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