterized by attacks of disabling daytime
    drowsiness and low alertness
  • Short sleep latency and sleep often begins with
    REM activity
  • 2/3 of cases are associated with cataplexy,
    triggered by strong emotion

28
Parasomnias
  • Disoriented Arousal
  • Sleepwalking
  • Night/Sleep Terrors
  • Hypnagogic Hallucinations
  • Sleep Paralysis
  • Nocturnal Seizures

29
Parasomnias, continued
  • REM Behavioral Disorder
  • Bruxism
  • Rhythmic Movement Disorder
  • Restless Legs Syndrome

30
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

31
Medications that may cause insomnia
  • Clonidine
  • Beta Blockers
  • Theophyline
  • Certain Antidepressants
  • Protriptyline, Fluoxetine
  • Decongestants
  • Stimulants
  • Alcohol

32
  • Exercise in morning or early afternoon lessens
    insomnia
  • Exercise close to bedtime worsens insomnia

33
Physical Exam
  • Anatomic features of obstructive sleep apnea
  • Neurologic exam in case of restless leg or other
    neurologic syndrome

34
Sleep Log
  • Maintain for 2-4 weeks
  • Sleep and wake times
  • Awakenings
  • Daytime naps and activities
  • Correlation with bed partner

35
Commercial Break
36
Remedy
  • Recovered Medical Equipment for the Developing
    World
  • 420 U.S. Hospitals recovered gt 50,000,000 worth
    of medical supplies in 2004
  • Remedy Lite - unwanted new supplies

37
Individuals 2 ways to help
Donate at www.REMEDYInc.org Shop through
www.iGive.com/REMEDYInc
38
Nonpharmacalogic Therapy
  • Cognitive Behavioral Therapy
  • Individual counseling- 6 sessions
  • Effective in 50 of patients

39
Relaxation Therapy
  • Recognize and control tension through
    systematically tensing and relaxing various
    muscle groups
  • Guided imagery and meditation
  • Biofeedback

40
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

41
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

42
Pharmacologic Therapy
  • Non-prescription
  • Prescription

43
Non-prescription Therapy
  • Valerian - An herbal medication that may be safe
    and effective to decrease sleep latency. May work
    better if taken regularly at night rather than
    PRN.
  • Main risk is uncontrolled manufacturing of herbal
    compounds

44
Melatonin
  • A natural hormone produced in the pineal gland
  • Circadian rhythm increases the blood level at
    night, especially when it is dark
  • Antioxidant properties
  • May be effective

45
What is the active ingredient in Tylenol PM?
46
Diphenhydramine hydrochloride
  • Main Ingredient in Tylenol PM, Sominex, Unisom,
    etc.
  • Antihistamine and anticholinergic agent
  • Non-specific and long lasting

47
Prescription Drugs
  • Benzodiazepines - most common
  • 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 slower rate of elimination may be more useful

48
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49
Concomitant Depression
  • Antidepressants with sedative properties
  • Trazodone (Desyrel)
  • Amitriptyline (Elavil)

50
Eszopiclone (Lunesta)
  • New class of non-benzodiazepine
  • May affect GABA receptor
  • Rapid onset, medium 1/2 life
  • No tolerance or withdrawal after 6 months of
    treatment
  • 1,2,3 mg. dose

51
Rozerem (ramelteon)
  • Unscheduled prescription drug
  • Acts on Melatonin receptors
  • No activity on the following receptors
  • GABA, neuropeptides, cytokines,seratonin,
    dopamine, noradrenaline, acetylcholine, or opioid

52
Rozerem, continued
  • Given to 14 subjects with history of abuse of
    sedative/hypnotics or anxiolitics Result no
    potential for abuse
  • Dosage-8 mg. (not with or immediately following a
    high fat meal

53
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

54
The End
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