1 / 82

Insomnia

Learn about chronic insomnia prevalence, effective treatment options, pathophysiology, risk factors, and health implications. Understand the impact of insomnia across the lifespan and its association with psychiatric disorders.

elanor
Download Presentation

Insomnia

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related