iNSOMNIA

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iNSOMNIA

• El-Sayed Saleh, M.D.
• Ass. Prof. of Psychiatry

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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 hypo-thalamus
  regulate sleep through GABA and acetylcholine

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Sleep Stages ___________________________
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Stages of sleep___________________________

• 1. NREM Sleep
• A. Stage 1
• B. Stage 2
• C. Stage 3
• D. Stage 4
• 2. REM Sleep

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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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• 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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Philagrypnia

• Ability to stay alert with very little sleep

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Sleep disorders (ICSD 2)

1. Insomnia.
2. Sleep Related Breathing Disorders.
3. Hypersomnia.
4. Cicadian Rhythm Sleep Disorder.
5. Parasomnia.
6. Sleep related Movement Disorder.

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Important facts

• Sleep disorders are common
• Sleep disorders are serious
• Sleep disorders are treatable
• Sleep disorders are under diagnosed

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iNSOMNIA
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Insomnia definition

• Insomnia is defined as difficulty with the
  initiation, maintenance 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
• The normal requirement for sleep ranges between 4
  and 10 hours
• Insomnia is a symptom, not a disorder by itself

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Poor Sleep Maintenance

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

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Types of insomnia

• Transient insomnia
• lt 4 weeks triggered by excitement or stress,
  occurs when away from home
• Short-term
• 4 wks to 6 months , ongoing stress at home or
  work, medical problems, psychiatric illness
• Chronic
• Poor sleep every night or most nights for gt 6
  months, psychological factors (prevalence 9)

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

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Scope of the Problem

• 1997 survey of almost 2000 health maintenance
  organization (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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Possible causes of insomnia
Headache Bad or vivid dreams Problems of breathing Chest pain/heartburn Need to pass urine or move bowels Abdominal pains Fever/night sweats Leg cramps Fear/anxiety Depression
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Medications and insomnia
Type of medication Example
CNS stimulants D-amphetamine
Blood pressure drugs ? - blockers, ? - blockers
Respiratory medicines Albuterol, Theophylline
Decongestants Phenylephrine, Pseudoephedrine
Hormones Thyroxin, Corticosteroids
Other substances Alcohol, Nocotine, Caffeine
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Insomnia associated features

• At least one (or more) of the following
• Fatigue or malaise
• Attention, concentration impairment
• Social/ vocational dysfunction/ poor work
• Mood disturbance or irritability
• Daytime sleepiness

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Insomnia resultant problems

• Reduction in motivation, energy or initiative
• Proneness for errors or accidents at work or
  while driving
• Tension, headaches or gastrointestinal symptoms
  in response to sleep loss
• Concerns or worries about sleep
• Secondary psychiatric problems

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Consequences

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

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Insomnia assessment

• Determine the pattern of sleep problem
  (frequency, associated events, how long it takes
  to go to sleep, and how long the patient can stay
  asleep)
• Include a full history of alcohol and caffeine
  intake and other factors that might affect sleep
• Review current medications that patient is taking
  to eliminate these as possible causes
• Take a history to rule out physical cause and/or
  psychosocial cause

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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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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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Management of insomnia___________________________
_

• Good Sleep History
• Rule out primary psychiatric disorders
• Rule out adverse effects of medications
• Sleep Diary
• Good Sleep Hygiene Measures
• Interventions CB therapy, medications

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Management of insomnia___________________________

• Treat underlying Medical Condition
• Treat underlying Psychiatric Condition
• Improve sleep hygiene
• Change environment
• CBT primary insomnias, transient insomnia
• Pharmacological
• Light, melatonin, or chronotherapy for
  circadian disorders

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Nonpharmacalogic Therapy

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

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Non pharmacological treatments
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Cognitive Behaviour Therapy (CBT)_____________
_______________
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Bed room__________________________

• Temperature
• Fresh air
• SS
• Comfortable bed

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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 20
  min, and go to another room
• No daytime napping

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Sleep hygiene__________________________

• Behaviours that interfere with sleep
• Caffeine
• Alcohol
• Nicotine
• Daytime napping
• Exercise lt 4hrs before bed

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Relaxation training__________________________

• Progressive muscle relaxation
• Diaphragmatic breathing
• Biofeedback
• Meditation, Yoga
• Hypnosis to ? anxiety tension at bedtime

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Thought stopping__________________________

• Interrupt unwanted pre-sleep cognitive activity
  by instructing patient to repeat sub-vocally
  the every 3 sec (articulatory suppression)
• To yell sub-vocally stop (thought stopping)

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Behavioural therapies__________________________

• Explicit instruction to stay awake when they go
  to bed Aim is to reduce anxiety associated with
  trying to fall asleep Paradoxical intention
• Alter irrational beliefs about sleep, provide
  accurate information that counteracts false
  beliefs Cognitive restructuring
• Patient imagines 6 common objects (candle, kite,
  fruit, hourglass, blackboard, light bulb)
  emphasis on imagining shape, colour, texture
  Imagery training

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Benzodiazepine receptor agonists_________________
_________

• Benzodiazepines
• Lorazepam
• Clonezepam
• Temazepam
• Flurazepam
• Quazepam
• Alprazolam
• Triazolam
• Estazolam

• Non Benzodiazepines
• Zolpidem
• Zolpidem CR
• Zeleplon
• Eszopiclone
• Both these classes act on the GABAA receptors
  (BzRA) in PCN

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Other classes of medications_____________________
_____

• Antidepressants
• Trazadone
• Mirtazapine
• Doxepin
• Amitryptyline
• Antipsychotics
• Olanzapine
• Quitiepine

• Melatonin Receptor Agonists
• Melatonin
• Ramelteon
• Miscellaneous
• Valerian
• Diphenhydramine
• Cyclobenzaprine
• Hydroxyzine
• Alcohol

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BzRAs side effects and safety__________________
________

• Anterograde amnesia
• Residual sedation longer acting BzRAs
• Rebound Insomnia?
• Abuse and dependence?
• Mostly used short term (2 weeks)
• When used as a sleeping aid dose escalation rare
• No physical dependence with night time use
• Low psychological dependence with night time use
• Increased fall risk, cognitive effects in the
  elderly

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Benzodiazepines____________________________

• Benzodiazepines (GABA receptor agonist)
• Transient insomnia, (max 2 wks, ideally 2-3/wk)
• Long ½ life - nitrazepam
• Medium ½ life - temazepam
• Short ½ life - diazepam
• Poor functional day time status, cognitive
  impairment, daytime sleepiness, falls and
  accidents, depression
• Acute withdrawal, confusion, psychosis, fits -
  may occur up to 3/52 from stopping

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Benzodiazepine use____________________________

• Benzodiazepines are the drugs of choice for the
  treatment of insomnia.
• Flurazepam can be used for up to one month with
  little tolerance.
• Temazepam can be used for up to three months with
  little tolerance.
• Intermittent use recommended (every three days).
  Use for no longer than 3 6 months.

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Benzodiazepine use____________________________

• Half-life is an important factor
• Benzodiazepines with long half lives (e.g.,
  flurazepam) produce sustained sleep, but
  increased risk of daytime somnolence
• Benzodiazepines with short half lives may be best
  for patients with difficulty falling asleep, but
  can produce rebound insomnia
• Development of tolerance can produce rebound
  insomnia in compounds with short half lives

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Benzodiazepine abuse____________________________

• Benzodiazepines have relatively low abuse
  potential.
• Prolonged use can lead to withdrawal symptoms
  headache, irritability, dizziness, abnormal sleep
• Rebound insomnia - triazolam

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Benzodiazepine toxicity__________________________
__

• Low toxicity when taken alone
• In combination can be fatal
• Flumanzenil is a benzodiazepine antagonist that
  can be used to block adverse effects of
  benzodiazepines
• Stomach pump, charcoal, hemodialysis

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Non benzodiazepines____________________________

• Act at the benzodiazepine receptor
• Less risk of dependence
• Zaleplon short ½ life
• Zolipidem, Zopiclone slightly longer ½ life
• No difference in effectiveness safety
• More expensive
• Only to be used if adverse effects to BZP

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Zolpidem____________________________

• Short half life
• Does not produce rebound insomnia
• Low abuse potential
• Less likely to produce withdrawal symptoms
• Rebound insomnia after first night of withdrawal,
  but soon resolves

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Barbiturates____________________________
Drug Duration of action Half-life
Phenobarbital Long 24 140 hrs.
Butabarbital Intermediate 34 42 hrs.
Amobarbital Short-intermediate 8 42 hrs.
Pentobarbital Short-intermediate 15 48 hrs.
Secobarbital Short-intermediate 19 34 hrs.
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Barbiturates - neurochemistry____________________
________

• Enhance GABAA receptor activity
• Increase Cl- conductance through site separate
  from that of benzodiazepines
• Thiopental also inhibits GABA transaminase
• Also block glutamate receptor-mediated excitation

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Barbiturates - effects___________________________
_

• Progression of effects
• Anxiolytic,Sedation, General anesthesia
• Medullary paralysis, Death
• Decrease stage III, IV, REM sleep, sleep latency
• Tolerance develops to shortening REM sleep
• Produce REM rebound
• Anxiolytic, but with substantial drowsiness and
  ataxia. Anticonvulsant activity.

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Other drugs____________________________

• TCA - Amitriptyline, if depression also an issue
• Antihistamines Promethazine
• Melatonin
• Hormone secreted by pineal gland, effects
  circadian rhythm, synthesised at night
• Use to counteract jet lag (2-5mg _at_ bedtime for
  Four nights after arrival)
• Synthetic analogue of malatonin - Remelteon
• Used in paediatric sleep disorders

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Thank You All Have Good Dreams