Post on 21-Dec-2015
Sleep Problems and Sleep Problems and Alcohol Use DisordersAlcohol Use Disorders
Fauzia Mahr, MDFauzia Mahr, MD
Penn State Milton S. Hershey Penn State Milton S. Hershey Medical CenterMedical Center
1© AMSP 2011
Scope of ProblemScope of Problem
2© AMSP 2011
Scope of ProblemScope of Problem
Insomnia cost > US $100 billion/yr.Insomnia cost > US $100 billion/yr.
Alcohol related insomnia = $18.5 billion/yr.Alcohol related insomnia = $18.5 billion/yr.
7% US 7% US alcohol abuse alcohol abuse
10% 10% alcohol dependence. alcohol dependence.
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Insomnia & FunctionalityInsomnia & Functionality
2.5 X 2.5 X motor vehicle accidents motor vehicle accidents
quality of lifequality of life
productivity/job satisfactionproductivity/job satisfaction4© AMSP 2011
Other ConsequencesOther Consequences
depression / anxietydepression / anxiety
immunityimmunity
B.P. / cardiovascular dx.B.P. / cardiovascular dx.
mortalitymortality
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Sleep and SubstancesSleep and Substances
Alcohol, cocaine, caffeine Alcohol, cocaine, caffeine poor sleep poor sleep
Poor sleep Poor sleep risk substance use risk substance use
disorders (SUD’s)disorders (SUD’s)
Alcohol + sleep Alcohol + sleep most studied most studied
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This Lecture ReviewsThis Lecture Reviews
Definitions : SleepDefinitions : Sleep
Definitions: SubstancesDefinitions: Substances
Effects of alcohol on sleepEffects of alcohol on sleep
TreatmentTreatment7© AMSP 2011
Normal SleepNormal Sleep
Reversible unresponsiveness to Reversible unresponsiveness to environmentenvironment
Two StagesTwo Stages
Rapid Eye Movement Sleep [ REM ]Rapid Eye Movement Sleep [ REM ]
Non-Rapid Eye Movement Sleep [NREM]Non-Rapid Eye Movement Sleep [NREM]
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Normal Sleep CycleNormal Sleep Cycle
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A PICTURE OF NORMAL SLEEP8-Hr EEG Recording in a Healthy Person
Hours in Bed
0 1 2 3 4 5 6 7 8
Slow-Wave Sleep (N3)
Stage 2 Sleep (N2)
Stage 1 Sleep (N1)
REM Sleep ( R )
Wake
NREM SleepNREM Sleep
First ½ of nightFirst ½ of night Serotonin / nor epinephrineSerotonin / nor epinephrine
Stage 1 and 2 = low arousal thresholdStage 1 and 2 = low arousal threshold
Stage 3 and 4 = slow wave sleep =deepStage 3 and 4 = slow wave sleep =deep
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NREM StagesNREM Stages
Stage 1 Stage 1 1-7 minutes1-7 minutes
Stage 2 Stage 2 25 minutes25 minutes
Stage 3 & 4 Stage 3 & 4 Time variesTime varies
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REM SleepREM Sleep
22ndnd ½ night ½ night
REM REM dreaming, limb paralysis dreaming, limb paralysis
AcetylcholineAcetylcholine
Dopamine/ norepinephrine / epinephrineDopamine/ norepinephrine / epinephrine
With ageWith age
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Sleep DefinitionsSleep Definitions
Sleep Latency Sleep Latency time to go to sleeptime to go to sleep
15-20 minutes15-20 minutes
REM Latency REM Latency sleep to first REM sleep to first REM
episodeepisode
90-120 minutes90-120 minutes
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InsomniaInsomnia
Problem initiating sleepProblem initiating sleep
Problem maintain sleepProblem maintain sleep
Non-restful sleepNon-restful sleep
Early morning awakeningEarly morning awakening
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DSM IV Primary InsomniaDSM IV Primary Insomnia
Difficulty starting / maintaining sleep Difficulty starting / maintaining sleep X 1 monthX 1 month
Disturbance Disturbance functionfunction
Disturbance Disturbance due to other condition due to other condition15© AMSP 2011
This Lecture ReviewsThis Lecture Reviews
Definitions : Sleep Definitions : Sleep ✓✓
Definitions: SubstancesDefinitions: Substances
Effects of alcohol on sleepEffects of alcohol on sleep
TreatmentTreatment16© AMSP 2011
DepressantsDepressants
Depression of brain tissuesDepression of brain tissues
Alcohol, benzodiazepines, barbituratesAlcohol, benzodiazepines, barbiturates
Sleep with intoxicationSleep with intoxication
Sleep with withdrawalSleep with withdrawal
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StimulantsStimulants
Stimulation of brain tissuesStimulation of brain tissues
Cocaine, amphetamine, caffeineCocaine, amphetamine, caffeine
Sleep with intoxicationSleep with intoxication
Sleep with withdrawalSleep with withdrawal
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AlcoholAlcohol
CNS CNS depressant depressant
Acute + chronic use disrupts sleepAcute + chronic use disrupts sleep
50% alcoholics use for sleep50% alcoholics use for sleep
Alc. as self medication 2X in alcoholicsAlc. as self medication 2X in alcoholics
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Alcohol Use DisordersAlcohol Use Disorders
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Alcohol abuse
1 + in same 12 mos.:
- Role obligations
-Hazardous use
-Legal problems
-Interpersonal problems
- Dependence
Alcohol dependence
3+ in same 12 mos:
-Tolerance
-Withdrawal
- Amts. - Time
-Desire/inability to
- Other activities
- Consequences
Alcohol withdrawal
2+:
- Sweating, pulse
-Tremor
-Nausea/vomitting
-Insomnia
-Anxiety/agitation
-Seizures
This Lecture ReviewsThis Lecture Reviews
Definitions : Sleep Definitions : Sleep ✓✓
Definitions: Substances Definitions: Substances ✓✓
Effects of alcohol on sleepEffects of alcohol on sleep
TreatmentTreatment21© AMSP 2011
Alcohol Related InsomniaAlcohol Related Insomnia
Insomnia in alcoholics 2X gen pop.Insomnia in alcoholics 2X gen pop.
Prevalence with :Prevalence with :
AgeAge
Severity alcoholismSeverity alcoholism
7+ yrs. heavy drinking7+ yrs. heavy drinking
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Acute Use and SleepAcute Use and Sleep
11stst ½ Night ½ Night::
Sleep latencySleep latency
REMREM
Other stagesOther stages
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Acute Use and SleepAcute Use and Sleep
22ndnd ½ Night: ½ Night:
Sleep quantitySleep quantity
AwakeningsAwakenings
REMREM24© AMSP 2011
How Alcohol Disrupts SleepHow Alcohol Disrupts Sleep
Complex mechanism Complex mechanism involves HPA axisinvolves HPA axis
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How Alcohol Disrupts SleepHow Alcohol Disrupts Sleep
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Alcohol and Sleep ApneaAlcohol and Sleep Apnea
Acute alcohol Acute alcohol inspiratory resistance inspiratory resistance
Contributes to sleep apneaContributes to sleep apnea
2 X sleep latency2 X sleep latency
20% ↓ sleep time20% ↓ sleep time
2 X 2 X ↑↑ premature death premature death
27© AMSP 2011
This Lecture ReviewsThis Lecture Reviews
Definitions : Sleep Definitions : Sleep ✓✓
Definitions: Substances Definitions: Substances ✓✓
Effects of alcohol on sleep Effects of alcohol on sleep ✓✓
TreatmentTreatment28© AMSP 2011
Treatment GuidelinesTreatment Guidelines
AssessmentAssessment
EducationEducation
Sleep Assessment instrumentsSleep Assessment instruments
Behavior therapiesBehavior therapies
MedicationMedication29© AMSP 2011
Assessment &TreatmentAssessment &Treatment
Identify Alcohol useIdentify Alcohol use Detailed historyDetailed history Assessment instrumentsAssessment instruments
10 Item Alcohol Use disorder 10 Item Alcohol Use disorder
Identification Test [ AUDIT ]Identification Test [ AUDIT ]
4 Item CAGE questionnaire4 Item CAGE questionnaire
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Detoxification & Rehabilitation Detoxification & Rehabilitation
Physical exam & labsPhysical exam & labs
ReassuranceReassurance
Benzodiazepines [BZDs]Benzodiazepines [BZDs]
MotivateMotivate
TherapyTherapy
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EducationEducation
Sleep disruption due to Alcohol useSleep disruption due to Alcohol use
May persist up to 6 monthsMay persist up to 6 months
Sleeping pills may worsen problemSleeping pills may worsen problem
Body must adjust to Body must adjust to Alcohol Alcohol
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Pittsburg Rating ScalePittsburg Rating Scale
Sleep self reportSleep self report
Sleep quality & disturbanceSleep quality & disturbance
Sleep prob. 1 mo. +Sleep prob. 1 mo. +
19 items / 7 Components19 items / 7 Components
Scores 0-21Scores 0-21
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Sleep DiarySleep Diary
Self assessment toolSelf assessment tool
No scoringNo scoring
Daily x 2 weeksDaily x 2 weeks
Continuity of sleepContinuity of sleep
Weekly averages comparedWeekly averages compared
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Continuity Of SleepContinuity Of Sleep
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Time to bed
Time to wake
Minutes to fall asleep
# & duration of wakings
Final awakening
Minutes awake in bed
Sleep HygieneSleep Hygiene
Good sleeping habitsGood sleeping habits Same bedtime / wake timeSame bedtime / wake time Use bed for sleepUse bed for sleep After 6 PM :After 6 PM :
alcohol ,nicotine , caffeine & large alcohol ,nicotine , caffeine & large mealsmeals
Strenuous exercise Strenuous exercise
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Cognitive Behavioral TherapyCognitive Behavioral Therapy
Avoids medicationAvoids medication Time limitedTime limited Targets cognitive distortionsTargets cognitive distortions
HopelessnessHopelessness Catastrophic thinkingCatastrophic thinking Loss of controlLoss of control
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Relaxation TrainingRelaxation Training
ArousalArousal
Collaborate to choose methodCollaborate to choose method
Progressive muscle relaxationProgressive muscle relaxation
Diaphragmatic breathingDiaphragmatic breathing
BiofeedbackBiofeedback
MeditationMeditation38© AMSP 2011
MelatoninMelatonin
MelatoninMelatonin Restores circadian rhythmRestores circadian rhythm Secreted by pineal glandSecreted by pineal gland Regulated by light stimulusRegulated by light stimulus in alcoholismin alcoholism
Dose = 6 mg nightlyDose = 6 mg nightly
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BenzodiazepinesBenzodiazepines
Avoid if possibleAvoid if possible
Discourage daily useDiscourage daily use
GABA GABA
SedatingSedating
Similar effect as AlcoholSimilar effect as Alcohol
Abuse / Dependence potentialAbuse / Dependence potential40© AMSP 2011
Less Addictive MedicationLess Addictive Medication
Eszopiclone (Lunesta) 10 mg
Zolpidem ( Ambien) 10 mg
Zaleplon ( Sonata ) 10 mg
41© AMSP 2011
This Lecture ReviewsThis Lecture Reviews
Definitions : Sleep Definitions : Sleep ✓✓
Definitions: Substances Definitions: Substances ✓✓
Effects of alcohol on sleep Effects of alcohol on sleep ✓✓
Treatment Treatment ✓✓42© AMSP 2011