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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

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SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE


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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