Diplomate: American Academy of Sleep Medicine INSOMNIA Liphard O. D’Souza, M.D. Diplomate: American Academy of Sleep Medicine 6128 E. 38th St., Ste. 303 Tulsa, OK 74135 (918) 523-8572

Insomnia A broad term denoting unsatisfactory sleep Perception that sleep is inadequate or abnormal Common problem A symptom, not a disease or sign, therefore difficult to measure

Diagnosis Complaint that the sleep is: Brief or inadequate Light or easily disrupted Non-refreshing or non-restorative

International Congress of Sleep Disorders Classification Based on the duration of symptoms Transient or acute Few days to 2-4 weeks Chronic Persisting for more than 1-3 months

Definitions Mild Moderate Severe Almost nightly complaint of non-restorative sleep Associated with little or no impairment of social or occupational functioning Moderate Nightly complaints of disturbed sleep Mild to moderate impairment of social or occupational function Severe Severe daytime dysfunction

Classification Sleep initiating insomnia Sleep maintaining insomnia Early morning insomnia Short period of sleep Non-restorative sleep Multiple awakenings Combination of above patterns

Presentation Goals Review of normal sleep cycle Causes of insomnia Diagnosis and assessment of insomnia Treatment modalities

Stages of Sleep Non-Rapid Eye Movement (NREM) sleep Stage I Stage II Stages I & II are light sleep Stage III Stage IV Stages III & IV are deep sleep Rapid Eye Movement (REM) sleep

Normal Sleep Pattern

Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.) Why do we sleep? 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 Stages III & IV are involved in synaptic “pruning and tuning” Why do we get sleepy? Circadian factors Process S: linear increase in sleepiness Process C: rhythmic fluctuations of the circadian alert system Other factors: sleep duration, quality, time awake, etc.

Causes Insomnia is a downstream symptom of an upstream problem, for example: Medical Psychological/ Psychiatric Behavioral Parasomnias Drug-induced Combination of factors in chronic insomnia

Normal Sleep Values Normal sleep per day is between 6-8 hours, although some people can maintain a 4-6 hour cycle 4-6 NREM/REM cycles per night Sleep structure changes throughout life Wakefulness after sleep Less than 30 minutes Sleep Onset Latency (SOL) REM Sleep Latency 70-120 minutes

Epidemiology Studies throughout the world show that it occurs everywhere Depending on the area, study, etc., between 10-50% of the population are affected Increases with age Twice as common in females Up to the age of 30, there is little difference between sexes Beyond 30 years, it is more common in females Beyond 70 years, females are affected twice as much as males

Etiology Symptom of numerous diverse etiologies Usually due to more than one factor and each needs a separate evaluation In all cases, one should strive to find the cause as it will dictate the proper treatment

3 P’s of Acute Insomnia Predisposition Precipitation Perpetuation Anxiety, depression, etc. Precipitation Sudden change in life Perpetuation Poor sleep hygiene 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 Start aggressive treatment in the ACUTE phase, before the patient goes into CHRONIC insomnia

Acute Insomnia Resolves with the management of inciting factors Adjustment sleep disorder Acute stress such as momentous life events or unfamiliar sleep environments PSG: increased SOL, increased awakenings and sleep fragmentation with poor sleep efficiency More common in women and those with anxiety Jet Lag Symptoms last longer with eastbound travel Remits spontaneously in 2-3 days More common in the elderly

Chronic Insomnia Primary or Intrinsic Secondary or Extrinsic Causes Changes in circadian rhythm, behavior, environment Body movements in sleep Medical, neurological, psychiatric disorders Drugs

Primary/Intrinsic Insomnia Idiopathic Starts early in childhood, rare but relentless course Rare disorders affect both genders CNS abnormalities, unknown etiology, etc. Sleep State Misinterpretation (5%) Underestimate of the sleep obtained Females affected more than males Psychophysiological insomnia (30%) Maladaptive sleep-preventing behaviors develop and progress to become dominant factors Females more than males

Secondary/Extrinsic Insomnia Circadian rhythm sleep disorder: sleep attempted at a time when the circadian clock is promoting wakefulness Advanced sleep phase syndrome Delayed sleep phase syndrome Irregular sleep/wake patterns Non-24 hour sleep/wake syndrome Shift work sleep disorder Short sleeper

Environmental factors Behavioral disorders: rooted behaviors that are arousing and not conductive to sleep Inadequate sleep Limit setting sleep disorder Nocturnal eating/drinking syndrome Sleep onset association disorder Environmental factors Environmental sleep disorder Food allergy insomnia Toxin-induced sleep disorder

Medical Disorders: Respiratory Movement disorders PLMS disorder (5%) RLS syndrome (12%) REM behavior disorder Medical Disorders: Respiratory Altitude insomnia Central alveolar hypoventilation syndrome Central apnea syndrome COPD OSAS (4-6%) Sleep-related asthma

Medical: Musculoskeletal Medical: Cardiac Nocturnal myocardial ischemia Medical: GI Peptic ulcer disease GERD Medical: Musculoskeletal Fibromyalgia Arthritis Medical: Endocrine Hyperthyroidism Cushing’s disease Menstrual cycle association Pregnancy

Medical: Neurological Cerebral degeneration disorder Dementia Fatal familial insomnia Parkinson’s disease Sleep related epilepsy Sleep related headaches Medical: Psychiatric Alcoholism Anxiety disorders Mood disorders Panic disorders Psychosis Drug dependency

Pharmacological causes Alcohol dependent sleep disorder Hypnotic dependent sleep disorder Stimulus dependent sleep disorder Medications B-blockers Theophylline L-dopa

Parasomnia Events Physical phenomena occurring in sleep Confusional arousals Nightmares Nocturnal leg cramps Nocturnal paroxysmal dystonia REM sleep behavior disorder Rhythmic movement disorder Painful erections Sleep starts Sleep terrors Sleep walking Abnormal swallowing Hyperhidrosis Laryngospasms

Physical, Emotional, and Cognitive Effects of Insomnia Mood changes, irritability, poor concentration, memory defects, etc. Impairs creative thinking, verbal processing, problem solving Risk of errors, accidents due to excessive daytime sleepiness Markedly increases if awake more than 16-18 hours (micro-sleep attacks) Increased appetite, decreased body temperature Physiologic effects Rats die after 11-12 days of sleep deprivation Hippocampal atrophy in chronic jet lag or shift work

Evaluation HISTORY! Sleep diary Precipitating factors Psychiatric and medical disturbances Medications Sleep hygiene Circadian tendencies Cognitive distortions and conditional arousals Sleep diary

Evaluation PSG if PLMS or sleep-related breathing disorder or if CBT, sleep hygiene, pharmacological interventions fail as recommended by the AASM Not routinely employed in the evaluation of transient or chronic insomnia Should not be substituted for a careful clinical history

Epworth Sleepiness Scale 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: 0=no chance of dozing 1=slight chance 2=moderate chance 3=high chance Sitting and reading ____ Watching TV ____ Sitting inactive in a public place (ex. theater, meeting) ____ As a passenger in a car for an hour without a break ____ Lying down to rest in the afternoon ____ Sitting and talking to someone ____ In a car, while stopped for a few minutes in traffic ____ ____ Total Score Normal < 10 Severe > 15

Insomnia questionnaire I have real difficulty falling asleep. Thoughts race through my mind and this prevents me from sleeping. I wake during the night and can’t go back to sleep. I wake up earlier in the morning than I would like to. I’ll lie awake for half an hour or more before I fall asleep. I anticipate a problem with sleep almost every night If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep.

Treatment Selection Meet and educate about disease, goals, options, side effects, and document safety. Identify the 3 P’s. Intrinsic v. Extrinsic Treat perpetuating causes Sleep hygiene, progressive muscle relaxation, biofeedback, stimulus control, sleep restriction, cognitive behavior therapy (CBT), combination of medications and CBT

CBT Longest lasting improvements, assuming the precipitating cause is dealt with “counseling” or “talk through” therapy for thoughts and attitudes that may be leading to the sleep disturbances Identifying distorted attitudes or thinking that makes the patient anxious or stressed and replacing with more realistic or rational ones

CBT Examples “I need more hours of sleep or I will not function” “I can never die” Uses restructuring techniques Short circuit cycle of insomnia, cognitive distortions, distress Sleep hygiene, relaxation, stimulus control, sleep restrictions

Sleep Hygiene Exercise earlier during the day, and no more than 4-6 hours before sleep Keep bedroom dark and quiet, to be used only for sex or sleep Curtail time in bed to only when sleepy Fixed sleep/wake times for 365 days Avoid naps Avoid stimulus or stimulating activities before sleep or in bed No alcohol at least 4 hours before sleep, no caffeine after noon, and quit smoking!! Light snack before bedtime

Stimulus Control Use bedroom for sleep or sex only Go to bed only when tired and sleepy Remove clock from the bedroom to avoid constantly watching it Regular sleep/wake times Light therapy if required No bright lights when you wake up at night

Sleep Restriction An effective form of treatment Estimate the time actually asleep then limit bedtime to that amount, but no less than 5 hours Add time in bed gradually once the patient sleeps more than 85% of that time

Pharmacotherapy Nationally, there has been a decline in hypnotic usage with an increase in usage of non-hypnotics Trazadone Seroquel Self-medication with alcohol and over-the-counter medications Benadryl Nyquil

Hypnotics 5 questions to ask when choosing a hypnotic: Are you looking for sleep initiation or maintenance? What are the daytime residual effects of the drug? Does tolerance develop to this drug? Will rebound withdrawal insomnia occur when discontinued? What is the half-life of the medication?

Benzodiazepines Dose Half-life Comments Flurazepam(Dalmane) 15,30 mg   Dose Half-life Comments Flurazepam(Dalmane) 15,30 mg Long Daytime drowsiness common; rarely used Clonazepam(Klonopin) 0.5-2 mg Used for PLM, REM behavior disorder; can cause morning drowsiness Temazepam (Restoril) Intermediate Estazolam (ProSom) 1-2 mg Can cause agranulocytosis Triazolam (Halcion) 0.125,0.25 mg Short Rebound insomnia may occur Zolpidem (Ambien) 5,10 mg A nonbenzodiazepam Zopliclone (Sonata) Short , 1-1.5 hours A nonbenzodiazepam  

Recent Medication Additions Eszopiclone 1,2,3 mg Intermediate Approved for chronic insomnia (Lunesta) Action 6-8 hrs. Zolpidem 10 mg Action same as above (Amvien CR) Rozerem (Ramelton)

Alternative Medications Antidepressants Not much research Some, including SSRIs, can cause daytime drowsiness Melatonin Good for jet leg, especially in elderly, but not much information on long-term use Reported to cause depression, vasoconstriction Benadryl Rarely indicated, can cause a hangover Herbal supplements Use in conjunction with a sleep log

Conclusion Insomnia is a complex symptom with many causes and perpetuating influences It is nerve-racking for patients and physicians yet it is very remediable, if properly diagnosed and treated It should be aggressively treated as emerging evidence is that chronic insomnia can precipitate major depressive disorder Depression in turn confers an increased risk of suicide, cardiovascular disease, death, etc.