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A symptom, not a disease or sign, therefore difficult to ... Painful erections. Sleep starts. Sleep terrors. Sleep walking. Abnormal swallowing. Hyperhidrosis ... – PowerPoint PPT presentation

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  • Liphard O. DSouza, M.D.
  • Diplomate American Academy of Sleep Medicine
  • 6128 E. 38th St., Ste. 303
  • Tulsa, OK 74135
  • (918) 523-8572

  • A broad term denoting unsatisfactory sleep
  • Perception that sleep is inadequate or abnormal
  • Common problem
  • A symptom, not a disease or sign, therefore
    difficult to measure

  • Complaint that the sleep is
  • Brief or inadequate
  • Light or easily disrupted
  • Non-refreshing or non-restorative

International Congress of Sleep Disorders
  • Based on the duration of symptoms
  • Transient or acute
  • Few days to 2-4 weeks
  • Chronic
  • Persisting for more than 1-3 months

  • Mild
  • Almost nightly complaint of non-restorative sleep
  • Associated with little or no impairment of social
    or occupational functioning
  • Moderate
  • Nightly complaints of disturbed sleep
  • Mild to moderate impairment of social or
    occupational function
  • Severe
  • Nightly complaints of disturbed sleep
  • Severe daytime dysfunction

  • Sleep initiating insomnia
  • Sleep maintaining insomnia
  • Early morning insomnia
  • Short period of sleep
  • Non-restorative sleep
  • Multiple awakenings
  • Combination of above patterns

Presentation Goals
  • Review of normal sleep cycle
  • Causes of insomnia
  • Diagnosis and assessment of insomnia
  • Treatment modalities

Stages of Sleep
  • Non-Rapid Eye Movement (NREM) sleep
  • Stage I
  • Stage II
  • Stages I II are light sleep
  • Stage III
  • Stage IV
  • Stages III IV are deep sleep
  • Rapid Eye Movement (REM) sleep

Normal Sleep Pattern
  • Sleep is an integral portion of human existence
    which is sensitive to most physiological or
    pathological changes (aging, stress, illness,
  • Why do we sleep?
  • Not clear, but has to do with regeneration (NREM)
    and brain development/memory (REM) REM sleep is
    essential for the development of the mammalian
  • Stages III IV are involved in synaptic pruning
    and tuning
  • Why do we get sleepy?
  • Circadian factors
  • Process S linear increase in sleepiness
  • Process C rhythmic fluctuations of the circadian
    alert system
  • Other factors sleep duration, quality, time
    awake, etc.

  • Insomnia is a downstream symptom of an upstream
    problem, for example
  • Medical
  • Psychological/ Psychiatric
  • Behavioral
  • Parasomnias
  • Drug-induced
  • Combination of factors in chronic insomnia

Normal Sleep Values
  • Normal sleep per day is between 6-8 hours,
    although some people can maintain a 4-6 hour
  • 4-6 NREM/REM cycles per night
  • Sleep structure changes throughout life
  • Wakefulness after sleep
  • Less than 30 minutes
  • Sleep Onset Latency (SOL)
  • Less than 30 minutes
  • REM Sleep Latency
  • 70-120 minutes

  • Studies throughout the world show that it occurs
  • Depending on the area, study, etc., between
    10-50 of the population are affected
  • Increases with age
  • Twice as common in females
  • Up to the age of 30, there is little difference
    between sexes
  • Beyond 30 years, it is more common in females
  • Beyond 70 years, females are affected twice as
    much as males

  • Symptom of numerous diverse etiologies
  • Usually due to more than one factor and each
    needs a separate evaluation
  • In all cases, one should strive to find the cause
    as it will dictate the proper treatment

3 Ps of Acute Insomnia
  • Predisposition
  • Anxiety, depression, etc.
  • Precipitation
  • Sudden change in life
  • Perpetuation
  • Poor sleep hygiene
  • Precipitating causes lower the threshold for
    acute insomnia in people with predisposing and
    perpetuating causes as well as further lowers the
    threshold for chronic insomnia
  • Start aggressive treatment in the ACUTE phase,
    before the patient goes into CHRONIC insomnia

Acute Insomnia
  • Resolves with the management of inciting factors
  • Adjustment sleep disorder
  • Acute stress such as momentous life events or
    unfamiliar sleep environments
  • PSG increased SOL, increased awakenings and
    sleep fragmentation with poor sleep efficiency
  • More common in women and those with anxiety
  • Jet Lag
  • Symptoms last longer with eastbound travel
  • Remits spontaneously in 2-3 days
  • More common in the elderly

Chronic Insomnia
  • Primary or Intrinsic
  • Secondary or Extrinsic
  • Causes
  • Changes in circadian rhythm, behavior,
  • Body movements in sleep
  • Medical, neurological, psychiatric disorders
  • Drugs

Primary/Intrinsic Insomnia
  • Idiopathic
  • Starts early in childhood, rare but relentless
  • Rare disorders affect both genders
  • CNS abnormalities, unknown etiology, etc.
  • Sleep State Misinterpretation (5)
  • Underestimate of the sleep obtained
  • Females affected more than males
  • Psychophysiological insomnia (30)
  • Maladaptive sleep-preventing behaviors develop
    and progress to become dominant factors
  • Females more than males

Secondary/Extrinsic Insomnia
  • Circadian rhythm sleep disorder sleep attempted
    at a time when the circadian clock is promoting
  • Advanced sleep phase syndrome
  • Delayed sleep phase syndrome
  • Irregular sleep/wake patterns
  • Non-24 hour sleep/wake syndrome
  • Shift work sleep disorder
  • Short sleeper

  • Behavioral disorders rooted behaviors that are
    arousing and not conductive to sleep
  • Inadequate sleep
  • Limit setting sleep disorder
  • Nocturnal eating/drinking syndrome
  • Sleep onset association disorder
  • Environmental factors
  • Environmental sleep disorder
  • Food allergy insomnia
  • Toxin-induced sleep disorder

  • Movement disorders
  • PLMS disorder (5)
  • RLS syndrome (12)
  • REM behavior disorder
  • Medical Disorders Respiratory
  • Altitude insomnia
  • Central alveolar hypoventilation syndrome
  • Central apnea syndrome
  • COPD
  • OSAS (4-6)
  • Sleep-related asthma

  • Medical Cardiac
  • Nocturnal myocardial ischemia
  • Medical GI
  • Peptic ulcer disease
  • GERD
  • Medical Musculoskeletal
  • Fibromyalgia
  • Arthritis
  • Medical Endocrine
  • Hyperthyroidism
  • Cushings disease
  • Menstrual cycle association
  • Pregnancy

  • Medical Neurological
  • Cerebral degeneration disorder
  • Dementia
  • Fatal familial insomnia
  • Parkinsons disease
  • Sleep related epilepsy
  • Sleep related headaches
  • Medical Psychiatric
  • Alcoholism
  • Anxiety disorders
  • Mood disorders
  • Panic disorders
  • Psychosis
  • Drug dependency

  • Pharmacological causes
  • Alcohol dependent sleep disorder
  • Hypnotic dependent sleep disorder
  • Stimulus dependent sleep disorder
  • Medications
  • B-blockers
  • Theophylline
  • L-dopa

Parasomnia Events
  • Physical phenomena occurring in sleep
  • Confusional arousals
  • Nightmares
  • Nocturnal leg cramps
  • Nocturnal paroxysmal dystonia
  • REM sleep behavior disorder
  • Rhythmic movement disorder
  • Painful erections
  • Sleep starts
  • Sleep terrors
  • Sleep walking
  • Abnormal swallowing
  • Hyperhidrosis
  • Laryngospasms

Physical, Emotional, and Cognitive Effects of
  • Mood changes, irritability, poor concentration,
    memory defects, etc.
  • Impairs creative thinking, verbal processing,
    problem solving
  • Risk of errors, accidents due to excessive
    daytime sleepiness
  • Markedly increases if awake more than 16-18 hours
    (micro-sleep attacks)
  • Increased appetite, decreased body temperature
  • Physiologic effects
  • Rats die after 11-12 days of sleep deprivation
  • Hippocampal atrophy in chronic jet lag or shift

  • Precipitating factors
  • Psychiatric and medical disturbances
  • Medications
  • Sleep hygiene
  • Circadian tendencies
  • Cognitive distortions and conditional arousals
  • Sleep diary

  • PSG
  • if PLMS or sleep-related breathing disorder or if
    CBT, sleep hygiene, pharmacological interventions
    fail as recommended by the AASM
  • Not routinely employed in the evaluation of
    transient or chronic insomnia
  • Should not be substituted for a careful clinical

Epworth Sleepiness Scale
  • A good measure of excessive daytime
    sleepiness. How likely are you to doze off or
    fall asleep in the following situations, in
    contrast to feeling just tired? This refers to
    your usual way of life in recent times. Even if
    you have not done some of these things recently,
    try to work out how they would affect you. Use
    the following scale to choose the most
    appropriate number for each situation
  • 0no chance of dozing 1slight chance
    2moderate chance 3high chance
  • Sitting and reading
  • Watching TV
  • Sitting inactive in a public place (ex.
    theater, meeting) ____
  • As a passenger in a car for an hour without
    a break ____
  • Lying down to rest in the afternoon
  • Sitting and talking to someone
  • In a car, while stopped for a few minutes in
    traffic ____

  • ____
    Total Score
  • Normal lt 10 Severe gt 15

Insomnia questionnaire
  • I have real difficulty falling asleep.
  • Thoughts race through my mind and this prevents
    me from sleeping.
  • I wake during the night and cant go back to
  • I wake up earlier in the morning than I would
    like to.
  • Ill lie awake for half an hour or more before I
    fall asleep.
  • I anticipate a problem with sleep almost every
  • If you checked three or more boxes, you show
    symptoms of insomnia, a persistent inability to
    fall asleep or stay asleep.

Treatment Selection
  • Meet and educate about disease, goals, options,
    side effects, and document safety.
  • Identify the 3 Ps.
  • Intrinsic v. Extrinsic
  • Treat perpetuating causes
  • Sleep hygiene, progressive muscle relaxation,
    biofeedback, stimulus control, sleep restriction,
    cognitive behavior therapy (CBT), combination of
    medications and CBT

  • Longest lasting improvements, assuming the
    precipitating cause is dealt with
  • counseling or talk through therapy for
    thoughts and attitudes that may be leading to the
    sleep disturbances
  • Identifying distorted attitudes or thinking that
    makes the patient anxious or stressed and
    replacing with more realistic or rational ones

CBT Examples
  • I need more hours of sleep or I will not
  • I can never die
  • Uses restructuring techniques
  • Short circuit cycle of insomnia, cognitive
    distortions, distress
  • Sleep hygiene, relaxation, stimulus control,
    sleep restrictions

Sleep Hygiene
  • Exercise earlier during the day, and no more than
    4-6 hours before sleep
  • Keep bedroom dark and quiet, to be used only for
    sex or sleep
  • Curtail time in bed to only when sleepy
  • Fixed sleep/wake times for 365 days
  • Avoid naps
  • Avoid stimulus or stimulating activities before
    sleep or in bed
  • No alcohol at least 4 hours before sleep, no
    caffeine after noon, and quit smoking!!
  • Light snack before bedtime

Stimulus Control
  • Use bedroom for sleep or sex only
  • Go to bed only when tired and sleepy
  • Remove clock from the bedroom to avoid constantly
    watching it
  • Regular sleep/wake times
  • Light therapy if required
  • No bright lights when you wake up at night

Sleep Restriction
  • An effective form of treatment
  • Estimate the time actually asleep then limit
    bedtime to that amount, but no less than 5 hours
  • Add time in bed gradually once the patient sleeps
    more than 85 of that time

  • Nationally, there has been a decline in hypnotic
    usage with an increase in usage of non-hypnotics
  • Trazadone
  • Seroquel
  • Self-medication with alcohol and over-the-counter
  • Benadryl
  • Nyquil

  • 5 questions to ask when choosing a hypnotic
  • Are you looking for sleep initiation or
  • What are the daytime residual effects of the
  • Does tolerance develop to this drug?
  • Will rebound withdrawal insomnia occur when
  • What is the half-life of the medication?

A nonbenzodiazepam
Recent Medication Additions
  • Eszopiclone 1,2,3 mg Intermediate
  • Approved for chronic insomnia
  • (Lunesta) Action 6-8 hrs.
  • Zolpidem 10 mg Action same as above
  • (Amvien CR)
  • Rozerem
  • (Ramelton)

Alternative Medications
  • Antidepressants
  • Not much research
  • Some, including SSRIs, can cause daytime
  • Melatonin
  • Good for jet leg, especially in elderly, but not
    much information on long-term use
  • Reported to cause depression, vasoconstriction
  • Benadryl
  • Rarely indicated, can cause a hangover
  • Herbal supplements
  • Use in conjunction with a sleep log

  • Insomnia is a complex symptom with many causes
    and perpetuating influences
  • It is nerve-racking for patients and physicians
    yet it is very remediable, if properly diagnosed
    and treated
  • It should be aggressively treated as emerging
    evidence is that chronic insomnia can precipitate
    major depressive disorder
  • Depression in turn confers an increased risk of
    suicide, cardiovascular disease, death, etc.

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