1. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

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3. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. in the clinic Insomnia

4. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Which patient populations have the highest prevalence of insomnia?  Women  Especially in 3 rd trimester and after menopause  Elderly  Up to 65%  Those with coexisting medical disorders  Pulmonary disease, HF, and pain syndromes  Neurologic disease and psychiatric disorders  Others  Those taking specific medications or withdrawing from hypnotics or alcohol

5. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Should clinicians screen for insomnia, and if so, how?  Consider screening as part of regular patient care  Ask patients if they have  Difficulty initiating or maintaining sleep  Early morning waking  Nonrestorative sleep  Insomnia screening instruments  Sleep Condition Index questionnaire (2 questions)  Pittsburgh Sleep Quality Index  Insomnia Severity Index

6. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. CLINICAL BOTTOM LINE: Screening..  Incorporate screening as a regular part of patient care  High prevalence  Potential impact on health and quality of life  Screening is relatively straightforward and quick  Ask if initiating or maintaining sleep is difficult  Ask about early morning waking  Ask about nonrestorative sleep

7. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1.  When do activities occur  Going to bed, waking up, getting out of bed What are the components of a comprehensive sleep history?  How much sleep  Sleep latency, frequency of awakening, duration awake after awakening, total sleep time  Quality of sleep  How well rested do you feel after awakening?  Environmental factors  Light, sound, temperature, telephone, TV  Behaviors that might affect sleep  Sleep habits, daytime napping, exercise, stimulant use

8. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Which conditions should clinicians consider in the diagnosis and treatment of insomnia?  Sleep-related breathing disorders  Obstructive / central sleep apnea syndrome  Sleep-related movement disorders  Restless leg syndrome, periodic limb movement disorder, nocturnal leg cramps  Circadian rhythm sleep-wake disorders  Jet lag or shift work  The delayed or advanced sleep-phase syndrome  Parasomnias related to non-rapid eye movement

9. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1.  Identify signs of specific disorder contributing to sleep disruption  Thyroid dysfunction  Cardiopulmonary or neurologic disease  Obstructive sleep apnea syndrome What is the role of physical examination in the evaluation of patients with insomnia?

10. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1.  When a possible underlying sleep disorder is suspected  When insomnia may be linked to concomitant disease When should clinicians consider lab testing in the evaluation of insomnia?  Possible tests  Polysomnography  Multiple Sleep Latency Test  Sleep Actigraphy  Tests for disorders contributing to insomnia  Urine drug screening (to check for substance use)

11. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. CLINICAL BOTTOM LINE: Diagnosis...  Can be associated with:  Poor sleep environment  Medications or other substances that interfere with sleep  Underlying medical or psychological condition  Perform detailed sleep and medical history and physical exam  Potentially useful tools  Sleep questionnaires  Sleep diaries  Lab testing only if underlying conditions are suspected

12. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What is sleep hygiene, and what is its role in the treatment of patients with insomnia?  Good sleep hygiene behaviors  Maintain constant bed times and rising times  Allow adequate time for sleep (7 h to 8 h for adults)  Do not force sleep, and avoid clock watching  Maintain a quiet, dark bedroom  Remove potential disruptors of sleep (tv, phone)  Avoid sleep-fragmenting substances near bedtime  Exercise regularly but avoid exercise just before bedtime  Resolve stressful situations and relax before bedtime  Avoid daytime naps

13. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1.  Behavioral therapy is the primary therapy, particularly in chronic insomnia  Cognitive behavioral therapy  Sleep restriction  Stimulus control therapy  Relaxation techniques  Add other therapies only if behavioral therapy fails Are behavioral therapies useful in the treatment of patients with insomnia?

14. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1.  Alcohol  Reduces sleep latency + may improve early sleep  But highly disruptive of other sleep parameters  Antihistamines  Can cause mental & cognitive changes, motor impairment  Sedation may carry over until daytime  Melatonin  May improve sleep onset + maintenance  Regular structured exercise  Acupuncture/-pressure, tai-chi, yoga How should clinicians advise patients about the use of nonprescription agents in the treatment of insomnia?

15. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. When should clinicians consider prescription drug therapy for insomnia?  When other approaches prove inadequate  Considerations  The nature of the sleep disturbance  Whether insomnia is acute or chronic  Presence of other medical or psychiatric conditions  Side effects  Cost continued

16. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. FDA-approved prescription drug treatments for insomnia  Benzodiazepines (flurazepam, temazepam, triazolam)  Nonbenzodiazepine (zolpidem, eszopiclone, zaleplon)  Orexin-receptor antagonist (suvorexant)  Melatonin Receptor Agonists (ramelteon)  Antidepressants (doxepin)  Others options  Barbituates  Antipsychotics  Anticonvulsants continued

17. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Things to consider when prescribing drugs to treat insomnia  Use the minimal effective dose  Avoid medications with a long half-life  Be aware of potential drug-drug interactions  Caution patients about interaction with alcohol  Review potential side effects, especially daytime sleepiness  Agree on an appropriate duration of use  Start with a GABA agonist for acute or short-term insomnia  Look for rebound insomnia after discontinuation  Consider intermittent use of hypnotic medications when long- term therapy is required  Consider consultation with a sleep specialist before starting continuous, long-term therapy with hypnotic medication

18. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What is the appropriate duration of prescription drug therapy for insomnia?  Avoid prolonged or excessive therapy  Discuss risks and benefits of drug therapy  Continuous therapy  Limit to 1 month  Conduct periodic tapering and discontinuation trials to determine when continuous therapy can be stopped  As-needed therapy  Limit to 6 months  Reserve for patients who can assess when drug treatment will be helpful

19. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What are contraindications to drug therapy?  Sedating antihistamines  Cardiopulmonary disease, glaucoma, problems w/ urination  Sedative-hypnotics  If pregnant or breastfeeding  Underlying medical disorders in which sedation detrimental  Any sedating mediation  Alcohol or another sedating medication  Driving or using hazardous equipment  All medications  History of alcohol or drug abuse  Use more cautiously in elderly  Beware potential interaction with complementary and alternative medications

20. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. When should clinicians consider specialty referral for patients with insomnia?  Suspicion of an underlying sleep disorder  Poor response to behavioral interventions / drug therapy  Psychiatrist: possible psychiatric disorder  Pulmonologist: suspected sleep disordered  Otolaryngologist, oral surgeon, or dentist: excessive snoring or other oropharyngeal or airway issues  Neurologist: possible Parkinson disease, cerebrovascular disease, or dementia

21. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. How should clinicians manage insomnia in hospitalized patients?  Interventions in the hospital  Address sleep hygiene  Address hospital environmental issues  Consider discontinuing medications that may disrupt sleep  Treat pain and other medical conditions that impair sleep  Consider the effect of underlying medical conditions

22. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What type of follow-up care should clinicians provide for patients with insomnia?  Provide ongoing assessment of comorbidities  Educate about sleep hygiene and behavioral techniques  Monitor response and adjust therapy if medications used  Schedule more frequent visits for patients with psychophysiologic insomnia  Ensures patient understands and carries out behavioral recommendations

23. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. CLINICAL BOTTOM LINE: Treatment...  Initial therapy: address sleep hygiene factors + include CBT  Cognitive training  Sleep restriction  Stimulus control guidelines  Relaxation techniques  Refer to clinician trained in these techniques  If CBT unsuccessful, pharmacologic therapy may be warranted  Nonprescription treatments (antihistamines)  GABA agonists (nonbenzodiazepines preferred)  Antidepressants only if underlying depression present  Other medication classes lack evidence of effectiveness  Limit continuous use of sedative-hypnotics to 1 month  Longer use or intermittent use may be appropriate