insomnia

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insomnia

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

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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

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ROADMAP

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

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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

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Question 1

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

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Philagrypnia

• Ability to stay alert with very little sleep

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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

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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

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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

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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

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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

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

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

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QUESTION 4

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

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• 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

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• 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

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Question Not to be answered on keypadsWhat do
you call a nun who sleep walks?
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A Roamin Catholic
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QUESTION 5

• The consequences of Insomnia are all psychologic
  and financial.
• A. True
• B. False

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Consequences

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

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Physiologic Results

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

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Medical Consequences

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

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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

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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

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QUESTION 6

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

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Evaluation

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

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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

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Sleep Diary

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

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Causes of Insomnia

• Stress/Situational
• Fear
• Anger
• Depression
• Medical

• Behavioral factors
• Life-style
• Personality
• Medicine

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Medical Causes of Insomnia

• Pain
• GERD
• BPH
• OSA
• RLS
• Depression
• Anxiety

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Medications Causing Insomnia

• Clonidine Bronchodilators
• Beta Blockers Steroids
• Theophyline
• Certain Antidepressants
• Protriptyline, Fluoxetine
• Decongestants
• Stimulants
• Alcohol

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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.

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Causes of Insomnia

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

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QUESTION 7

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

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Physical Exam

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

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QUESTION 8

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

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?Laboratory?

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

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Question 9

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

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Treatment Options

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

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

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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

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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

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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

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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

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AASM Practice Parameters

• Psychologic and behavioral interventions are
  effective and recommended
• Sleep 2006 291415

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Pharmacologic Therapy

• Non-prescription
• Prescription

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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

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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

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Diphenhydramine hydrochloride

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

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Prescription Drugs

• Benzodiazepines
• Benzodiazepine receptor agonists
• Melatonin receptor agonists

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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

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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

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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

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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

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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

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Zaleplon (Sonata)

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

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Concommitant Depression

• Antidepressants with sedative properties
• Trazodone (Desyrel)
• Amitriptyline (Elavil)

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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

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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

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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

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When to Refer ?

• Resistant to Treatment
• Complex Co-morbidities
• Sleeping while Driving

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CODING

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

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ONE LAST, VERY EFFECTIVE TREATMENT OPTION
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ONE LAST, VERY EFFECTIVE TREATMENT OPTION

• Listen to this lecture

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Summary

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

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• EXTRAS

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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)

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• 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.

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Acupuncture

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

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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

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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.

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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.

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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