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Insomnia

Insomnia. Kevin A. Carter DO, FAASM Medical Director, Sleep Center at Kettering Medical Center. Pretest Question # 1. What is the Prevalence of Chronic Insomnia? 2% 10% 25% 35% 45%. Pretest Question # 2. What is the most effective stand-alone treatment for Chronic Insomnia?

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Insomnia

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  1. Insomnia Kevin A. Carter DO, FAASM Medical Director, Sleep Center at Kettering Medical Center

  2. Pretest Question # 1 • What is the Prevalence of Chronic Insomnia? • 2% • 10% • 25% • 35% • 45%

  3. Pretest Question # 2 • What is the most effective stand-alone treatment for Chronic Insomnia? • Sleep hygiene • Stimulus control • Sleep restriction • Relaxation training • Cognitive therapy

  4. Disclosures • None

  5. Objectives • Normal sleep • Definition/Diagnosis • Physiological consequences • Clinical features/risk factors • Treatment options

  6. Sleep Cycle

  7. Sleep Architecture

  8. Wake System

  9. Sleep System

  10. Sleep Physiology • Circadian Rhythms • > 24 hour (24.2 hours) • Entraining Agents • Light • #1 entraining agent • Stimulates wakefulness • ↓ Melatonin • Melatonin • Promotes sleep • ↑ prior to sleep • Others: • Activities, meals, social cues, and ambient temperature.

  11. Sleep Physiology

  12. Sleep Across the Lifespan • Ohayon M, Carskadon MA, Guilleminault C, et al: Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan. Sleep 2004;27:1255–1273

  13. What is Insomnia? • A complaint of: • Difficulty falling asleep • Difficulty staying asleep • Poor quality sleep • Associated with: • Distress • Impaired function

  14. Insomnia: Daytime Complaints • Fatigue, sluggishness • Sleepiness • Somatic complaints (aches & pains) • Stress about poor sleep • Mood disturbances • Poor concentration • Impaired performance

  15. Classification System for Insomnia • Chronic Insomnia (Prevalence = 10%) • 3 days/week • > 3 months • Short-Term Insomnia (Prevalence = 15-20%) • < 3 months • Other Insomnia Disorder • Nonspecific • Use sparingly

  16. Pathophysiology • Increased physiological arousal • Metabolic rate • Sympathetic activation • Hypothalamic-pituitary-adrenal axis • Increased alertness • Conditioned state of hyperarousal • Decreased sleep efficiency • Normal MSLT (Multiple sleep latency test)

  17. Higher Metabolic Rate • 340 • Insomniacs • Normals • 320 • 300 • 280 • V02 (ml/Min) • 260 • 240 • 220 • 200 • 5 • 10 • 15 • 25 • 30 • 35 • 20 • TIME (Hour)

  18. Activation of the Stress System in Chronic Insomnia • Plasma Cortisol, 2100-0030 h • Plasma ACTH, 2100-0030 h • 3.5 • * • 180 • 3 • * • 160 • 2.5 • 140 • 2 • 120 • 100 • 1.5 • 80 • 1 • 60 • 40 • 0.5 • 20 • 0 • 0 • 13 Healthy Controls • 11 Insomnia Patients • 13 Healthy Controls • 11 Insomnia Patients • * p = 0.004 • * p = 0.003

  19. Insomniacs Under-report Sleep Problems to Physicians • Percent of insomniacs who discussed any sleep problems with their physicians • Discussed sleep during visit for other purpose (26%) • Never discussed (69%) • Visited specifically to discuss sleep problem (5%)

  20. Major Risk Factors • Previous history of insomnia • Increasing age • Female gender • Psychiatric symptoms and disorders • Medical symptoms and disorders

  21. Risk Factors: Age and Gender • 60 • 60 • % of baseline • % (n = 1667) • Remission • Prevalence • Women • 50 • 50 • Men • 40 • 40 • 30 • 30 • 20 • 20 • 10 • 10 • 0 • 0 • Age • 18-44 • Age • 45-64 • > 64 • 18-44 • 45-64 • > 64

  22. Risk Factor: Women • Menstrual Phase and Menopausal Status • Menstrual phase worsens sleep in 31% of menstruating women • Self-reported insomnia increases with menopause • Self-reported Insomnia • n = 175 • 70 • 60 • 50 • 40 • Percent • 30 • 20 • 10 • 0 • Pre • Peri • Post • Menopausal stage

  23. Risk Factors: Psychiatric Symptoms and Disorders • 40 • 35 • 30 • 25 • Percent with moderate/severe insomnia • 20 • 15 • 10 • 5 • 0 • Physical & • psychiatric • No health • problem • Physical • problem only • Psychiatric • problem only

  24. Risk Factors for Insomnia: Medical Symptoms & Disorders • Poor Health Perception • Physical Limitation • Severe Pain • Rheumatic Disorders • Respiratory Disease • Migraine • Digestive Disease • Diabetes • Circulatory • Allergy • 0 • 1 • 2 • 3 • Odds Ratio

  25. Primary Insomnia

  26. Clinical Presentation • Predisposing, Precipitating and Perpetuating Factors

  27. Insomnia is a Risk Factor for Psychiatric Disorders • Incidence over 3.5 years • 18 * • 16 * • 14 • Insomnia n=240 • 12 • No Insomnia n=739 • 10 • Odds Ratio • * 95% C.I. for Odds Ratio • excludes 1.0 • 8 • 6 * • 4 • 2 • 0 • Depression • Anxiety • Alcohol • Drug

  28. Insomnia and Depression • Present in 50% - 95% • Impairs quality of life • Impairs response to depression therapy • Increases risk of depression recurrence and suicidality • Adapted from Buysse DJ et al. Psychiatry Res 1989;28.

  29. Quality of Life • Physical Role, General Role, Mental • Function Physical Pain Health Vitality Social Emotional Health • n = 3,445 • Katz DA, McHorney CA. The relationship between insomnia and health-related quality of life in patients with chronic illness. J Fam Pract 2002;51:229-235.

  30. Insomnia: Assessment • History • Questionnaires • Insomnia Severity Index, Epworth Sleepiness Scale • Physical Exam • Sleep Log/Diary • Minimum 7 days • Actigraphy • Polysomnography • Not recommended for insomnia workup, but may be needed for another suspected sleep disorder

  31. Assessment: Patient History • History of sleep complaint • Daytime symptoms • Sleep habits (24-hour sleep / wake cycle) • Risks / Precipitating Factors • Medical, neurological & psychiatric history • Medications • Health habits

  32. Examples

  33. Actigraphy • Normal • Insomnia • www.bmedical.com.au/resources/images/

  34. Sleep Trackers

  35. Sleep Trackers

  36. Management of Insomnia

  37. Treatment of Insomnia

  38. Nonpharmacologic Therapy: Behavioral Treatments • Sleep Hygiene • Stimulus Control • Sleep Restrictions • Relaxation Training • Cognitive Therapy • GOOD SLEEP • GOOD SLEEP • Circadian Rhythm Entrainment

  39. Behavioral Treatments

  40. Behavioral Treatment: Sleep Hygiene • Regularize sleep / wake schedule • Avoid stimulants and stimulating behavior • Establish relaxing bedtime routine • Provide conducive sleep environment • Limit daytime naps • Reduce/eliminate alcohol & caffeine • Obtain regular exercise • Avoid clock watching

  41. Behavioral Treatment: Stimulus Control • Use bed for sleep (and sex) • Go to bed only when sleepy • Get out of bed when unable to sleep • Wake up at a consistent time (including weekends) • Do not take daytime naps • Most effective stand-alone treatment.

  42. Behavioral Treatment: Sleep Restriction • Determine average time asleep • Set time in bed = time asleep • Consistent wake-up time • No daytime naps • If time asleep > 90% of time in bed then increase time in bed (15-30 minutes) • If time asleep < 80% of time in bed then decrease time in bed (15-30 minutes)

  43. Sleep Restriction

  44. Behavioral Treatment: Relaxation • Progressive muscle relaxation • Diaphragmatic breathing • Meditation and guided imagery • Biofeedback (EMG)

  45. Behavioral Treatment:Cognitive Therapy • Adapted from Morin CM. J Psychosom Res 1999;46.

  46. Nonpharmacologic Therapy: Circadian Rhythm Entrainment • Light Therapy • Morning light exposure for delayed sleep phase • Evening light exposure for advanced sleep phase • Behavioral Methods • Establish regular wake-up time

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