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  1. 1. INSOMNIA Liphard O. D’Souza, M.D. Diplomate: American Academy of Sleep Medicine 6128 E. 38 th St., Ste. 303 Tulsa, OK 74135 (918) 523-8572
  2. 2. Insomnia <ul><li>A broad term denoting unsatisfactory sleep </li></ul><ul><li>Perception that sleep is inadequate or abnormal </li></ul><ul><li>Common problem </li></ul><ul><li>A symptom, not a disease or sign, therefore difficult to measure </li></ul>
  3. 3. Diagnosis <ul><li>Complaint that the sleep is: </li></ul><ul><ul><li>Brief or inadequate </li></ul></ul><ul><ul><li>Light or easily disrupted </li></ul></ul><ul><ul><li>Non-refreshing or non-restorative </li></ul></ul>
  4. 4. International Congress of Sleep Disorders Classification <ul><li>Based on the duration of symptoms </li></ul><ul><li>Transient or acute </li></ul><ul><ul><li>Few days to 2-4 weeks </li></ul></ul><ul><li>Chronic </li></ul><ul><ul><li>Persisting for more than 1-3 months </li></ul></ul>
  5. 5. Definitions <ul><li>Mild </li></ul><ul><ul><li>Almost nightly complaint of non-restorative sleep </li></ul></ul><ul><ul><li>Associated with little or no impairment of social or occupational functioning </li></ul></ul><ul><li>Moderate </li></ul><ul><ul><li>Nightly complaints of disturbed sleep </li></ul></ul><ul><ul><li>Mild to moderate impairment of social or occupational function </li></ul></ul><ul><li>Severe </li></ul><ul><ul><li>Nightly complaints of disturbed sleep </li></ul></ul><ul><ul><li>Severe daytime dysfunction </li></ul></ul>
  6. 6. Classification <ul><li>Sleep initiating insomnia </li></ul><ul><li>Sleep maintaining insomnia </li></ul><ul><li>Early morning insomnia </li></ul><ul><ul><li>Short period of sleep </li></ul></ul><ul><li>Non-restorative sleep </li></ul><ul><ul><li>Multiple awakenings </li></ul></ul><ul><ul><li>Combination of above patterns </li></ul></ul>
  7. 7. Presentation Goals <ul><li>Review of normal sleep cycle </li></ul><ul><li>Causes of insomnia </li></ul><ul><li>Diagnosis and assessment of insomnia </li></ul><ul><li>Treatment modalities </li></ul>
  8. 8. Stages of Sleep <ul><li>Non-Rapid Eye Movement (NREM) sleep </li></ul><ul><ul><li>Stage I </li></ul></ul><ul><ul><li>Stage II </li></ul></ul><ul><ul><ul><li>Stages I & II are light sleep </li></ul></ul></ul><ul><ul><li>Stage III </li></ul></ul><ul><ul><li>Stage IV </li></ul></ul><ul><ul><ul><li>Stages III & IV are deep sleep </li></ul></ul></ul><ul><li>Rapid Eye Movement (REM) sleep </li></ul>
  9. 9. Normal Sleep Pattern
  10. 10. <ul><li>Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.) </li></ul><ul><li>Why do we sleep? </li></ul><ul><ul><li>Not clear, but has to do with regeneration (NREM) and brain development/memory (REM) – REM sleep is essential for the development of the mammalian brain </li></ul></ul><ul><ul><li>Stages III & IV are involved in synaptic “pruning and tuning” </li></ul></ul><ul><li>Why do we get sleepy? </li></ul><ul><ul><li>Circadian factors </li></ul></ul><ul><ul><li>Process S: linear increase in sleepiness </li></ul></ul><ul><ul><li>Process C: rhythmic fluctuations of the circadian alert system </li></ul></ul><ul><ul><li>Other factors: sleep duration, quality, time awake, etc. </li></ul></ul>
  11. 11. Causes <ul><li>Insomnia is a downstream symptom of an upstream problem, for example: </li></ul><ul><ul><li>Medical </li></ul></ul><ul><ul><li>Psychological/ Psychiatric </li></ul></ul><ul><ul><li>Behavioral </li></ul></ul><ul><ul><li>Parasomnias </li></ul></ul><ul><ul><li>Drug-induced </li></ul></ul><ul><ul><li>Combination of factors in chronic insomnia </li></ul></ul>
  12. 12. Normal Sleep Values <ul><li>Normal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle </li></ul><ul><li>4-6 NREM/REM cycles per night </li></ul><ul><li>Sleep structure changes throughout life </li></ul><ul><li>Wakefulness after sleep </li></ul><ul><ul><li>Less than 30 minutes </li></ul></ul><ul><li>Sleep Onset Latency (SOL) </li></ul><ul><ul><li>Less than 30 minutes </li></ul></ul><ul><li>REM Sleep Latency </li></ul><ul><ul><li>70-120 minutes </li></ul></ul>
  13. 13. Epidemiology <ul><li>Studies throughout the world show that it occurs everywhere </li></ul><ul><li>Depending on the area, study, etc., between 10-50% of the population are affected </li></ul><ul><li>Increases with age </li></ul><ul><li>Twice as common in females </li></ul><ul><ul><li>Up to the age of 30, there is little difference between sexes </li></ul></ul><ul><ul><li>Beyond 30 years, it is more common in females </li></ul></ul><ul><ul><li>Beyond 70 years, females are affected twice as much as males </li></ul></ul>
  14. 14. Etiology <ul><li>Symptom of numerous diverse etiologies </li></ul><ul><li>Usually due to more than one factor and each needs a separate evaluation </li></ul><ul><li>In all cases, one should strive to find the cause as it will dictate the proper treatment </li></ul>
  15. 15. 3 P’s of Acute Insomnia <ul><li>Predisposition </li></ul><ul><ul><li>Anxiety, depression, etc. </li></ul></ul><ul><li>Precipitation </li></ul><ul><ul><li>Sudden change in life </li></ul></ul><ul><li>Perpetuation </li></ul><ul><ul><li>Poor sleep hygiene </li></ul></ul><ul><li>Precipitating causes lower the threshold for acute insomnia in people with predisposing and perpetuating causes as well as further lowers the threshold for chronic insomnia </li></ul><ul><li>Start aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia </li></ul>
  16. 16. Acute Insomnia <ul><li>Resolves with the management of inciting factors </li></ul><ul><li>Adjustment sleep disorder </li></ul><ul><ul><li>Acute stress such as momentous life events or unfamiliar sleep environments </li></ul></ul><ul><ul><li>PSG: increased SOL, increased awakenings and sleep fragmentation with poor sleep efficiency </li></ul></ul><ul><ul><li>More common in women and those with anxiety </li></ul></ul><ul><li>Jet Lag </li></ul><ul><ul><li>Symptoms last longer with eastbound travel </li></ul></ul><ul><ul><li>Remits spontaneously in 2-3 days </li></ul></ul><ul><ul><li>More common in the elderly </li></ul></ul>
  17. 17. Chronic Insomnia <ul><li>Primary or Intrinsic </li></ul><ul><li>Secondary or Extrinsic </li></ul><ul><li>Causes </li></ul><ul><ul><li>Changes in circadian rhythm, behavior, environment </li></ul></ul><ul><ul><li>Body movements in sleep </li></ul></ul><ul><ul><li>Medical, neurological, psychiatric disorders </li></ul></ul><ul><ul><li>Drugs </li></ul></ul>
  18. 18. Primary/Intrinsic Insomnia <ul><li>Idiopathic </li></ul><ul><ul><li>Starts early in childhood, rare but relentless course </li></ul></ul><ul><ul><li>Rare disorders affect both genders </li></ul></ul><ul><ul><li>CNS abnormalities, unknown etiology, etc. </li></ul></ul><ul><li>Sleep State Misinterpretation (5%) </li></ul><ul><ul><li>Underestimate of the sleep obtained </li></ul></ul><ul><ul><li>Females affected more than males </li></ul></ul><ul><li>Psychophysiological insomnia (30%) </li></ul><ul><ul><li>Maladaptive sleep-preventing behaviors develop and progress to become dominant factors </li></ul></ul><ul><ul><li>Females more than males </li></ul></ul>
  19. 19. Secondary/Extrinsic Insomnia <ul><li>Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness </li></ul><ul><ul><li>Advanced sleep phase syndrome </li></ul></ul><ul><ul><li>Delayed sleep phase syndrome </li></ul></ul><ul><ul><li>Irregular sleep/wake patterns </li></ul></ul><ul><ul><li>Non-24 hour sleep/wake syndrome </li></ul></ul><ul><ul><li>Shift work sleep disorder </li></ul></ul><ul><ul><li>Short sleeper </li></ul></ul>
  20. 20. <ul><li>Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep </li></ul><ul><ul><li>Inadequate sleep </li></ul></ul><ul><ul><li>Limit setting sleep disorder </li></ul></ul><ul><ul><li>Nocturnal eating/drinking syndrome </li></ul></ul><ul><ul><li>Sleep onset association disorder </li></ul></ul><ul><li>Environmental factors </li></ul><ul><ul><li>Environmental sleep disorder </li></ul></ul><ul><ul><li>Food allergy insomnia </li></ul></ul><ul><ul><li>Toxin-induced sleep disorder </li></ul></ul>
  21. 21. <ul><li>Movement disorders </li></ul><ul><ul><li>PLMS disorder (5%) </li></ul></ul><ul><ul><li>RLS syndrome (12%) </li></ul></ul><ul><ul><li>REM behavior disorder </li></ul></ul><ul><li>Medical Disorders: Respiratory </li></ul><ul><ul><li>Altitude insomnia </li></ul></ul><ul><ul><li>Central alveolar hypoventilation syndrome </li></ul></ul><ul><ul><li>Central apnea syndrome </li></ul></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>OSAS (4-6%) </li></ul></ul><ul><ul><li>Sleep-related asthma </li></ul></ul>
  22. 22. <ul><li>Medical: Cardiac </li></ul><ul><ul><li>Nocturnal myocardial ischemia </li></ul></ul><ul><li>Medical: GI </li></ul><ul><ul><li>Peptic ulcer disease </li></ul></ul><ul><ul><li>GERD </li></ul></ul><ul><li>Medical: Musculoskeletal </li></ul><ul><ul><li>Fibromyalgia </li></ul></ul><ul><ul><li>Arthritis </li></ul></ul><ul><li>Medical: Endocrine </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><li>Cushing’s disease </li></ul></ul><ul><ul><li>Menstrual cycle association </li></ul></ul><ul><ul><li>Pregnancy </li></ul></ul>
  23. 23. <ul><li>Medical: Neurological </li></ul><ul><ul><li>Cerebral degeneration disorder </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Fatal familial insomnia </li></ul></ul><ul><ul><li>Parkinson’s disease </li></ul></ul><ul><ul><li>Sleep related epilepsy </li></ul></ul><ul><ul><li>Sleep related headaches </li></ul></ul><ul><li>Medical: Psychiatric </li></ul><ul><ul><li>Alcoholism </li></ul></ul><ul><ul><li>Anxiety disorders </li></ul></ul><ul><ul><li>Mood disorders </li></ul></ul><ul><ul><li>Panic disorders </li></ul></ul><ul><ul><li>Psychosis </li></ul></ul><ul><ul><li>Drug dependency </li></ul></ul>
  24. 24. <ul><li>Pharmacological causes </li></ul><ul><ul><li>Alcohol dependent sleep disorder </li></ul></ul><ul><ul><li>Hypnotic dependent sleep disorder </li></ul></ul><ul><ul><li>Stimulus dependent sleep disorder </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><ul><li>B-blockers </li></ul></ul></ul><ul><ul><ul><li>Theophylline </li></ul></ul></ul><ul><ul><ul><li>L-dopa </li></ul></ul></ul>
  25. 25. Parasomnia Events <ul><li>Physical phenomena occurring in sleep </li></ul><ul><ul><li>Confusional arousals </li></ul></ul><ul><ul><li>Nightmares </li></ul></ul><ul><ul><li>Nocturnal leg cramps </li></ul></ul><ul><ul><li>Nocturnal paroxysmal dystonia </li></ul></ul><ul><ul><li>REM sleep behavior disorder </li></ul></ul><ul><ul><li>Rhythmic movement disorder </li></ul></ul><ul><ul><li>Painful erections </li></ul></ul><ul><ul><li>Sleep starts </li></ul></ul><ul><ul><li>Sleep terrors </li></ul></ul><ul><ul><li>Sleep walking </li></ul></ul><ul><ul><li>Abnormal swallowing </li></ul></ul><ul><ul><li>Hyperhidrosis </li></ul></ul><ul><ul><li>Laryngospasms </li></ul></ul>
  26. 26. Physical, Emotional, and Cognitive Effects of Insomnia <ul><li>Mood changes, irritability, poor concentration, memory defects, etc. </li></ul><ul><li>Impairs creative thinking, verbal processing, problem solving </li></ul><ul><li>Risk of errors, accidents due to excessive daytime sleepiness </li></ul><ul><ul><li>Markedly increases if awake more than 16-18 hours (micro-sleep attacks) </li></ul></ul><ul><li>Increased appetite, decreased body temperature </li></ul><ul><li>Physiologic effects </li></ul><ul><ul><li>Rats die after 11-12 days of sleep deprivation </li></ul></ul><ul><ul><li>Hippocampal atrophy in chronic jet lag or shift work </li></ul></ul>
  27. 27. Evaluation <ul><li>HISTORY! </li></ul><ul><ul><li>Precipitating factors </li></ul></ul><ul><ul><li>Psychiatric and medical disturbances </li></ul></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Sleep hygiene </li></ul></ul><ul><ul><li>Circadian tendencies </li></ul></ul><ul><ul><li>Cognitive distortions and conditional arousals </li></ul></ul><ul><li>Sleep diary </li></ul>
  28. 28. Evaluation <ul><li>PSG </li></ul><ul><ul><li>if PLMS or sleep-related breathing disorder or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASM </li></ul></ul><ul><ul><li>Not routinely employed in the evaluation of transient or chronic insomnia </li></ul></ul><ul><ul><li>Should not be substituted for a careful clinical history </li></ul></ul>
  29. 29. Epworth Sleepiness Scale <ul><li>A good measure of excessive daytime sleepiness. How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would affect you. Use the following scale to choose the most appropriate number for each situation: </li></ul><ul><li>0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance </li></ul><ul><li>Sitting and reading ____ </li></ul><ul><li>Watching TV ____ </li></ul><ul><li>Sitting inactive in a public place (ex. theater, meeting) ____ </li></ul><ul><li>As a passenger in a car for an hour without a break ____ </li></ul><ul><li>Lying down to rest in the afternoon ____ </li></ul><ul><li>Sitting and talking to someone ____ </li></ul><ul><li>In a car, while stopped for a few minutes in traffic ____ </li></ul><ul><li>____ Total Score </li></ul><ul><li>Normal < 10 Severe > 15 </li></ul>
  30. 30. Insomnia questionnaire <ul><li>I have real difficulty falling asleep. </li></ul><ul><li>Thoughts race through my mind and this prevents me from sleeping. </li></ul><ul><li>I wake during the night and can’t go back to sleep. </li></ul><ul><li>I wake up earlier in the morning than I would like to. </li></ul><ul><li>I’ll lie awake for half an hour or more before I fall asleep. </li></ul><ul><li>I anticipate a problem with sleep almost every night </li></ul><ul><li>If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep. </li></ul>
  31. 31. Treatment Selection <ul><li>Meet and educate about disease, goals, options, side effects, and document safety. </li></ul><ul><li>Identify the 3 P’s. </li></ul><ul><li>Intrinsic v. Extrinsic </li></ul><ul><li>Treat perpetuating causes </li></ul><ul><ul><li>Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT </li></ul></ul>
  32. 32. CBT <ul><li>Longest lasting improvements, assuming the precipitating cause is dealt with </li></ul><ul><li>“ counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances </li></ul><ul><li>Identifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones </li></ul>
  33. 33. CBT Examples <ul><li>“I need more hours of sleep or I will not function” </li></ul><ul><li>“I can never die” </li></ul><ul><li>Uses restructuring techniques </li></ul><ul><li>Short circuit cycle of insomnia, cognitive distortions, distress </li></ul><ul><li>Sleep hygiene, relaxation, stimulus control, sleep restrictions </li></ul>
  34. 34. Sleep Hygiene <ul><li>Exercise earlier during the day, and no more than 4-6 hours before sleep </li></ul><ul><li>Keep bedroom dark and quiet, to be used only for sex or sleep </li></ul><ul><li>Curtail time in bed to only when sleepy </li></ul><ul><li>Fixed sleep/wake times for 365 days </li></ul><ul><li>Avoid naps </li></ul><ul><li>Avoid stimulus or stimulating activities before sleep or in bed </li></ul><ul><li>No alcohol at least 4 hours before sleep, no caffeine after noon, and quit smoking!! </li></ul><ul><li>Light snack before bedtime </li></ul>
  35. 35. Stimulus Control <ul><li>Use bedroom for sleep or sex only </li></ul><ul><li>Go to bed only when tired and sleepy </li></ul><ul><li>Remove clock from the bedroom to avoid constantly watching it </li></ul><ul><li>Regular sleep/wake times </li></ul><ul><li>Light therapy if required </li></ul><ul><li>No bright lights when you wake up at night </li></ul>
  36. 36. Sleep Restriction <ul><li>An effective form of treatment </li></ul><ul><li>Estimate the time actually asleep then limit bedtime to that amount, but no less than 5 hours </li></ul><ul><li>Add time in bed gradually once the patient sleeps more than 85% of that time </li></ul>
  37. 37. Pharmacotherapy <ul><li>Nationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics </li></ul><ul><ul><li>Trazadone </li></ul></ul><ul><ul><li>Seroquel </li></ul></ul><ul><li>Self-medication with alcohol and over-the-counter medications </li></ul><ul><ul><li>Benadryl </li></ul></ul><ul><ul><li>Nyquil </li></ul></ul>
  38. 38. Hypnotics <ul><li>5 questions to ask when choosing a hypnotic: </li></ul><ul><ul><li>Are you looking for sleep initiation or maintenance? </li></ul></ul><ul><ul><li>What are the daytime residual effects of the drug? </li></ul></ul><ul><ul><li>Does tolerance develop to this drug? </li></ul></ul><ul><ul><li>Will rebound withdrawal insomnia occur when discontinued? </li></ul></ul><ul><ul><li>What is the half-life of the medication? </li></ul></ul>
  39. 39. Benzodiazepines     A nonbenzodiazepam   Dose Half-life Comments Flurazepam(Dalmane) 15,30 mg Long Daytime drowsiness common; rarely used Clonazepam(Klonopin) 0.5-2 mg Long Used for PLM, REM behavior disorder; can cause morning drowsiness Temazepam (Restoril) 15,30 mg Intermediate   Estazolam (ProSom) 1-2 mg Intermediate Can cause agranulocytosis Triazolam (Halcion) 0.125,0.25 mg Short Rebound insomnia may occur Zolpidem (Ambien) 5,10 mg Short A nonbenzodiazepam Zopliclone (Sonata) 5,10 mg Short , 1-1.5 hours    
  40. 40. Recent Medication Additions <ul><li>Eszopiclone 1,2,3 mg Intermediate </li></ul><ul><ul><ul><ul><ul><li>Approved for chronic insomnia </li></ul></ul></ul></ul></ul><ul><li>(Lunesta) Action 6-8 hrs. </li></ul><ul><li>Zolpidem 10 mg Action same as above </li></ul><ul><li>(Amvien CR) </li></ul><ul><li>Rozerem </li></ul><ul><li>(Ramelton) </li></ul>
  41. 41. Alternative Medications <ul><li>Antidepressants </li></ul><ul><ul><li>Not much research </li></ul></ul><ul><ul><li>Some, including SSRIs, can cause daytime drowsiness </li></ul></ul><ul><li>Melatonin </li></ul><ul><ul><li>Good for jet leg, especially in elderly, but not much information on long-term use </li></ul></ul><ul><ul><li>Reported to cause depression, vasoconstriction </li></ul></ul><ul><li>Benadryl </li></ul><ul><ul><li>Rarely indicated, can cause a hangover </li></ul></ul><ul><li>Herbal supplements </li></ul><ul><ul><li>Use in conjunction with a sleep log </li></ul></ul>
  42. 42. Conclusion <ul><li>Insomnia is a complex symptom with many causes and perpetuating influences </li></ul><ul><li>It is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treated </li></ul><ul><li>It should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder </li></ul><ul><ul><li>Depression in turn confers an increased risk of suicide, cardiovascular disease, death, etc. </li></ul></ul>