Insomnia and Sleep Impact on Chronic Disease for ...

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Insomnia and Sleep Impact on Chronic Disease

Angela Golden, DNP, FNP-C, FAANP

Objectives •  At the end of the presentation the participant

will be able to: – define insomnia – analyze current research demonstrating

sleeps impact on chronic disease – summarize current best evidence for

treatment of insomnia

Disclosures •  none

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Copyright notice •  © Angela K. Golden| Do not reproduce,

cite or use for any purposes without explicit permission from the author any part of this presentation in any form. Requests for permission to make copies or use any part of the presentation please contact at [email protected]

Statement of Liability The presentation information has been thoroughly researched and is evaluated for accuracy. Clinical practice is a constantly changing process and new information becomes available every day each provider is responsible to consult additional resources and apply information to their clinical practice as appropriate in addition to this presentation. NP from Home, LLC disclaims any liability, loss, injury or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this presentation.

Sleep Facts

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Source: https://sleepfoundation.org/sleep-polls-data/other-polls/2012-bedroom-poll

Interesting Facts about Sleep

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Weekdays Weekends

good sleep few nights

•  40% state they did not get enough sleep on workdays •  less women were getting sleep needs met •  gap widened for weekends for those with needs met by two hours

Interesting Facts about Sleep •  Sleep duration decreased by

1.5-2 hours 1960 – 2000 •  >30% of adults report <6 hrs/

night per night •  90% of Americans used some

type of electronics at least a few nights per week within 1 hr of bedtime

Epidemiology and Risk Factors •  30 % general population have sleep

disruption - 10 % sx daytime impairment •  Risks

•  Older age •  African Americans •  Increased stress •  Lower income •  Night shift or major time work shift

Source: https://www.nhlbi.nih.gov/health/health-topics/topics/inso/causes (2011)

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Sleep Scales •  Epworth Sleepiness Scale •  Athens Insomnia Scale •  Insomnia Severity Index •  Sleep Disordered Questionnaire •  Insomnia Symptom

Questionnaire •  Brief Insomnia Questionnaire •  Pittsburgh Sleep Quality

Questionnaire •  STOP/BANG

Chronic Disease and Sleep

Chronic Disease •  Inadequate or poor sleep

–  increase risk of chronic disease •  increased BP •  impaired blood glucose •  increased inflammation •  change in hormone levels

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Chronic Disease •  Poor sleep and Obesity

•  increase in coritsol •  increase in secretion of insulin •  lower levels of leptin •  higher levels of ghrelin

Chronic Disease •  Poor sleep and Diabetes

•  increased risks of Type 2 DM •  processing of glucose impaired

Chronic Disease •  Poor sleep and Heart

Disease •  increased risk of CHD in

women •  Sleep apnea increases HTN,

CVA, CHD and arrhythmias

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Chronic Disease •  Poor sleep and Heart Disease

•  sympathetic nervous system •  Normal sleep – plasma renin activity &

sympathovagal balance blood pressure, renin & aldosterone

•  Sleep disturbance •  = increase in renin, aldosterone, as well

as C-reactive protein, interleukin-6 •  Insomnia link to change in lifestyle

may add to HD affect

Chronic Disease •  Poor sleep and Mood Disorders

•  less happiness •  increased anger and exhaustion

INSOMNIA

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Clinical Diagnosis •  ICSD-3 (2014) Chronic Insomnia

–  AKA Chronic, primary, secondary, comorbid, behavioral insomnia of childhood, sleep-onset association disorder, limit-setting sleep disorder

1.  difficulty initiating, maintaining, or waking up too early

2.  despite adequate opportunity 3.  daytime impairment 4.  not better explained by another sleep

disorder 5.  Occurs at least 3 times a wk for 3 mos

Clinical Diagnosis •  ICSD-3 (2014) Short Term

Insomnia – AKA Acute, adjustment 1.  difficulty initiating, maintaining, or

waking up too early 2.  despite adequate opportunity 3.  daytime impairment 4.  not better explained by another

sleep disorder 5.  Occurs at less than three months

Clinical Diagnosis •  ICSD-3 (2014) Other Insomnia

–  AKA none –  difficulty initiating & maintaining sleep –  do not meet full criteria of chronic or short-term

•  DSM5 –  complaint of dissatisfaction with sleep quantity or quality –  sleep disturbance causes clinically significant distress or

impairment –  same timeline as chronic –  listed under sleep-wake disorders

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Coding Insomnia •  ICSD-3 (2014 update)

– Chronic insomnia – Acute insomnia – Other insomnia

•  DSM-5 –  Insomnia Disorder

•  ICD-10 –  Insomnia, unspecified G47.00 –  Insomnia due to medical

condition G47.01

Insomnia Pathophysiology •  increased physiological arousal

– elevated cortisol, adrenocorticotropic hormone and CRF levels

–  increased frequency EEG activity during NREM sleep

–  Increased SNS activity and HPA axis •  no structural brain pathology

Differential Diagnosis •  Other sleep disorders

– Sleep apnea – Circadian Rhythm Sleep Disorders – Movement Disorders – Parasomnias

•  Comorbid conditions – Medications – Medical conditions – TREAT both

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Evaluation

Evaluation •  Clinical history

•  Structured interview •  Review of PMH •  Review of medications •  Consider use of sleep

questionnaires •  http://www.stopbang.ca/osa/

screening.php •  VA site Insomnia Severity Index

https://www.myhealth.va.gov/mhv-portal-web/web/myhealthevet/healthy-sleep

Insomnia Evaluation •  Sleep log – paper or apps

–  Difficulty falling asleep –  Difficulty staying asleep –  Combination

•  Consideration of referral for Polysomnography or sleep specialist

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Treatment Options

Treatment Goals •  improve

•  sleep quality •  related daytime impairments

Insomnia Treatment •  Sleep Hygiene •  CBT-I •  Pharmacology

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Sleep Hygiene •  Creating a good sleep

setting •  Having a calming

bedtime routine •  Avoiding naps •  Minimizing nighttime

light

•  Exercising earlier •  Avoid caffeine late in

the day •  Limiting alcohol •  Eating light dinner •  Avoid nicotine in the

evening

CBTi •  modifies perpetuating factors to intervene

–  Sleep consolidation •  consolidated then incrementally increased

– Stimulus control •  associations between bed and sleep

– Sleep hygeine – Cognitive therapy

•  identifying and modifying maladaptive thoughts about sleep

– Relaxation training

CBT-I •  In person

•  Resources •  http://www.absm.org/

BSMSpecialists.aspx •  https://www.behavioralsleep.org/

index.php/united-states-sbsm-members

•  On line •  www.shuti.me (evidence based

program) •  http://www.cbtforinsomnia.com/

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Pharmaceutical Options

Pharmacology •  benzodiazepine receptor agonists •  nonbenzodiazepine receptor agonists •  selective melatonin receptor agonist •  orexin receptor antagonist •  others

Benzodiazepine receptor agonists •  intermediate-acting

forms •  temazepam •  estazolam

•  short-acting forms •  triazolam (Halcion)

PEARL:

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Nonbenzodiazepine Receptor Agonists •  eszopiclone

(Lunesta) •  zolpidem

(Ambien, Ambien CR, Intermezzo, Zolpimist, Edluar)

•  zaleplon (Sonata)

PEARLS:

Selective melatonin receptor agonist •  ramelteon (Rozerem)

PEARLS • 

Orexin receptor antagonist •  suvorexant (Belsomra)

PEARLS • 

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Others •  Sedating antidepressants

•  only doxepin has evidence – most insomnia endpoints improved – doses 1- 6mg (Roth, et al and Krystal, et al 2010)

•  Antihistamines •  most common OTC – significant

next day sedation

Others •  Melatonin

•  +/- evidence

•  Alternative and herbal medications •  Valerian root most studied with

conflicting results

Others •  Acupressure

•  Devices

•  Cerêve Sleep System •  reduce latency to stage 1 & 2

by cooling forehead

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Referrals

•  CBTI •  Concern for other sleep disorder •  CBTI and a trial of medication

ineffective •  History of long term chronic

insomnia •  Comorbid conditions – especially

substance abuse or psychiatric disorders

Case Study •  39 yom travel nurse •  social single parent – 17 yo and 14 yo •  PMH: hypothyroidism (stable 10 yrs) - synthroid

125mcg •  BMI of 27 •  Sleep hx: Difficulty getting to sleep; lays awake

sometimes for “hours”; often wakes & unable to get back to sleep easily

•  Tried numerous OTC & trazadone w/o success •  Sleep Hygeine for 2 months •  Trouble sleeping 4-5 nights out of 7 •  Denies snoring (states ex-wife nor children

complained of any snoring)

Case Study •  Decision tree for treatment

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NP from Home, LLC

Angela Golden POB 25959

Munds Park, AZ 886017 (m) 928-814-8011 (f)

888-877-4669 [email protected]

twitter: @DrAngieNP

References 1.  Insomnia Affects Empathy in Health Care Workers. Krishnamurthy, V., Bazan,

L, Roth, T., & Drake, C. (2015). SLEEP 2015. Abstract ID: 0689.http://journalsleep.org/Resources/Documents/2015AbstractSupplement.pdf . Last retrieved January 6, 2017.

2.  Hartescu, I., Morgan, K., & Stevinson, C. (2015). Increased physical activity improves sleep and mood outcomes in inactive people with insomnia: a randomized controlled trial. Journal of Sleep Research. Oct;24(5):526-34.

3.  Trauer, James M JM (08/2015). "Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis.". Annals of internal medicine (0003-4819), 163 (3), p. 191.

4.  http://healthysleep.med.harvard.edu/healthy/matters/consequences/sleep-and-disease-risk last retrieved January 6, 2017.

5.  https://www.ntnu.edu/hunt/hunt-surveys last retrieved January 6, 2017 insomnia and Heart Failure (also published http://www.nhs.uk/news/2013/03March/Pages/Dont-lose-sleep-over-heart-failure-risk-from-insomnia.aspx)

References 6.  http://www.acc.org/latest-in-cardiology/articles/2016/08/02/07/25/insomnia-and-

heart-disease?w_nav=LC Last retrieved January 7, 2017 7.  Sands-Lincoln, M., Loucks, E. B., Lu, B., Carskadon, M. A., Sharkey, K.,

Stefanick, M. L. Ockene, J., Shah, N., Hairston, K., Robinson, J., Limacher, M., Hale, L., & Eaton, C. B. (2013). Sleep Duration, Insomnia, and Coronary Heart Disease Among Postmenopausal Women in the Women’s Health Initiative. Journal of Women’s Health, 22(6), 477–486. http://doi.org/10.1089/jwh.2012.3918

8.  Laugsand, L. E., Strand, L.B., Platou, C., Vatten, L.J., and Janzsky, I. Insomnia and the risk of incident heart failure: a population study. European Heart Journal 6 March 2013 doi:10.1093/eurheartj/eht019

9.  Liu, Y., Wheaton, A. G., Chapman, D. P., & Croft, J. B. (2013). Sleep Duration and Chronic Diseases among US Adults Age 45 Years and Older: Evidence From the 2010 Behavioral Risk Factor Surveillance System. Sleep, 36(10), 1421–1427. http://doi.org/10.5665/sleep.3028

10. Nedeltcheva AV, Kilkus JM, Imperial J, Kasza K, Schoeller DA, Penev PD. Sleep curtailment is accompanied by increased intake of calories from snacks. Am J Clin Nutr. 2009;89:126–133.

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References 11.  Kumar B, Tilea A, Gillespie BW, Zhang X, Kiser M, Eisele G, Finkelstein F,

Kotanko P, Levin N, Rajagopalan S, Saran R. Significance of self-reported sleep quality (SQ) in chronic kidney disease (CKD): the Renal Research Institute (RRI)-CKD study. Clin Nephrol. 2010;73:104–114.

12.  Cappuccio FP, D'Elia L, Strazzullo P, Miller MA. Quantity and quality of sleep and incidence of type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2010;33:414–420.

13.  Soehner, Adriane M; Kaplan, Katherine A; Harvey, Allison G Prevalence and clinical correlates of co-occurring insomnia and hypersomnia symptoms in depression. Journal of Affective Disorders (J AFFECT DISORD), Oct2014; 167: 93-97.

14.  Insomnia severity Index at VA site https://www.myhealth.va.gov/mhv-portal-web/self-management?p_p_auth=N7pI3Tgq&p_p_id=101&p_p_lifecycle=0&p_p_state=maximized&p_p_mode=view&_101_struts_action=%2Fasset_publisher%2Fview_content&_101_returnToFullPageURL=%2Fmhv-portal-web%2Fweb%2Fmyhealthevet%2Fself-management&_101_assetEntryId=10782580&_101_type=content&_101_urlTitle=insomnia-severity-ind-4&_101_redirect=https%3A%2F%2Fwww.myhealth.va.gov%2Fmhv-portal-web%2Fself-management%3Fp_p_id%3D3%26p_p_lifecycle%3D0%26p_p_state%3Dmaximized%26p_p_mode%3Dview%26_3_groupId%3D0%26_3_keywords%3Dinsomnia%26_3_struts_action%3D%252Fsearch%252Fsearch%26_3_redirect%3D%252Fmhv-portal-web%252Fweb%252Fmyhealthevet%252Fself-management&inheritRedirect=true Last retrieved January 7, 2017

References 15. Sleep Logs

–  http://yoursleep.aasmnet.org/pdf/sleepdiary.pdf –  https://sleepfoundation.org/sites/default/files/SleepDiaryv6.pdf

16. Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia: an American Academy of Sleep Medicine review. Sleep 1999;22:134-56.

17. Mindell JA, Kuhn B, Lewin DS, et al. Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep 2006;29:1263-76.

18. Wu JQ, Appleman ER, Salazar RD, Ong JC. Cognitive behavioral therapy for insomnia comorbid with psychiatric and medical conditions: a meta-analysis. JAMA Intern Med 2015;175:1461-72.

19. Conley S, Redeker NS. Cognitive behavioral therapy for insomnia in the context of cardiovascular conditions. Curr Sleep Med Rep 2015;1:157-65.

20. Ritterband, L., Thorndike, F., Ingersoll, K., Lord, H., Gonder-Frederick, L., Frederick, C., Quigg, M., Cohn, W., Morin, C. (2016) Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up. JAMA Psychiatry; DOI: 10.1001/jamapsychiatry.2016.3249

References 21. Roth T, Heith Durrence H, Jochelson P, Peterson G, Ludington E, Rogowski R, et al.

Efficacy and safety of doxepin 6 mg in a model of transient insomnia. Sleep Med. 2010 Oct. 11(9):843-7.

22. Krystal AD, Durrence HH, Scharf M, Jochelson P, Rogowski R, Ludington E, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep. 2010 Nov. 33(11):1553-61.

23. Rondanelli M, Opizzi A, Monteferrario F, Antoniello N, Manni R, Klersy C. The effect of melatonin, magnesium, and zinc on primary insomnia in long-term care facility residents in Italy: a double-blind, placebo-controlled clinical trial. J Am Geriatr Soc. 2011 Jan. 59(1):82-90.

24. Fernández-San-Martín MI, Masa-Font R, Palacios-Soler L, Sancho-Gómez P, Calbó-Caldentey C, Flores-Mateo G. Effectiveness of Valerian on insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Med. 2010 Jun. 11(6):505-11.

25. Sun JL, Sung MS, Huang MY, Cheng GC, Lin CC. Effectiveness of acupressure for residents of long-term care facilities with insomnia: a randomized controlled trial. Int J Nurs Stud. 2010 Jul. 47(7):798-805.

26. Billioti de Gage, S., Ducret, T., Kurth, T., Verdoux, H., Tournier, M., Pariente, A., & Begaud, B. (2014). Benzodiazepine use and risk of Alzheminer’s disease: case-control study. British Medical Journal, 349. doi: 10.1136/bmj.g5205.

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LIMITED PRESCRIBING INFORMATION AS A REFERENCE

Benzodiazepine receptor agonists

•  temazepam •  BBW: Risk with concomitant opioid use •  Adult dosing: 7.5-30 mg q hs •  Contraindication/Caution: pulmonary impairment, seizure hx,

alcohol use or abuse, drug abuse hx, renal/hepatic impairment, elderly, hx of depression, CP450 3A medications

•  Adv rx: WD with abrupt dc, seizures, hypotension, complex sleep-related behavior, COMMON: fatigue, headache, confusion, anxiety, libido changes, appetite changes, constipation

•  Pregnancy Category X •  Schedule Category: IV •  Monitoring: LFTs and CBC if prolonged use

Limited information ONLY Source: epocrates, drugs.com, and product insert


•  estazolam •  BBW: Risk with concomitant opioid use •  Adult dosing: 1-2 mg qhs prn – start 0.5 mg in elderly •  Contraindication/Caution: pulmonary impairment, seizure hx,

alcohol use or abuse, drug abuse hx, renal/hepatic impairment, elderly, hx of depression, caution if smoking habit changes, CP450 3A medications

•  Adv rx: WD with abrupt dc, seizures, hypotension, complex sleep-related behavior, COMMON: fatigue, headache, confusion, anxiety, libido changes, appetite changes, constipation

•  Pregnancy Category: X •  Schedule Category: IV •  Monitoring: CBC if prolonged use


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•  triazolam •  BBW: Risk with concomitant opioid use •  Adult dosing: 0.25 mg q hs – start with 0.125mg (max 0.25mg in

elderly) – shorter acting •  Contraindication/Caution: pulmonary impairment, seizure hx,

alcohol use or abuse, drug abuse hx, renal/hepatic impairment, elderly, CP450 3A medications

•  Adv rx: hypotension, complex sleep-related behavior COMMON: drowsiness, HA, dizziness, nervousness, coordination disorders, GI (N/V)

•  Pregnancy Category X •  Schedule Category: IV •  Monitoring: CBC if prolonged use


Nonbenzodiazepine Receptor Agonists

•  eszopiclone •  BBW: none •  Adult dosing: 1-3 mg q hs •  Contraindication/Caution: impair daytime functioning, should

not exceed 2 mg in patients with severe hepatic impairment, depression, CYP3A4 medications concomitantly

•  Adv rx: thrombophlebitis, anorexia, anemia, WD with abrupt dc, complex sleep-related behavior, abnormal gait, COMMON: HA, dry mouth, dyspepsia, N/V, dizziness, nervousness, unpleasant taste, peripheral edema

•  Pregnancy Category: C •  Schedule Category: IV •  Monitoring: for prolonged use CBC



•  zolpidem •  BBW: none •  Adult dosing:

•  Women •  sleep onset – 5 mg po qhs (max 10mg). 6.25 - 12.5mg ER (must be at least 7 hours before planned

awakening) •  sleep maintenance – 6.25mg – 12.5mg ER (must be at least 7 hours before planned awakening) •  middle of night awakening 1.75mg SL x 1 per night prn (may repeat if more than 4 hours left before planned

awakening) reevaluate if more than 7-10 days

•  Men •  sleep onset – 5 – 10 mg po qhs. 12.5mg ER (must be at least 7 hours before planned awakening), can start

lower at 6.25mgER •  sleep maintenance – 6.25mg – 12.5mg ER (must be at least 7 hours before planned awakening) •  middle of night awakening 3.5mg SL x 1 per night prn (may repeat if more than 4 hours left before planned


•  Elderly •  sleep onset – 5 mg po qhs or 6.25 ER (must be at least 7 hours before planned awakening) •  sleep maintenance – 6.25mg ER (must be at least 7 hours before planned awakening) •  middle of night awakening 1.75mg SL x 1 per night prn (may repeat if more than 4 hours left before planned



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•  zolpidem

•  Contraindication/Caution: impair daytime functioning, pulmonary impairment, depression, CYP3A4 medications concomitantly

•  Adv rx: WD with abrupt dc, complex sleep-related behavior, hypotension, allergic rx, tachycardia, anxiety, anemia. COMMON: HA, drowsiness, dizziness, diarrhea, dry mouth, back pain, lethargy, pharyngitis, ataxia, confusion, euphoria, arthralgia

•  Pregnancy Category: C •  Schedule Category: IV



•  zaleplon •  BBW: none •  Adult dosing: 5-10 mg qhs max 20 mg (elderly max 10mg) •  Contraindication/Caution: impair daytime functioning,

pulmonary impairment, hepatic impairment, elderly, depression, CYP3A4 medications concomitantly

•  Adv rx: complex sleep-related behavior, allergic rx, aggressive behavior, suicidality, hallucinations COMMON: HA, dizziness, nausea, paresthesia, dysmenorrhea, tremor

•  Pregnancy Category: C •  Schedule Category: IV


Selective melatonin receptor agonist •  ramelteon • BBW: none • Adult dosing: 8mg PO qhs (avoid with high fat meal) • Contraindication/Caution: History of angioedema with previous ramelteon therapy (do not rechallenge); concurrent use with fluvoxamine, severe hepatic impairment, significant number of medication interactions • Adv rx: complex sleep-related behavior, prolactin levels increased, testosterone levels decreased COMMON: dizziness, somnolence, fatigue, insomnia worsened, depression, nausea, taste changes, myalgias, • Pregnancy Category: C • Schedule Category: rx


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Orexin receptor antagonist •  suvorexant • BBW: none • Adult dosing: 10 mg qhs (max 20mg) for sleep onset or maintenance; give > 7h before planned awakening – give w/o food for faster onset. • Contraindication/Caution: narcolepsy, CYP3A inhibitors, obesity (especially women), significant med-med interactions, drug abuse hx, severe hepatic impairment, pulmonary impairment • Adv rx: REM sleep effects, sleep-related activities, daytime fatigue, sleep paralysis, COMMON: drowsiness, HA, dizziness, abnormal thinking, diarrhea, cough • Pregnancy Category: C • Schedule Category: IV


Sedating antidepressant

•  doxepin • BBW: increased suicidality in children, adolescents and young adults with MDD • Adult dosing: 10-50mg qhs (reduce in elderly), taper gradually to d/c • Contraindication/Caution: acute-angle glaucoma, bipolar disorder, CYP450 interactions, • Adv rx: skin rash, esoinophilia, bone marrow depression, COMMON: dry mouth, blurred vision, constipation, urinary retention, hypotension, N/V, indigestion, taste distrubances, wt gain • Pregnancy Category: B • Schedule Category: RX • Monitoring: CBC with prolonged use


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