Insomnia

1. Insomnia Simon Tucker Swindon/Bath GP Registrar DRC September 2005

2. What is it? • Trouble falling asleep, staying asleep, waking too early, or not feel rested after sleep. • Most adults need about 7-8 hrs a night, as we age, sleep patterns change, sleep less at night and take naps in the day.

3. Types of insomnia • Transient insomnia • <4/52, triggered by excitement or stress, occurs when away from home • Short-term • 4/52-6/12, ongoing stress at home or work, medical problems, psychiatric illness • Chronic • Poor sleep every night or most nights for > 6/12, psychological factors (prevalence 9%)

4. Medical problems • Depression • Hyperthyroidism • Arthritis, chronic pain • Benign prostatic hypertrophy • Headaches • Sleep apnoea • Sleep related periodic leg movement, Restless legs • GOR

5. Other factors • Caffeine • Nicotine • Alcohol • Exercise • Noise • Light • Hunger

6. The bedroom • Temperature, fresh air • S&S • Comfortable bed

7. C.B.T. & insomnia • Over 40yrs research has shown C.B.T is effective in treatment insomnia but effect is not as great then when applied to other psychological disorders.

8. Stimulus control • Go to bed when sleepy • Only S & S in bedroom • Get up the same time every morning • Get up when sleep onset does not occur in 10 min, and go to another room • No daytime napping • Rational is that insomnia in the result of maladaptive conditioning between the environment (bedroom) and sleep incompatible behaviours. Aim is to reverse this –ve association by limiting the sleep incompatible behaviours engaged within the bedroom environment. • Richard Bootzin 1972

9. Sleep hygiene • Education about behaviours that interfere with sleep • Caffiene • Alcohol • Nicotine • Day time napping • Exercise < 4hrs before bed • “education” is followed by monitoring of “sleep-unfriendly” behaviours to improve compatibility of patients lifestyle with sleep.

10. Relaxation training • Progressive muscle relaxation • Diaphragmatic breathing • Autogenic training • Biofeedback • Meditation • Yoga • Hypnosis • Reduce anxiety and tension at bedtime

11. Sleep restriction • Sleep record for 2/52, calculate the average total asleep time (ATST) • Time in bed (TIB) = ATST + 30 min • TIB increased every few weeks by 15 min if sleeping well but still having daytime sleepiness • Grew out of observation that insomniacs stay in bed hoping this will produce more sleep time, instead it breaks up sleep over a longer time period and increases frustration • Arthur Spielman.1987

12. Thought stopping • Interrupt unwanted pre-sleep cognitive activity by instructing patient to repeat sub-vocally “the” every 3 sec (articulatory suppression) • or to yell sub-vocally “stop” (thought stopping)

13. Paradoxical intention • Explicit instruction to stay awake when they go to bed • Aim is to reduce anxiety associated with trying to fall asleep

14. Cognitive restructuring • Alter irrational beliefs about sleep, provide accurate information that counteracts false beliefs.

15. Imagery training • Patient imagines 6 common objects (candle, hourglass, blackboard, kite, light bulb, fruit) • Emphasis on imagining shape, colour, texture

16. Drugs • Benzodiazepines (GABA rec. agonist) • Transient insomnia, (max 2/52, ideally 2-3/7) • Long ½ life, nitrazepam • Med ½ life temazepam • Short ½ life diazepam • Poor functional day time status, cognitive impairment, daytime sleepiness, falls and accidents, depression, dependence (DTB Dec 04) • Acute withdrawal, confusion, psychosis, fits, D.T’s • May occur up to 3/52 from stopping

17. Z drugs • Act at the benzodiazepine receptor • Less risk of dependence • Zaleplon short ½ life • Zolipidem, Zopiclone slightly longer ½ life • NICE 2004 • No consistant difference found for effectiveness and safety • More expensive • Only use if adverse effects to BZP

18. Other drugs • TCA • Amitriptyline, if depression also an issue • Antihistamines • Promethazine OTC • Chloral hydrate

19. melatonin • Hormone secreted by pineal gland, effects circadian rhythm, synthesised at night • Use to counteract jet lag (2-5mg @ bedtime for 4 night nights after arrival, Cochrane) • Used in paediatric sleep disorders (severe learning difficulties, visually handicapped.) • Can’t be prescribed

20. What about kids?

21. Controlled crying • From 9/12 • Bedtime routine • Regular bedtime, say goodnight • Leave to cry, checking every 5 – 10 – 15 min, (may also need a graded withdrawal phase) • Works for bed time and middle night waking • during checks, minimal stimulation • can work in 3/7 • Maternal instinct is main barrier to effectiveness

22. bibliography • Americaninsomniaassociation.org • Familydoctor.org • Gpnotebook.co.uk • Cognitive behavioural therapy for primary insomnia: can we rest yet? Harvey A, Tang N. Sleep medicine reviews Vol 7, No3, 237-262, 2003 • BNF