It focuses on sleep medicine - sleep disorders, sleep stages, DSM classification, types, classifications, and pharmacological and non pharmacological management.

1. INSOMNIA & SLEEP MEDICINE
PRESENTED BY: DR KD DELE
DEPT. OF FAMILY MEDICINE
DORA NGINZA HOSPITAL

2. SLEEP IS….
• Active
• Complex
• Highly Regulated
• Involves different areas in the brain
• Purpose is not understood
• Essential to life/necessary
• We all do it

3. SLEEP DISORDERS…
• Sleep disorders are common
• Sleep disorders are serious
• Sleep disorders are treatable
• Sleep disorders are underdiagnosed

4. SLEEP STAGES
• Non-Rapid eye movement (NREM)
• Stage 1: transition to sleep, 5% of total time
• Stage 2: 50% of total time
• Stage 3 & 4: Most restorative sleep , slow wave sleep, 20-25% of
total sleep time
• Rapid eye movement (REM): 20-25% of total sleep time (When we
dream)

5. STAGES OF NREM
• Stage 1:
• Produces sleep cycle brain waves referred to as Theta waves,
consisting of a 4-7 cycle per second rhythm. Light sleep
• Stage 2:
• The brain generates sleep spindles. Spindles are a 12-14 rhythm that
lasts a half of a second. Sleep talking usually occurs during stages 1
and 2 of NREM sleep. Sleep talking is usually mumbled and not fully
understandable.

6. STAGES OF NREM
• Stage 3:
• Delta waves are produced during this stage. These brain waves
become slower when the sleep cycle begins. During this stage the
heart rate, blood pressure and arousal decline.
• Stage 4:
• Very similar to stage 3 because Delta waves continue in the brain.
During this stage of sleep most dreams and nightmares occur.

7. SLEEP STAGES

8. REM &
NON-REM
NON-RAPID EYE MOVEMENT (NREM)
Light sleep to deep
Lasts 4-7 hours a night
RAPID EYE MOVEMENT (REM)
increased RR, irregular, shallow
Increased HR, BP
Jerky eyes
Temporary paralysis
Erections
Lose temperature regulation

9. SLEEP STAGES
• Normal sleep starts with stage 1-2-3-4-3-2-REM
• The cycle repeats at 10-120 (90) minute intervals
• There are 3 to 4 cycles a night
• Stage 3 & 4 are more prominent in the first half of the night and
decrease as time goes on
• REM is less prominent in the first half of the night and increases as
time goes by

10. SLEEP CYCLE

11. iNSOMNIA

12. INSOMNIA
• insomnia is difficulty
falling asleep or
staying asleep, even
when a person has the
chance to do so.

13. DIAGNOSTIC CRITERIA: DSM-5
• The predominant complaint is a global sleep dissatisfaction with one
or more of the following symptoms:
1. Difficulty initiating sleep (in children: without caregiver
intervention).
2. Difficulty maintaining sleep (e.g., frequent or prolonged
awakenings with difficulty returning to sleep) (in children:
without caregiver intervention).
3. Early morning awakening (e.g., premature awakening with
inability to return to sleep).
4. Nonrestorative sleep (adults).
5. Resistance to going to bed (children).

14. DIAGNOSTIC CRITERIA: DSM-5
• In addition…
• The sleep disturbance causes clinically significant distress or
impairment in social, occupational, educational, academic,
behavioural, or other important areas of functioning.
• The sleep difficulty occurs at least 3 nights per week.
• The sleep difficulty is present for at least 3 months.
• The sleep difficulty occurs despite adequate opportunity for sleep.

15. DIAGNOSTIC CRITERIA: DSM-5
• In addition…
• The insomnia is not better explained by and does not occur
exclusively during the course of another sleep-wake disorder
(e.g., narcolepsy, a breathing-related sleep disorder, a circadian
rhythm sleep-wake disorder, a parasomnia).
• The insomnia is not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication).
• Coexisting mental disorders and medical conditions do not
adequately explain the predominant complaint of insomnia.

16. RISK FACTORS
• increasing age- esp. >60 d.t health and sleep pattern changes
• Females- hormones esp. menstruation and menopause
• psychiatric illness- may be a symptom for
• medical co-morbidities
• impaired social relationships
• Shift workers
• Travel long distances

17. TYPES
• Insomnia can be classified as transient, acute, or chronic.

18. TRANSIENT INSOMNIA
• Transient insomnia lasts for less than a week.
• It can be caused by another disorder, by changes in the sleep
environment, by the timing of sleep, severe depression, or by
stress.
• Its consequences – sleepiness and impaired psychomotor
performance – are similar to those of sleep deprivation.

19. ACUTE INSOMNIA
• Acute insomnia is the inability to consistently sleep well for a
period of less than a month.
• Insomnia is present when there is difficulty initiating or
maintaining sleep or when the sleep that is obtained is non-
refreshing or of poor quality.
• These problems occur despite adequate opportunity and
circumstances for sleep and they must result in problems with
daytime function.
• Acute insomnia is also known as short term insomnia or stress
related insomnia.

20. ACUTE INSOMNIA: CAUSES
• Situational stress (e.g., occupational, interpersonal, financial,
academic, medical, jet lag)
• Withdrawal from substances
• Environmental stressors (e.g., noise, hospitalization)
• Death or illness of a loved one

21. CHRONIC INSOMNIA
• Chronic insomnia lasts for longer than a month.
• It can be caused by another disorder, or it can be a primary disorder.
• People with high levels of stress hormones or shifts in the levels of
cytokines are more likely than others to have chronic insomnia.
• Its effects can vary according to its causes.
• They might include muscular weariness, hallucinations, and/or
mental fatigue.
• Chronic insomnia can cause double vision.

22. CAUSES OF CHRONIC INSOMNIA
• Primary sleep disorder
• idiopathic, central sleep apnoea, restless leg syndrome
• Psychiatric conditions:
• anxiety, depression, mania, schizophrenia

23. CAUSES OF CHRONIC INSOMNIA
• Medications and substances:
• Anticholinergic agents; antidepressants (SSRIs,bupropion,
antiepileptics, nicotine , oral contraceptives, thyroid, ETOH
withdrawal
• Medical disorders:
• cancer, chronic pain, congestive heart failure, COPD, end-stage
renal disease, gastroesophageal reflux disease, HIV/AIDS,
hyperthyroidism, nocturia

24. EVALUATION OF INSOMNIA

26. EVALUATION: SLEEP DIARY
• A two-week sleep diary should record information on bedtime,
rising time, daytime naps, sleep-onset latency, number of
nighttime awakenings, total sleep time, and the patient's mood
on arousal.
• Questions should include daytime symptoms such as somnolence
and frequency of napping.

27. EVALUATION: Actigraphy
• An activity monitor or motion detector, typically
worn on the wrist, records movement.
• The absence of movement for a given continuous
period is consistent with sleep.
• Usually has a memory chip so better than a sleep
diary, objective.

28. EVALUATION: Polysomnography – multiple
sleep latency testing(MSLT)
• Polysomnography -multiple sleep latency testing(MSLT)
• Useful if sleep apnea or periodic limb movement disorder is
suspected.
• Measures brain and muscle activity and oxygen saturation
• Used when behavioral and psychopharmacologic treatments are
unsuccessful

29. EVALUATION: Neuroimaging
• Neuroimaging
• Indicated if a structural lesion (e.g., mass lesion, arteriovenous
malformation) is suspected on history and examination

30. TREATMENTS FOR INSOMNIA

31. Treatment: Nonpharmacologic Treatments for Insomnia
• Cognitive behavioural therapy
• Helps change incorrect beliefs and attitudes about sleep (e.g.,
unrealistic expectations, misconceptions amplifying consequences of
sleeplessness)
• keep regular bedtime and wake time
• Relaxation therapy
• Tensing and relaxing different muscle groups;
• breathing exercises,
• guided imagery meditation;
• hypnosis.

32. Treatment: Non-pharmacologic Treatments for Insomnia
• Sleep hygiene
• Associate time spent in bed with time spent sleeping. E.g go to
bed when sleepy and get out if you’ve been awake 20 min.
• Remain passively awake
• Light therapy (stimulus control) - Used to change your internal
clock

33. Good sleeping habits (sleep hygiene):
• Before getting into bed –
• Establish a routine for bedtime
• Create a positive sleep environment
• Relax before getting into bed
• Avoid alcohol, smoking and caffeine for at least a few hours
before bedtime
• Do not go to bed unless you are sleepy
• Reduce exposure to electronics (e.g., smartphones, tablets)
within one hour of bedtime; it’s best to keep these out of the
bedroom

34. Good sleeping habits:
• While in bed –
• Turn your clock around and use your alarm, if needed
• If you can’t fall asleep in 20 minutes, get out of bed and do
something relaxing until you are sleepy
• Use your bed for sleep only

35. Good sleeping habits:
• In the morning and daytime –
• Wake up at the same time each morning, even on weekends
• Avoid daytime naps
• Avoid caffeine, especially in the late afternoon and evening
• Exercise regularly, but not within four hours of bedtime

36. ALTERNATIVE THERAPY
• Acupuncture
• Yoga
• Meditation
• Herbal and over the counter meds:
• Melatonin- normally produced by the body,
considered safe for use for a few weeks only
• Valerian- dietary supplement, mildly
sedating. ? increased risk of liver damage,
taper off
• Lavender, St Johns wort
• Alcohol- CNS stimulant and depressant, !abuse

37. PHARMACOLOGIC THERAPY
• Guidelines for Prescribing Hypnotics
• Initiate hypnotic use while identifying and addressing specific behaviours,
circumstances, and underlying disorders contributing to insomnia
• Prescribe the lowest effective dose of the hypnotic
• Prescribe hypnotics for short durations (two to four weeks) and intermittently
(duration based on patient's return to an acceptable sleep cycle)
• Avoid hypnotic use or exercise caution if patient has a history of substance
abuse, myasthenia gravis, respiratory impairment, or acute CVA
• Watch for requests for escalating doses or resistance to tapering or
discontinuing hypnotics
• Hypnotics should be discontinued gradually (i.e., tapered); physician should be
alert for adverse effects (especially rebound insomnia) and withdrawal
phenomena

38. BENZODIAZEPINE HYPNOTICS
• Benzodiazepines bind to GABA and GABA-A receptors, acting as
antagonists
• Benzodiazepines increase sleep time and improve sleep quality by
reducing sleep-onset latency and wakefulness after sleep onset and by
increasing sleep efficiency .
• Tolerance and dependence occur with prolonged use (more than four
weeks use increases the likelihood of dependence)
• Estazolam, flurazepam, triazolam, and temazepam are all examples

39. NON BENZODIAZEPINE HYPNOTICS
• The newer nonbenzodiazepines selectively bind to type 1
benzodiazepine receptors in the CNS.
• Unlike benzodiazepines, the non benzodiazepines have minimal impact
on NREM sleep stages and no REM sleep rebound.
• Nonbenzodiazepines undergo hepatic degradation, and doses should be
reduced in older patients and in those with hepatic dysfunction or
kidney disease.
• They can cause impaired memory and psychomotor retardation.
• Zolpidem, zaleplon and eszopiclone are all examples

40. ANTIHISTAMINES
• Nearly 25 percent of patients with insomnia use over-the-counter
sleep aids .
• Only minimally effective in inducing sleep
• May reduce sleep quality
• Can cause residual drowsiness.
• E.g diphenhydramine and doxylamine

41. ANTIDEPRESSANTS
• Produce sedation by blocking acetylcholine, noradrenalin, and
serotonin presynaptic receptors.
• Good for patients with insomnia and coexisting depression.
• For insomnia alone use low doses.
• e.g. amitriptyline, remero, oleptro

42. OTHERS
• Other drug options:
• Barbiturates
• Opiates – good in pain induced insomnia, produce sedation and analgesia

44. THANK YOU