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Insomnia- What the Internist Needs to Know

Insomnia- What the Internist Needs to Know. Buzzzzzzzz. Sleep. Terms: Initiation/latency (going to sleep) Duration (early wakening) Consolidation/maintenance (staying asleep continuously) Quality (feeling refreshed by sleep). Introduction Consequences of insomnia Basic sleep physiology

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Insomnia- What the Internist Needs to Know

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  1. Insomnia-What the Internist Needs to Know Buzzzzzzzz

  2. Sleep Terms: • Initiation/latency (going to sleep) • Duration (early wakening) • Consolidation/maintenance (staying asleep continuously) • Quality (feeling refreshed by sleep)

  3. Introduction • Consequences of insomnia • Basic sleep physiology • Insomnia: definition and epidemiology • Insomnia: types • Insomnia: initial evaluation • Insomina: treatment

  4. Case Study • 60 yo female with depression, anxiety, OSA presented with insomnia, with problems initiating and maintaining. CPAP routine and problems. • PMH: depression, anxiety, OSA, glaucoma, HLP, HTN, osteopenia, migraines • Meds: zocor, fosinopril, flonase, xalatan, calcium, mvi, vit C • SH: no tob, etoh, drugs, caffeine. Exercises daily. • PE: 131/81, 72, 20, 97.9, BMI 25. unremarkable. • Previously tried: • paxil x1 month (HA, palpitations) • trazodone (HA) • wellbutrin (never took) - felt R>B • Rozerum – didn’t tolerate • ambien CR x3 months (palpitations)-slept 6-7 hours • sonata 10mg (worked, but told only could be used short-term) • lunesta 2mg (HA) • Pamelor – never took 2/2 concerns about her glaucoma

  5. Consequences of insomnia: why this lecture is important • General medical health: ↑hospitalizations, HA, stomach discomfort, diarrhea, palpitations, non-specific pain, daytime fatigue, weakness, cardiovascular disease (↑CNS, HTN; *OSA), decreased immune function (↓NK cells), ↑substance abuse • Public health: car crashes, absenteeism • Behavioral health: more time shopping, watching tv, relaxing vs. spending more time talking with people, studying, working • Psychiatric sequelae: mood disorders, other • Cognitive performance: attention, memory, reasoning, problem-solving, reaction time.

  6. International Congress and Symposium Series. 2006.

  7. ICSS. 2006.

  8. Sleep-Basic Physiology • Sleep Cycles (q 90 minutes) • REM (20-25%) • NON-REM • Stage 1 (5%-transition) • Stage 2 (40-50%) • Stage 3/4 (20%-slow delta wave sleep) ICSS. 2006.

  9. Sleep-Regulation • Homeostatic: drive for sleep • Primary centers: hypothalamus, thalamus (gateway to activation of cortex) • Neurotransmitters: gamma aminobutyric acid (GABA), adenosine (stimulated by caffeine), melatonin. • Circadian: daytime alertness • Primary centers: hypothalamus (suprachiasmic nucleus), brainstem nuclei, basal forebrain • Neurotransmitters: histamine, catecholamines, serotonin, dopamine, hypocretin, acetylcholine. ICSS. 2006.

  10. Sleep (cont.) • Normal changes over time • Age: ↓ sleep efficiency (time sleeping/time in bed) • ↓ in stages 3 and 4 and ↑ in stages 1 and 2. • Can lead to more night-time falls with bad sequelae • Etiology: Inactivity, dissatisfaction with social life, poor sleep habits, medical and psychiatric conditions, medications, not age per se.

  11. Pediatrics 2003;111:302-307.

  12. Sleep (cont.) • Differences with women. • Have less of a decreased in slow-wave sleep (SWS) and their circadian rhythm is more robust. • BUT: 2/3 of sleep complaints to PCM are from women.

  13. Insomnia • Definition: all 3 required • Difficulty with initiation of sleep, maintenance of sleep, early waking, chronically nonrestorative, or poor quality • Problems occur despite adequate opportunity for sleep. • Impaired sleep results in daytime deficits in function. • Fatigue or malaise • Poor attention or concentration • Social or vocational dysfunction • Mood disturbance • Daytime sleepiness (not a prerequisite for diagnosis) • Reduced motivation or energy • Increased errors or accidents • Tension, headache, or gastrointestinal symptoms • Ongoing worry about sleep International classification of sleep disorders. 2005.

  14. Epidemiology • Prevalence • Depends on study design and definition of insomnia • Review of 50 studies: 10% • Survey of primary care patients: 69% (only 17% report problems to PCM) • National survey of institutionalized patients: 35% in the last year • Increases with age: 57% of elderly with chronic insomnia; only 12% had normal sleep. • More prevalent in women: 50% more than men. • More prevalent in unemployed, divorced, widowed, separated, or of lower socioeconomic status. Insomnia in primary care patients. Sleep 1999. Prevalence and correlates. Arch Gen Psychiatry 1985. Epidemiology of insomnia. Sleep Med Rev 2002. Sleep complaints among elderly persons. Sleep 1995; 18:425.

  15. ICSS. 2006.

  16. Types of Insomnia • Classification systems • International classification of sleep disorders (ICSD) • Diagostic classification of sleep and arousal disorders (DCSAD) • Diagnostic and statistical manual of mental disorders, 4th edn (DSM-IV) • International classification of diseases (ICD)

  17. Insomnia is Multifactorial • Contributing factors (Spielman and Glovinsky- Sleep 1999;22(2):S347-S353.) • Predisposing factors • Alterable: smoking • Non-alterable: genetics, sex, age • Precipitating factors: life-stressor, acute illness • Perpetuating factors: chronic illness Figure 1.1 Insomnia: principles and management Insomnia. Principles and Management. Szuba. Cambridge. 2003.

  18. Insomnia of short duration: <3 months • Acute: temporally related to stressor • Synonyms: • adjustment insomnia • short-term insomnia • stress-related insomnia • transient insomnia • Stressors: physical, psychological, psychosocial, interpersonal, environmental • Circadian rhythm sleep disorders • Jet lag • Shift work • High altitude insomnia

  19. Types of Chronic Insomnia • Prevalence: 10%, >80% with s/sx >/ 2-3 yr after onset • Inadequate sleep hygiene • Psychophysiological insomnia • Synonyms: • Primary insomnia • Chronic insomnia • Learned insomnia • Conditioned insomnia • Required physiologic activation of CNS, not just inadequate quantity or poor quality; measurable (cardiac, metabolic, hormonal, EEG) • Symptoms: onset – racing thoughts, difficult to relax, cycle of focusing on in ability to initiate sleep

  20. Types of Chronic Insomnia (cont.) • Idiopathic insomnia • Synonyms: • Life-long insomnia • Childhood onset insomnia • Incidence: <1% young adults and adolescents • Symptoms: difficulty initiating and maintaining • Begins in infancy or early childhood • Cause: idiopathic. • Associated with learning disabilities and ADHD. • Neurochemical imbalance • Clustering in families • Dx only after excluded other medical, neurological, and psychiatric disorders.

  21. Types of Chronic Insomnia (cont.) • Behavioral insomnia of childhood • Learned specific circumstances in order to sleep. • Examples: parent, toy, blanket, pacifier • Incidence: to some extent 10-30% children, starting at 6 months.

  22. Types of Chronic Insomnia (cont.) • Paradoxial insomnia • Synonyms: • Sleep state misperceptions • Subjective insomnia • Pseudoinsomnia • Sleep hypochondriasis • Symptoms: subjective insomnia, even when EEG shows normal sleep stages. • Gross overestimation of sleep onset and total sleep time • Dx: requires EEG (incidence therefore unknown). High frequency EEG, ↑metabolic rate during sleep. • DDx: psychophysiological insomnia

  23. Types of Chronic Insomnia (cont.) • Insomnia associated with another condition • Coexistence vs. being secondary to. When co-existing condition adequately treated, insomnia often persists. • Medical conditions: 10% of pts with insomnia have chronic condition or take Rx. Conversely, 40% of pts with medical problems have insomnia.

  24. Pulmonary (>50% have insomnia). Postural changes↑WOB, secretions pool in aw, nocturnal bronchoconstriction; Rx COPD Bronchial asthma Cardiovascular Heart failure (30%): Cheyne-stokes breathing Ischemic heart disease Nocturnal angina Rheumatologic Arthritis Fibromyalgia Musculoskeletal: Chronic pain Endocrinologic Menopause Hyperthyroidism Diabetes Pheochromocytoma Urinary: nocturia Gastrointestinal: GERD Other Lyme disease AIDS Chronic fatigue syndrome Types of Chronic Insomnia (cont.) – Co-existing Medical Conditions

  25. Types of Chronic Insomnia (cont.) • Psychiatric disorders: • 45% pts with insomnia have psychiatric d/o • Insomnia may precedes psychiatric dz (controversial: causal or a marker?) • Comorbidity not simply causal • Examples: • Depression – early awakening • Anxiety – difficulties with sleep initiation • Substance abuse – i.e. pt with insomnia are more sensitive to caffeine. • PTSD – dx includes sleep disturbances

  26. Diagnostic Overlap • S-sleep disturbances • I-decreased interest • G-excessive guilt • E-decreased energy • C-decreased concentration • P-psychomotor agititation • S-suicidal ideation

  27. Diagnositic Overlap (cont.) • Anxiety • Sleep initiation, restless sleep (maintenance), difficulty concentrating, irritability • PTSD • Recurrent distressing dreams of the event (one of the B Criteria)

  28. ICSS. 2006.

  29. Types of Chronic Insomnia (cont.) • Neurological diseases • Neurodegenerative disease • Alzheimers disease • Parkinson disease • Neuromuscular disorders: Peripheral neuropathies • Cerebral hemispheric and brain stem strokes • Brain tumors • TBI causing post-traumatic insomnia • Headache syndromes • Fatal familial insomnia – a rare prion disease; degeneration of mediodorsal nucleus

  30. Types of Chronic Insomnia (cont.) • Medications • CNS stimulants • CNS depressants • Bronchodilators • Antidepressants • Beta agonist • Glucocorticoids

  31. Types of Chronic Insomnia (cont.) • Sleep disorders • Sleep disordered breathing • Apnea • Obstructive sleep apnea (normal oxygenation, snore): 10% with insomnia. • Central apnea. Cheyne-stokes breathing • Respiratory alkalosis • Heart failure (EF<40%) • Stroke • Pickwickian syndrome (“obesity hypoventilation syndrome”). • Requires daytime hypercapnea, Hypopnea/apnea, ↓O2 sat. • Leads to pHTN RHF (cor pulmonale) • Usually also have OSA.

  32. Types of Chronic Insomnia (cont.) • Sleep disorders (cont.) • Restless legs syndrome • Periodic limb movements • Circadian rhythm disorders • Delayed sleep phase syndrome (much more common than advanced SPS). • Advanced sleep phase syndrome

  33. Review of Types with Synonyms • Insomnia of short duration: • Acute: adjustment insomnia, short-term insomnia, stress-related insomnia, transient insomnia • Circadian rhythm sleep disorders • High altitude insomnia • Insomnia of longer duration: • Inadequate sleep hygiene • Psychophysiological insomnia: Primary insomnia,Chronic insomnia, Learned insomnia, Conditioned insomnia • Idiopathic insomnia: Life-long insomnia, Childhood onset insomnia • Behavioral insomnia of childhood • Paradoxial insomnia: Sleep state misperceptions, Subjective insomnia, Pseudoinsomnia, Sleep hypochondriasis • Insomnia associated with another condition: medical, psychological, neuromuscular, medications, sleep disorders

  34. Evaluation • History • Medication review: current; prior sleep meds • Explore co-morbidities • Sleep hygiene • Bed-partner history • Sleep diary • Sleep study • Differential Diagnosis • Short duration sleep: some people simply require less sleep. • Sleep deprivation: will rapidly fall asleep if given the chance. • Sleepy vs. fatigue • Epworth sleepiness scale.

  35. Epworth Sleepiness Scale

  36. Sleep Journal

  37. When to Refer to Sleep Study? • Paradoxical insomnia • Sleep disordered breathing • Parasomnias: d/o with abnl psyiological or behavioral events during sleep, not changes ni amount or timing of sleep • Movement disorders • Behavioral disturbances • Not simply for chronic insomnia

  38. Non-pharmacologic Treatment • Stimulus control • Sleep-restriction • Relaxation therapy • Sleep hygiene • Education NEJM 2009;353(8):803-809.

  39. Pharmacologic Treatment • Terms • Tolerance: Reduction in drug effect requiring an increase in dosage to maintain the same response. • Physiologic dependence: The state of response to a drug whereby removal of the drug evokes unpleasant symptoms, usually the opposite of the drug’s effects. • Phychologic dependence: The state of response to a drug whereby the drug taker feels compelled to use the drug and suffers anxiety when separated from the drug. Pharmacology. Katzung. 1998.

  40. Pharmacologic Treatment • Non-benzodiazepines • >Antidepressants >Atypical antipsychotics • >Melatonin >other herbals • >Antihistamines • Benzodiazepines/BZ-receptor agonists GABAa receptor-chloride ion channel macromolecular complex. http://www.mona.uwi.edu/fpas/courses/physiology/neurophysiology/GABAreceptorA.jpg

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

  42. General Guidelines • BZD • for short-term insomnia. • If for chronic insomnia, 3-4 nights/week max 3 weeks. • BZD/BZD-receptor agonists • Data limited by length of studies (longest is 6 months-Lunesta) • Lowest possible dose, intermittently, shortest duration possible. • Sleep initiation: short-acting (rebound) • Sleep maintenance/early wakening: intermediate (rare rebound) • Avoid in apnea, substance abuse, or pregnancy. • Caution in the elderly, especially long-acting (dose reduction). • Long-acting good only if also pt has daytime anxiety • Ambien: little or no rebound • Sonata: no rebound, can take in middle of the night • Lunesta: no tolerance after 6 months Pharmacotherapy Handbook. 2000. NEJM 2009;353(8):803-809

  43. Specific Treatments for Sleep Disordered Breathing • OSA (briefly) • Tx for insomnia, heart failure and pulmonary HTN • CPAP desensitization (next slide) • CPAP interfaces • Avoid/limit BZD like temazepam ( acute airway crisis) • Pickwickian syndrome: • CPAP • tracheostomy if decompensated

  44. CPAP Desensitization STEP 1: • 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 can do this without anxiety or concern for five consecutive days, then go to Step 2. STEP 2: • 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 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. STEP 3: • 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 Step 4. STEP 4: • 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 to Step 5. STEP 5: • Use nCPAP for your entire night’s sleep. This treatment was published by Doctors Edinger and Radtke, from Duke University, in 1993.

  45. Conclusion • Sleep complaints are common, and often not brought up with doctor: ask the patient. • Evaluation is based on a good understanding of the etiologies of insomnia. • Bed-partner history • Explore co-morbidities • Insomnia is considered to coexist with other medical and psychiatric conditions, not necessarily to cause them. • Age: associated features, not age per se • Treatment includes both non-pharmacologic (best to try first) and pharmacologic • Sleep hygiene

  46. Questions?

  47. References • 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. • International classification of sleep disorders: diagnostic and coding manual. 2nd ed, American Academy of Sleep Medicine, Westchester, IL 2005. • Ohayon, MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Medicine Review 2002; 6:97 • 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; 42:225. • Foley, DJ. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995; 18:425. • 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. • Insomnia. Principles and Management. Szuba. Cambridge. 2003. • Silber, M.H. Clinical Practice: Chronic Insomnia. New England Journal of Medicine 2009 Aug 25;353(8):803-809. • Iglostein I. Sleep Duration From Infancy to Adolescence: Reference Values and Generational Trends. Pediatrics 2003;111:302-307. • 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, 2009. • Bonnet. Diagnostic Evaluation of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, 2009. • Pharmacotherapy Handbook. Wells, B. Second Edition. Appleton & Lange. 2000. • Pharmacology – Examination & Board Review. Katzung. McGraw Hill. 1998. • Special thanks to David Bradshaw, MD

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