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Insomnia. David A. Garfunkel, M.D. August 31, 2005. Irrelevant Fact Sleep Physiology Joke Scope of the Problem Diagnosis Commercial Break Non-Pharmacologic Treatment Pharmacologic Treatment. Who was the 2004 U.S. Open Tennis Woman’s Winner?. Svetlana Kuznetsova. Definitions.

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David A. Garfunkel, M.D.

August 31, 2005

Irrelevant Fact
  • Sleep Physiology
  • Joke
  • Scope of the Problem
  • Diagnosis
  • Commercial Break
  • Non-Pharmacologic Treatment
  • Pharmacologic Treatment
  • Sleep is a state of unconsciousness in which the brain is relatively more responsive to internal than to external stimuli
  • Mechanisms within the brainstem and hypothalamus regulate sleep through GABA and acetylcholine
  • Ability to stay alert with very little sleep
purpose of sleep
Purpose of Sleep
  • Speculative
  • NREM sleep may allow decrease in metabolic demand and allow replenishment of glycogen stores
  • Oscillating depolarization's and repolarizations consolidate and and remove redundant or excess synapses
rem sleep
REM sleep
  • Generated by mesencephalic and pontine cholinergic neurons
  • Characterized by muscle atonia, cortical activation, low voltage desynchronization of the EEG, and rapid eye movements
REM sleep has both tonic and phasic qualities
  • Other features include periodic skeletal muscle twitches, increased heart rate variability and increased respiratory rate
circadian sleep rhythm
Circadian sleep rhythm
  • One of several intrinsic rhythms modulated by the hypothalamus
  • Without external stimulus, the suprachiasmatic nucleus sets the rhythm to approximately 25 hours
  • A nerve tract directly from the retina helps regulate us to 24 hours days.
  • Melatonin is a modulator of light entrainment and is secreted maximally by the pineal gland during the night
Insomnia is defined as difficulty with the initiation, maintenance, duration, or quality of sleep that results in the impairment of daytime functioning, despite adequate opportunity and circumstances for sleep.
  • Patient’s subjective dissatisfaction with the sleep quality and quantity
Transient Insomnia - Symptoms present for less than one week
  • Short Term Insomnia - Symptoms for 1-4 weeks
  • Chronic Insomnia - Symptoms present for more than one month
poor sleep maintenance
Poor Sleep Maintenance
  • Waking after sleep has been initiated, but before desired waking time
Initiation of Sleep = Time to fall asleep
    • Standard - less than 30 minutes
  • Sleep Efficiency = Time sleeping/ Time in bed
    • Standard - Greater than 85%
    • May be caused by awakening frequently during the night with subsequent difficulty in re-initiating sleep, or awakening too early without being able to go back to sleep at all
sleep requirements
Sleep Requirements
  • Average - 7 1/2 to 8 1/2hrs/night
  • Range (for adults) - 5-9 hrs/night
  • Steadily decreases from birth to old age
  • newborns sleep 14-16 hours/24 hours
  • Elderly spend less time sleeping per night, but increase in sleep latency and more frequent arousals make their requirement in bed longer.
scope of the problem
Scope of the Problem
  • 2003 Sleep in America poll, which included 1,506 adults ages 55 to 84 from various parts of the United States, found a prevalence of insomnia in 48 percent.
scope of the problem20
Scope of the Problem
  • 1997 survey of almost 2000 HMO patients showed that 10% had current major insomnia as defined as taking more than 2 hours to fall asleep each night.
  • Only 5% spoke to their physician about it
  • Over 38 million prescriptions per year for sleeping pills
  • Mood Disturbance
  • Depression and/or Anxiety
  • Poor memory
  • Difficulty concentrating
  • Motor vehicle and other accidents
normal sleep physiology
Normal Sleep Physiology
  • Stages
    • 1 - light sleep, 5-10% of total sleep time, transition between awake and asleep
    • 2 - 40-50% of total sleep time
    • 3,4 - deep or delta wave sleep, occurs mostly early in the night
    • REM sleep, 20-25% of sleep
    • All 4 stages repeat in ultradian rhythm of about 90 minutes
There are 4-5 cycles in a normal night’s sleep
  • First REM- 10 minutes, but later REM periods may exceed 60 minutes
diagnosis other sleep disorders
Diagnosis- other sleep disorders
  • Hypersomnia - Excessive sleepiness, despite up to 12 hrs./night of sleep
  • Gradual onset
  • Usually appears before age 25
  • Recurrent hypersomnia - Kleine Levin Syndrome
  • May be due to depression
  • Immune mediated destruction of hypocretin secreting neurons in the pineal gland
  • Not related to melatonin
  • Inherited on multiple genes, dominant with incomplete penetrance
  • CSF levels of hypocretin is low and is a useful test
The normal physiologic components of REM sleep, dreaming and muscle tone are separated and can occur while the patient is awake, resulting in half sleep dreams, cataplexy and sleep paralysis
Characterized by attacks of disabling daytime drowsiness and low alertness
  • Short sleep latency and sleep often begins with REM activity
  • 2/3 of cases are associated with cataplexy, triggered by strong emotion
  • Disoriented Arousal
  • Sleepwalking
  • Night/Sleep Terrors
  • Hypnagogic Hallucinations
  • Sleep Paralysis
  • Nocturnal Seizures
parasomnias continued
Parasomnias, continued
  • REM Behavioral Disorder
  • Bruxism
  • Rhythmic Movement Disorder
  • Restless Legs Syndrome
sleep history
Sleep History
  • Timing of insomnia
  • Sleep schedule
  • Sleep environment
  • Sleep habits
  • Symptoms of other sleep disorders
  • Daytime effects
  • Medications, caffeine
  • Life stressors and worry over insomnia
medications that may cause insomnia
Medications that may cause insomnia
  • Clonidine
  • Beta Blockers
  • Theophyline
  • Certain Antidepressants
    • Protriptyline, Fluoxetine
  • Decongestants
  • Stimulants
  • Alcohol
Exercise in morning or early afternoon lessens insomnia
  • Exercise close to bedtime worsens insomnia
physical exam
Physical Exam
  • Anatomic features of obstructive sleep apnea
  • Neurologic exam in case of restless leg or other neurologic syndrome
sleep log
Sleep Log
  • Maintain for 2-4 weeks
    • Sleep and wake times
    • Awakenings
    • Daytime naps and activities
    • Correlation with bed partner
  • Recovered Medical Equipment for the Developing World
  • 420 U.S. Hospitals recovered > $50,000,000 worth of medical supplies in 2004
  • Remedy Lite - unwanted new supplies
individuals 2 ways to help
Individuals: 2 ways to help

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nonpharmacalogic therapy
Nonpharmacalogic Therapy
  • Cognitive Behavioral Therapy
    • Individual counseling- 6 sessions
    • Effective in 50% of patients
relaxation therapy
Relaxation Therapy
  • Recognize and control tension through systematically tensing and relaxing various muscle groups
  • Guided imagery and meditation
  • Biofeedback
stimulus control therapy
Stimulus Control Therapy
  • Reassociate the bed with sleepiness rather than wakefulness
    • No reading, TV, eating or working in bed
    • Lying down only when sleepy
    • If unable to sleep after 15-20 minutes, get out of bed and do something else
sleep restriction therapy
Sleep-restriction Therapy
  • Eliminate excess time in bed awake
  • Purposefully limit sleep, which leads to more efficient and effective sleep habits.
  • Gradually allow more time in bed as insomnia resolves
pharmacologic therapy
Pharmacologic Therapy
  • Non-prescription
  • Prescription
non prescription therapy
Non-prescription Therapy
  • Valerian - An herbal medication that may be safe and effective to decrease sleep latency. May work better if taken regularly at night rather than PRN.
  • Main risk is uncontrolled manufacturing of herbal compounds
  • A natural hormone produced in the pineal gland
  • Circadian rhythm increases the blood level at night, especially when it is dark
  • Antioxidant properties
  • May be effective
diphenhydramine hydrochloride
Diphenhydramine hydrochloride
  • Main Ingredient in Tylenol PM, Sominex, Unisom, etc.
  • Antihistamine and anticholinergic agent
  • Non-specific and long lasting
prescription drugs
Prescription Drugs
  • Benzodiazepines - most common
  • If the problem is falling asleep, use medication with a rapid onset of action
    • Very short 1/2 life may be associated with increased risk of rebound anxiety
  • If the problem is staying asleep, a hypnotic with a slower rate of elimination may be more useful
concomitant depression
Concomitant Depression
  • Antidepressants with sedative properties
    • Trazodone (Desyrel)
    • Amitriptyline (Elavil)
eszopiclone lunesta
Eszopiclone (Lunesta)
  • New class of non-benzodiazepine
  • May affect GABA receptor
  • Rapid onset, medium 1/2 life
  • No tolerance or withdrawal after 6 months of treatment
  • 1,2,3 mg. dose
rozerem ramelteon
Rozerem (ramelteon)
  • Unscheduled prescription drug
  • Acts on Melatonin receptors
  • No activity on the following receptors
    • GABA, neuropeptides, cytokines,seratonin, dopamine, noradrenaline, acetylcholine, or opioid
rozerem continued
Rozerem, continued
  • Given to 14 subjects with history of abuse of sedative/hypnotics or anxiolitics; Result: no potential for abuse
  • Dosage-8 mg. (not with or immediately following a high fat meal
sedative hypnotic medication general rules
Sedative-hypnotic Medication General rules
  • Symptomatic relief, not a cure
  • Combine with nonpharmacologic treatment
  • Smallest effective dose for the shortest possible time
  • Avoid alcohol
  • Pregnancy is a contraindication
  • Taper off to avoid rebound insomnia