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Insomnia Adam Hajduk
Sleep disorders are common
Sleep disorders are serious
Sleep disorders are treatable
Sleep disorders are under diagnosed
Important facts
OBJECTIVE
Physiology
Definition and classification
Prevalence
Pathogenesis
Impact
Pharmacologic treatment
Cognitive-behavioral therapy
Sleep Stages
REM Sleep ~20% of night
NREM Sleep ~80% of night
Wake 2/3 of life
Sleep among older adults
Falling asleep takes longer
Dozens of awakenings during the night
Despite the above, over a 24-hour period older adults accumulate the same amount of total sleep as younger people
Older adults more likely to nap during the day
Older adults do need the same amount of sleep as they did when they were younger
What is Insomnia?
Classified as the inability to get enough sleep despite adequate time.
Initiating (sleep latency > 30 minutes)
Trouble maintaining sleep [eg. Insomnia in older people]
Chronically non-restorative sleep (Poor quality)
Early Morning Wake-Ups [eg. Depressia]
Causes many problems in daytime functioning
Sleep patterns in insomnia
Sleep onset insomnia Difficulty falling asleep (longer time to sleep onset)
Sleep maintenance insomnia Difficulty staying asleep (frequent nocturnal awakenings)
Early morning insomnia Waking too early in the morning (short period of sleep)
Nonrestorative sleep Fatigue despite adequate sleep duration
Multiple awakenings
Combination of above patterns
Insomnia is not defined by the number of hours
of sleep, but rather, by an individual‗s ability to
sleep long enough to feel healthy and alert during
the day.
The normal requirement for sleep ranges between 4 and 10 hours
Insomnia is a symptom, not a disorder by itself
What is Insomnia?
Epidemiology of insomnia
30-50% of American adults experience insomnia during a 1 year period
Prevalence of chronic/severe insomnia is 10%
49% of adults surveyed were dissatified with their sleep > 5 nights per month
50% of patients presenting to primary care physicians experience insomnia
NHLBI working group on Insomnia. Bethesda, Md: NHLBI; 1998. NIH Publication 98-4088
Smith MT, et al. Am J psychiatry. 2002; 159:5-11
Hajak G et al. Eur Psychiatry. 2003; 18:201-8
Ringdahl EN et al. J Am Board Fam Pract. 2004; 17:212-219
Classifications of Insomnia
Acute (Transient) vs. Short-term vs. Chronic This is based on how long the patient suffers from symptoms of insomnia
Primary vs. Secondary This is based on what is causing a patient to suffer from lack of sleep
Duration of insomnia
Transient insomnia: episodic Significant life stress; fear, anger Acute illness Jet lag
Short-term insomnia: few days to 3 weeks Major life event Substance abuse
Chronic insomnia: longer than 3 weeks Chronic or Psychiatric illness Primary and comorbid insomnia
Primary Insomnia
Also referred to as Idiopathic
This is diagnosed when a patient has no other cause of insomnia other than the fact they cannot sleep
Secondary Insomnia
This is also more commonly referred to as Comorbid Insomnia
When insomnia is being caused by some other outside factor, illness, or disorder including:
Psychiatric Disorders
Drug Abuse
Medical Problems
Other Sleep Disorders disruptive to sleep Restless Leg Syndrome
Sleep Apnea
Somnolence
Consequenses of insomnia
Daytime Fatigue, Daytime sleepiness
Lack of energy
Irritability, Negative mood
Difficulty concentrating
Impaired performance
Social or vocational dysfuncion
Nighttime Ongoing worry about sleep
Difficulty falling asleep
Difficulty maintaining sleep
Waking up too early
Not feeling refreshed upon waking
Consequenses of insomnia
Worsens psychiatric disorders More sadness, depression, and anxiety
Prolongs medical illnesses
Reduced quality of life
Increased accident risk
Cognitive impairment
Interpersonal difficulties With families, friends, and at work
Diagnosing Insomnia
The diagnosis of insomnia can often be difficult and is a prolonged process
Sleep logs
Watching symptoms for weeks at a time
It is often very underdiagnosed due to both patient and physician misunderstandings
Doctors don‘t routinely ask about it
Patients don‘t think it‘s important enough to bring up in a normal check up
Goes overlooked
Types of Sleep Studies
1. Polysomnogram (PSG) – most common study performed. This study records brain electrical activity, eye movements, heart rate, breathing, muscle activity, BP, and saturation levels.
2. Multiple sleep latency test (MSLT)- records whether you fall asleep during the test and what types/stages the patient is having.
3. Actigraphy- device that is placed on as a wristwatch, evaluates sleep habits.
Treatment of Insomnia
Insomnia is not a disorder that can necessarily be ―cured‖
Symptoms treated in order to relieve patient of distress
Treated by two different methods Non-Pharmacological Treatment
Pharmacological Treatment
Pharmacological Treatment
4 Classes of Prescription Agents Benzodiazepines
Benzodiazepine Receptor Agonists
Melatonin Receptor Agonists
Antidepressants/Antipsychotics
Some supplements are thought to help as well
Benzodiazepines
Extremely high potential for abuse with prolonged use as well as tolerance
Decreased reaction time
Unsteadiness of gait—can lead to falls
Cognitive impairment & memory problems
Risk of tolerance
Risk of withdrawal (and rebound insomnia)
Risk of abuse
Benzodiazepines 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
Benzodiazepines Adverse Effects
Daytime drowsiness
Somnolence
Dizziness
GI upset
Hallucinations
Agitation Headache Nausea/diarrhea Fatigue Ataxia
Extremely high potential for abuse with prolonged use
Risk of tolerance
Risk of withdrawal (and rebound insomnia)
Decreased reaction time
Cognitive impairment memory problems
Non Benzodiazepines
How do they help? Decrease number of awakening, improve sleep duration and quality
Medication examples: Zaleplon (Sonata)
Zolpidem (Ambien)
Ezopiclone (Lunesta)
Non Benzodiazepines 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
Adverse Effects (non benzo)
Headache
Dizziness
Nausea/Abdominal pain
Somnolence
Unpleasant dreams
Habit forming with long term use
Benzodiazepines prescribing guidelines
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?
Melatonin Agonist
How do they help? Decrease sleep onset
FDA approved for sleep onset insomnia
No limitation on duration of use
Non-sedating
Medication: Ramelteon (Rozerem) Single dose: 8 mg
Take about 30 minutes prior to bedtime
Antidepressants
How do they help? Sedating due to anticholinergic and antihistaminergic activity
Reduce time to sleep onset
Decrease number of awakening
Improve sleep duration and quality
Improve stage 4 NREM (Deep sleep)
Decrease REM phase
Antidepressants
Some physicians prefer this mode of treatment over benzodiazepines because of the far less potential for dependency
Can produce anticholinergic effects if used too long: Constipation Weight Gain Dry mouth Urinary retention
Antidepressant Medications
Amitriptyline (Elavil)
Trazodone (Trittico)
Doxepin(Adapin)
Opipramol (Pramolan)
Mianserin (Lerivon)
Mirtazapin (Mirtazen)
Antihistamines
Antihistamines increase sedation.
Medications: Diphenhydramine (Benadryl) Hydroxizine
Adverse Effects: Fatigue Dizziness Dry mouth Urinary retention
Non-Prescription Supplements Valerian
This is an herb that is thought to interact at the GABAA receptor because of it‘s sedative properties similar to other drugs that act at that receptor
Can cause some nausea, upset stomach, dizziness, and long-lasting fatigue
Is included on the FDA‘s Generally Recognized as Safe List
Most commonly used drugs for insomnia
1. Trazodone
2. Zolpidem
3. Amitriptyline
4. Mirtazapine
5. Temazepam
6. Quetiapine
7. Zaleplon
8. Clonazepam
9. Hydroxyzine
10. Alprazolam
11. Lorazepam
12. Olanzapine
13. Flurazepam
14. Doxepin
15. Estazolam
16. Diphenhydramine
Walsh et al, 2005