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Insomnia

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Title: Insomnia


1
Insomnia
  • Victoria E Judd M.D.

2
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3
Sleep Quotes
  • People who say they sleep like a baby usually
    don't have one.  Leo J. Burke
  • If people were meant to pop out of bed, we'd all
    sleep in toasters.  Author unknown
  • O sleep, O gentle sleep,Nature's soft nurse, how
    have I frighted thee,That thou no more wilt
    weigh my eyelids downAnd steep my sense in
    forgetfulness?William Shakespeare, Henry IV,
    Part I

4
Insomnia
  • No disclosures

5
Objectives
  • Learn about sleep
  • List pathogenesis/types of insomnia
  • Discuss epidemiology of insomnia
  • Learn about the impact of insomnia
  • List common etiologies of insomnia
  • Discuss therapy
  • -Cognitive-behavioral therapy
  • -Pharmacologic treatment

6
Sleep Is
  • Active
  • Complex
  • Highly Regulated
  • Involves different areas in the brain
  • Purpose is not understood
  • Essential to life/necessary
  • We all do it

7
Sleep Deprivation
  • Our 24/7 lifestyle can be deleterious
  • Trying to push through the night and stifle a
    yawn, yet that yawn is the first sign that youre
    not so awake as you might like to think after
    18 hours in the absence of sleep, your reaction
    time slows from ¼ of a second to ½ of a second,
    and then becomes still longer

8
Sleep Deprivation
  • One starts experiencing several bouts of
    micro-sleep and so, while driving you zone
    out for say 20 seconds and drift out of your
    lane, or if studying late then you find yourself
    rereading the same passage thus your reaction
    time becomes roughly equivalent to a person with
    a blood alcohol level of 0.08, sufficient to get
    you arrested in 49 states

9
Sleep Deprivation
  • Charles Augustus Lindbergh, in 1927, in his
    Spirit of St. Louis, during his 1st solo Atlantic
    crossing from Long Island to Paris, experienced
    visual hallucinations which remitted with
    recovery sleep
  • There is a 10 increase in MVAs following
    switching to daylight savings when the day is
    shortened by 1 hour

10
Consequences of Insomnia
11
Sleep Deprivation
  • Mood disturbance with irritability, transient
    paranoia, disorientation, performance deficits,
    severe fatigue or hypomania all sequelae of
    prolonged sleep deprivation
  • Chronic sleep deprivation may reach a point at
    which the very ability to catch up on sleep is
    damaged, such that whats lost is lost
  • Bodes ill for students, soldiers, et. al, trying
    to acquire new information while sleep-deprived

12
Sleep Disorders
  • Sleep disorders are common
  • Sleep disorders are serious
  • Sleep disorders are treatable
  • Sleep disorders are underdiagnosed

13
Sleep
  • Sleep Stages
  • Stage 1- transition to sleep, 5 of total time
  • Stage 2- 50 of total time
  • Stage 3 4- Most restorative sleep , slow wave
    sleep, 20-24 of total sleep time
  • Rapid eye movement (REM)- 20-25 of total sleep
    time (When we dream)

14
Sleep
  • Normal sleep starts with stage 1-2-3-4-3-2-REM
  • The cycle repeats at 10-120 (90) minute intervals
  • There are 3 to 4 cycles a night
  • Stage 3 4 are more prominent in the first half
    of the night and decrease as time goes on
  • REM is less prominent in the first half of the
    night and increases as time goes by

15
Sleep Cycle
16
Sleep
  • Sleep varies with age
  • Infants sleep 66 of the day
  • Young adults sleep 33 of the day
  • Older adults sleep less, wake more, have less
    stage 3, 4 and REM sleep
  • More REM sleep better learning in students
  • The last 2 hours of REM sleep tend to be the most
    important for integrating new information

17
The Need For Sleep
  • Over the years, the need for REM sleep decreases
    considerably, while the need for NREM sleep
    diminishes less sharply

18
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19
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20
Insomnia - DSM IV criteria
  1. Difficulty initiating or maintaining sleep, or
    non-restorative sleep, for at least 1 month.
  2. Clinically significant distress or impairment in
    social/occupational functioning
  3. Not exclusively due to another sleep disorder
  4. Not exclusively due to another mental disorder
  5. Not due to the physiological effects of a
    substance or a medical disorder

21
Insomnia
  • Insomnia is present when all three of the
    following criteria are met
  • A complaint of difficulty initiating sleep,
    difficulty maintaining sleep, or waking up too
    early.
  • The above sleep difficulty occurs despite
    adequate opportunity and circumstances for sleep.
  • The impaired sleep produces deficits in daytime
    function.

22
Features of Insomnia
  • Problems initiating sleep (greater than 30
    minutes)
  • Frequent and/or prolonged nocturnal awakenings
  • Early morning awakenings with an inability to
    return to sleep
  • Poor sleep quality and sleep efficiency
  • Cognitive arousal typically reported
  • Severity is judged along several dimensions,
    including frequency, intensity and duration of
    sleep difficulties. Also impact on daytime
    functioning, mood and quality of life.

23
Insomnia-Hyperarousal
  • In experimental models of insomnia, healthy
    subjects deprived of sleep do not demonstrate the
    same abnormalities in metabolism, daytime
    sleepiness, and personality as subjects with
    insomnia. In an experimental model in which
    healthy subjects were given caffeine, causing a
    state of hyperarousal, the healthy subjects had
    changes in metabolism, daytime sleepiness, and
    personality similar to the subjects with
    insomnia.
  • These results support a theory that insomnia is a
    manifestation of hyperarousal. In other words,
    the poor sleep itself may not be the cause of the
    daytime dysfunction, but merely the nocturnal
    manifestation of a general disorder of
    hyperarousability.

24
Impact of Insomnia
  • Biological
  • Poor function of immune system
  • Functional impairments
  • Increased risk of accidents
  • More likely to report lack of concentration and
    motivation
  • Reduced productivity, work/school absenteeism
  • Increased use of health care services

25
Impact of Insomnia
  • Psychological health
  • Increases risk of developing depression,
    anxiety or substance dependence
  • Risk factor in suicide
  • (Ohayon et al., 1997 Harvey, 2001 Ancoli-Israel
    Roth, 1999 McCrae Lichstein, 2001)

26
Impact of Insomnia
  • Knutson et al found that the quantity and quality
    of sleep correlate with future blood pressure. In
    an ancillary to the Coronary Artery Risk
    Development in Young Adults (CARDIA) cohort
    study, measurement of sleep for 3 consecutive
    days in 578 subjects showed that shorter sleep
    duration and lower sleep maintenance predicted
    both significantly higher blood pressure levels
    and adverse changes in blood pressure over the
    next 5 years.

27
Types of Insomnia, Time
  • Transient insomnia episodic
  • Acute illness
  • Jet lag
  • Shift change
  • Short-term insomnia few days to 3 weeks
  • Major life event
  • Substance abuse
  • Chronic insomnia longer than 4 weeks
  • Chronic illness
  • Psychiatric illness

28
Circadian Related Insomnia, Time
  • Time zone change (jet lag) syndrome
  • Shift work sleep disorder
  • Irregular sleep-wake pattern
  • Delayed sleep phase syndrome
  • Advanced sleep phase syndrome
  • Non-24-hour sleep-wake disorder
  • Circadian rhythm sleep disorder
  • Shifts with age (adolescent or elderly)

29
Chronic Insomnia
  • Complaint of poor sleep causing distress or
    impairment for 1 to 6 months or longer
  • Average less than 6.5 hours sleep per day
  • Or 3 episodes per week of
  • Taking longer than 30 minutes to fall asleep
  • Waking up during the night for at least an hour
  • Not accounted for by another sleep disorder,
    mental illness, medical illness or substance
    abuse.

30
Types of Insomnia
  • Primary insomnia
  • Idiopathic insomnia Insomnia arising in infancy
    or childhood with a persistent, unremitting
    course
  • Psychophysiologic insomnia Insomnia due to a
    maladaptive conditioned response in which the
    patient learns to associate the bed environment
    with heightened arousal rather than sleep onset
    often associated with an event causing acute
    insomnia, with the sleep disturbance persisting
    despite resolution of the precipitating factor
  • Paradoxical insomnia (sleep-state misperception)
    Insomnia characterized by a marked mismatch
    between the patients description of sleep
    duration and objective polysomnographic findings

31
Types of Insomnia
  • Secondary insomnia
  • Adjustment insomnia Insomnia associated with
    active psychosocial stressors
  • Inadequate sleep hygiene Insomnia associated
    with lifestyle habits that impair sleep
  • Insomnia due to a psychiatric disorder Insomnia
    due to an active psychiatric disorder, such as
    anxiety or depression
  • Insomnia due to a medical condition Insomnia
    due to a condition such as the restless legs
    syndrome, chronic pain, nocturnal cough or
    dyspnea, or hot flashes
  • Insomnia due to a drug or substance Insomnia
    due to consumption or discontinuation of
    medication, drugs of abuse, alcohol, or caffeine

32
Proper Diagnosis
  • The medical interview is everything
  • Focus on underlying causes
  • Sleep partner should be present for the interview
    if possible
  • Full medication list is required (OTC, Rx,
    Natural)
  • Substances and alcohol use

33
Interview
  • Sleep historyis there trouble with
  • - falling asleep?
  • - maintaining sleep?
  • - not being able to go back to sleep?
  • - early awakenings?
  • - not feeling rested?
  • - daytime consequences?

34
Interview
  • Daytime consequences can you function/stay awake
    to drive?
  • Do you experience (or bed-partner report) Leg or
    arm jerking while asleep? (periodic limb movement
    disorder)
  • Loud snoring/gasping/choking, or stopping
    breathing when asleep? (sleep apnea)
  • Uncomfortable feelings in your legs that go away
    with moving them? (restless leg syndrome)

35
Interview
  • Patients with insomnia typically feel fatigued
    during the day, but are unable to fall asleep if
    given a chance to lie down to take a nap.
  • Patients with poor nocturnal sleep due to other
    sleep disorders readily fall asleep during the
    day. ( Except poor sleep hygiene.)

36
Interview
  • Usual bedtime
  • Usual morning awakening time
  • Time spent in bed awake prior to sleeping, and
    following the onset of sleep
  • Estimated time spent asleep
  • Do you take anything to make you sleep?
  • Do you drink to help you go to sleep?
  • What else do you do in your bedroom?

37
Interview
  • Anything disruptive to sleep?
  • Computer
  • Noises
  • Lights
  • Snoring partner/roommate
  • Partner/roommate with different bed/wake times
  • TV
  • Pets
  • Not feeling safe where you sleep

38
Interview
  • Do you consume nicotine, caffeine, alcohol,
    other stimulants, decongestants prior to bedtime?
  • Half lives are important!
  • Do you smoke/eat when you wake up, or perform
    other tasks like cleaning?
  • Do you check the clock when you wake up early?
  • What is your pre-bedtime routine exercise, work,
    TV, eating?

39
Interview-Stimulants
  • Some Common Sources
  • Coffee a cup of Joe with 100-150 mg of caffeine
    1 mg of amphetamine
  • Red Bull 250 mL 80 mg of caffeine
  • Bakers Chocolate 1 oz 26 mg of caffeine
  • Tea variable

40
Interview
  • Medical issues
  • Medication changes
  • Lifestyle issues
  • Work stress
  • School stress
  • Financial stress
  • Relationship stress
  • Complaints from partner

41
Stressful Life Events
  • Loss of a loved one
  • Divorce/Separation
  • Loss of employment
  • Arguments
  • Particularly happy or sad events
  • Work demands
  • School demands
  • Injuries
  • Illnesses

42
Medical Conditions Associated With Insomnia
  • Hyperthyroidism
  • Arthritis or any other chronic painful condition
  • Chronic lung or kidney disease
  • Cardiovascular disease (heart failure, CAD)
  • Heartburn (GERD)
  • Neurological disorders (epilepsy, Alzheimers,
    headaches, stroke, tumors, Parkinsons Disease)
  • Diabetes
  • Menopause/Menstrual disorders

43
Some Medications that Cause Insomnia
  • Alcohol
  • Caffeine/chocolate
  • Nicotine/nicotine patch
  • Beta blockers
  • Calcium channel blockers
  • Bronchodilators
  • Corticosteroids
  • Decongestants
  • Antidepressants
  • Thyroid hormones
  • Anticonvulsants
  • High blood pressure medications

44
Psychiatric Causes of Insomnia
  • Depression
  • Generalized Anxiety Disorder
  • Stress
  • Post Traumatic Stress Disorder
  • Obsessive Compulsive Disorder
  • Adjustment disorders
  • Personality disorders
  • Bipolar disorder
  • Dysthymia
  • Anxiety
  • Psychosis including schizophrenia

45
Types of Insomnia
  • Comorbid insomnia
  • Sleep disturbance is comorbid with an underlying
    problem

46
Causes of Insomnia
47
Epidemiology
  • More than half of adults in the U.S. said they
    experienced insomnia at least a few nights a week
    during the past year
  • Nearly one-third said they had insomnia nearly
    every night
  • Increases with age
  • The most frequent health complaint after pain
  • Twice as common in women as in men

48
Epidemiology
  • 69 have insomnia-occasional 50 and chronic 19
  • 35 percent insomnia during the previous year (50
    serious)
  • Approximately 10 of individuals develop chronic
    insomnia with related daytime consequences

49
Insomnia
  • Variables associated with the onset of insomnia
    include
  • a previous episode of insomnia
  • a family history of insomnia
  • a predisposition toward being more easily aroused
    from sleep
  • poorer self-rated health
  • more body pain

50
CONTRIBUTING FACTORS TO DEVELOPMENT OF INSOMNIA
  • Predisposing factors
  • Personality
  • Sleep-wake cycle
  • Circadian rhythm
  • Coping mechanisms
  • Age
  • Precipitating factors
  • Situational
  • Environmental
  • Medical
  • Psychiatric
  • Medications
  • Perpetuating factors
  • Conditioning
  • Substance abuse
  • Performance anxiety
  • Poor sleep hygiene

51
Most Common Daytime Complaints
  • Fatigue or malaise
  • Poor attention or concentration
  • Social, school, or vocational dysfunction
  • Mood disturbance-More sadness, depression, and
    anxiety
  • Daytime sleepiness
  • Cognitive impairment
  • School or work days missed

52
Most Common Daytime Complaints
  • Reduced motivation or energy
  • Increased errors or accidents
  • Tension, headache, or gastrointestinal symptoms
  • Ongoing worry about sleep
  • Risk taking behavior
  • Deficits in academic performance
  • Poorer Health

53
Consequences of Insomnia
  • The National Sleep Foundation found that students
    who reported insufficient sleep performed worse
    on tests had lower grades. Those who reported
    getting enough sleep had As and Bs.
  • Thus students who are chronically sleepy may
    chose easier courses in college. Thus limiting
    their future options.

54
Consequences of Insomnia
  • Even though students may compensate by getting
    extra sleep on the weekend, this is not enough to
    compensate for the lost sleep during the week,
    resulting in a mounting sleep deficit.

55
Consequences of Insomnia
  • Worsens psychiatric disorders
  • Prolongs medical illnesses
  • Reduced quality of life
  • Higher health care costs

56
Depression and Insomnia
  • Insomnia is both a risk factor for depression and
    a consequence of depression
  • Could effective management of insomnia decrease
    the incidence of depression?
  • Could effective management of insomnia modify the
    risk for relapsing depression?

57
Insomnia Assessment
  • Interview
  • Physical exam
  • Labs TSH Free T4, Glucose and Hgb A1C, BUN
    Cr, Iron Studies
  • Psychometric
  • Anxiety Depression Questionnaires
  • Sleep Disorders Questionnaire

58
Measures of Sleep
  • Insomnia Severity Index
  • Epworth Sleepiness Scale (not good for insomnia)
  • Sleep Diaries
  • Reports of partner

59
How to keep track of your sleep
  • Daily sleep diary or sleep log
  • Bedtime
  • Falling asleep time
  • Nighttime awakenings
  • Time to get back to sleep
  • Waking up time
  • Getting out of bed time
  • Naps

60
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61
Non-drug treatments
  • Cognitive-behavioral therapy (CBTI)
  • Stimulus control
  • Cognitive therapy
  • Sleep restriction
  • Relaxation training
  • Sleep hygiene
  • Cognitive therapy

62
Insomnia - CBTI model (Espie,91)
63
CBTI
  • Stimulus control
  • Sleep hygiene
  • Sleep restriction
  • Relaxation
  • Paradoxical intention
  • Cognitive restructuring
  • Worry postponement

64
  • Insomnia
  • Stimulus Control
  • Insomnia is a conditioned response to temporal
    and
  • environmental cues
  • Promote consistent sleep / wake cycle
  • Re-associate the bedroom with sleeping
  • Well established stand alone treatment

65
BEHAVIORAL TREATMENTS
  • Stimulus control therapy
  • Assumes that there is a learned associated
    between wakefulness and the bedroom
  • To break the cycle, the patient must not spend
    time wide awake in the bedroom
  • Go to bed only when sleepy
  • Do not use the bedroom for sleep-incompatible
    activities
  • Leave the bedroom if awake for more than 20
    minutes
  • Return to bed only when sleepy
  • Repeat if necessary
  • Do not nap during the day
  • Arise at the same time every morning

66
  • Insomnia
  • Sleep Hygiene Education
  • Factors that affect sleep, e.g. caffeine,
    alcohol, etc.
  • Not primary cause of insomnia but can maintain
    problem
  • Limited benefits if used alone, Not sufficient
    as a stand alone treatment
  • Specific behaviors will directly interfere with
    the ability to sleep
  • The behaviors can be changed with education

67
Sleep Hygiene
  • Having good sleep hygiene knowledge is weakly
    associated with good sleep hygiene but is not
    related to overall sleep quality.
  • Practicing good sleep hygiene is strongly related
    to good sleep quality.

68
Sleep Hygiene
  • Fix a bedtime and an awakening time
  • Avoid napping during the day
  • Avoid alcohol, nicotine, chocolate before bed
  • Avoid caffeine containing beverages 4 6 hours
    before bedtime
  • Avoid heavy, spicy, acidic or sugary foods before
    bed
  • Regular exercise is good, not before bedtime
  • Comfortable bedding
  • Bedroom cool, dark, quiet
  • Bedroom reserved for sleep and sex NOT a work
    room

69
Sleep Hygiene
  • Avoid trying to sleep
  • You cant make yourself sleep, but you can set
    the stage for sleep to occur naturally
  • Avoid a visible bedroom clock with a lighted dial
  • Dont let yourself repeatedly check the time!
  • Turn the clock around or put it under the bed

70
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71
More healthy sleep habits
  • Expose yourself to bright light at the right time
  • Morning, if you have trouble falling asleep at
    night
  • Night, if you want to stay awake longer at night
  • Establish a regular sleep schedule
  • Get up at the same time 7 days a week
  • Go to bed at the same time each night
  • Exercise every day - exercise improves sleep!
  • Deal with your worries before bedtime
  • Plan for the next day before bedtime
  • Set a worry time earlier in the evening
  • Keep a journal

72
More healthy sleep habits
  • Adjust the bedroom environment
  • Sleep is better in a cool room, around 65 F.
  • Darker is better
  • If you get up during the night to use the
    bathroom, use minimum light
  • Use a white noise machine, a fan, or ear plugs to
    drown out other sounds
  • Make sure your bed and pillow are comfortable
  • If you have a partner who snores, kicks, etc.,
    you may have to move to another bed (try white
    noise first) (try ear plugs)
  • Change resident hall quiet hours

73
Healthy Sleep Habits
  • Boring activities reading the phone book,
  • count, etc.
  • TV/video games do not count as relaxing or
    boringthe flashing lights stimulate the brain.

74
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75
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76
  • Insomnia
  • Sleep Restriction
  • Reducing time in bed to match sleep obtained
  • To increase sleep efficiency
  • Adherence is problematic
  • Probably efficacious treatment

77
Sleep Restriction - best if done with a
professional
  • Cut bedtime to the actual amount of time you
    spend asleep (not in bed), but no less than 4
    hours per night
  • No additional sleep is allowed outside these
    hours
  • Record on your daily sleep log the actual amount
    of sleep obtained

78
Sleep Restriction (contd)
  • Compute sleep efficiency (total time asleep
    divided by total time in bed)
  • Based on average of 5 nights sleep efficiency,
    increase sleep time by 15 minutes if efficiency
    is gt85-90
  • With elderly, increase sleep time if efficiency
    gt80 and allow 30 minute nap.

79
Sleep Restriction
  • If sleep efficiency falls to less than 80,
    decrease time in bed by 15 minutes
  • Have set, daytime hours (whenever possible).
  • As sleep consolidation improves, time in bed (and
    asleep) increases.
  • Creates a mild state of sleep deprivation, and
    thus promotes more rapid sleep onset and more
    efficient sleep

80
  • Insomnia
  • Relaxation
  • To deactivate arousal system
  • Various types - muscular, imaging, hypnosis,
    etc.
  • Well established treatment

81
BEHAVIORAL TREATMENTS
  • Plan a relaxation period before bed, develop a
    bedtime routine.
  • Relaxation Therapy
  • Progressive muscle relaxation best
  • EMG Biofeedback best
  • Meditation
  • Imagery training
  • Self-hypnosis
  • Diaphragmatic breathing

82
Relaxation training
  • More effective than no treatment, but not as
    effective as sleep restriction
  • More useful with younger compared with older
    adults
  • Engage in any activities that you find relaxing
    shortly before bed or while in bed
  • Can include listening to a relaxation tape,
    soothing music, muscle relaxation exercises, a
    pleasant image

83
  • Insomnia
  • Paradoxical Intention
  • Engage in the feared outcome (not sleeping)
  • Break cycle of performance anxiety
  • Large variance in response

84
Paradoxical Intention Treatment
  • Paradoxical intention treatment is based on the
    concept that performance anxiety helps prevent
    proper sleep.
  • The treatment involves persuading the individual
    with insomnia to engage in the most feared
    behavior, which to that individual is "staying
    awake."
  • As the patient stops trying to fall asleep, the
    performance anxiety of trying to fall asleep
    slowly disappears.
  • Studies show this approach is more effective than
    control groups.

85
  • Insomnia
  • Cognitive Restructuring
  • Identify thought processes to reduce anxiety
  • Includes self-talk, distraction, rationalization
  • Helpful in altering dysfunctional sleep beliefs
  • Postponing worry episodes
  • Limited benefits if used alone, Not sufficient
    as a stand alone treatment

86
Cognitive Restructuring
  • Identify beliefs about sleep that are incorrect
  • Challenge their truthfulness
  • Substitute realistic thoughts

87
False beliefs about insomnia
  • Misconceptions about causes of insomnia
  • Insomnia is a normal part of aging.
  • Unrealistic expectations re sleep needs
  • I must have 8 hours of sleep each night.
  • Faulty beliefs about insomnia consequences
  • Insomnia can make me sick or cause a mental
    breakdown.
  • Misattributions of daytime impairments
  • Ive had a bad day because of my insomnia.
  • I cant have a normal day after a sleepless
    night.

88
More common myths about insomnia
  • Misconceptions about control and predictability
    of sleep
  • I cant predict when Ill sleep well or badly.
  • Myths about what behaviors lead to good sleep
  • When I have trouble getting to sleep, I should
    stay in bed and try harder.

89
EFFICACY OF CBTI FOR INSOMNIA
90
EFFICACY OF CBT FOR INSOMNIA
91
Benefits of CBTI
  • Benefits are long-lasting, even after therapy is
    over
  • Relatively free of medical risks
  • No significant interactions with other medical
    treatments

92
The Down Side of CBTI
  • Monetary cost (repeated visits to a provider)
  • Improvement may not occur for several weeks
  • Requires time and motivation
  • Daytime sleepiness during sleep restriction
  • Lack of access to a trained therapist
  • Lack of therapist expertise

93
Combined Treatment
  • CBTI can be used along with medications.
  • For example, medications can provide rapid relief
    and CBTI can lead to long-lasting results.
  • The use of medication prior to the initiation of
    behavioral therapy appears to be less effective.

94
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95
Treatment of Insomnia
  • Pharmacologic
  • Sleeping Pills-Prescription
  • Over the Counter

96
Pharmacologic Treatment of Insomnia
  • Historic trials
  • Fermented beverages
  • Plant preparations
  • Laudanum (opium/alcohol)
  • Chloral hydrate (Mickey Finn)
  • Barbiturates
  • Current
  • Antihistamines
  • Benzodiazepine hypnotics
  • Nonbenzodiazepine hypnotics
  • Selective melatonin receptor agonist
  • Investigational compounds

97
MOST COMMONLY USED DRUGS FOR INSOMNIA
  • Trazodone
  • Zolpidem
  • Amitriptyline
  • Mirtazapine
  • Temazepam
  • Quetiapine
  • Zaleplon
  • Clonazepam
  • Hydroxyzine
  • Alprazolam
  • Lorazepam
  • Olanzapine
  • Flurazepam
  • Doxepin
  • Cyclobenzaprine
  • Diphenhydramine

98
Treatment of Insomnia
  • If you have to use drugs
  • (Pharmacotherapy Guidelines)
  • Use the lowest therapeutic dose
  • Use for the shortest duration necessary
  • Discontinue medication gradually
  • Be alert for rebound insomnia
  • Use agents with short half-lives to minimize
    daytime sedation
  • Best if started with CBTI

99
Sleeping Pills
  • Most common treatment approach
  • Drowsiness common the next day
  • NOT meant for chronic insomnia
  • Effective for short-term (a couple weeks)
    insomnia only
  • Tolerance and dependency may develop
  • Withdrawal, rebound, relapse may occur
  • But commonly used, despite the above
  • 5-10 of adults have used a benzodiazepine in
    past year as a sleep aid
  • 10-20 of those over age 65 use sleeping pills

100
Drug Treatment
  • Benzodiazepines-Approved by FDA
  • Non-benzodiazepine hypnotics-Approved by FDA
  • Melatonin receptor agonists-Approved by FDA
  • Antidepressants
  • Antipsychotics
  • Antihistamines

101
Benzodiapines
  • Many end in pam or lam
  • clonazepam (Klonopin)
  • lorazepam (Ativan)
  • diazepam (Valium)
  • alprazolam (Xanax)
  • temazepam (Restoril)
  • triazolam (Halcion)

102
BZRA HYPNOTICS IN THE US
DRUG BRAND HALF-LIFE (hrs) DOSE (mg)
Estazolam ProSom 8-24 1,2
Flurazepam Dalmane 48-120 15,30
Quazepam Doral 48-120 7.5,15
Temazepam Restoril 8-20 7.5,15,22.5,30
Triazolam Halcion 2-4 0.125,0.25
103
BZRA PRESCRIBING GUIDELINES
  • Bedtime dosing
  • Avoid hazardous activities after dose
  • Allow sufficient time in bed
  • Dose adjustments
  • Elderly and debilitated patients
  • Hepatic impairment
  • Nightly vs. as needed dosing
  • Middle of the night dosing?
  • Taper dose on discontinuation?
  • Do not use in pregnant patients

104
Benefits of Benzodiazepines
  • Enhance sleep
  • Decrease anxiety
  • Muscle relaxant

105
BZRA DISCONTINUATION EFFECTS
  • Rebound insomnia sleep worsened relative to
    baseline for 1-2 days
  • Recrudescence return of original insomnia
    symptoms
  • Withdrawal new cluster of symptoms not present
    prior to treatment

106
BZRA ADVERSE EFFECTS
  • Residual effects
  • Dizziness
  • Headache
  • Blurred vision
  • Nausea/diarrhea
  • Fatigue
  • Anterograde amnesia
  • Sonambulism/complex sleep behavior

107
Side Effects of Benzodiazepines
  • Daytime sedation
  • Decreased reaction time
  • Unsteadiness of gaitcan lead to falls, ataxia
  • Cognitive impairment memory problems
  • Risk of tolerance
  • Risk of withdrawal (and rebound insomnia)
  • Risk of abuse (do not use them in patients with a
    history of substance abuse)

108
Non-BZRA HYPNOTICS IN THE US
DRUG BRAND HALF-LIFE (hrs) DOSE (mg)
Zolpidem Ambien 1.5-2.4 5,10
Zolpidem ER Ambien CR 2.8-2.9 6.25,12.5
Zaleplon Sonata 1 5,10
Eszopiclone Lunesta 5-7 1,2,3
109
Benefits of Non-benzodiazepines Hypnotics
  • Bind to sub-types of GABA receptors that
    specifically modulate sleep and therefore are
    thought to have less unwanted side effects
  • Tolerance and abuse have not been shown to be a
    major problem in the general population
  • In general have shorter duration of action than
    most benzodiazepines and therefore are less
    likely to cause next day sedation

110
Side Effects of Non-benzodiazepines Hypnotics
  • Drowsiness
  • Dizziness
  • Unsteadiness of gait
  • Rebound insomnia
  • Memory impairment

111
FDA Indications
  • Sleep onset only zolpidem (Ambien) and zaleplon
    (Sonata)
  • Sleep onset and sleep maintenance zolpidem ER
    (Ambien ER) and eszopiclone (Lunesta)
  • Eszopiclone (Lunesta) does not have a FDA
    restriction on duration of usage

112
FDA Indications
  • Benzodiazepine receptor agonists
  • Benzodiazepine hypnotics
  • Temazepam (Restoril) (generic available)
  • Flurazepam (Dalmane) (generic available)
  • Nonbenzodiazepine hypnotics
  • Zolpidem (Ambien) (generic available)
  • Zaleplon (Sonata) (generic available)
  • Eszopiclone (Lunesta) ( no generic available)
  • Selective melatonin receptor agonist
  • Ramelteon (Rozerem) (no generic available)

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Ramelteon
  • Brand name is Rozerem
  • Selective agonist at MT1 and MT2 melatonin
    receptors
  • FDA approved for sleep-onset insomnia
  • Only medication FDA approved for insomnia that is
    not a controlled substance because it does not
    seem to lead to abuse or withdrawal
  • Associated with headache, dizziness, drowsiness,
    fatigue and nausea
  • Avoid with hepatic impairment and in pregnant
    women

114
Ramelteon
  • FDA approved for sleep onset insomnia
  • No limitation on duration of use
  • Non-sedating
  • Single dose 8 mg
  • Take about 30 minutes prior to bedtime
  • Half-life 1-2.6 hrs
  • No generic yet

115
First Generation Antihistamine
  • Postsynaptic histaminic and muscarinic blockade
  • Diphenhydramine
  • Regulated by the FDA
  • Half-life 8 hrs
  • Rapid tolerance to sedating effects
  • Pill strengths (mg) 25, 37.5, 50

116
First Generation Antihistamine
  • Potential adverse effects
  • Residual effects
  • Delirium
  • Dry mouth
  • Constipation
  • Blurred vision
  • Urinary retention
  • Narrow angle glaucoma exacerbation
  • Paradoxical reaction

117
Anti-depressants
  • Commonly used for insomnia but are not FDA
    approved
  • Trazodone
  • Doxepin (Sinequan)
  • Amitriptyline
  • Mirtazapine (Remeron)

118
Trazadone
  • Used at much lower doses for insomnia than
    depression
  • The most commonly prescribed agent for treating
    insomnia across all classes of medications
  • No good research to support its use
  • Major side effects sedation, dizziness, dry
    mouth, orthostatic hypotension, priapism (rare)

119
The Tricyclic Antidepressants
  • amitriptyline (Elavil)
  • doxepin (Sinequan)
  • Side effects dry mouth, urinary retention,
    dizziness, daytime sedation, suppression of REM
    sleep, QT prolongation
  • Used at much lower doses for insomnia than
    depression

120
Mirtazapine
  • Brand name Remeron
  • Associated with weight gain, increased appetite,
    daytime sedation and dizziness

121
Antipsychotics
  • Called the atypical antipsychotics
  • Block dopamine from binding to receptors in the
    brain
  • Only use is for treating comorbid insomnia in
    patients with primary indication for their use
  • Examples
  • risperidone (Risperdal)
  • olanzapine (Zyprexa)
  • quetiapine (Seroquel)
  • ziprasidone (Geodon)

122
Anticonvulsants
  • Low doses have some sedating and sleep promoting
    effects
  • The data is sparse

123
Dietary Supplements
  • Not FDA regulated
  • Valerian
  • Kava-Kava
  • Melatonin
  • Passion flower
  • Skullcap
  • Lavender
  • Hops

124
Dietary/Herbal Sleep Preparations(pea-shooters
in the armamentarium)
  • Mostly L-Tryptophan, Valerian, Kava-kava
  • L-Tryptophan precursor of Serotonin, a substrate
    for Melatonin in milk (doesnt need to be
    warmed) turkey FDA has limited availability
    after gt 1,500 cases of Eosinophilia Myalgia
    Syndrome with at least 37 deaths in 1989

125
Dietary/Herbal (continued)
  • Valerian (derivative of Valeriana officinalis
    plant) mechanism may be via inhibiting GABA
    reuptake or inhibiting postsynaptic potentials
    through activation of adenosine receptors in
    cortical neurons in one study, little
    difference vs. Benadryl - inhibitor of CYP3A4
    withdrawal when extensive use, similar to that
    seen with BZDs risk of hepatotoxicity
    delirium

  • Sleep, 2005, 28 1465-1471

126
Dietary/Herbal (continued)
  • Kava-kava from root of Piper methysticum plant
    endogenous to Western Pacific, and used as
    hypnotic anxiolytic banned in many countries
    due to reports of serious hepatoxicity
  • ______________________
  • Others Melatonin (OTC), Chamomilla (Sleepy-Time
    Tea), Passiflora

127
Do Not Mix Medications
  • Heath Ledger had insomnia and passed away from an
    accidental overdose of the following medications
  • oxycodone
  • hydrocodone
  • diazepam
  • temazepam
  • alprazolam
  • doxylamine

128
Other Treatments of Insomnia
  • Acupuncture

129
Cultural Issues of Insomnia
  • How long to sleep at night
  • How long to nap
  • Is insomnia to due too much work, physical
    ailments, etc.
  • Is insomnia a disease, a complaint, a disorder, a
    symptom, a finding

130
Brief Behavioral Treatment Plan for Insomnia
  • Initial Visit
  • (1) Screen positive for possible insomnia.
  • (2) Assign sleep log and teach how to complete it
    on daily basis for 2 weeks.
  • (3) Teach how to calculate a daily sleep
    efficiency score.
  • Sleep efficiency is calculated by taking the
    ratio of actual time spent asleep to time spent
    in bed (expressed as a percentage, with higher
    numbers indicating better sleep efficiency).

131
Brief Behavioral Treatment Plan for Insomnia
  • First Treatment Session (2 weeks later)
  • (1) Review of sleep log, including sleep
    efficiency score, especially to see the amount of
    time napping.
  • (2) Discussion of bedtime habits (e.g.,
    television watching, reading, worrying, etc.).
  • (3) Brief sleep education consisting of
    individual differences in sleep needs, the
    effects of aging on sleep, and the influence of
    sleep drive and circadian rhythms on sleep.
  • (4) Teach stimulus control techniques including
    (a) eliminating nonsleep-related activities from
    bed and bedroom, (b) following a consistent
    sleep-wake schedule, and (c) avoiding daytime
    napping.

132
Brief Behavioral Treatment Plan for Insomnia
  • Second Treatment Session (4 weeks after initial
    visit)
  • (1) Review of first treatment session
    instructions.
  • (2) Problem-solving of any potential treatment
    adherence problems.
  • (3) Possible modification of patient's sleep
    strategy and instructions to encourage future
    independent trouble-shooting.

133
Brief Behavioral Treatment Plan for Insomnia
  • Edinger and Sampson conducted a randomized trial
    of primary care patients with insomnia.
  • Their abbreviated behavioral therapy of two
    25-minute sessions was compared with a control
    group receiving 2 sessions of standard sleep
    hygiene instructions.
  • Those in the treatment group had greater
    improvements in their sleep efficiency and
    reductions in their time awake after sleep onset
    than the control group.
  • This treatment can be successfully done by
    nonmental health professionals, providers,
    working in primary care settings.

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136
Take Home Points
  • In practice parameters for nonpharmacologic
    treatments for chronic insomnia, the American
    Academy of Sleep Medicine recommends stimulus
    control as the approach with the best scientific
    evidence for effectiveness.
  • Progressive muscle relaxation, paradoxical
    intention, and biofeedback are 3 treatments that
    have the next best scientific evidence for
    effectiveness, while sleep restriction and
    multicomponent cognitive behavioral therapy are
    recommended as options.
  • Focusing on sleep hygiene and single component
    cognitive therapy may also be effective, but
    these approaches do not currently have sufficient
    scientific evidence to recommend them as
    evidence-based treatment. This is due to the
    insufficient number of clinical trials studying
    the effectiveness of these treatments alone,
    without their being part of any combined
    treatment regimen.

137
Take Home Points
  • In the immediate short term (i.e., first week),
    medications can produce improvement at a much
    greater rate than nonmedication treatments.
  • In the intermediate term (i.e., 3-8 weeks), a
    meta-analysis indicates that behavioral treatment
    for insomnia is just as effective as medication
    treatment.

138
Take Home Points
  • There is the possibility that this effectiveness
    of behavioral treatment is because it is more
    intensive than medication treatment in that there
    is a greater duration of contact with the
    healthcare professional.
  • Over the long term (i.e., 6-24 months), patients
    receiving nonpharmacologic therapies enjoy long
    lasting relief while many of those treated with
    medication return to their baseline insomnia
    levels.
  • In summary, behavioral therapy is best for
    chronic insomnia and helpful for all types.

139
Take Home Points
  • Insomnia is defined by having daytime symptoms.
  • There are two pathways for treating insomnia
    medications and CBTI. They can be used at the
    same time.
  • All treatments have their pluses and their
    minuses. Providers look at the patients
    impairment and weigh that against the risk of
    treatment.

140
Take Home Points
  • Patients with insomnia typically feel fatigued
    during the day, but are unable to fall asleep if
    given a chance to lie down to take a nap.
  • Patients with poor nocturnal sleep due to other
    sleep disorders readily fall asleep during the
    day.

141
Take Home Points
  • Many of the most common drugs for insomnia are
    not FDA approved for that purpose.
  • No drug for insomnia is completely safe or free
    of the risk of side effects.
  • Be sure that your patients informs you of all
    medications they are taking, including
    over-the-counter and herbal ones.

142
Take Home Points
  • Multidimensional Cognitive Behavioral Therapy
    works better than both placebo and
    pharmacotherapy (medicines) in short and long
    term cases
  • Interventions for sleep practices may need to be
    culture specific

143
Recommendations
  • Acknowledge that students sleep habits are
    significant concerns
  • Educational programs have been shown to be more
    effective the pharmacologic and CBTI long term
  • Examine course schedules, offer sections later in
    the day
  • Examine how campus and community environments
    contribute to sleep difficulties

144
Recommendations
  • Do activities, schedules, sports, work routines
    contribute to sleep difficulties
  • Review life style issues sleep, etc at all
    clinic visits
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