insomnia- what the internist needs to know. sleep terms: initiation/latency (going to sleep)...

Insomnia-Insomnia-What the Internist What the Internist

Needs to KnowNeeds to Know

SleepSleep

Terms:Terms: Initiation/latency (going to sleep)Initiation/latency (going to sleep) Duration (early wakening)Duration (early wakening) Consolidation/maintenance (staying Consolidation/maintenance (staying

asleep continuously)asleep continuously) Quality (feeling refreshed by sleep)Quality (feeling refreshed by sleep)

IntroductionIntroduction Consequences of insomniaConsequences of insomnia Basic sleep physiologyBasic sleep physiology Insomnia: definition and epidemiologyInsomnia: definition and epidemiology Insomnia: typesInsomnia: types Insomnia: initial evaluationInsomnia: initial evaluation Insomina: treatmentInsomina: treatment

Case StudyCase Study 60 yo female with depression, anxiety, OSA presented with 60 yo female with depression, anxiety, OSA presented with

insomnia, with problems initiating and maintaining. CPAP routine insomnia, with problems initiating and maintaining. CPAP routine and problems.and problems.

PMH: depression, anxiety, OSA, glaucoma, HLP, HTN, PMH: depression, anxiety, OSA, glaucoma, HLP, HTN, osteopenia, migrainesosteopenia, migraines

Meds: zocor, fosinopril, flonase, xalatan, calcium, mvi, vit CMeds: zocor, fosinopril, flonase, xalatan, calcium, mvi, vit C SH: no tob, etoh, drugs, caffeine. Exercises daily.SH: no tob, etoh, drugs, caffeine. Exercises daily. PE: 131/81, 72, 20, 97.9, BMI 25. unremarkable.PE: 131/81, 72, 20, 97.9, BMI 25. unremarkable. Previously tried: Previously tried:

paxilpaxil x1 month (HA, palpitations) x1 month (HA, palpitations) trazodonetrazodone (HA) (HA) wellbutrinwellbutrin (never took) - felt R>B (never took) - felt R>B Rozerum – didn’t tolerateRozerum – didn’t tolerate ambien CRambien CR x3 months (palpitations)-slept 6-7 hours x3 months (palpitations)-slept 6-7 hours sonatasonata 10mg (worked, but told only could be used short-term) 10mg (worked, but told only could be used short-term) lunestalunesta 2mg (HA) 2mg (HA) Pamelor Pamelor – never took 2/2 concerns about her glaucoma– never took 2/2 concerns about her glaucoma

Consequences of insomnia: Consequences of insomnia: why this lecture is why this lecture is

importantimportant General medical healthGeneral medical health: ↑hospitalizations, HA, : ↑hospitalizations, HA,

stomach discomfort, diarrhea, palpitations, non-stomach discomfort, diarrhea, palpitations, non-specific pain, daytime fatigue, weakness, specific pain, daytime fatigue, weakness, cardiovascular disease (↑CNS, HTN; *OSA), cardiovascular disease (↑CNS, HTN; *OSA), decreased immune function (↓NK cells), decreased immune function (↓NK cells), ↑substance abuse↑substance abuse

Public healthPublic health: car crashes, absenteeism: car crashes, absenteeism Behavioral healthBehavioral health: more time shopping, watching : more time shopping, watching

tv, relaxing vs. spending more time talking with tv, relaxing vs. spending more time talking with people, studying, workingpeople, studying, working

Psychiatric sequelaePsychiatric sequelae: mood disorders, other: mood disorders, other Cognitive performanceCognitive performance: attention, memory, : attention, memory,

reasoning, problem-solving, reaction time.reasoning, problem-solving, reaction time.

International Congress and Symposium Series. 2006.

ICSS. 2006.

Sleep-Basic PhysiologySleep-Basic Physiology

Sleep Cycles (q Sleep Cycles (q 90 minutes)90 minutes) REM (20-25%)REM (20-25%) NON-REMNON-REM

Stage 1 (5%-Stage 1 (5%-transition)transition)

Stage 2 (40-50%)Stage 2 (40-50%) Stage 3/4 (20%-Stage 3/4 (20%-

slow delta wave slow delta wave sleep)sleep)

ICSS. 2006.

Sleep-RegulationSleep-Regulation Homeostatic: drive for sleepHomeostatic: drive for sleep

Primary centers: Primary centers: hypothalamus, thalamus hypothalamus, thalamus (gateway to activation of (gateway to activation of cortex)cortex)

Neurotransmitters: Neurotransmitters: gamma gamma aminobutyric acid (GABA),aminobutyric acid (GABA), adenosine (stimulated by adenosine (stimulated by caffeine), melatonin.caffeine), melatonin.

Circadian: daytime alertnessCircadian: daytime alertness Primary centers: Primary centers:

hypothalamus (suprachiasmic hypothalamus (suprachiasmic nucleus), brainstem nuclei, nucleus), brainstem nuclei, basal forebrainbasal forebrain

Neurotransmitters: histamine, Neurotransmitters: histamine, catecholamines, serotonin, catecholamines, serotonin, dopamine, hypocretin, dopamine, hypocretin, acetylcholine.acetylcholine.

ICSS. 2006.

Sleep (cont.)Sleep (cont.)

Normal changes over timeNormal changes over time Age: ↓ sleep efficiency (time Age: ↓ sleep efficiency (time

sleeping/time in bed)sleeping/time in bed) ↓ ↓ in stages 3 and 4 and ↑ in stages 1 and in stages 3 and 4 and ↑ in stages 1 and

2.2. Can lead to more night-time falls with bad Can lead to more night-time falls with bad

sequelaesequelae Etiology: Etiology: Inactivity, dissatisfaction Inactivity, dissatisfaction

with social life, poor sleep habits, with social life, poor sleep habits, medical and psychiatric conditions, medical and psychiatric conditions, medications, not age medications, not age per se.per se.

Pediatrics 2003;111:302-307.

Sleep (cont.)Sleep (cont.)

Differences with women. Differences with women. Have less of a decreased in slow-wave sleep Have less of a decreased in slow-wave sleep

(SWS) and their circadian rhythm is more (SWS) and their circadian rhythm is more robust.robust.

BUT: 2/3 of sleep complaints to PCM are BUT: 2/3 of sleep complaints to PCM are from women.from women.

InsomniaInsomnia Definition: all 3 requiredDefinition: all 3 required

Difficulty with initiation of sleep, maintenance of sleep, Difficulty with initiation of sleep, maintenance of sleep, early waking, chronically nonrestorative, or poor qualityearly waking, chronically nonrestorative, or poor quality

Problems occur despite adequate opportunity for sleep.Problems occur despite adequate opportunity for sleep. Impaired sleep results in daytime deficits in function.Impaired sleep results in daytime deficits in function.

Fatigue or malaiseFatigue or malaise Poor attention or concentrationPoor attention or concentration Social or vocational dysfunctionSocial or vocational dysfunction Mood disturbanceMood disturbance Daytime sleepiness Daytime sleepiness (not a prerequisite for diagnosis)(not a prerequisite for diagnosis) Reduced motivation or energyReduced motivation or energy Increased errors or accidentsIncreased errors or accidents Tension, headache, or gastrointestinal symptomsTension, headache, or gastrointestinal symptoms Ongoing worry about sleepOngoing worry about sleep

International classification of sleep disorders. 2005.International classification of sleep disorders. 2005.

EpidemiologyEpidemiology PrevalencePrevalence

Depends on study design and definition of insomniaDepends on study design and definition of insomnia Review of 50 studies: 10%Review of 50 studies: 10% Survey of primary care patients: 69% Survey of primary care patients: 69% (only 17% (only 17%

report problems to PCM)report problems to PCM) National survey of institutionalized patients: 35% National survey of institutionalized patients: 35%

in the last yearin the last year Increases with age: 57% of elderly with chronic Increases with age: 57% of elderly with chronic

insomnia; only 12% had normal sleep.insomnia; only 12% had normal sleep. More prevalent in women: 50% more than men. More prevalent in women: 50% more than men. More prevalent in unemployed, divorced, widowed, More prevalent in unemployed, divorced, widowed,

separated, or of lower socioeconomic status.separated, or of lower socioeconomic status.

Insomnia in primary care patients. Sleep 1999. Insomnia in primary care patients. Sleep 1999. Prevalence and correlates. Arch Gen Psychiatry 1985.Prevalence and correlates. Arch Gen Psychiatry 1985.Epidemiology of insomnia. Sleep Med Rev 2002.Epidemiology of insomnia. Sleep Med Rev 2002.Sleep complaints among elderly persons. Sleep 1995; 18:425.Sleep complaints among elderly persons. Sleep 1995; 18:425.

ICSS. 2006.

Types of InsomniaTypes of Insomnia

Classification systemsClassification systems International classification of sleep International classification of sleep

disorders (ICSD)disorders (ICSD) Diagostic classification of sleep and arousal Diagostic classification of sleep and arousal

disorders (DCSAD)disorders (DCSAD) Diagnostic and statistical manual of mental Diagnostic and statistical manual of mental

disorders, 4th edn (DSM-IV)disorders, 4th edn (DSM-IV) International classification of diseases (ICD)International classification of diseases (ICD)

Insomnia is Insomnia is MultifactorialMultifactorial

Contributing factors Contributing factors (Spielman and (Spielman and Glovinsky- Sleep Glovinsky- Sleep 1999;22(2):S347-S353.)1999;22(2):S347-S353.) Predisposing factorsPredisposing factors

Alterable: smokingAlterable: smoking Non-alterable: genetics, sex, Non-alterable: genetics, sex,

ageage Precipitating factors: life-Precipitating factors: life-

stressor, acute illnessstressor, acute illness Perpetuating factors: Perpetuating factors:

chronic illnesschronic illness

Figure 1.1 Insomnia: principles and management

Insomnia. Principles and Management. Szuba. Cambridge. 2003.

Insomnia of short duration: Insomnia of short duration: <3 months<3 months

Acute: temporally related to Acute: temporally related to stressorstressor Synonyms: Synonyms:

adjustment insomniaadjustment insomnia short-term insomniashort-term insomnia stress-related insomniastress-related insomnia transient insomniatransient insomnia

Stressors: physical, psychological, Stressors: physical, psychological, psychosocial, interpersonal, psychosocial, interpersonal, environmentalenvironmental

Circadian rhythm sleep disordersCircadian rhythm sleep disorders Jet lagJet lag Shift workShift work

High altitude insomniaHigh altitude insomnia

Types of Chronic Types of Chronic InsomniaInsomnia

Prevalence: 10%, >80% with s/sx >/ 2-3 yr Prevalence: 10%, >80% with s/sx >/ 2-3 yr after onsetafter onset

Inadequate sleep hygieneInadequate sleep hygiene Psychophysiological insomniaPsychophysiological insomnia

Synonyms:Synonyms: Primary insomniaPrimary insomnia Chronic insomniaChronic insomnia Learned insomniaLearned insomnia Conditioned insomniaConditioned insomnia

Required physiologic activation of CNS, not just Required physiologic activation of CNS, not just inadequate quantity or poor quality; inadequate quantity or poor quality; measurablemeasurable (cardiac, metabolic, hormonal, EEG) (cardiac, metabolic, hormonal, EEG)

Symptoms: onset – racing thoughts, difficult to relax, Symptoms: onset – racing thoughts, difficult to relax, cycle of focusing on in ability to initiate sleepcycle of focusing on in ability to initiate sleep

Types of Chronic Insomnia Types of Chronic Insomnia (cont.)(cont.)

Idiopathic insomniaIdiopathic insomnia Synonyms: Synonyms:

Life-long insomniaLife-long insomnia Childhood onset insomniaChildhood onset insomnia

Incidence: <1% young adults and adolescentsIncidence: <1% young adults and adolescents Symptoms: difficulty initiating and maintainingSymptoms: difficulty initiating and maintaining Begins in infancy or early childhoodBegins in infancy or early childhood Cause: idiopathic. Cause: idiopathic.

Associated with learning disabilities and ADHD.Associated with learning disabilities and ADHD. Neurochemical imbalanceNeurochemical imbalance Clustering in familiesClustering in families

Dx only after excluded other medical, Dx only after excluded other medical, neurological, and psychiatric disorders.neurological, and psychiatric disorders.


Behavioral insomnia of childhoodBehavioral insomnia of childhood Learned specific circumstances in order Learned specific circumstances in order

to sleep.to sleep. Examples: parent, toy, blanket, pacifierExamples: parent, toy, blanket, pacifier Incidence: to some extent 10-30% Incidence: to some extent 10-30%

children, starting at 6 months.children, starting at 6 months.


Paradoxial insomniaParadoxial insomnia Synonyms: Synonyms:

Sleep state misperceptionsSleep state misperceptions Subjective insomniaSubjective insomnia PseudoinsomniaPseudoinsomnia Sleep hypochondriasisSleep hypochondriasis

Symptoms: subjective insomnia, even when Symptoms: subjective insomnia, even when EEG shows EEG shows normal sleep stages.normal sleep stages.

GrossGross overestimation of sleep onset and total overestimation of sleep onset and total sleep timesleep time

Dx: requires EEG (incidence therefore Dx: requires EEG (incidence therefore unknown). High frequency EEG, ↑metabolic unknown). High frequency EEG, ↑metabolic rate during sleep.rate during sleep.

DDx: DDx: psychophysiological insomniapsychophysiological insomnia


Insomnia associated with another Insomnia associated with another conditioncondition Coexistence vs. being secondary to. Coexistence vs. being secondary to.

When co-existing condition When co-existing condition adequately treated, insomnia often adequately treated, insomnia often persists.persists.

Medical conditions: 10% of pts with Medical conditions: 10% of pts with insomnia have chronic condition or take insomnia have chronic condition or take Rx. Conversely, 40% of pts with medical Rx. Conversely, 40% of pts with medical problems have insomnia.problems have insomnia.

Types of Chronic Insomnia Types of Chronic Insomnia (cont.) – (cont.) –

Co-existing Medical ConditionsCo-existing Medical Conditions Pulmonary (>50% have Pulmonary (>50% have

insomnia). Postural insomnia). Postural changeschanges↑WOB, ↑WOB, secretions pool in aw, secretions pool in aw, nocturnal nocturnal bronchoconstriction; Rxbronchoconstriction; Rx COPDCOPD Bronchial asthmaBronchial asthma

CardiovascularCardiovascular Heart failure (30%): Heart failure (30%):

Cheyne-stokes breathingCheyne-stokes breathing Ischemic heart diseaseIschemic heart disease Nocturnal anginaNocturnal angina

RheumatologicRheumatologic ArthritisArthritis FibromyalgiaFibromyalgia

Musculoskeletal: Chronic Musculoskeletal: Chronic painpain

EndocrinologicEndocrinologic MenopauseMenopause HyperthyroidismHyperthyroidism DiabetesDiabetes PheochromocytomaPheochromocytoma

Urinary: nocturiaUrinary: nocturia Gastrointestinal: GERDGastrointestinal: GERD OtherOther

Lyme diseaseLyme disease AIDSAIDS Chronic fatigue syndromeChronic fatigue syndrome


Psychiatric disorders: Psychiatric disorders: 45% pts with insomnia have psychiatric d/o45% pts with insomnia have psychiatric d/o Insomnia may precedes psychiatric dz Insomnia may precedes psychiatric dz

(controversial: causal or a marker?)(controversial: causal or a marker?) Comorbidity not simply causalComorbidity not simply causal Examples:Examples:

Depression – early awakeningDepression – early awakening Anxiety – difficulties with sleep initiationAnxiety – difficulties with sleep initiation Substance abuse – i.e. pt with insomnia are more Substance abuse – i.e. pt with insomnia are more

sensitive to caffeine.sensitive to caffeine. PTSD – dx includes sleep disturbancesPTSD – dx includes sleep disturbances

Diagnostic OverlapDiagnostic Overlap

S-sleep disturbancesS-sleep disturbances I-decreased interestI-decreased interest G-excessive guiltG-excessive guilt E-decreased energyE-decreased energy C-decreased concentrationC-decreased concentration P-psychomotor agititationP-psychomotor agititation S-suicidal ideationS-suicidal ideation

Diagnositic Overlap Diagnositic Overlap (cont.)(cont.)

AnxietyAnxiety Sleep initiation, restless sleep Sleep initiation, restless sleep

(maintenance), difficulty concentrating, (maintenance), difficulty concentrating, irritabilityirritability

PTSDPTSD Recurrent distressing dreams of the Recurrent distressing dreams of the

event (one of the B Criteria)event (one of the B Criteria)

ICSS. 2006.


Neurological diseasesNeurological diseases Neurodegenerative diseaseNeurodegenerative disease Alzheimers diseaseAlzheimers disease Parkinson diseaseParkinson disease Neuromuscular disorders: Peripheral Neuromuscular disorders: Peripheral

neuropathiesneuropathies Cerebral hemispheric and brain stem strokesCerebral hemispheric and brain stem strokes Brain tumorsBrain tumors TBI causing post-traumatic insomniaTBI causing post-traumatic insomnia Headache syndromesHeadache syndromes Fatal familial insomnia – a rare prion disease; Fatal familial insomnia – a rare prion disease;

degeneration of mediodorsal nucleusdegeneration of mediodorsal nucleus


MedicationsMedications CNS stimulantsCNS stimulants CNS depressantsCNS depressants BronchodilatorsBronchodilators AntidepressantsAntidepressants Beta agonistBeta agonist GlucocorticoidsGlucocorticoids


Sleep disordersSleep disorders Sleep disordered breathingSleep disordered breathing

ApneaApnea Obstructive sleep apnea (normal Obstructive sleep apnea (normal

oxygenation, oxygenation, snoresnore): 10% with insomnia.): 10% with insomnia. Central apnea. Cheyne-stokes breathingCentral apnea. Cheyne-stokes breathing

Respiratory alkalosisRespiratory alkalosis Heart failure (EF<40%)Heart failure (EF<40%) StrokeStroke

Pickwickian syndrome (“obesity Pickwickian syndrome (“obesity hypoventilation syndrome”).hypoventilation syndrome”).

Requires daytime hypercapnea, Hypopnea/apnea, Requires daytime hypercapnea, Hypopnea/apnea, ↓O2 sat.↓O2 sat.

Leads to pHTNLeads to pHTN RHF (cor pulmonale) RHF (cor pulmonale) Usually also have OSA.Usually also have OSA.


Sleep disorders (cont.)Sleep disorders (cont.) Restless legs syndromeRestless legs syndrome Periodic limb movementsPeriodic limb movements Circadian rhythm disordersCircadian rhythm disorders

Delayed sleep phase syndrome (much more Delayed sleep phase syndrome (much more common than advanced SPS).common than advanced SPS).

Advanced sleep phase syndromeAdvanced sleep phase syndrome

Review of Types with Review of Types with SynonymsSynonyms

Insomnia of short duration: Insomnia of short duration: Acute: Acute: adjustment insomnia, short-term insomnia, stress-related adjustment insomnia, short-term insomnia, stress-related

insomnia, transient insomniainsomnia, transient insomnia Circadian rhythm sleep disordersCircadian rhythm sleep disorders High altitude insomnia High altitude insomnia

Insomnia of longer duration: Insomnia of longer duration: Inadequate sleep hygieneInadequate sleep hygiene Psychophysiological insomnia: Psychophysiological insomnia: Primary insomnia,Primary insomnia, Chronic Chronic

insomnia, Learned insomnia, Conditioned insomniainsomnia, Learned insomnia, Conditioned insomnia Idiopathic insomnia: Idiopathic insomnia: Life-long insomnia, Childhood onset Life-long insomnia, Childhood onset

insomniainsomnia Behavioral insomnia of childhoodBehavioral insomnia of childhood Paradoxial insomnia: Paradoxial insomnia: Sleep state misperceptions, Subjective Sleep state misperceptions, Subjective

insomnia, Pseudoinsomnia, Sleep hypochondriasisinsomnia, Pseudoinsomnia, Sleep hypochondriasis Insomnia associated with another condition: medical, Insomnia associated with another condition: medical,

psychological, neuromuscular, medications, sleep disorderspsychological, neuromuscular, medications, sleep disorders

EvaluationEvaluation HistoryHistory

Medication review: current; prior sleep medsMedication review: current; prior sleep meds Explore co-morbiditiesExplore co-morbidities Sleep hygieneSleep hygiene Bed-partner historyBed-partner history Sleep diarySleep diary

Sleep studySleep study Differential DiagnosisDifferential Diagnosis

Short duration sleep: some people simply require less Short duration sleep: some people simply require less sleep.sleep.

Sleep deprivation: will rapidly fall asleep if given the Sleep deprivation: will rapidly fall asleep if given the chance.chance.

Sleepy vs. fatigueSleepy vs. fatigue Epworth sleepiness scale.Epworth sleepiness scale.

Epworth Sleepiness ScaleEpworth Sleepiness Scale

Sleep JournalSleep JournalName:Name: SunSun MonMon TuesTues

Complete in the Complete in the morningmorning

Bedtime (date/time)Bedtime (date/time)

Rise time (date/time)Rise time (date/time)

Estimated time to fall asleepEstimated time to fall asleep

Estimated number of awakening and total Estimated number of awakening and total time awaketime awake

Estimated amount of sleep obtainedEstimated amount of sleep obtained

Complete at Complete at bedtimebedtime

Naps (number, time, and duration)Naps (number, time, and duration)

Alcoholic drinks (number and time)Alcoholic drinks (number and time)

List stresses of the dayList stresses of the day

Rate how you felt todayRate how you felt today1 = Very tired/sleepy1 = Very tired/sleepy2 = Somewhat tired/sleepy2 = Somewhat tired/sleepy3 = Fairly alert3 = Fairly alert4 = Wide awake4 = Wide awake

Irritability levelIrritability level1 = None1 = None2 = Some2 = Some3 = Moderate3 = Moderate4 = Fairly high4 = Fairly high5 = High5 = High

Sleep medicationsSleep medications

When to Refer to Sleep When to Refer to Sleep Study?Study?

Paradoxical insomniaParadoxical insomnia Sleep disordered breathingSleep disordered breathing Parasomnias: d/o with abnl psyiological Parasomnias: d/o with abnl psyiological

or behavioral events during sleep, not or behavioral events during sleep, not changes ni amount or timing of sleepchanges ni amount or timing of sleep

Movement disordersMovement disorders Behavioral disturbancesBehavioral disturbances Not simply for chronic insomniaNot simply for chronic insomnia

Non-pharmacologic Non-pharmacologic TreatmentTreatment

Stimulus controlStimulus control Sleep-restrictionSleep-restriction Relaxation therapyRelaxation therapy Sleep hygieneSleep hygiene EducationEducation

NEJM 2009;353(8):803-809.

Pharmacologic Pharmacologic TreatmentTreatment

TermsTerms ToleranceTolerance: Reduction in drug effect requiring an : Reduction in drug effect requiring an

increase in dosage to maintain the same response.increase in dosage to maintain the same response. Physiologic dependencePhysiologic dependence: The state of response to : The state of response to

a drug whereby removal of the drug evokes a drug whereby removal of the drug evokes unpleasant symptoms, usually the opposite of the unpleasant symptoms, usually the opposite of the drug’s effects.drug’s effects.

Phychologic dependencePhychologic dependence: The state of response to : The state of response to a drug whereby the drug taker feels compelled to a drug whereby the drug taker feels compelled to use the drug and suffers anxiety when separated use the drug and suffers anxiety when separated from the drug.from the drug.

Pharmacology. Katzung. 1998.Pharmacology. Katzung. 1998.

Pharmacologic Pharmacologic TreatmentTreatment Benzodiazepines/BZ-Benzodiazepines/BZ-

receptor agonistsreceptor agonists•Non-benzodiazepines>Antidepressants >Atypical antipsychotics>Melatonin >other herbals>Antihistamines

http://www.mona.uwi.edu/fpas/courses/physiology/neurophysiology/GABAreceptorA.jpg

GABAa receptor-chloride ion channel macromolecular complex.

NEJM 2009;353(8):803-809

General GuidelinesGeneral Guidelines BZD BZD

for short-term insomnia.for short-term insomnia. If for chronic insomnia, 3-4 nights/week max 3 weeks.If for chronic insomnia, 3-4 nights/week max 3 weeks.

BZD/BZD-receptor agonistsBZD/BZD-receptor agonists Data limited by length of studies (longest is 6 months-Lunesta)Data limited by length of studies (longest is 6 months-Lunesta) Lowest possible dose, intermittently, shortest duration possible.Lowest possible dose, intermittently, shortest duration possible. Sleep initiation: short-acting (rebound)Sleep initiation: short-acting (rebound) Sleep maintenance/early wakening: intermediate (rare rebound)Sleep maintenance/early wakening: intermediate (rare rebound) Avoid in apnea, substance abuse, or pregnancy.Avoid in apnea, substance abuse, or pregnancy. Caution in the elderly, especially long-acting (dose reduction).Caution in the elderly, especially long-acting (dose reduction). Long-acting good only if also pt has daytime anxietyLong-acting good only if also pt has daytime anxiety Ambien: little or no reboundAmbien: little or no rebound Sonata: no rebound, can take in middle of the nightSonata: no rebound, can take in middle of the night Lunesta: no tolerance after 6 monthsLunesta: no tolerance after 6 months

Pharmacotherapy Handbook. 2000.Pharmacotherapy Handbook. 2000.NEJM 2009;353(8):803-809

Specific Treatments for Specific Treatments for Sleep Disordered BreathingSleep Disordered Breathing

OSA (briefly)OSA (briefly) Tx for insomnia, heart failure and Tx for insomnia, heart failure and

pulmonary HTNpulmonary HTN CPAP desensitization (next slide)CPAP desensitization (next slide) CPAP interfacesCPAP interfaces Avoid/limit BZD like temazepam (Avoid/limit BZD like temazepam ( acute acute

airway crisis)airway crisis) Pickwickian syndrome: Pickwickian syndrome:

CPAPCPAP tracheostomy if decompensatedtracheostomy if decompensated

CPAP DesensitizationCPAP DesensitizationSTEP 1:STEP 1: Wear the nCPAP mask or nasal pillows at home, while awake in the evening Wear the nCPAP mask or nasal pillows at home, while awake in the evening

and performing normal evening activities, for about one hour daily. When you and performing normal evening activities, for about one hour daily. When you can do this without anxiety or concern for five consecutive days, then go to can do this without anxiety or concern for five consecutive days, then go to Step 2.Step 2.

STEP 2:STEP 2: Connect the pressure device and tubing to the CPAP pressurizer. The Connect the pressure device and tubing to the CPAP pressurizer. The

pressurizer will be set to a pressure of 6 CN H20. Turn on the machine, and pressurizer will be set to a pressure of 6 CN H20. Turn on the machine, and breathe through it at home and at rest, for one hour daily. When you can do breathe through it at home and at rest, for one hour daily. When you can do this without anxiety or concern for five consecutive days, then go to Step 3.this without anxiety or concern for five consecutive days, then go to Step 3.

STEP 3:STEP 3: Wear the entire nCPAP apparatus for a scheduled one hour nap. When you Wear the entire nCPAP apparatus for a scheduled one hour nap. When you

can do this without anxiety or concern for five consecutive days, then go to can do this without anxiety or concern for five consecutive days, then go to Step 4.Step 4.

STEP 4:STEP 4: Wear the entire nCPAP apparatus for 4-5 hours of sleep each night. When Wear the entire nCPAP apparatus for 4-5 hours of sleep each night. When

you can do this without anxiety or concern for five consecutive days, then go you can do this without anxiety or concern for five consecutive days, then go to Step 5.to Step 5.

STEP 5:STEP 5: Use nCPAP for your entire night’s sleep.Use nCPAP for your entire night’s sleep.

This treatment was published by Doctors Edinger and Radtke, from Duke University, in 1993.This treatment was published by Doctors Edinger and Radtke, from Duke University, in 1993.

ConclusionConclusion Sleep complaints are common, and often not Sleep complaints are common, and often not

brought up with doctor: ask the patient. brought up with doctor: ask the patient. Evaluation is based on a good understanding Evaluation is based on a good understanding

of the etiologies of insomnia.of the etiologies of insomnia. Bed-partner historyBed-partner history Explore co-morbiditiesExplore co-morbidities Insomnia is considered to coexist with other Insomnia is considered to coexist with other

medical and psychiatric conditions, not medical and psychiatric conditions, not necessarily to cause them.necessarily to cause them.

Age: associated features, not age Age: associated features, not age per seper se Treatment includes both non-pharmacologic Treatment includes both non-pharmacologic

(best to try first) and pharmacologic(best to try first) and pharmacologic Sleep hygieneSleep hygiene

Questions?Questions?

ReferencesReferences International Congress and Symposium Series 262. Update on the Science, Diagnosis, and International Congress and Symposium Series 262. Update on the Science, Diagnosis, and

Management of Insomnia. Richardson, G. The royal Society of Medicine Press Ltd. 2006.Management of Insomnia. Richardson, G. The royal Society of Medicine Press Ltd. 2006. International classification of sleep disorders: diagnostic and coding manual. 2nd ed, American International classification of sleep disorders: diagnostic and coding manual. 2nd ed, American

Academy of Sleep Medicine, Westchester, IL 2005.Academy of Sleep Medicine, Westchester, IL 2005. Ohayon, MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Ohayon, MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep

Medicine Review 2002; 6:97Medicine Review 2002; 6:97 Shochat, T. Insomnia in primary care patients. Sleep 1999; 22 Supplement 2:S359.Shochat, T. Insomnia in primary care patients. Sleep 1999; 22 Supplement 2:S359. Mellinger, GD. Insomnia and its treatment. Prevalence and correlates. Arch Gen Psychiatry. 1985; Mellinger, GD. Insomnia and its treatment. Prevalence and correlates. Arch Gen Psychiatry. 1985;

42:225.42:225. Foley, DJ. Sleep complaints among elderly persons: an epidemiologic study of three communities. Foley, DJ. Sleep complaints among elderly persons: an epidemiologic study of three communities.

Sleep 1995; 18:425.Sleep 1995; 18:425. Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of 1991 National Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of 1991 National

Sleep Foundation Survey. I. Sleep 1999;22(2):S347-S353.Sleep Foundation Survey. I. Sleep 1999;22(2):S347-S353. Insomnia. Principles and Management. Szuba. Cambridge. 2003.Insomnia. Principles and Management. Szuba. Cambridge. 2003. Silber, M.H. Clinical Practice: Chronic Insomnia. New England Journal of Medicine 2009 Aug Silber, M.H. Clinical Practice: Chronic Insomnia. New England Journal of Medicine 2009 Aug

25;353(8):803-809.25;353(8):803-809. Iglostein I. Sleep Duration From Infancy to Adolescence: Reference Values and Generational Iglostein I. Sleep Duration From Infancy to Adolescence: Reference Values and Generational

Trends. Pediatrics 2003;111:302-307.Trends. Pediatrics 2003;111:302-307. Bonnet. Types of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, 2009.Bonnet. Types of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, 2009. Bonnet. Overview of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, Bonnet. Overview of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13,

2009.2009. Bonnet. Diagnostic Evaluation of Insomnia. UpToDate. Last updated October 16, 2008. Accessed Bonnet. Diagnostic Evaluation of Insomnia. UpToDate. Last updated October 16, 2008. Accessed

January 13, 2009.January 13, 2009. Pharmacotherapy Handbook. Wells, B. Second Edition. Appleton & Lange. 2000.Pharmacotherapy Handbook. Wells, B. Second Edition. Appleton & Lange. 2000. Pharmacology – Examination & Board Review. Katzung. McGraw Hill. 1998.Pharmacology – Examination & Board Review. Katzung. McGraw Hill. 1998. Special thanks to David Bradshaw, MDSpecial thanks to David Bradshaw, MD

insomnia- what the internist needs to know. sleep terms: initiation/latency (going to sleep)...

Documents

maintenance of sleep

initiation of sleep

sleep complaints

poor sleep habits

impaired sleep results

slowwave sleep sws

daytime fatigue

reaction time