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InsomniaIs Not An Ambien Deficiency Disease

10 Essential Questions

Janet E. Tatman, PhD, PA-CFellow American Academy of Sleep Medicine

Certified in Behavioral Sleep Medicine

“I Can’t Sleep”

EITHER• c/o difficulty initiating or maintaining sleep• early morning awakening• resistance to a reasonable bedtime• difficulty sleeping w/o parent or caregiver intervention

WITH• negative health, behavioral, social or occupational effects

FOR• at least 3 X per week for at least 3 months (chronic)

International Classification of Sleep Disorders, 3rd Ed

Chronic = 10% of populationShort term = 30-35% in any given year

How Much Sleep DoWe Need?

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Wisconsin Sleep Cohort Data

Taheri et al 2004

7.7 hrs sleep predicted minimum BMIN = 1024

Getting Enough Sleep

Recommended Amount of Sleep for a Health Adult: A Joint Consensus Statement of the

American Academy of Sleep Medicine and Sleep Research Society

7 or more hours

SLEEP, Vol 38, No 6, 2015

Respect Individual Differences

…best indicator of an individual’s need for sleep is the amount that is

required to feel rested and well the next day

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Normal Variants

•Short sleeper

•Long sleeperand

•Older sleepers

Problems Sleeping

(Is insomnia a “disease” or a “symptom?”)

Bottom line?…

…it may be a “symptom”(of something else)

…and is often a “disease”(in its own right)

…skilled history-taking can reveal the difference

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Sleep History

• Rule in or out• Restless Legs Syndrome

• Sleep Disordered Breathing

• Parasomnia, especially Nightmares or Sleep-Related Eating Disorder

• Evaluate sleep/wake schedule

Timing Is Everything

• Encourage a separate appointment whenever possible

• Emphasize how important resolving this problem is for short and long term health

• Help the patient feel how seriously you take their problem

Probes

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Questions 1 & 2

• After getting into bed, if you had to lie completely still without moving for 15 minutes, could you do it?

• Does your bedpartner c/o that you move around too much before or during sleep?

• Are you “fidgety” in the evening before bed or after getting into bed?

• Do you get any disagreeable sensations that go away when you move?

RLS as Risk Factor• Depression occurs in 40% of RLS patients

• Blood pressure increases significantly after each leg kick (PLMS)

• Heart rate increases significantly after each leg kick (PLMS)

• After controlling for age, sex, race, BMI, diabetes, BP, BP meds, cholesterol status, and smoking history…

…the odds ratio for the presence of cardiovascular disease among RLS patients was 2.1…

…for those with symptoms 16-23 nights per month it was 3.5

Winkelman et al 2008

The REST Study

• RLS Epidemiology, Symptoms, and Treatment

• Screening questionnaire (N = 23,052)• 11.1% w/ RLS sx• 3.4% were “sufferers” (sx 2+ times/wk plus negative daytime consequences)

• 65% of the “sufferers” consulted an MD in previous 12 months• Only 13% of these were actually given a correct diagnosis

• PCPs notes documented likely RLS sx in only 38% of the “sufferers”• But only 25% of these were actually given a diagnosis of RLS

Hening, W et al 2004

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Treatment?

• CHECK IRON STATUS! (Serum ferritin should be ≥ 50 g/L)

• Appropriate med, dosed carefully!

o Augmentation w/ dopamine agonists is in presence of low ferritin!*

• Regular monitoring

CAVEAT! — RLS is NOT diagnosable by sleep study!Periodic Limb Movements MAY be…

*Trenkwalder et al 2008

Questions 3 & 4• Do you snore? (Does it bother others in your household?)

• Has anyone ever told you that they could see you have pauses in breathing during sleep?

• Do you ever wake gasping, snorting, or short of breath?

• Do you have: HTN, cardiac disease, cerebrovascular disease, diabetes, metabolic syndrome, minimal cognitive impairment, excessive nocturia, etc.?

• Does the patient have retrognathia?

Question 5

• Do you have periods of the daytime when you’re really sleepy or

do you need a daily nap?

• Use EPWORTH SLEEPINESS SCALE (scores ≥ 10 are abnormal)

(See https://www.slhn.org/docs/pdf/neuro-epworthsleepscale.pdf)

CAVET!: Many insomniacs w/ sleep-disordered breathing are NOT sleepy!

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Epworth Sleepiness Scale Name: __________________________________ Today’s date: _________________Your age (Yrs): _______________ Your sex (M / F): _____________ 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 haven’t done some of these things recently try to work out how they would have affected you.

Use the following scale to choose the most appropriate number for each situation:0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

It is important that you answer each question as best you can. Situation Chance of Dozing (0-3)Sitting and reading

Watching TV

Sitting, inactive in a public place (e.g. a theatre or a meeting) _________

As a passenger in a car for an hour without a break

Lying down to rest in the afternoon when circumstances permit

Sitting and talking to someone

Sitting quietly after a lunch without alcohol

In a car, while stopped for a few minutes in the traffic

THANK YOU FOR YOUR COOPERATION©M.W. Johns 1990-97

[see John, MW. [1993] Chest 103:30-36]

Prevalence

• Patients with insomnia complaints are more likely to have untreated OSA:o 29% (N=200) older adults had moderate OSA (Gooneratneet et al, 2006)

o 29% (N=80) had moderate OSA and 43% had mild to moderate OSA (Lichstein et al, 2005)

o 67% (N=394) had mild to severe OSA (Guilleminaulet et al, 2005)

• Occult sleep disordered breathing in older vets w/ insomnia (Fung et al, 2013)

o N = 435, mean age 72 + 8o Prevalence of mild to moderate OSA was 47%

Question 6

• Any problems with bad dreams, nightmares, or physically acting out dreams? Injuries?

• Chronic nightmare sufferers & sleepwalkers often fear sleep / avoid it

• Patients w/ parasomnias (like REM Sleep Behavior Disorder) often are embarrassed about their symptoms…and may not tell you

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Treatment of Parasomnias With Risk of Injury

…such as REM Sleep Behavior Disorder, Sleepwalking, others

o Environmental (for safety) & medical

o Get a specialist very familiar with these disorders involved!

o Medication often needed for safety!

Behavioral Treatment of Nightmares

• Meta-analysis of 4 studies comparing prazosin & Imagery Rehearsal Therapy

o Equivalent results for nightmare frequency, sleep quality, and posttraumatic stress symptoms

o Adding CBT for insomnia to IRT showed improvement in sleep quality than prazosin

Seda, G 2015

Question 7

• Do you ever eat or fix food during the night with or without remembering it in the morning?

• How do you know this?• Please tell me of some instances.• Any weight gain?• Any associated changes in medication, life stress, etc?

May be triggered or worsened by certain meds!

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Sleep-Related Eating Disorder

• 17% in an inpatient eating disorders group had SRED• 9% in an outpatient eating disorders group

• 5% in an unselected university student group

• 60-83% are female

• Mean duration of symptoms prior to clinical presentation = 4-15 years

International Classification of Sleep Disorders, 3rd Ed.

Question 8

• Do you have trouble relaxing and feeling ready for bed?

• Consider RLS

• Consider anxiety / current stressors

• Consider substance misuse or abuse, e.g., Etoh, caffeine, drugs

• Consider lifestyle issues, e.g. work and domestic habits, late evening TV or other electronic device

Question 9

• Do you sleep much longer on weekends than during the week?

• LIFESTYLE / SCHEDULING!

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Corrective Strategies

• Get up at the same time every morning, 7 days per week!

• No napping, or at least no more than occasional 5 minute power naps.

• Have 1 - 1 ½ hours of routine “wind down” time before bed.

• Use additional behavioral treatments prn.

Question 10

• Could you please fill out this table about your sleep scheduling for me?

Sleep ScheduleUsual Earliest Latest

Bedtime

Lights out

Time it takes to get to sleep?

Wake time

Get up time

How many times do you wake up on an average night? How long does it take you to get back to sleep after waking up? How many naps do you take each day, and how long do they last?

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Analyzing the Sleep Schedule

• Understand that subjective estimates are often inaccurate—but they are actually quite valid as indicators of change over time

• Look for large irregularities or variability

• Note big discrepancies between time in or out of bed & actual sleep time

• Note napping and consider causes

Behavioral Treatments

…That Really Do Work!

Drugs vs. Behavioral Treatment

Comparable treatment effects

More rapid improvement w/ sleep medication

More sustained improvement w/Cognitive Behavioral Therapy for Insomnia

(CBT-I)

Morin et al 1999 JAMAMcClusky et al 1991 Am J Psychiatry

?

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Watch Out!

• Zolpidem is well known to trigger dangeroussleepwalking incidents, including sleep driving,as well as episodes of sleep-related eating

- possibly less likely w/ eszopiclone

COGNITIVE BEHAVIORAL THERAPY

• Relaxation Training

• Sleep Restriction Therapy

• Timed Bright Light Exposure

• Education in Realistic Expectations

-used singly or in combination

Relaxation Techniques

• physical and mental relaxationo relaxed breathing and body awarenesso pleasant mental imagery

• self-hypnosis, meditation

• biofeedback

• music

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Sleep Restriction Therapy

• used for highly fragmented sleep(problems with sleep maintenance)…especially w/ excessive time in bed

• ACCEPTS mild daytime sleepiness as atemporary side effect

• might take 6-8 weeks, often less

• probably retrains circadian/ultradian rhythms

Spielman et al 1987

Sleep Restriction Therapy: Pre and Post

Procedure for SRT Chose a realistic, restricted time in bed

Establish wake-up time, then calculate bedtime Plan activities thoughtfully Expect temporary difficulties Log sleep

If TIB is aggressively restricted, extend time in bed gradually in 15 min increments when sleep efficiency > 90%

Get the clock out of sight!

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Calculate average Time in Bed, average Total Sleep Time use these to choose new restricted Time in Bedl

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Contraindications to SRT

• ANY other primary disorder of sleep until treated (e.g., sleep apnea)

• Major depression or other acute or severe psychiatric disorder, until treated

• Circadian Rhythm Disorder

• Shift Work Sleep Disorder

Timed Bright Light Exposure

• resets circadian clock

• establishes new circadian phase

• time of exposure critical

• must be daily initially

Timed Bright Light Exposure

Be outdoors as early as possible after waking up in the morning for 30 min.

The activity does not matter and you can bein the shade. Just getting your eyes exposed toambient outdoor light is all that’s needed.

Start with 7 days a week; may cut back when things are stable to maybe 4-5 times / wk.

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Thoughts About Insomnia It’s a chemical imbalance I can’t control it I can’t function the next day I must get 8 hours every night A bad night predicts more bad

nights I’ll get really sick When I don’t sleep, I need to

stay in bed more

Concluding Thoughts

• “Insomnia” may be symptom or disease• Thorough screening for underlying cause(s) is warranted• Behavioral treatments often significantly preferable to meds• Behavioral treatments are not hard to learn and apply• PAs are well-positioned to become competent providers of

behavioral therapy for insomnia!

REFERENCES2005 Sleep in America Poll http://sleepfoundation.org/sites/default/files/2005_summary_of_findings.pdf

Brass, S et al. J Clin Sleep Med 2014;10(9):1025-1031.

Carskadon, M & Acebo C. SLEEP 2002;25(6);606-614.

Franco, R et al. J Clin Sleep Med 2008;4(10):45-49.

Fung, C et al. J Clin Sleep Med 2013;9(11):1173-1178.

Gooneratneet, N et al. Arch Int Med 2006;166:1732-1738.

Guilleminault, C et al. J Psychosom Res 2002;53:611-615.

Hening, W et al. Sleep Medicine 2004(5):237-246.

International Classification of Sleep Disorders, 3rd Ed, 2014.American Academy of Sleep Medicine.

Jacobs, G et al. Arch Int Med 2004;164:1888-1896.

John, M. Chest 1993;103:30-36.

Krakow, B et al. SLEEP 2012;35(12):1685-1692.

Kripke, D et al. Arch Gen Psychiatry 1979;36(1):103-116.

Lichstein, K et al. J Consult Clin Psychol 1999;67:405-410.

Lee, J et al. J Clin Sleep Med 2013;9(5):455-459.

McClusky, H et al. Am J Psychiatry 1991;148(1):121-126.

Morin, C et al. JAMA 1999;281(11):991-999.

Postuma et al. Mov Disord 2012;27(7):913-916.

Seda, G et al. J of Clin Sleep Med 2015;11(1):11-22.

Silva, G et al. J Clin Sleep Med 2014;10(7):779-786.

Spielman, A et al. SLEEP 1987;10(1):45-56.

Taheri, S et al. PloS Med 2004;1(3):e62 doi:10.1371/journal.pmed.0010062

Trenkwalder, C et al. Sleep Med 2008;9:572-574.

Viola-Saltzman, M et al. J Clin Sleep Med 2010;6(5):423-427.

Wesström, J et al. J Clin Sleep Med 2014;10(5):527-533.

Williams, R et al. EEG of Human Sleep: Clinical Applications. 1974.

Winkleman, J Neurology 2008; Jan 1;70(1):35-42.

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FromN

ightwalkers,

New

sletter of the Restless Legs Syndrome Foundation,

Spring 2006 (see ww

w.rls.org)

Page 1

Page 2

We sleep,but the loom of life never stops,and the pattern which was weaving

when the sun went downis weaving

when it comes up in the morning.

Henry Ward Beecher