sleep disorders and insomnia in hiv disease l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE PowerPoint Presentation
Download Presentation
SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE

Loading in 2 Seconds...

play fullscreen
1 / 77

SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE - PowerPoint PPT Presentation


  • 409 Views
  • Uploaded on

SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE Overview Significant numbers of patients with HIV/AIDS complain of sleep difficulties Sleep problems in HIV/AIDS are associated with significant co-morbidity

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE' - niveditha


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.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
sleep disorders and insomnia in hiv disease

SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE

American Psychiatric Association Office on HIV Psychiatry- Sleep

overview
Overview
  • Significant numbers of patients with HIV/AIDS complain of sleep difficulties
  • Sleep problems in HIV/AIDS are associated with significant co-morbidity
  • Patients with sleep difficulties should be carefully evaluated so that treatment can be initiated promptly to avoid further complications

American Psychiatric Association Office on HIV Psychiatry- Sleep

objectives
Objectives
  • To recognize sleep disorders in HIV disease
  • To understand treatment of HIV-related sleep disorders

American Psychiatric Association Office on HIV Psychiatry- Sleep

outline
Outline
  • Properties of Insomnia
  • Physiology of Normal Sleep
  • Insomnia in HIV
  • Sleep Disturbances in HIV
  • Disorder of Initiating and Maintaining Sleep (DIMS)
  • Major Depressive Disorder (MDD)
  • Anxiety Disorders
  • Evaluation of Insomnia Variations
  • Treatment of HIV-associated Sleep Disorders

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia definition
Insomnia: Definition
  • The subjective complaint of insufficient, inadequate, or poor quality sleep characterized by
    • Difficulty initiating sleep
    • Difficulty maintaining sleep
    • Early morning awakening (EMA)
    • Experiencing nonrestorative sleep
  • Associated disturbance of daytime function such as fatigue, mood disturbance, cognitive inefficiency, irritability, or impaired performance

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia definition continued
Insomnia: Definition(continued)
  • Acute insomnia
    • Transient
    • Short term
  • Chronic insomnia
    • Primary

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia introduction
Insomnia: Introduction
  • Typically mistaken for “short” or “poor” sleep
  • Difficult to objectify (similar to pain)
  • Function of sleep not well understood
  • Mechanisms for insomnia not known

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia consequences
Diminished sense of well-being

Increased absenteeism and disability

Lower functional performance

Increased inefficiency  increased frequency of accidents

Fatigue

Loss of enjoyment

Diminished coping capacity

Memory loss

Self-medication

Intensified pain

Poor mood

Insomnia – Consequences

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia classification
Insomnia: Classification
  • DSM-IV
  • International Classification of Sleep Disorders

American Psychiatric Association Office on HIV Psychiatry- Sleep

normal sleep physiology
Normal Sleep: Physiology
  • Dynamic process usually organized into REM and non-REM (NREM) sleep
  • NREM is further organized into stages: 1, 2, 3, and 4
    • NREM stages 3 and 4 are often considered as delta or slow wave sleep
      • Physiologically, they are most important components of sleep activity

American Psychiatric Association Office on HIV Psychiatry- Sleep

normal sleep physiology continued
Normal Sleep: Physiology(continued)
  • Sleep proceeds normally through NREM 1-4 and returns to stage 2 before entering the first REM period ~ 70-90 minutes after sleep onset
  • Stage 2 sleep is associated with changes in immunologic functions with decreased production of TNF-alpha and IL-1B and increased production of IL-2

American Psychiatric Association Office on HIV Psychiatry- Sleep

normal sleep physiology continued12
Normal Sleep: Physiology(continued)
  • NREM and REM alternate about 90 minutes apart
    • REM increases in length as the night progresses
  • Delta sleep tapers off during the night

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia in hiv infection
Insomnia in HIV Infection
  • 30 - 40% of patients complain of some difficulty sleeping in the previous year
  • As many as 50% have experienced insomnia at some time in their life
  • Between 10-20% of patients characterize their sleep problems as constant and severe
    • MNA (67%) > DFA (56%) > EMA (48%)

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia in hiv infection continued
Insomnia in HIV Infection(continued)
  • Insomnia results from various causes in HIV infection
    • Stage of HIV disease
    • Associated medical factors
      • Fever, pain, dehydration, nutrition
    • Degree of CNS disease
    • Concurrent HIV related medication

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia in hiv infection continued15
Insomnia in HIV Infection(continued)
  • Other factors involved in HIV related insomnia
    • Individual’s sleep wake cycle
    • Life events
    • Coping mechanisms
    • Substance abuse
    • Poor sleep hygiene
    • Psychiatric problems

American Psychiatric Association Office on HIV Psychiatry- Sleep

sleep disturbance in hiv
Sleep Disturbance in HIV
  • Polysomnography studies
    • Shorter total sleep time
    • Longer sleep onset latency
    • Reduced sleep efficiency
    • More frequent awakenings
    • More time spent awake

American Psychiatric Association Office on HIV Psychiatry- Sleep

sleep disturbance in hiv continued
Sleep Disturbance in HIV(continued)
  • Increased stage-1 sleep
  • Decreased stage-2 sleep
  • Reduced REM latency while percentage of slow wave sleep and REM sleep unchanged
  • In aymptomatic patients without any sleep complaints, similar sleep abnormalities present but in milder forms
  • Sleep decrements are associated with decreased proliferative response of lymphocytes to mitogen stimulation

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia in hiv disease
Insomnia in HIV Disease
  • One third of patients with pts with symptomatic HIV sought medical help specifically for this problem
    • Only 5% received a formal psychiatric consult
  • 25% of patients w/sleep problems used OTC meds
  • 27% used alcohol as a sleeping aid
  • 15% used hypnotic
    • 61% use them for > 1 year
    • Most commonly used agent was temazepam

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia social impact
Insomnia: Social Impact
  • Naval student performance: poor sleepers received fewer promotions, had lower pay grades, had higher attrition and frequent hospitalizations
    • Raises questions about cognitive performance in HIV disease
  • Habitual short sleep duration (< 7 hours) is associated with increased mortality

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia social problems
Insomnia: Social Problems
  • Impaired relationships
  • Difficulty coping with problems
  • Trouble concentrating and memory problems
  • Increased risk of accidents
  • Poor work performance
  • Poor mental health

American Psychiatric Association Office on HIV Psychiatry- Sleep

disorder of initiating maintaining sleep dims psychophysiological
Disorder of Initiating & Maintaining Sleep (DIMS) -Psychophysiological
  • Patients often describe themselves as light sleepers affected by environmental factors
  • Patients will note improved ability to sleep away for their usual sleep environment
  • Typically overly concerned about their insomnia and their perceived consequences which is in excess of objectively verifiable deficit

American Psychiatric Association Office on HIV Psychiatry- Sleep

physiological dims
Physiological DIMS
  • Psychological factors
  • Physiological factors
  • Altered perception of physiological events
  • Conditioned phenomena

American Psychiatric Association Office on HIV Psychiatry- Sleep

physiological dims psychological factors
Physiological DIMS: Psychological Factors
  • High levels of stress
    • Negative life events, interpersonal loss or change
  • Highly anxious personality style
  • Increased levels of psychological symptoms
  • High trait anxiety

American Psychiatric Association Office on HIV Psychiatry- Sleep

physiological dims physiological factors continued
Physiological DIMS:Physiological Factors(continued)
  • Increased levels of physiological arousal
    • Higher body temperature, skin resistance, peripheral vasoconstriction, heart and respiratory rates
  • Increased polysomnographic abnormalities
    • Longer sleep latency, decreased total sleep time, decreased sleep efficiency, MNA
  • Normal sleep architecture

American Psychiatric Association Office on HIV Psychiatry- Sleep

physiological dims abnormal perceptions
Physiological DIMS:Abnormal Perceptions
  • Inaccurate perception of their sleep and waking state
  • Overestimate the degree of their insomnia
  • When awakened from stage 2 sleep, 80% will claim they were awake
  • Auditory arousal thresholds are no different from controls or so-called “good” sleepers

American Psychiatric Association Office on HIV Psychiatry- Sleep

phyisiological dims conditioned factors
Phyisiological DIMS:Conditioned Factors
  • Attempts to sleep are inadvertently coupled to thoughts, attitudes, behaviors or conditions which are incompatible with sleep
  • Two types of conditioned reinforcers:
      • Internal (fear of sleeplessness, frustration, internalization of problems)
      • External (watching TV, eating, reading, lying awake)

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia secondary psychiatric disorders
Insomnia: Secondary Psychiatric Disorders
  • Major Depressive Disorder
  • Manic Depressive Illness
  • Anxiety Disorders
  • Substance Dependence
  • Organic Mental Disorders
  • Schizophrenia

American Psychiatric Association Office on HIV Psychiatry- Sleep

major depressive disorder mdd
Major Depressive Disorder (MDD)
  • Two weeks of a pervasive change in mood or loss of interest or pleasure in association with:
    • Insomnia or hypersomnia
    • Weight change
    • Psychomotor agitation / retardation
    • Loss of energy / fatigue
    • Cognitive inefficiency
    • Feelings of worthlessness or guilt
    • Thoughts of death or suicide

American Psychiatric Association Office on HIV Psychiatry- Sleep

major depressive disorder
Major Depressive Disorder

sig: E caps

American Psychiatric Association Office on HIV Psychiatry- Sleep

major depressive disorder30
Major Depressive Disorder
  • Sleepdisturbance
  • Interest
  • Guilt, worthless, hopeless, hapless
  • Energy
  • Concentration / Attention
  • Appetite or weight change
  • Psychomotor agitation or retardation
  • Suicide (passive or active)

American Psychiatric Association Office on HIV Psychiatry- Sleep

mdd electroencephalographic studies
MDD Electroencephalographic Studies
  • Prolonged sleep latency
  • Frequent MNA
  • EMA
  • Poor sleep efficiency < 75%
  • Decreased delta sleep
  • Shortened REM latency
  • Redistribution of REM sleep

American Psychiatric Association Office on HIV Psychiatry- Sleep

mdd electroencephalographic studies continued
MDD ElectroencephalographicStudies(continued)
  • Results consistent over a wide range of age groups
  • Found in both inpatients and outpatients
  • Vary according to subtype of depression
      • Psychotic depression - shorter REM latency
      • Bipolar: mania - severe sleep continuity disturbances
      • Bipolar: depressed - long REM latency

American Psychiatric Association Office on HIV Psychiatry- Sleep

anxiety disorders
Anxiety Disorders
  • Generalized anxiety disorder
  • Panic Disorder
  • Obsessive Compulsive Disorder
  • Post-traumatic Stress Disorder

American Psychiatric Association Office on HIV Psychiatry- Sleep

generalized anxiety gad
Generalized Anxiety (GAD)
  • Symptoms occurring for the majority of days in a 6-month period:
      • Excessive anxiety or worry
      • Insomnia
      • Irritability
      • Muscle tension
      • Impaired social and occupational functioning
  • Decreased delta sleep and increased sleep continuity disturbance

American Psychiatric Association Office on HIV Psychiatry- Sleep

obsessive compulsive ocd
Obsessive Compulsive (OCD)
  • Recurrent and intrusive, undesired thoughts
  • Rituals or ruminations interfere with sleep
  • Decreased sleep time
  • Decreased delta sleep
  • Decreased REM latency
      • Less intense early REM
      • Increased stage 1 sleep

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia circadian rhythm disturbances
Insomnia: Circadian Rhythm Disturbances
  • Transient Disorders
    • “Jet lag” desynchrony between the individual’s biological clock and the environmental clock of destination
    • “Shift work” associated with premature awakenings, DFA, fatigue
  • Persistent Disorders
    • Delayed sleep phase syndrome
    • Advanced sleep phase syndrome
    • Hypemycthemeral

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia substance induced
Alcohol

Sedative-hypnotics

Stimulants

Anticonvulsants

Theophylline

Beta-blockers

Decongestants

Heroin/opioids

AZT, ddI, ddC

DHPG, acyclovir

Interleukin-2

Trimethoprim sulfa

Dapsone

Amphotericin-B

Fluconazole

Protease inhibitors

Insomnia: Substance Induced

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia due to general medical condition
Insomnia: Due to General Medical Condition
  • Cardiovascular: CHF, PND, CAD, HPTN, arrhythmia's
  • Pulmonary: Apnea, asthma, COPD, alveolar hypoventilation
  • GI: GER, PUD, hepatic failure
  • Renal: RF, UTI, polyuria (any type)
  • Endocrine: DM, hypo- or hyperthyroidism
  • Allergies

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia due to general medical condition continued
Insomnia: Due to General Medical Condition(continued)
  • Uncontrolled or poorly controlled pain
  • Conditioned or procedural anxiety
  • Sleep interruption secondary to medication compliance

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia due to general medical condition continued40
Insomnia Due to General Medical Condition(continued)
  • Rheumatology: Arthritis, collagen-vascular disorders
  • Pregnancy
  • Neurologic: Delirium, TBI, coma, CVA, myoclonus, MD, dementia, migraines, epilepsy
  • Non-specific: ICU, post-op, pain, pruritus, fever, cough

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia evaluation
Insomnia: Evaluation
  • Clinical Interview
      • Patient
      • Bed partner
  • Symptom-Syndromal Approach
      • DFA, MNA, EMA
      • Onset
      • Psychosocial stress
      • Medications
      • Illnesses

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia evaluation continued
Insomnia: Evaluation(continued)
  • Duration
      • Transient (several days)
      • Short-term (< 3 weeks)
      • Chronic (> 3 weeks)
  • Progression
      • Stable, worse or better
      • Any new symptoms
  • Daytime symptoms
      • Fatigue, drowsiness, cognitive changes

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia evaluation continued43
Insomnia: Evaluation(continued)
  • Patient’s response to the problem
  • Past treatments
  • Past psychiatric and medical history
  • Family history
  • Sleep diary or log
  • Psychological tests
  • Physical examination and laboratory tests
  • Polysomnography

American Psychiatric Association Office on HIV Psychiatry- Sleep

insomnia treatment
Insomnia: Treatment
  • When is treatment necessary?
      • Use sleep log to assess efficiency
      • Keep log for one week
      • Calculate sleep efficiency =
      • (time in bed - time in bed awake) X 100
      • time in bed
      • < 85% -- formal treatment should be considered

American Psychiatric Association Office on HIV Psychiatry- Sleep

treatment nonpharmacologic
Treatment: Nonpharmacologic
  • Sleep hygiene rules
      • Curtail time in bed
        • Overall sleep needs do not change much from age 20-70
        • Inquire about sleep habits prior to insomnia
        • Recommend bedtime be strictly held to that amount
        • If amount is unknown, prescribe 7 hours
      • Never try to make yourself sleep
        • The more you try the less it works
        • Trying increases arousal so it is counterproductive
      • Eliminate the bedroom clock - don’t pressure yourself to sleep

American Psychiatric Association Office on HIV Psychiatry- Sleep

treatment nonpharmacologic continued
Treatment: Nonpharmacologic(continued)
  • Sleep hygiene rules - cont’d
      • Exercise - Sleep tends to be related to core body temperature
        • We sleep best during the trough of core temperature
        • Exercise increases core body temperature
        • DON’T exercise just before bedtime BUT DO exercise 4-6 hours before sleeptime
      • For non- exerciser, taking a hot bath for 20 minutes two hours before going to bed will lead to a compensatory drop in temperature which will aid sleep

American Psychiatric Association Office on HIV Psychiatry- Sleep

treatment nonpharmacologic continued47
Treatment: Nonpharmacologic(continued)
  • Sleep hygiene cont’d
    • Avoid coffee, alcohol, tea, nicotine & chocolate
    • Regularize bedtime
    • Eat a light bedtime snack
      • Hunger disrupts sleep
      • Eating releases enzymes which may promote sleep
      • Warm milk after a high carbohydrate snack with 50 mg pyridoxine may induce sleep
    • Schedule “thinking” time during the day or early evening

American Psychiatric Association Office on HIV Psychiatry- Sleep

treatment nonpharmacologic continued48
Treatment: Nonpharmacologic(continued)
  • Sleep hygiene cont’d
      • Relaxation training and tapes
        • Must become proficient
        • One shot deal does not do it
        • Practice during the day then use at night
        • Ability to focus one’s attention is what is important NOT muscle relaxation per se
      • Cognitive refocusing to counter maladaptive thinking
      • Review psychological issues

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments sedative hypnotics
Pharmacologic Treatments: Sedative Hypnotics
  • Barbiturates
    • Primary action is CNS depression
      • Side-effects: hangover, GI distress, myalgias, respiratory depression, paradoxical excitement

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments sedative hypnotics continued
Pharmacologic Treatments: Sedative Hypnotics(continued)
  • Barbiturates cont’d
      • Tolerance develops early and physical dependence is common
      • Serious withdrawal reactions can occur
      • Drug interactions secondary to hepatic microsomal system by enzyme induction
      • Avoid use with alcohol
      • Low therapeutic index
        • More toxic than benzodiazepines
        • Risks outweigh their benefits
  • Should avoid use of barbiturates in HIV patients

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines bzd
Pharmacologic Treatments: Benzodiazepines (BZD)
  • Most frequently prescribed hypnotics
  • Only 5 FDA approved
    • flurazepam (Dalmane)
    • quazepam (Doral)
    • estazolam (ProSom)
    • temazepam (Restoril)
    • triazolam (Halcion)
  • Exact hypnotic mechanism unknown

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines continued
Pharmacologic Treatments: Benzodiazepines(continued)
  • Typically, short acting agents are preferred
    • Lorazepam, temazepam, and triazolam are the most frequently prescribed
    • All three disrupt sleep architecture
    • Occasional use may be helpful (1-2x/week) after a few (2-3) consecutive nights of poor sleep
    • AVOID using BZDs in the middle of the night
    • AVOID combining with alcohol

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines continued53
Pharmacologic Treatments: Benzodiazepines(continued)
  • Adverse effects: drowsiness, ataxia, syncope, liver dysfunction, amnesia, granulocytopenia
  • Short acting agents are specifically associated with rebound insomnia, daytime anxiety, and EMA
  • Habituation is common as well as tolerance and physical dependence with marked withdrawal syndrome

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines continued54
Pharmacologic Treatments: Benzodiazepines(continued)
  • Addiction - rare except in patients who spell:
    • Transient
    • Regressive
    • Overanxious
    • Unstable
    • Bulemic
    • Labile
    • Episodes

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines continued55
Pharmacologic Treatments: Benzodiazepines(continued)
  • Estazolam (ProSom)
    • Triazolobenzodiazopine similar to triazolam (Halcion)
    • Intermediate half-life
    • Should be avoided with protease inhibitors
  • Quazepam (Doral)
    • Selective BZD1 receptor agonist
    • Long half-life
    • Hangover effect
    • Highly lipophilic
    • Active metabolite similar to Flurazepam

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines continued56
Pharmacologic Treatments: Benzodiazepines(continued)
  • Benzodiazepines that are “safe” to use with protease inhibitors, ketoconazole, macrolide antibiotics and any other drugs that inhibit CYP 450 3A4 isoform
    • Lorazepam
    • Temazepam
    • Oxazepam

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments benzodiazepines continued57
Pharmacologic Treatments: Benzodiazepines(continued)
  • Benzodiazepines to specifically avoid with protease inhibitors, ketoconazole, macrolide antibiotics and any other drugs that inhibit CYP 450 3A4 isoform
    • Alprazolam
    • Triazolam
    • Estazolam
    • Midazolam

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments
Pharmacologic Treatments
  • Chloral hydrate
    • CNS depressant
    • Active metabolite = Trichloroacetic acid has a half-life of 4 days
  • Antihistamines
    • H1 blocking effect induces sleep
    • Hydroxyzine preferred (less anticholinergic)
    • S/Es: GI, drowsy, drying, urinary frequency, palpitations, HAs, excitement, tolerance

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments antidepressants
Pharmacologic Treatments: Antidepressants
  • TCAs
    • Variable sedative effects
    • Suppress REM & increase duration of NREM sleep
    • Sedating effects correlate with antihistamine effect
    • AMI and DOX are the most frequently Rx’d
    • S/E: blurry vision, orthostasis, constipation, urinary frequency and retention, memory

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments antidepressants continued
Pharmacologic Treatments: Antidepressants(continued)
  • Trazodone
    • Mimics BZDs
    • Doses: 25 - 200 mg may be sufficient
    • Little anticholinergic effects
    • No reported development of tolerance or abuse
    • Priapism rare - all male patients should be warned

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments antidepressants continued61
Pharmacologic Treatments: Antidepressants(continued)
  • Mirtazapine (Remeron)
    • Noradrenergic antagonist and specific serotonergic antagonist
      • Low doses 7.5-15 mg may help even severe insomnia
      • High affinity for H-1 centrally
        • Sedating
        • Appetite stimulation
      • Low affinity for CYP-450 isoforms
        • Theoretically safe with protease inhibitors

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments antidepressants continued62
Pharmacologic Treatments: Antidepressants(continued)
  • Nefazodone – SSRI/SNRI which has specific restorative effects on sleep architecture without causing sedation
    • Metabolism involves the 3A4 isoform of P450
    • Should be avoided in patients receiving protease inhibitors and any other drugs that inhibit P450 3A4 isoform

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments imidazopyridines
Pharmacologic Treatments: Imidazopyridines
  • Zolpidem (Ambien)
    • Novel non-BZD hypnotic
    • Selectively binds the omega subunit of GRSC potentiating GABAergic transmission
    • Causes sedation without neuromuscular, anxiolytic, or anticonvulsant effects
    • Short half-life: 2.5 hours
    • No active metabolites

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zolpidem
Pharmacologic Treatments: Zolpidem
  • Shortens the time to Stage 1 sleep
  • Increases sleep duration
  • No discernable effects on sleep architecture at recommended doses
  • Long term use does not lead to tolerance, loss of efficacy, withdrawal, rebound or abuse

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zolpidem continued
Pharmacologic Treatments: Zolpidem(continued)
  • Rapidly absorbed from the GI tract
  • First pass results in a bioavailability of 70%
  • Peak plasma level in 2 hours
  • Highly protein bound
  • Does not affect respiration or ABGs during sleep in healthy or geriatric patients
  • Avoid in sleep apnea patients

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zolpidem continued66
Pharmacologic Treatments: Zolpidem(continued)
  • Adverse effects
    • Lightheadedness / dizziness (5.2%)
    • Somnolence (5.2%)
    • Headache (3%)
    • GI distress (3.6%)
      • Nausea
      • Diarrhea
    • Fatigue
    • No psychomotor impairment or evidence for acute withdrawal reaction

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zolpidem continued67
Pharmacologic Treatments: Zolpidem(continued)
  • Drug interactions
    • None reported with psychotropics except
      • IMI levels decreased by 20%
      • Decreased level of alertness noted with TCAs
    • No effects with cimetidine, ranitidine, H2 antagonists, or warfarin
    • Additive sedative effects with concomitant administration of chlorpromazine
    • Additive psychomotor effects with alcohol

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zolpidem continued68
Pharmacologic Treatments: Zolpidem(continued)
  • Dosage and administration: 5-10 mg at bedtime
    • May increase to 20 mg if needed
  • Use half the dose in patients with liver cirrhosis
  • Use with caution in renal dysfunction
  • Shown to be effective for up to 1 year of use

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zolpidem continued69
Pharmacologic Treatments: Zolpidem(continued)
  • Little experience specifically with HIV patients
    • Caution in neurologically symptomatic patients
    • Modify dosing in patients with hepatic dysfunction
    • Relative contraindication in patients receiving protease inhibitors

American Psychiatric Association Office on HIV Psychiatry- Sleep

pharmacologic treatments zaleplon
Pharmacologic Treatments: Zaleplon
  • Non-benzodiazepine receptor agonist
  • Binds with selective affinity to BZ1 receptor
    • Clinical significance is unknown
  • Similar to zolpidem except it is ultra-short acting

American Psychiatric Association Office on HIV Psychiatry- Sleep

hypersomnia in hiv infection
Hypersomnia in HIV Infection
  • Usually common in advanced disease
  • Associated with extreme fatigue
  • Contributes significantly to excess morbidity and disability
  • May be related to elevated levels of TNF
  • Treatment – limited experience
    • Psychomotor stimulants may be helpful

American Psychiatric Association Office on HIV Psychiatry- Sleep

conclusions
Conclusions
  • Insomnia is the most prevalent sleep complaint in HIV disease
  • Insomnia is a symptom of many disorders rather than a single illness or condition
  • It occurs in transient, short-term and chronic forms

American Psychiatric Association Office on HIV Psychiatry- Sleep

conclusions continued
Conclusions(continued)
  • The majority of insomnias in HIV disease are associated with five general categories of disturbances
    • Psychophysiological factors
    • Psychiatric disorders
    • Circadian rhythm disturbances
    • Substance use
    • Medical complications

American Psychiatric Association Office on HIV Psychiatry- Sleep

conclusions continued74
Conclusions(continued)
  • Assessment includes
    • Clinical interview
    • Sleep log
    • Psychological tests
    • Polysomnography
  • Treatment should consist of a combination of behavioral treatments with pharmacotherapies

American Psychiatric Association Office on HIV Psychiatry- Sleep

conclusions continued75
Conclusions(continued)
  • Pharmacologic strategies include the use of
    • Sedative-hypnotics
    • Antidepressants
    • Antihistamines
    • New BZ1 receptor agonists (zolpidem and zaleplon)

American Psychiatric Association Office on HIV Psychiatry- Sleep