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B. Wayne Blount, MD, MPH Professor, Emory S.O.M. insomnia. OBJECTIVES. Define & Classify Insomnia State the incidence & prevalence of Insomnia List Common Symptoms of Insomnia Explain how insomnia is Diagnosed List pharmacologic & non-pharmacologic treatment strategies for insomnia.

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B wayne blount md mph professor emory s o m l.jpg

B. Wayne Blount, MD, MPH

Professor, Emory S.O.M.

insomnia


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OBJECTIVES

  • Define & Classify Insomnia

  • State the incidence & prevalence of Insomnia

  • List Common Symptoms of Insomnia

  • Explain how insomnia is Diagnosed

  • List pharmacologic & non-pharmacologic treatment strategies for insomnia


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ROADMAP

  • Definition

  • Epidemiology

  • Diagnosis

  • Treatment

    • Non-pharmacologic

    • Pharmacologic

      • Usual meds

      • Alternatives

  • Summary


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Definitions

  • 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


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Question 1

  • What is “Philagrypnia”?

  • Hint: you have all experienced it.


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Philagrypnia

  • Ability to stay alert with very little sleep


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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 remove redundant or excess synapses


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QUESTION 2

  • Sleep cycles are controlled by

  • A. The Pontine

  • B. The Hypothalamus

  • C. One’s sleep partner

  • D. The Caudate Nucleus

  • The Sandman

  • Hint: All of you have one of these also


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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


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QUESTION 3

Which of the following is/are true about sleep requirements?

a. Average needed is 7 1/2 to 8 1/2hrs/night

b. Range (for adults) - 5-9 hrs/night

c. Steadily decreases from birth to old age

  • Elderly spend less time sleeping per night, and increase sleep latency with more frequent arousals

  • All of the above


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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


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  • Insomnia

  • Difficulty initiating or maintaining sleep, Waking up too early, or sleep that is nonrestorative.

  • Patient’s subjective dissatisfaction with sleep quality or quantity


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QUESTION 4

  • Traditionally there are how many types of Insomnia?

  • A. 1

  • B. 2

  • C. 3

  • D. 4


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  • 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


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Question: Not to be answered on keypads:What do you call a nun who sleep walks?


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A Roamin’ Catholic


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QUESTION 5

  • The consequences of Insomnia are all psychologic and financial.

  • A. True

  • B. False


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Consequences

  • Mood Disturbance

  • Depression and/or Anxiety

  • Poor memory

  • Difficulty concentrating

  • Motor vehicle and other accidents

  • Higher Health care use

  • Impaired Work Performance


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Physiologic Results

  • Elevated:

    • Body temp

    • Resting Heart rate

    • Heart rate variability

    • Cortisol level

    • Beta wave activity


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Medical Consequences

  • Exaccerbates :

    • CV DZ

    • DM

    • GERD

    • Pain Syndromes

    • Parkinson’s

    • COPD

    • Depression

    • PTSD

    • Substance Abuse


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Scope of the Problem

  • 20% of population have insomnia

  • Only 5% tell their physician about it

  • Over 38 million prescriptions per year for sleeping pills

  • 39% of adults sleep less than 7 hours on weeknights

  • 54% of people over 55 report insomnia once a week or more


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SOME FACTS ABOUT INSOMNIA

  • Average number of fatal crashes caused by drowsy driving each year: 1,550

  • 39% of Health care workers have had a near miss accident at work because of fatigue

  • 19% of health workers report worsening a patient’s condition because of fatigue

  • 44% of law enforcement workers report having taken unnecessary risks while tired

  • 80% of US regional pilots report they sometimes nod off in the cockpit

"I can't sleep", Arlene Weintraub, Business Week, 1/26/2004, Issue 3867


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QUESTION 6

  • The most important part of evaluating a patient’s insomnia is the history.

  • A. True

  • B. False


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Evaluation

  • Patient & Family History

    • Sleep Diary

    • Questionnaires

      Looking for Obvious causes

  • P.E.


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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


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Sleep Diary

  • Maintain for 2-4 weeks

    • Sleep and wake times

    • Awakenings

    • Daytime naps and activities

    • Correlation with bed partner


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Causes of Insomnia

  • Stress/Situational

  • Fear

  • Anger

  • Depression

  • Medical

  • Behavioralfactors

  • Life-style

  • Personality

  • Medicine


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Medical Causes of Insomnia

  • Pain

  • GERD

  • BPH

  • OSA

  • RLS

  • Depression

  • Anxiety


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Medications Causing Insomnia

  • Clonidine Bronchodilators

  • Beta Blockers Steroids

  • Theophyline

  • Certain Antidepressants

    • Protriptyline, Fluoxetine

  • Decongestants

  • Stimulants

  • Alcohol


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Causes of Insomnia

  • Disruption of sleep patterns

    • shift working, children

  • Environmental factors

    • temperature, humidity, light

  • Inability to sleep

    • the mind might be overactive, running possible scenarios, problem solving, etc.


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Causes of Insomnia

  • Daytime Naps

  • Environmental Noise

  • Bedroom Conditions

  • Poor Sleep Habits

  • Fatal Familial Insomnia : genetic; 28 families


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QUESTION 7

  • The P.E. of the insomniac patient is

  • A. Focused

  • B. Similar to a complete physical

  • C. Doesn’t need to be done


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Physical Exam

  • Anatomic features of obstructive sleep apnea

  • Neurologic exam in case of restless leg or other neurologic syndrome


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QUESTION 8

  • The laboratory work-up for insomnia needs to be extensive.

  • A. True

  • B. False


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?Laboratory?

  • Multiple Sleep Latency Test (MSLT)

  • Polysomnography (PSG)

  • Usually not needed

  • Get when treatment

    isn’t working


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Question 9

  • Which of the following treatments should be included in every insomniac’s treatment plan?

  • A. Non-Pharmacologic

  • B. Pharmacologic

  • C. Both


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Treatment Options

  • Cognitive Behavioral Therapy

  • Relaxation Therapy

  • Sleep Hygiene

  • Light Therapy

  • Pharmacologic

    • Non-Prescriptive

    • Prescriptive


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Relaxation Therapy

  • Recognize /control tension by systematically tensing and relaxing various muscle groups

  • Guided imagery and meditation

  • Biofeedback

  • Calming tapes

  • Effective in 50-70%

  • More effective in non-elderly


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Sleep Hygiene (Do in ALL patients)

  • Stimulus Control Avoid Alcohol

  • Sleep Restriction Caffeine

  • Temporally Correct exercise

  • Control Environmental Noise

  • A Regular Schedule Darker Room

  • Use bed only for S & S Cooler Room

  • Avoid clock watching

  • Effective in 70-80%


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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

    • No Naps


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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


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AASM Practice Parameters

  • Psychologic and behavioral interventions are effective and recommended

  • Sleep 2006; 29:1415


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Pharmacologic Therapy

  • Non-prescription

  • Prescription


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Non-prescription Therapy

  • Valerian - An herbal medication

  • Inhibits breakdown of GABA

  • May be safe and effective to decrease sleep latency. May work better if taken regularly at night rather than PRN.

  • Little evidence; SOR ‘I’ Bandolier

  • Main risk is uncontrolled manufacturing of herbal compounds


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Melatonin

  • Not effective in treating most sleep disorders

  • Not effective in jet lag

  • Not effective in shift work insomnia

  • Is safe with short-term use

  • SOR ‘B’ AHRQ

  • www.ahqr.gov/clinic/tp/melatntp.htm


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Diphenhydramine hydrochloride

  • Main Ingredient in Tylenol PM, Sominex, Unisom, etc.

  • Antihistamine and anticholinergic agent

  • Non-specific and long lasting

  • Side effects, esp. in elderly


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Prescription Drugs

  • Benzodiazepines

  • Benzodiazepine receptor agonists

  • Melatonin receptor agonists


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Benzodiazepines

  • Most commonly used

  • 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 longer ½ life may be more useful

  • Rebound insomnia if d/c’d abruptly

  • SOR for elderly ‘C’ Bandolier


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Benzodiazepines

  • 7 approved in US

  • Increase stage 2 sleep; decrease stages 1 & 4

  • Decreased Sleep latency by 4.2 minutes

  • Increased total sleep duration by 61.8 minutes

  • Side Effects :

    • Daytime Drowsiness

    • Dizziness

    • Dependence


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Benzodiazepine agonists

  • Eszopiclone ; Lunesta

    • 5-7 hr ½ life; use for sleep maintenance

  • Zolpidem : Ambien :

    • 3 hrs; Sleep latency

  • Zaleplon : Sonata :

    • 1 hr; latency

      No evidence that there is a difference in these meds


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Eszopiclone (Lunesta)

  • New class of non-benzodiazepine

  • May affect GABA receptor

  • Rapid onset, 1/2 life = 6 hrs

  • No tolerance or withdrawal after 6 months of treatment

  • 1,2,3 mg. dose

  • HA, taste & somnolence


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Zolpidem (Ambien)

  • Little effect on sleep stages

  • No tolerance out to 35 days of use

  • 10-20 mg

  • Elderly or liver dz: 5 mg

  • ½ life = 2.5 hrs

  • No active metabolites


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Zaleplon (Sonata)

  • No rebound nor withdrawal

  • 10 mg or elderly = 5 mg

  • ½ life = 1 hr

  • Side effects = HA, dizzy, somnolence


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ConcommitantDepression

  • Antidepressants with sedative properties

    • Trazodone (Desyrel)

    • Amitriptyline (Elavil)


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Rozerem (ramelteon)

  • Unscheduled prescription drug

  • Acts on Melatonin receptors

  • Short ½ life : 2-5 hrs.

  • Sleep Onset

  • Side Effects : Increased Prolactin, dizzy

  • No activity on the following receptors

    • GABA, neuropeptides, cytokines,seratonin, dopamine, noradrenaline, acetylcholine, or opioid


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Treatment Principles

  • Start with Non-Pharmacologic

  • Transient Insomnia :

    • Usually does not require pharmacologic treatment

  • Short Term :

    • If affecting QOL, consider Bz RAs

  • Chronic :

    • Try Non-pharmacologic, then pharmacologic


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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

  • Monitor for Side effects


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When to Refer ?

  • Resistant to Treatment

  • Complex Co-morbidities

  • Sleeping while Driving


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CODING

  • Insomnia 780.52

  • Adjustment 307.41

  • ETOH 291.82

  • Drug 292.85

  • Medical DZ 327.01

  • Mental 327.02

  • Nonorganic 307.41




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Summary

  • Common

  • Look for comorbidities

  • The Patient assessment

  • Treatment



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Quiz

  • Answer the questions below:

    hardly ever (1 point), sometimes (2), almost always (3)

    After you have answered all of the questions, add up your points.

  • I sleep right through my alarm and then can barely roust myself from bed. (1) (2) (3)

  • I get annoyed by trivial matters because I am tired. (1) (2) (3)

  • I have a difficult time concentrating or find myself dozing off during the day. (1) (2) (3)

  • Fatigue causes me to turn down social engagements and other activities that I normally enjoy. (1) (2) (3)

  • I catch colds and the flu easily. (1) (2) (3)

  • I'm needlessly grumpy with my mate or family members because I'm tired. (1) (2) (3)

  • I need caffeine to stay alert during the day and/or alcohol to help me relax at night. (1) (2) (3)

  • I struggle to keep my eyes open when I drive at night. (1) (2) (3)

  • At bedtime, I am asleep five minutes after my head hits the pillow. (1) (2) (3)

  • I wake up during the night and find it difficult to fall back to sleep. (1) (2) (3)


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  • to 15: YOU'RE A GOOD SLEEPER. Your dreams are sweet and long enough.

  • 16 to 24: YOUR SLEEP DEBT IS GROWING. Since you can't cram more hours into a day, try leaving a few things out: Let your kids go to bed without a bath or permit yourself to serve a family meal that doesn't contain all the basic food groups. One activity to make more time for is exercise. A workout during the day--though not within three hours of bedtime, when it can wind you up--helps many folks sleep better. And regardless of the pace of your day, unwind before bedtime by reading, knitting, watching television, or doing whatever relaxes you. By the way, making love is believed by many researchers to be the best natural sedative of all.

  • 25-30: YOU'RE EXHAUSTED. Researchers suggest you force yourself to go to bed an hour or so earlier for at least ten days. Keep a diary noting how refreshed you feel and how "your ability to carry out difficult tasks improves during the experiment; the extra Zs may be all you need. But if that doesn't do the trick, you may suffer from depression, insomnia, or sleep apnea, a condition that recent research found causes its typically unknowing sufferers (9 percent of women, 24 percent of men) to stop breathing dozens of times a night for up to a minute at a stretch.

"How sleep deprived are you?", Valeri Fahey, Health, Sept. 1993, Vol 7 Issue 5


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Acupuncture

  • Don’t know

  • ‘ I ‘ SOR

  • Cochrane

  • www.cochrane.org/reviews/en/ab005472.html


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Useful Websites

  • The sleep IQ test:

    http://www.sleepfoundation.org/nsaw/sleepiq99i.cfm

  • Sleep meditation quilt square: A couple of simple things to remember and a cool site.http://www.irvingstudios.com/child_abuse_survivor_monument/Water_files/water14_help_with_sleep/help_with_sleep.html

  • Practice parameters for treating chronic primary insomnia in the elderly. Nat’l. Guideline Clearinghouse; www.guidelines.gov

  • http://cks.library.nhs.uk/insomnia/view_whole_guidance


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Bibliography

  • Manifestations & management of chronic insomnia in adults. NIH Consensus & Stae-of-the-Science Statements, Vol 22, # 2, June 13-15, 2005.

  • Silber MH. Chronic insomnia. NEJM. 2005;353:803-10

  • Summers Mo, et al. Recent developments in the classification, evaluation & treatment of insomnia. Chest. 2006; 130: 276-86

  • International Classification of Sleep Disorders

    : Diagnostic & Coding Manual. Amer Acad Sleep Medicine, 2005.


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Bibliography

  • Ozminkowski, RJ et al. The direct and indirect costs of untreated insomnia in adults in the US. Sleep. 2007;30:263-73.

  • Candaras MM. Sleep Review 2006;7: 38

  • Ramakrishnan K. Treatment options for insomnia. AFP 2007;76:517-26, 527-8.


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Benzodiazepines

  • Name ½ life Dose Metab?

  • Estazolam 12-15 1-2 No

  • Flurazepam 8 15-30 Yes

  • Quazepam 39 7.5-15 Yes

  • Temazepam 10-15 15-30 No

  • Triazolam 2 0.125-.25 No

  • Lorazepam

  • Clonazepam


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