INSOMNIA

Liphard O. D’Souza, M.D.Diplomate: American Academy of Sleep

Medicine6128 E. 38th St., Ste. 303

Tulsa, OK 74135(918) 523-8572

InsomniaA broad term denoting unsatisfactory sleepPerception that sleep is inadequate or abnormalCommon problemA symptom, not a disease or sign, therefore difficult to measure

DiagnosisComplaint that the sleep is:

Brief or inadequateLight or easily disruptedNon-refreshing or non-restorative

International Congress of Sleep Disorders Classification

Based on the duration of symptomsTransient or acute

Few days to 2-4 weeks

ChronicPersisting for more than 1-3 months

DefinitionsMild

Almost nightly complaint of non-restorative sleep Associated with little or no impairment of social or occupational functioning

ModerateNightly complaints of disturbed sleepMild to moderate impairment of social or occupational function

SevereNightly complaints of disturbed sleepSevere daytime dysfunction

ClassificationSleep initiating insomniaSleep maintaining insomniaEarly morning insomnia

Short period of sleep

Non-restorative sleepMultiple awakeningsCombination of above patterns

Presentation GoalsReview of normal sleep cycleCauses of insomniaDiagnosis and assessment of insomniaTreatment modalities

Stages of SleepNon-Rapid Eye Movement (NREM) sleep

Stage I Stage II

Stages I & II are light sleep

Stage IIIStage IV

Stages III & IV are deep sleep

Rapid Eye Movement (REM) sleep

Normal Sleep Pattern

Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.)Why do we sleep?

Not clear, but has to do with regeneration (NREM) and brain development/memory (REM) – REM sleep is essential for the development of the mammalian brainStages III & IV are involved in synaptic “pruning and tuning”

Why do we get sleepy?Circadian factorsProcess S: linear increase in sleepinessProcess C: rhythmic fluctuations of the circadian alert systemOther factors: sleep duration, quality, time awake, etc.

CausesInsomnia is a downstream symptom of an upstream problem, for example:

MedicalPsychological/ PsychiatricBehavioralParasomniasDrug-inducedCombination of factors in chronic insomnia

Normal Sleep ValuesNormal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle4-6 NREM/REM cycles per nightSleep structure changes throughout lifeWakefulness after sleep

Less than 30 minutes

Sleep Onset Latency (SOL) Less than 30 minutes

REM Sleep Latency70-120 minutes

EpidemiologyStudies throughout the world show that it occurs everywhereDepending on the area, study, etc., between 10-50% of the population are affectedIncreases with ageTwice as common in females

Up to the age of 30, there is little difference between sexesBeyond 30 years, it is more common in femalesBeyond 70 years, females are affected twice as much as males

EtiologySymptom of numerous diverse etiologiesUsually due to more than one factor and each needs a separate evaluationIn all cases, one should strive to find the cause as it will dictate the proper treatment

3 P’s of Acute InsomniaPredisposition

Anxiety, depression, etc.

PrecipitationSudden change in life

PerpetuationPoor sleep hygiene

Precipitating causes lower the threshold for acute insomnia in people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomniaStart aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia

Acute InsomniaResolves with the management of inciting factorsAdjustment sleep disorder

Acute stress such as momentous life events or unfamiliar sleep environmentsPSG: increased SOL, increased awakenings and sleep fragmentation with poor sleep efficiencyMore common in women and those with anxiety

Jet LagSymptoms last longer with eastbound travelRemits spontaneously in 2-3 daysMore common in the elderly

Chronic InsomniaPrimary or Intrinsic Secondary or ExtrinsicCauses

Changes in circadian rhythm, behavior, environmentBody movements in sleepMedical, neurological, psychiatric disordersDrugs

Primary/Intrinsic InsomniaIdiopathic

Starts early in childhood, rare but relentless courseRare disorders affect both gendersCNS abnormalities, unknown etiology, etc.

Sleep State Misinterpretation (5%)Underestimate of the sleep obtainedFemales affected more than males

Psychophysiological insomnia (30%)Maladaptive sleep-preventing behaviors develop and progress to become dominant factorsFemales more than males

Secondary/Extrinsic Insomnia

1. Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness

Advanced sleep phase syndromeDelayed sleep phase syndromeIrregular sleep/wake patternsNon-24 hour sleep/wake syndromeShift work sleep disorderShort sleeper

2. Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep

Inadequate sleepLimit setting sleep disorderNocturnal eating/drinking syndromeSleep onset association disorder

3. Environmental factorsEnvironmental sleep disorderFood allergy insomniaToxin-induced sleep disorder

4. Movement disordersPLMS disorder (5%)RLS syndrome (12%)REM behavior disorder

5. Medical Disorders: RespiratoryAltitude insomniaCentral alveolar hypoventilation syndromeCentral apnea syndromeCOPDOSAS (4-6%)Sleep-related asthma

6. Medical: CardiacNocturnal myocardial ischemia

7. Medical: GIPeptic ulcer diseaseGERD

8. Medical: MusculoskeletalFibromyalgiaArthritis

9. Medical: EndocrineHyperthyroidismCushing’s diseaseMenstrual cycle associationPregnancy

10.Medical: NeurologicalCerebral degeneration disorderDementiaFatal familial insomniaParkinson’s diseaseSleep related epilepsySleep related headaches

11.Medical: PsychiatricAlcoholismAnxiety disordersMood disordersPanic disordersPsychosisDrug dependency

12.Pharmacological causesAlcohol dependent sleep disorderHypnotic dependent sleep disorderStimulus dependent sleep disorderMedications

B-blockersTheophyllineL-dopa

Parasomnia EventsPhysical phenomena occurring in sleep

Confusional arousalsNightmaresNocturnal leg crampsNocturnal paroxysmal dystoniaREM sleep behavior disorder

Rhythmic movement disorderPainful erectionsSleep startsSleep terrorsSleep walkingAbnormal swallowingHyperhidrosisLaryngospasms

Physical, Emotional, and Cognitive Effects of

InsomniaMood changes, irritability, poor concentration, memory defects, etc.Impairs creative thinking, verbal processing, problem solvingRisk of errors, accidents due to excessive daytime sleepiness

Markedly increases if awake more than 16-18 hours (micro-sleep attacks)

Increased appetite, decreased body temperaturePhysiologic effects

Rats die after 11-12 days of sleep deprivationHippocampal atrophy in chronic jet lag or shift work

EvaluationHISTORY!

Precipitating factorsPsychiatric and medical disturbancesMedicationsSleep hygieneCircadian tendenciesCognitive distortions and conditional arousals

Sleep diary

EvaluationPSG

if PLMS or sleep-related breathing disorder or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASMNot routinely employed in the evaluation of transient or chronic insomniaShould not be substituted for a careful clinical history

Epworth Sleepiness Scale A good measure of excessive daytime sleepiness. How likely are you to

doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation:

0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance

Sitting and reading ____ Watching TV ____ Sitting inactive in a public place (ex. theater, meeting) ____ As a passenger in a car for an hour without a break ____ Lying down to rest in the afternoon ____ Sitting and talking to someone ____ In a car, while stopped for a few minutes in traffic ____ ____ Total Score Normal < 10 Severe > 15

Insomnia questionnaire

I have real difficulty falling asleep. Thoughts race through my mind and this prevents me

from sleeping. I wake during the night and can’t go back to sleep. I wake up earlier in the morning than I would like to. I’ll lie awake for half an hour or more before I fall asleep. I anticipate a problem with sleep almost every night

If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep.

Treatment Selection1. Meet and educate about disease, goals,

options, side effects, and document safety.

2. Identify the 3 P’s.3. Intrinsic v. Extrinsic4. Treat perpetuating causes

Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT

CBTLongest lasting improvements, assuming the precipitating cause is dealt with“counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbancesIdentifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones

CBT Examples“I need more hours of sleep or I will not function”“I can never die”Uses restructuring techniquesShort circuit cycle of insomnia, cognitive distortions, distressSleep hygiene, relaxation, stimulus control, sleep restrictions

Sleep HygieneExercise earlier during the day, and no more than 4-6 hours before sleepKeep bedroom dark and quiet, to be used only for sex or sleepCurtail time in bed to only when sleepyFixed sleep/wake times for 365 daysAvoid napsAvoid stimulus or stimulating activities before sleep or in bedNo alcohol at least 4 hours before sleep, no caffeine after noon, and quit smoking!!Light snack before bedtime

Stimulus ControlUse bedroom for sleep or sex onlyGo to bed only when tired and sleepyRemove clock from the bedroom to avoid constantly watching itRegular sleep/wake timesLight therapy if requiredNo bright lights when you wake up at night

Sleep RestrictionAn effective form of treatmentEstimate the time actually asleep then limit bedtime to that amount, but no less than 5 hoursAdd time in bed gradually once the patient sleeps more than 85% of that time

PharmacotherapyNationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics

TrazadoneSeroquel

Self-medication with alcohol and over-the-counter medications

BenadrylNyquil

Hypnotics5 questions to ask when choosing a hypnotic:

1. Are you looking for sleep initiation or maintenance?

2. What are the daytime residual effects of the drug?

3. Does tolerance develop to this drug?4. Will rebound withdrawal insomnia occur

when discontinued?5. What is the half-life of the medication?

Benzodiazepines  Dose Half-life Comments

Flurazepam(Dalmane) 15,30 mg Long Daytime drowsiness common; rarely used

Clonazepam(Klonopin) 0.5-2 mg Long Used for PLM, REM behavior disorder; can cause morning drowsinessTemazepam (Restoril) 15,30 mg Intermediate  

Estazolam (ProSom) 1-2 mg Intermediate Can cause agranulocytosis

Triazolam (Halcion) 0.125,0.25 mg Short Rebound insomnia may occur

Zolpidem (Ambien) 5,10 mg Short A nonbenzodiazepam

Zopliclone (Sonata) 5,10 mg Short , 1-1.5 hours  

 

 

 

A nonbenzodiazepam

Recent Medication Additions

Eszopiclone 1,2,3 mgIntermediate Approved for chronic insomnia

(Lunesta) Action 6-8 hrs.Zolpidem 10 mg Action same as above

(Amvien CR)Rozerem(Ramelton)

Alternative MedicationsAntidepressants

Not much researchSome, including SSRIs, can cause daytime drowsiness

MelatoninGood for jet leg, especially in elderly, but not much information on long-term useReported to cause depression, vasoconstriction

BenadrylRarely indicated, can cause a hangover

Herbal supplementsUse in conjunction with a sleep log

ConclusionInsomnia is a complex symptom with many causes and perpetuating influencesIt is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treatedIt should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder

Depression in turn confers an increased risk of suicide, cardiovascular disease, death, etc.