Insomnia

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Insomnia

• David A. Garfunkel, M.D.
• August 31, 2005

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• Irrelevant Fact
• Sleep Physiology
• Joke
• Scope of the Problem
• Diagnosis
• Commercial Break
• Non-Pharmacologic Treatment
• Pharmacologic Treatment

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Who was the 2004 U.S. Open Tennis Womans Winner?
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Svetlana Kuznetsova
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Definitions

• Sleep is a state of unconsciousness in which the
  brain is relatively more responsive to internal
  than to external stimuli
• Mechanisms within the brainstem and hypothalamus
  regulate sleep through GABA and acetylcholine

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Philagrypnia

• Ability to stay alert with very little sleep

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Purpose of Sleep

• Speculative
• NREM sleep may allow decrease in metabolic demand
  and allow replenishment of glycogen stores
• Oscillating depolarization's and repolarizations
  consolidate and and remove redundant or excess
  synapses

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REM sleep

• Generated by mesencephalic and pontine
  cholinergic neurons
• Characterized by muscle atonia, cortical
  activation, low voltage desynchronization of the
  EEG, and rapid eye movements

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• REM sleep has both tonic and phasic qualities
• Other features include periodic skeletal muscle
  twitches, increased heart rate variability and
  increased respiratory rate

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Circadian sleep rhythm

• One of several intrinsic rhythms modulated by the
  hypothalamus
• Without external stimulus, the suprachiasmatic
  nucleus sets the rhythm to approximately 25 hours
• A nerve tract directly from the retina helps
  regulate us to 24 hours days.
• Melatonin is a modulator of light entrainment and
  is secreted maximally by the pineal gland during
  the night

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• Insomnia is defined as difficulty with the
  initiation, maintenance, duration, or quality of
  sleep that results in the impairment of daytime
  functioning, despite adequate opportunity and
  circumstances for sleep.
• Patients subjective dissatisfaction with the
  sleep quality and quantity

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• Transient Insomnia - Symptoms present for less
  than one week
• Short Term Insomnia - Symptoms for 1-4 weeks
• Chronic Insomnia - Symptoms present for more than
  one month

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Poor Sleep Maintenance

• Waking after sleep has been initiated, but before
  desired waking time

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• Initiation of Sleep Time to fall asleep
• Standard - less than 30 minutes
• Sleep Efficiency Time sleeping/ Time in bed
• Standard - Greater than 85
• May be caused by awakening frequently during the
  night with subsequent difficulty in re-initiating
  sleep, or awakening too early without being able
  to go back to sleep at all

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• Some patients may not meet any of the above
  conditions, but awake feeling poorly rested.

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Sleep Requirements

• Average - 7 1/2 to 8 1/2hrs/night
• Range (for adults) - 5-9 hrs/night
• Steadily decreases from birth to old age
• newborns sleep 14-16 hours/24 hours
• Elderly spend less time sleeping per night, but
  increase in sleep latency and more frequent
  arousals make their requirement in bed longer.

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What do you call a nun who sleep walks?
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A Roamin Catholic
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Scope of the Problem

• 2003 Sleep in America poll, which included 1,506
  adults ages 55 to 84 from various parts of the
  United States, found a prevalence of insomnia in
  48 percent.

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Scope of the Problem

• 1997 survey of almost 2000 HMO patients showed
  that 10 had current major insomnia as defined as
  taking more than 2 hours to fall asleep each
  night.
• Only 5 spoke to their physician about it
• Over 38 million prescriptions per year for
  sleeping pills

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Consequences

• Mood Disturbance
• Depression and/or Anxiety
• Poor memory
• Difficulty concentrating
• Motor vehicle and other accidents

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Normal Sleep Physiology

• Stages
• 1 - light sleep, 5-10 of total sleep time,
  transition between awake and asleep
• 2 - 40-50 of total sleep time
• 3,4 - deep or delta wave sleep, occurs mostly
  early in the night
• REM sleep, 20-25 of sleep
• All 4 stages repeat in ultradian rhythm of about
  90 minutes

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• There are 4-5 cycles in a normal nights sleep
• First REM- 10 minutes, but later REM periods may
  exceed 60 minutes

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Diagnosis- other sleep disorders

• Hypersomnia - Excessive sleepiness, despite up to
  12 hrs./night of sleep
• Gradual onset
• Usually appears before age 25
• Recurrent hypersomnia - Kleine Levin Syndrome
• May be due to depression

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Narcolepsy

• Immune mediated destruction of hypocretin
  secreting neurons in the pineal gland
• Not related to melatonin
• Inherited on multiple genes, dominant with
  incomplete penetrance
• CSF levels of hypocretin is low and is a useful
  test

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• The normal physiologic components of REM sleep,
  dreaming and muscle tone are separated and can
  occur while the patient is awake, resulting in
  half sleep dreams, cataplexy and sleep paralysis

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• Characterized by attacks of disabling daytime
  drowsiness and low alertness
• Short sleep latency and sleep often begins with
  REM activity
• 2/3 of cases are associated with cataplexy,
  triggered by strong emotion

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Parasomnias

• Disoriented Arousal
• Sleepwalking
• Night/Sleep Terrors
• Hypnagogic Hallucinations
• Sleep Paralysis
• Nocturnal Seizures

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Parasomnias, continued

• REM Behavioral Disorder
• Bruxism
• Rhythmic Movement Disorder
• Restless Legs Syndrome

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Sleep History

• Timing of insomnia
• Sleep schedule
• Sleep environment
• Sleep habits
• Symptoms of other sleep disorders
• Daytime effects
• Medications, caffeine
• Life stressors and worry over insomnia

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Medications that may cause insomnia

• Clonidine
• Beta Blockers
• Theophyline
• Certain Antidepressants
• Protriptyline, Fluoxetine
• Decongestants
• Stimulants
• Alcohol

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• Exercise in morning or early afternoon lessens
  insomnia
• Exercise close to bedtime worsens insomnia

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Physical Exam

• Anatomic features of obstructive sleep apnea
• Neurologic exam in case of restless leg or other
  neurologic syndrome

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Sleep Log

• Maintain for 2-4 weeks
• Sleep and wake times
• Awakenings
• Daytime naps and activities
• Correlation with bed partner

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Commercial Break
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Remedy

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Nonpharmacalogic Therapy

• Cognitive Behavioral Therapy
• Individual counseling- 6 sessions
• Effective in 50 of patients

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Relaxation Therapy

• Recognize and control tension through
  systematically tensing and relaxing various
  muscle groups
• Guided imagery and meditation
• Biofeedback

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Stimulus Control Therapy

• Reassociate the bed with sleepiness rather than
  wakefulness
• No reading, TV, eating or working in bed
• Lying down only when sleepy
• If unable to sleep after 15-20 minutes, get out
  of bed and do something else

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Sleep-restriction Therapy

• Eliminate excess time in bed awake
• Purposefully limit sleep, which leads to more
  efficient and effective sleep habits.
• Gradually allow more time in bed as insomnia
  resolves

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Pharmacologic Therapy

• Non-prescription
• Prescription

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Non-prescription Therapy

• Valerian - An herbal medication that may be safe
  and effective to decrease sleep latency. May work
  better if taken regularly at night rather than
  PRN.
• Main risk is uncontrolled manufacturing of herbal
  compounds

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Melatonin

• A natural hormone produced in the pineal gland
• Circadian rhythm increases the blood level at
  night, especially when it is dark
• Antioxidant properties
• May be effective

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What is the active ingredient in Tylenol PM?
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Diphenhydramine hydrochloride

• Main Ingredient in Tylenol PM, Sominex, Unisom,
  etc.
• Antihistamine and anticholinergic agent
• Non-specific and long lasting

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Prescription Drugs

• Benzodiazepines - most common
• If the problem is falling asleep, use medication
  with a rapid onset of action
• Very short 1/2 life may be associated with
  increased risk of rebound anxiety
• If the problem is staying asleep, a hypnotic with
  a slower rate of elimination may be more useful

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Concomitant Depression

• Antidepressants with sedative properties
• Trazodone (Desyrel)
• Amitriptyline (Elavil)

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Eszopiclone (Lunesta)

• New class of non-benzodiazepine
• May affect GABA receptor
• Rapid onset, medium 1/2 life
• No tolerance or withdrawal after 6 months of
  treatment
• 1,2,3 mg. dose

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Rozerem (ramelteon)

• Unscheduled prescription drug
• Acts on Melatonin receptors
• No activity on the following receptors
• GABA, neuropeptides, cytokines,seratonin,
  dopamine, noradrenaline, acetylcholine, or opioid

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Rozerem, continued

• Given to 14 subjects with history of abuse of
  sedative/hypnotics or anxiolitics Result no
  potential for abuse
• Dosage-8 mg. (not with or immediately following a
  high fat meal

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Sedative-hypnotic Medication General rules

• Symptomatic relief, not a cure
• Combine with nonpharmacologic treatment
• Smallest effective dose for the shortest possible
  time
• Avoid alcohol
• Pregnancy is a contraindication
• Taper off to avoid rebound insomnia

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The End