© copyright annals of internal medicine, 2014 ann int med. 161 (4): itc4-1. * for best viewing:...
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (4): ITC4-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (4): ITC4-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 161 (4): ITC4-1.
Which patient populations have the highest prevalence of insomnia?
Women
Especially in 3rd 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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?
© Copyright Annals of Internal Medicine, 2014Ann 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)
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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?
© Copyright Annals of Internal Medicine, 2014Ann 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?
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
© Copyright Annals of Internal Medicine, 2014Ann 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
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