insomnia presentation

SLEEPSLEEPand and

INSOMNIAINSOMNIA

Lynn N. Stewart, M.D.Lynn N. Stewart, M.D.

Travis County Wellness and Health Travis County Wellness and Health ClinicClinic

Austin, TXAustin, TX

ObjectivesObjectivesBy the conclusion of this lecture, you will be able to:By the conclusion of this lecture, you will be able to:

Learn about the process of sleepLearn about the process of sleep Identify 4 main categories of insomniaIdentify 4 main categories of insomniaClassify insomnia by stageClassify insomnia by stageList at least 5 common etiologies of List at least 5 common etiologies of

insomniainsomniaDiscuss 5 or more principles of sleep Discuss 5 or more principles of sleep

hygienehygieneGive 5 guidelines for drug therapyGive 5 guidelines for drug therapy

Why do we care about sleep?Why do we care about sleep?

Sleep is a necessary restorative process Sleep is a necessary restorative process that affects all aspects of functioning.that affects all aspects of functioning.

Sleep is an active process for the brain.Sleep is an active process for the brain.Early in sleep slow-rolling eye movements Early in sleep slow-rolling eye movements

occur (non-rapid eye movement).occur (non-rapid eye movement).Later—deeper in sleep–rapid eye Later—deeper in sleep–rapid eye

movements (REM) are associated with movements (REM) are associated with irregular breathing and increased heart irregular breathing and increased heart raterate

Sleep Stages and their functionSleep Stages and their functionNon-rapid Eye Movement (NREM)Non-rapid Eye Movement (NREM)

Stage 1: transition to sleepStage 1: transition to sleep 5% total time5% total time

Stage 2: 50% total timeStage 2: 50% total timeStages 3 and 4: slow-wave sleepStages 3 and 4: slow-wave sleep

10-20% total sleep time10-20% total sleep timeRestful and restorative sleep Restful and restorative sleep

achieved hereachieved hereRapid Eye Movement (REM)Rapid Eye Movement (REM)

20-25% total sleep time20-25% total sleep time

Sleep Cycle and ArchitectureSleep Cycle and Architecture

Normal, healthy people start with NREM1 Normal, healthy people start with NREM1 then NREM 2, 3, 4, 3, 2, and then REM.then NREM 2, 3, 4, 3, 2, and then REM.

Cycle repeats at 90-120 minute intervalsCycle repeats at 90-120 minute intervalsTotal cycle repeats 3-4 times a nightTotal cycle repeats 3-4 times a nightNREM 3 and 4: more prominent is first half NREM 3 and 4: more prominent is first half

of the night, and decrease later on.of the night, and decrease later on.REM: less prominent in the early night, REM: less prominent in the early night,

and increases as the night progressesand increases as the night progresses

Sleep at different agesSleep at different ages

Sleep varies with ageSleep varies with age Infants sleep 66% of the day; adults, 33%Infants sleep 66% of the day; adults, 33%Elderly have a reduction in the depth, Elderly have a reduction in the depth,

intensity , and continuity of sleep:intensity , and continuity of sleep: Increased sleep latencyIncreased sleep latencyDecreased REM latencyDecreased REM latencyReduced NREM 3 and 4 Reduced NREM 3 and 4 Reduced total REM amountReduced total REM amountFrequent awakeningsFrequent awakenings

So what keeps us awake?So what keeps us awake? The Reticular Activating System (RAS) of the The Reticular Activating System (RAS) of the

brain plays is mostly responsible for keeping us brain plays is mostly responsible for keeping us awake and alert.awake and alert.

Narcolepsy is a clinical syndrome of daytime Narcolepsy is a clinical syndrome of daytime sleepiness with cataplexy (bilateral muscle sleepiness with cataplexy (bilateral muscle weakness leading to partial or complete weakness leading to partial or complete collapse), hypnagogic hallucinations, and sleep collapse), hypnagogic hallucinations, and sleep paralysis, and is associated with disordered paralysis, and is associated with disordered REM sleep. Not all are required for the REM sleep. Not all are required for the syndrome. A loss of orexin and hypocretin syndrome. A loss of orexin and hypocretin neuropeptides is typically found.neuropeptides is typically found.

Types of InsomniaTypes of Insomnia

Is the problem not being able to fall Is the problem not being able to fall asleep?asleep?

→→Problems falling asleep are referred to as Problems falling asleep are referred to as problems with “sleep latency.”problems with “sleep latency.”

Is the problem staying asleep?Is the problem staying asleep?

→→Problems staying asleep are referred to Problems staying asleep are referred to as problems with “sleep maintenance.”as problems with “sleep maintenance.”

Why Are We Talking About Why Are We Talking About This?This?

Up to 40% of adults are affectedUp to 40% of adults are affected1/3 adults are affected intermittently1/3 adults are affected intermittently10% are chronic10% are chronicTreatment alone costs $2-11 billionTreatment alone costs $2-11 billionTotal financial impact: $35 billionTotal financial impact: $35 billion Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic Morin CM, Hauri PJ, Espie CA, et al. Nonpharmacologic treatment of chronic

insomnia: an American Academy of Sleep Medicine Review. insomnia: an American Academy of Sleep Medicine Review. Sleep.Sleep. 1999;22:1134- 1999;22:1134-11561156

Silber MH. Chronic insomnia. Silber MH. Chronic insomnia. N Engl J Med.N Engl J Med.2005;353:803-8102005;353:803-810 Saul S. Record sales of sleeping pills are causing worries. Saul S. Record sales of sleeping pills are causing worries. New York Times.New York Times. Feb 7, Feb 7,

2006.2006.

DefinitionDefinition

The The subjectivesubjective experience of inadequate experience of inadequate or poor quality sleepor poor quality sleep

““I’M UP”I’M UP” II - - difficultydifficulty IInitiating sleepnitiating sleep

MM - - difficulty difficulty MMaintaining sleepaintaining sleep

UU - - UUnrefreshing sleepnrefreshing sleep

PP - - PPremature awakeningremature awakening

Daytime ConsequencesDaytime Consequences

Tiredness and lack of energyTiredness and lack of energyPoor concentration and performancePoor concentration and performance Irritability and/or depressionIrritability and/or depressionFeeling unwellFeeling unwellLess able to enjoy lifeLess able to enjoy life Increased illnessIncreased illness

Real ConsequencesReal Consequences

AbsenteeismAbsenteeismPresenteeismPresenteeismSocial disabilitySocial disability Increased Increased

healthcare healthcare utilizationutilization

Fewer promotionsFewer promotions

Auto accidentsAuto accidentsInsomniacs have Insomniacs have

2.5x more 2.5x more accidents due to accidents due to fatiguefatigue

DepressionDepression

Real ConsequencesReal ConsequencesSleep deprivation (less than 6 hours of Sleep deprivation (less than 6 hours of

sleep a night) is an independent predictor sleep a night) is an independent predictor of future weight gain AND obesity in of future weight gain AND obesity in women.women.

RR=1.32 for gaining >15kg (>33#) over 16 RR=1.32 for gaining >15kg (>33#) over 16 years for those who sleep 5 hours/night; years for those who sleep 5 hours/night; RR=1.12 for 6 hours/night when compared RR=1.12 for 6 hours/night when compared against those who slept 7 hours/night against those who slept 7 hours/night (after adjusting for exercise and caloric (after adjusting for exercise and caloric intake).intake).

Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Worcester, Sharon. “Sleep duration, weight gain are linked in women,” Family Family Practice News Practice News 36 (15 Oct 2006):44.36 (15 Oct 2006):44.

Sleep DeprivationSleep Deprivation

Inadequate opportunity for sleepInadequate opportunity for sleepFeel sleepy during the dayFeel sleepy during the day

insomniacs typically feel tired, not insomniacs typically feel tired, not sleepysleepy

Fall asleep at inappropriate timesFall asleep at inappropriate timesSuch as while driving, at work during Such as while driving, at work during

an interview, while at family events.an interview, while at family events.

Hyper Arousal State from InsomniaHyper Arousal State from Insomnia

Increased (short-term only)Increased (short-term only)::Metabolic rateMetabolic rateHeart rateHeart rateTemperatureTemperatureCatecholamine metabolitesCatecholamine metabolitesStress hormone levelsStress hormone levelsFast EEG activity (electrical recording of brain Fast EEG activity (electrical recording of brain

activity=Electro Encephalo Gram)activity=Electro Encephalo Gram)

Risk Factors for InsomniaRisk Factors for Insomnia

Prior episodePrior episode Female gender (1.3x)Female gender (1.3x) Age > 65 (1.5x)Age > 65 (1.5x)

half the population half the population over age 65over age 65

40% of all hypnotic 40% of all hypnotic scriptsscripts

SnoringSnoring

Depression (which Depression (which comes first?)comes first?)

Lower Lower socioeconomic socioeconomic statusstatus

Divorce / SeparationDivorce / Separation WidowhoodWidowhood Concurrent medical Concurrent medical

problemsproblems

Stages of InsomniaStages of Insomnia

Transient: < 4 nights (days to weeks)Transient: < 4 nights (days to weeks)Acute: > 2 nights a week for 2 weeksAcute: > 2 nights a week for 2 weeksChronic: 3 or more nights a week, for Chronic: 3 or more nights a week, for

4 or more weeks (months to years)4 or more weeks (months to years)Critical: The inability to sleep during Critical: The inability to sleep during

lectureslectures

Psychiatric Causes of InsomniaPsychiatric Causes of Insomnia

DepressionDepression Generalized Anxiety Generalized Anxiety

DisorderDisorder StressStress Post Traumatic Post Traumatic

Stress DisorderStress Disorder Obsessive Obsessive

Compulsive Compulsive DisorderDisorder

Adjustment Adjustment disordersdisorders

Personality Personality disordersdisorders

Bipolar disorderBipolar disorder DysthymiaDysthymia AnxietyAnxiety Psychosis including Psychosis including

schizophreniaschizophrenia

Medical Causes of InsomniaMedical Causes of Insomnia

PainPain NeuropathyNeuropathy FibromyalgiaFibromyalgia Osteoarthritis Osteoarthritis Rheumatoid arthritisRheumatoid arthritis Chronic back painChronic back pain

CardiovascularCardiovascular Congestive heart Congestive heart

failurefailure DyspneaDyspnea Nocturnal anginaNocturnal angina

PulmonaryPulmonary COPDCOPD AsthmaAsthma Obstructive Sleep apneaObstructive Sleep apnea Mixed Sleep apneaMixed Sleep apnea Obesity-hypoventilation Obesity-hypoventilation

SyndromeSyndrome

GastrointestinalGastrointestinal GastroEsophageal GastroEsophageal

Reflux Disease Reflux Disease (GERD)(GERD)

Medical Causes of InsomniaMedical Causes of Insomnia

GenitourinaryGenitourinary Benign Prostatic Benign Prostatic

HypertrophyHypertrophy NocturiaNocturia IncontinenceIncontinence

Endocrine/MetabolicEndocrine/Metabolic Hormonal disruptionsHormonal disruptions MenopauseMenopause Thyroid diseaseThyroid disease Endocrine hormone-Endocrine hormone-

secreting tumorssecreting tumors

NeurologicNeurologic Alzheimer’sAlzheimer’s Huntington’sHuntington’s Parkinson’sParkinson’s Central Sleep apneaCentral Sleep apnea SeizuresSeizures Headaches (cluster, Headaches (cluster,

migraine)migraine) Fatal Familial Insomnia Fatal Familial Insomnia

(yes, it is fatal, and (yes, it is fatal, and familial)familial)

You’d already know about You’d already know about it if it is in your familyit if it is in your family

DyssomniaDyssomnia Dyssomnias are sleep disorders Dyssomnias are sleep disorders

characterized by insomnia, excessive characterized by insomnia, excessive sleepiness, or abnormal sleep-wake timingsleepiness, or abnormal sleep-wake timing

Sleep DisordersSleep DisordersRestless LegsRestless Legs

Trouble falling asleep Trouble falling asleep Patient very aware of movement/sensationsPatient very aware of movement/sensations

Periodic Limb Movement DisorderPeriodic Limb Movement DisorderUnrefreshing sleep, hypersomniaUnrefreshing sleep, hypersomniaLeg contractions during stages 1 & 2Leg contractions during stages 1 & 2

Patient usually unaware of movementPatient usually unaware of movement

Intrinsic DyssomniaIntrinsic Dyssomnia

Psychophysiological Psychophysiological insomnia insomnia

Sleep state Sleep state misperception misperception

Idiopathic insomnia Idiopathic insomnia Narcolepsy Narcolepsy Hypersomnia Hypersomnia

Recurrent, idiopathic, Recurrent, idiopathic, post-traumaticpost-traumatic

Restless legs Restless legs syndromesyndrome

Obstructive sleep Obstructive sleep apnea syndromeapnea syndrome

Central sleep apnea Central sleep apnea syndrome syndrome

Central alveolar Central alveolar hypoventilation hypoventilation syndromesyndrome

Periodic limb Periodic limb movement disordermovement disorder

Intrinsic sleep Intrinsic sleep disorder NOSdisorder NOS

Extrinsic DyssomniaExtrinsic Dyssomnia Inadequate sleep Inadequate sleep

hygiene hygiene Environmental sleep Environmental sleep

disorderdisorder Altitude insomnia Altitude insomnia Adjustment sleep Adjustment sleep

disorder disorder Insufficient sleep Insufficient sleep

syndromesyndrome Limit-setting sleep Limit-setting sleep

disorder disorder Sleep-onset association Sleep-onset association

disorderdisorder Food allergy insomniaFood allergy insomnia

Nocturnal eating Nocturnal eating (drinking) syndrome (drinking) syndrome

Hypnotic-dependent Hypnotic-dependent sleep disorder sleep disorder

Stimulant-dependent Stimulant-dependent sleep disordersleep disorder

Alcohol-dependent Alcohol-dependent sleep disordersleep disorder

Toxin-induced sleep Toxin-induced sleep disorderdisorder

Extrinsic sleep Extrinsic sleep disorder NOS disorder NOS

Circadian DyssomniaCircadian Dyssomnia

Time zone change (jet lag) syndrome Time zone change (jet lag) syndrome Shift work sleep disorder Shift work sleep disorder Irregular sleep-wake patternIrregular sleep-wake patternDelayed sleep phase syndromeDelayed sleep phase syndromeAdvanced sleep phase syndromeAdvanced sleep phase syndromeNon-24-hour sleep-wake disorder Non-24-hour sleep-wake disorder Circadian rhythm sleep disorder NOS Circadian rhythm sleep disorder NOS Shifts with age (adolescent or elderly)Shifts with age (adolescent or elderly)

ParasomniasParasomnias

Parasomnias are sleep disorders characterized Parasomnias are sleep disorders characterized by abnormal behavioral or physiological events by abnormal behavioral or physiological events which occur during sleep or during sleep-wake which occur during sleep or during sleep-wake transitions.transitions.

Parasomnias typically do not cause insomnia or Parasomnias typically do not cause insomnia or excessive sleepiness, but some are dangerous excessive sleepiness, but some are dangerous to the patient or others. to the patient or others.

Most are “normal” if done while awakeMost are “normal” if done while awake More common in children than adultsMore common in children than adults Most do not require therapyMost do not require therapy

Parasomnias ContinuedParasomnias Continued Arousal disorders:Arousal disorders:

Confusional arousalsConfusional arousals SleepwalkingSleepwalking Sleep terrors Sleep terrors

Sleep-wake Sleep-wake transition disorders:transition disorders: Rhythmic movement Rhythmic movement

disorderdisorder Sleep startsSleep starts Sleep talkingSleep talking Nocturnal leg cramps Nocturnal leg cramps

Parasomnias Parasomnias usually associated usually associated with REM sleep:with REM sleep: Nightmares Nightmares Sleep paralysisSleep paralysis Impaired sleep-related Impaired sleep-related

penile erectionspenile erections Sleep-related painful Sleep-related painful

erections erections REM sleep-related sinus REM sleep-related sinus

arrest REM sleep arrest REM sleep behavior disorderbehavior disorder

Parasomnias ContinuedParasomnias Continued Parasomnias NOSParasomnias NOS

Sleep bruxism (tooth grinding)Sleep bruxism (tooth grinding) Sleep enuresis (bed-wetting)Sleep enuresis (bed-wetting) Sleep-related abnormal swallowing syndrome Sleep-related abnormal swallowing syndrome Nocturnal paroxysmal dystomia Nocturnal paroxysmal dystomia Sudden unexplained nocturnal death syndrome Sudden unexplained nocturnal death syndrome Primary snoring Primary snoring Infant sleep apnea Infant sleep apnea Congenital central hypoventilation syndrome Congenital central hypoventilation syndrome Sudden infant death syndrome Sudden infant death syndrome Benign neonatal sleep myoclonus Benign neonatal sleep myoclonus Other parasomnia NOSOther parasomnia NOS

Pharmacologic Causes of InsomniaPharmacologic Causes of Insomnia

AntidepressantsAntidepressantsSteroidsSteroidsDecongestantsDecongestantsCaffeineCaffeine

Coffee, tea, Coffee, tea, chocolatechocolate

AlcoholAlcoholNicotineNicotine

AntihypertensivesAntihypertensivesAnticholinergicsAnticholinergicsHormonesHormonesAntineoplasticsAntineoplasticsCNS stimulantsCNS stimulantsMiscellaneousMiscellaneous

Dilantin, sinemetDilantin, sinemet

Behavioral CausesBehavioral Causes

Poor sleep hygiene (more later)Poor sleep hygiene (more later)PsychophysiologicPsychophysiologic

Learned behaviorLearned behaviorWorring about getting to sleep/Worring about getting to sleep/

trying too hard to sleeptrying too hard to sleepLeads to increased anxiety and arousalLeads to increased anxiety and arousalPerpetuates insomniaPerpetuates insomnia

DiagnosisDiagnosis

The medical interview is everythingThe medical interview is everything focus on underlying causesfocus on underlying causesSleep partner should be present for the Sleep partner should be present for the

interview if possibleinterview if possibleFull medication list is requiredFull medication list is requiredBe prepared to ask very direct questions Be prepared to ask very direct questions

about substances and alcohol useabout substances and alcohol use

Medical InterviewMedical Interview

Current state of complaintCurrent state of complaintOnset, duration, frequency of insomniaOnset, duration, frequency of insomniaSleep history… is the trouble with:Sleep history… is the trouble with:

falling asleep?falling asleep?maintaining sleep?maintaining sleep?not being able to go back to sleep once up?not being able to go back to sleep once up?early awakenings?early awakenings?not feeling rested?not feeling rested?

Medical InterviewMedical Interview

Daytime consequencesDaytime consequences

can you function/stay awake to drive?can you function/stay awake to drive?Do you experience (or bed-partner report):Do you experience (or bed-partner report):

Leg or arm jerking while asleep?Leg or arm jerking while asleep?

Loud snoring/gasping/choking, or stopping Loud snoring/gasping/choking, or stopping breathing when asleep?breathing when asleep?

Uncomfortable feelings in your legs that go Uncomfortable feelings in your legs that go away with moving them?away with moving them?

Sleep HabitsSleep Habits

Usual bedtimeUsual bedtimeUsual morning awakening timeUsual morning awakening timeTime spent in bed awake prior to sleeping, Time spent in bed awake prior to sleeping,

and following the onset of sleepand following the onset of sleepEstimated time spent asleepEstimated time spent asleepDo you take anything to make you sleep?Do you take anything to make you sleep?Do you drink to help you go to sleep?Do you drink to help you go to sleep?What else do you do in your bedroom?What else do you do in your bedroom?

Sleep HabitsSleep Habits

Anything disruptive to sleep?Anything disruptive to sleep? InfantsInfantsNoisesNoisesLightsLightsSnoring partnerSnoring partnerPartner with different bed/wake timesPartner with different bed/wake timesTVTVPetsPetsNot feeling safe where you sleepNot feeling safe where you sleep

Sleep Habits (bad!)Sleep Habits (bad!)

Do you consume: nicotine, caffeine, alcohol, Do you consume: nicotine, caffeine, alcohol, other stimulants, decongestants prior to other stimulants, decongestants prior to bedtime? Half lives are important!bedtime? Half lives are important! tt1/21/2 nicotine = 1 hour, t nicotine = 1 hour, t1/21/2 caffeine = 6 hours, caffeine = 6 hours, tt1/21/2 alcohol depends on how much you’ve had alcohol depends on how much you’ve had

Do you smoke/eat when you wake up, or Do you smoke/eat when you wake up, or perform other tasks like cleaning?perform other tasks like cleaning?

Do you check the clock when you wake up?Do you check the clock when you wake up? What is your pre-bedtime routine: exercise, What is your pre-bedtime routine: exercise,

work, TV, eating?work, TV, eating?

Half-lives: why you can’t go to sleep at 10pm Half-lives: why you can’t go to sleep at 10pm if your last coffee was at noon.if your last coffee was at noon.

0

10

20

30

40

50

60

70

80

90

100

12 noon 6pm 12 midnight 6am

% caffeine still inbody

What’s New With You?What’s New With You?

Medical issuesMedical issuesMedication changesMedication changesLifestyle issuesLifestyle issues

Work stressWork stressSchool stressSchool stressFinancial stressFinancial stressRelationship changes/stressRelationship changes/stressComplaints from partnerComplaints from partner

Physical ExamPhysical Exam

For primary insomnia there are no For primary insomnia there are no characteristic exam findingscharacteristic exam findings

Evaluate for symptoms/findings that Evaluate for symptoms/findings that suggest an underlying explanationsuggest an underlying explanation

Sleep DiariesSleep Diaries

Usually kept daily for 1-2 weeksUsually kept daily for 1-2 weeksHelp delineate variability in sleep from Help delineate variability in sleep from

day-to-dayday-to-dayMay identify contributing factorsMay identify contributing factorsMay help patient more accurately May help patient more accurately

perceive sleepperceive sleep

Sleep DiariesSleep Diaries

BedtimeBedtime Time to sleep onsetTime to sleep onset Number of Number of

awakeningsawakenings Time out of bed in Time out of bed in

morningmorning Total sleep time Total sleep time

(estimated)(estimated)

Use of sleep Use of sleep medications or medications or other substancesother substances

Quality of sleepQuality of sleepDaytime symptomsDaytime symptomsCaffeine logCaffeine logExercise logExercise log

Sample Sleep DiarySample Sleep Diary

Example Sleep PatternsExample Sleep Patterns

NormalNormal InsomniaInsomnia DepressionDepression

Or anxietyOr anxiety

Sleep onsetSleep onset

(minutes)(minutes)

1010 4545 4545

AwakeningsAwakenings 22 66 2+2+

Early Early Morning Morning AwakeningsAwakenings

NoNo YesYes YesYes

Total Time Total Time Asleep Asleep

7.5 hours7.5 hours ~5.5 hours~5.5 hours 6.0 hours6.0 hours

Treatment GoalsTreatment Goals

Alleviate underlying problemsAlleviate underlying problemsPrevent progression from acute to chronicPrevent progression from acute to chronic Improve quality of lifeImprove quality of lifeTreat depressionTreat depressionTreat medical conditionsTreat medical conditionsLimit all medications whenever possibleLimit all medications whenever possible

Acute InsomniaAcute Insomnia

Often does not require treatmentOften does not require treatmentShould be treated when:Should be treated when:

Daytime consequences warrant treatmentDaytime consequences warrant treatmentEpisodes last more than a few daysEpisodes last more than a few daysEpisodes become predictableEpisodes become predictable

Treating acute insomnia may help promote Treating acute insomnia may help promote sleep hygienesleep hygiene

Get a sleep diary from the patientGet a sleep diary from the patient

Chronic InsomniaChronic Insomnia

Usually requires many different Usually requires many different approachesapproaches

Treat underlying condition firstTreat underlying condition firstMay need behavioral and May need behavioral and

pharmacologic therapypharmacologic therapyTreatment should be collaborativeTreatment should be collaborativeGet a sleep diary from the patientGet a sleep diary from the patient

Sleep HygieneSleep HygieneHygiene: from where is the term derived?Hygiene: from where is the term derived?Hygeia (also Hygea, Hygia, Hygieia) This Hygeia (also Hygea, Hygia, Hygieia) This

is derived from the name of the Greek is derived from the name of the Greek goddess of health known as Hygeia the goddess of health known as Hygeia the daughter of Aesculapius/Asklepios and daughter of Aesculapius/Asklepios and sister to Panacea. While her father and sister to Panacea. While her father and sister were connected with the treatment sister were connected with the treatment of existing disease Hygeia was regarded of existing disease Hygeia was regarded as being concerned with the preservation as being concerned with the preservation of good health or the prevention of of good health or the prevention of disease. disease.

Sleep Hygiene--BasicsSleep Hygiene--Basics

Don’t spend excessive time in bed, Don’t spend excessive time in bed, including daytime napping.including daytime napping.

Get into bed when sleepy.Get into bed when sleepy.Maintain a regular sleep/wake scheduleMaintain a regular sleep/wake scheduleBed is for sleep and sex only, not TV!Bed is for sleep and sex only, not TV! Increase exercise and fitnessIncrease exercise and fitnessAvoid caffeine and nicotine at least 4-6 Avoid caffeine and nicotine at least 4-6

hours before going to bed.hours before going to bed.

Sleep Hygiene--BasicsSleep Hygiene--Basics Never use alcohol to go to sleep.Never use alcohol to go to sleep.

It induces sleep, but causes frequent awakeningsIt induces sleep, but causes frequent awakenings Decreases REM sleep, increases stages 3 & 4Decreases REM sleep, increases stages 3 & 4 Chronic use causes insomnia, which can persist up to Chronic use causes insomnia, which can persist up to

a year after cessation of all drinkinga year after cessation of all drinking

Avoid excessive liquids or a heavy meal in the Avoid excessive liquids or a heavy meal in the evening.evening.

Minimize noise, light, and temperature extremes Minimize noise, light, and temperature extremes during sleep.during sleep.

Move alarm clock away from bed if it is Move alarm clock away from bed if it is distractingdistracting

Sleep Hygiene--RelaxationSleep Hygiene--RelaxationPlan a relaxation period before bed, Plan a relaxation period before bed,

develop a bedtime routine.develop a bedtime routine.Attempts to address somatic and cognitive Attempts to address somatic and cognitive

arousalarousalRelaxation Therapy:Relaxation Therapy:

Progressive muscle relaxationProgressive muscle relaxationEMG BiofeedbackEMG BiofeedbackMeditationMeditation Imagery trainingImagery trainingSelf-hypnosisSelf-hypnosisDiaphragmatic breathingDiaphragmatic breathing

Sleep Hygiene—Sleep RestrictionSleep Hygiene—Sleep Restriction

If unable to fall asleep within an If unable to fall asleep within an acceptable amount of time (15-20 min), acceptable amount of time (15-20 min), leave the bedroom, engage in a relaxing leave the bedroom, engage in a relaxing activity until sleepy, and then return to activity until sleepy, and then return to bed. This is called sleep restrictionbed. This is called sleep restriction

Repeat as necessary.Repeat as necessary.Boring activities (reading the phone book) Boring activities (reading the phone book)

count. TV/video games doesn’t count as count. TV/video games doesn’t count as relaxing or boring—the flashing lights relaxing or boring—the flashing lights stimulate the brain.stimulate the brain.

Sleep Hygiene—Sleep RestrictionSleep Hygiene—Sleep Restriction

Sleep Restriction TherapySleep Restriction TherapyTrack average total sleep time per nightTrack average total sleep time per nightSpend Spend onlyonly this amount of time in bed; this amount of time in bed;

minimum being 4.5 hours.minimum being 4.5 hours.Once 90% of time in bed is spent asleep Once 90% of time in bed is spent asleep

(sleep efficiency), increase total time in (sleep efficiency), increase total time in bed by 15 minutes every 5-7 days. bed by 15 minutes every 5-7 days.

Sleep Hygiene—Sleep RestrictionSleep Hygiene—Sleep Restriction If sleep efficiency falls to less than 80%, If sleep efficiency falls to less than 80%,

decrease time in bed by 15 minutesdecrease time in bed by 15 minutesWork set, daytime hours (whenever Work set, daytime hours (whenever

possible).possible).As sleep consolidation improves, time in As sleep consolidation improves, time in

bed (and asleep) increases.bed (and asleep) increases.Creates a mild state of sleep deprivation, Creates a mild state of sleep deprivation,

and thus promotes more rapid sleep onset and thus promotes more rapid sleep onset and more efficient sleep.and more efficient sleep.

Sleep Hygiene—Cognitive Therapy Sleep Hygiene—Cognitive Therapy

Cognitive Therapy works to change beliefs Cognitive Therapy works to change beliefs about insomnia:about insomnia:Misconceptions about the causesMisconceptions about the causesPerformance anxiety and loss of control over Performance anxiety and loss of control over

the ability to sleepthe ability to sleepUnrealistic sleep expectationsUnrealistic sleep expectations

Identify and replace dysfunctional beliefs and Identify and replace dysfunctional beliefs and attitudes about sleepattitudes about sleep

For example, questioning the idea that you must For example, questioning the idea that you must sleep 8 hours to function effectivelysleep 8 hours to function effectively

Behavioral TherapiesBehavioral Therapies

Reliable and enduring improvements for Reliable and enduring improvements for chronic insomniacschronic insomniacsSleep latency insomniacs fell asleep faster Sleep latency insomniacs fell asleep faster

than 81% of untreated controlsthan 81% of untreated controlsSleep maintenance insomniacs slept longer Sleep maintenance insomniacs slept longer

than 74% of untreated controlsthan 74% of untreated controlsMay be used in combination with other May be used in combination with other

techniques or medicationstechniques or medications

Stimulus Control TherapyStimulus Control Therapy

Based on premise that insomnia is a Based on premise that insomnia is a conditioned response based on cues conditioned response based on cues associated with sleepassociated with sleep

Trains the brain to associate the bed / Trains the brain to associate the bed / bedroom with sleepbedroom with sleep

Leave the bedroom if not sleeping within Leave the bedroom if not sleeping within 15-20 minutes15-20 minutes

Effective for sleep onset and sleep-Effective for sleep onset and sleep-maintenancemaintenance

Other TherapiesOther TherapiesRegular exerciseRegular exercise

Helpful if timed in the late afternoonHelpful if timed in the late afternoonAny exercise, regardless of time of day, helpsAny exercise, regardless of time of day, helps

Promotes sleep depth and qualityPromotes sleep depth and qualityMay be stimulating if done in closer to May be stimulating if done in closer to

bedtimebedtime

PhototherapyPhototherapyExposure to daytime bright light is helpful in Exposure to daytime bright light is helpful in

treating those with slow or fast circadian treating those with slow or fast circadian cyclescycles

May be especially helpful in the elderlyMay be especially helpful in the elderly

What works best?What works best?

Multicomponent cognitive behavior Multicomponent cognitive behavior therapy works better than both placebo therapy works better than both placebo and pharmacotherapy (medicines) in short and pharmacotherapy (medicines) in short and long term cases.and long term cases.

Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy Jacobs GD, Pace-Schott EF, Stickgold R, et al. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. comparison. Arch Intern MedArch Intern Med. 2004; 164: 1888-1896. 2004; 164: 1888-1896

Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. insomnia: a meta-analysis of treatment efficacy. Am J PsychiatrAm J Psychiatr. 1994; 151: . 1994; 151: 1172-1180.1172-1180.

Murtagh DR, Greenwood KM. Identifying effective psychological treatments Murtagh DR, Greenwood KM. Identifying effective psychological treatments for insomnia: a meta-analysis. for insomnia: a meta-analysis. J Consult Clin PsycholJ Consult Clin Psychol. 1995; 63:79-89.. 1995; 63:79-89.

If you have to use drugs: If you have to use drugs: Pharmacotherapy GuidelinesPharmacotherapy Guidelines

Use the lowest Use the lowest therapeutictherapeutic dose doseUse for the shortest duration Use for the shortest duration

necessarynecessaryDiscontinue medication graduallyDiscontinue medication graduallyBe alert for rebound insomniaBe alert for rebound insomniaUse agents with short half-lives to Use agents with short half-lives to

minimize daytime sedationminimize daytime sedation

Drugs that make you sleepDrugs that make you sleep

Drugs that make you sleep are called Drugs that make you sleep are called “hypnotics”.“hypnotics”.

There are many types of hypnotics:There are many types of hypnotics: Sedating antihistamines (over the counter)Sedating antihistamines (over the counter) Herbals (over the counter)Herbals (over the counter) Benzodiazepines (prescription/controlled)Benzodiazepines (prescription/controlled) Benzodiazepine-Like (prescription/controlled)Benzodiazepine-Like (prescription/controlled) Melatonin receptor agonists (prescription)Melatonin receptor agonists (prescription) Antidepressants (prescription)Antidepressants (prescription) Antipsychotics (prescription)Antipsychotics (prescription)

Over the Counter Medicines—FDA Over the Counter Medicines—FDA approved and regulatedapproved and regulated

Sedating antihistamines: Sedating antihistamines: diphenhydramine (Benadryl) and diphenhydramine (Benadryl) and

doxylaminedoxylamineNighttime Sleep Aid Nighttime Sleep Aid Sleep Aid Liqui-Gels Sleep Aid Liqui-Gels Maxium Strength Unisom Nighttime Sleep AidMaxium Strength Unisom Nighttime Sleep AidTylenol PMTylenol PM

OTC Medicines—FDA approved OTC Medicines—FDA approved and regulatedand regulated

Sedating antihistamines continued:Sedating antihistamines continued: Not addictive, but tolerance develops Not addictive, but tolerance develops

quicklyquicklyDaytime sleepiness, anticholinergic side Daytime sleepiness, anticholinergic side

effects commoneffects commonDry mouth, constipation, urinary retention, Dry mouth, constipation, urinary retention,

memory impairment, confusion (dries up memory impairment, confusion (dries up sinuses if post nasal drip is what keeps you sinuses if post nasal drip is what keeps you up)up)

OTC Medicines--herbalsOTC Medicines--herbals

Not FDA regulated:Not FDA regulated:Valerian rootValerian root

Used for anxiety, and as a sleep aidUsed for anxiety, and as a sleep aidDosing uncertainDosing uncertainPowerful odorPowerful odor

Kava-kavaKava-kavaCan cause liver failureCan cause liver failureDosing uncertain Dosing uncertain Sateia MJ, Nowell PD. Insomnia. Sateia MJ, Nowell PD. Insomnia. LancetLancet. 2004; 364:1959-1973. 2004; 364:1959-1973

OTC Medicines--herbalsOTC Medicines--herbals

Melatonin—hormone made by the pituitary Melatonin—hormone made by the pituitary gland in the brain (at night/when dark)gland in the brain (at night/when dark)Best for shift work/jet lag; shifts sleep to dark Best for shift work/jet lag; shifts sleep to dark

hourshours Schenck CH, Mahowald MW, Sack RL. Assessment and management of Schenck CH, Mahowald MW, Sack RL. Assessment and management of

insomnia JAMA 2003;289:2475-2479.insomnia JAMA 2003;289:2475-2479.

For insomnia not related to shift work/jet lag, For insomnia not related to shift work/jet lag, there is NO convincing evidence it works.there is NO convincing evidence it works.

Silber MH, Chronic insomnia. Silber MH, Chronic insomnia. N Engl J Med. N Engl J Med. 2005;353:803-8102005;353:803-810 Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of Almeida Montes LG, Ontiveros Uribe MP, Cortez Sotres J, et al. Treatment of

primary insomnia with melatonin: a double-blind, placebo-controlled, crossover primary insomnia with melatonin: a double-blind, placebo-controlled, crossover study. study. J Psychiatry Neurosc.J Psychiatry Neurosc. 2003; 28: 191-196 2003; 28: 191-196

Prescription Medicines: Prescription Medicines: BenzodiazepinesBenzodiazepines

Non-selectivelyNon-selectively bind to the bind to the benzodiazepine-GABA (Gamma-benzodiazepine-GABA (Gamma-AminoButyric Acid) receptor complex in AminoButyric Acid) receptor complex in the brainthe brain

Effective in inducing, maintaining, and Effective in inducing, maintaining, and consolidating sleep; and in decreasing consolidating sleep; and in decreasing daytime consequences of insomniadaytime consequences of insomnia


Side effects include daytime drowsiness, Side effects include daytime drowsiness, anterograde amnesia, impairments in anterograde amnesia, impairments in memory and psychomotor performance.memory and psychomotor performance.

Addiction, habituation, tolerance, rebound Addiction, habituation, tolerance, rebound insomnia, withdrawal symptoms, anxiety insomnia, withdrawal symptoms, anxiety can all occur with benzo usecan all occur with benzo use

When combined with alcohol, When combined with alcohol, benzodiazepines can be deadly.benzodiazepines can be deadly.

Increases fall risk in the elderly (and Increases fall risk in the elderly (and concomitant hip fractures)concomitant hip fractures)


No one medicine in the class works any No one medicine in the class works any better than any other medicine.better than any other medicine.

Those with a short half-life work better for Those with a short half-life work better for those who have trouble falling asleepthose who have trouble falling asleep

Those with a longer half-life work better for Those with a longer half-life work better for those who cannot stay asleepthose who cannot stay asleep

No benzodiazepine is FDA approved for No benzodiazepine is FDA approved for chronicchronic use (think vioxx)! use (think vioxx)!

Presciption Medicines: Presciption Medicines: Benzodiazepines—how they workBenzodiazepines—how they work

Generic name (brand)--duration/onset of effectsGeneric name (brand)--duration/onset of effects used forused for

Triazolam (Halcion) – short/rapidTriazolam (Halcion) – short/rapid sleep onset insomnia; pregnancy category Xsleep onset insomnia; pregnancy category X

Estazolam (ProSom) – intermed/rapid Estazolam (ProSom) – intermed/rapid both sleep onset and maintenance insomnia; preg category Xboth sleep onset and maintenance insomnia; preg category X

Temazepam (Restoril) – intermed/slowTemazepam (Restoril) – intermed/slow Sleep maintenance; pregnancy category XSleep maintenance; pregnancy category X

Flurazepam (Dalmane) – long/intermedFlurazepam (Dalmane) – long/intermed Sleep maintenance—active metabolite for over 100 hours; XSleep maintenance—active metabolite for over 100 hours; X

Quazepam (Doral) – long/intermedQuazepam (Doral) – long/intermed Sleep maintenance—active metabolite for over 100 hoursSleep maintenance—active metabolite for over 100 hours

Prescription Medicines: Prescription Medicines: Benzodiazepine InformationBenzodiazepine Information

10-15% of users take them regularly for 10-15% of users take them regularly for more than a year (not FDA approved)more than a year (not FDA approved)

Many patients (not all) develop physical Many patients (not all) develop physical dependence and/or tolerancedependence and/or tolerance

Once an effective dose is established, Once an effective dose is established, higher doses typically only increase side higher doses typically only increase side effectseffects

Sudden withdrawal can be dangerous to Sudden withdrawal can be dangerous to the patientthe patient

Prescription Medicines: Prescription Medicines: Benzodiazepine ContraindicationsBenzodiazepine Contraindications

Pregnant women (most are category X)Pregnant women (most are category X)Untreated sleep-related breathing disorderUntreated sleep-related breathing disorderAlcohol or substance abuseAlcohol or substance abusePatients who might need to awaken and Patients who might need to awaken and

function during their normal sleep periodfunction during their normal sleep periodParents, doctors, fire-fighters, etc.Parents, doctors, fire-fighters, etc.

Monitor those with hepatic, renal, or Monitor those with hepatic, renal, or pulmonary disease; and use with cautionpulmonary disease; and use with caution

Prescription Medicines: Prescription Medicines: Benzodiazepine-LikeBenzodiazepine-Like

Benzodiazepine-Like medicines Benzodiazepine-Like medicines selectivelyselectively bind to the benzo-GABA receptor.bind to the benzo-GABA receptor.The benzos we learned about before are non-The benzos we learned about before are non-

selective; there should be fewer side effects selective; there should be fewer side effects with the Benzo-Like meds than true benzos.with the Benzo-Like meds than true benzos.

Exact mechanism of action is unknownExact mechanism of action is unknownHelp people go to sleep (sleep latency), Help people go to sleep (sleep latency),

and stay asleep (sleep maintenance).and stay asleep (sleep maintenance).


Eszopiclone (Lunesta)—intermed/rapidEszopiclone (Lunesta)—intermed/rapid Sleep maintenance (metallic taste); pregnancy category CSleep maintenance (metallic taste); pregnancy category C

Zolpidem (Ambien)—short/rapidZolpidem (Ambien)—short/rapid Sleep latency; side effects include: sleepwalking, sleep-Sleep latency; side effects include: sleepwalking, sleep-

related eating disorder; pregnancy category B (?C)related eating disorder; pregnancy category B (?C)

Zolpidem controlled release (Ambien CR)—Zolpidem controlled release (Ambien CR)—intermed/rapidintermed/rapid

Sleep latency, sleep maintenance; pregnancy category CSleep latency, sleep maintenance; pregnancy category C

Zaleplon (Sonata)—ultrashortZaleplon (Sonata)—ultrashort Sleep latency, can take in the middle of the night if you Sleep latency, can take in the middle of the night if you

awaken; pregnancy category Cawaken; pregnancy category C


Zolpidem (Ambien) and Zaleplon (Sonata)Zolpidem (Ambien) and Zaleplon (Sonata)Zolpidem t ½ = 2.5 hours; no residual Zolpidem t ½ = 2.5 hours; no residual

effects if taken 5 hours before awakening; effects if taken 5 hours before awakening; works well for freq. awakenings; Preg. B, works well for freq. awakenings; Preg. B, and generally regarded safe in nursingand generally regarded safe in nursing

Zaleplon t ½ = 1 hour; no residual effects if Zaleplon t ½ = 1 hour; no residual effects if taken > 2 hours before awakening; works taken > 2 hours before awakening; works well for terminal insomnia; Preg. Cwell for terminal insomnia; Preg. C

Relatively new = relatively expensiveRelatively new = relatively expensive

Prescription Medicines: Prescription Medicines: Melatonin-Receptor AgonistMelatonin-Receptor Agonist

Ramelteon (Rozerem)—short duration: 1-2.5 hrsRamelteon (Rozerem)—short duration: 1-2.5 hrsSleep latency, not sleep maintenanceSleep latency, not sleep maintenancemay increase prolactin levels (meaning you may may increase prolactin levels (meaning you may

lactate—typically undesired, especially in men) lactate—typically undesired, especially in men) Dizziness, nausea, headache all commonDizziness, nausea, headache all commonNo dependence, withdrawal, or rebound insomnia!No dependence, withdrawal, or rebound insomnia!NOT a controlled substanceNOT a controlled substanceNew medicine, long-term effects unknown; New medicine, long-term effects unknown;

pregnancy category C, pregnancy category C, activity not through GABA receptor complexactivity not through GABA receptor complexDo not take after a high-fat mealDo not take after a high-fat meal

Prescription Medicines: Prescription Medicines: Other Drugs (antidepressants)Other Drugs (antidepressants)

Amitriptyline (Elavil)Amitriptyline (Elavil) Tricyclic antidepressant, inhibits norepinephrine and Tricyclic antidepressant, inhibits norepinephrine and

serotonin uptake in the CNS—pregnany category Cserotonin uptake in the CNS—pregnany category C Doxepin (Adapin)Doxepin (Adapin)

Tricyclic antidepressant, inhibits norepinephrine and Tricyclic antidepressant, inhibits norepinephrine and serotonin uptake in the CNS—pregnancy category Cserotonin uptake in the CNS—pregnancy category C

Trazadone (Desyrel)Trazadone (Desyrel) sedating antidepressant (non-TCA/non SSRI)—cat. Csedating antidepressant (non-TCA/non SSRI)—cat. C

Mirtazapine (Remeron)Mirtazapine (Remeron) Sedating antidepressant, antagonizes alpha2-Sedating antidepressant, antagonizes alpha2-

adrenergic and serotonin 5-HT2 receptors (tetracyclic)adrenergic and serotonin 5-HT2 receptors (tetracyclic)—pregnancy category C—pregnancy category C

Prescription Medicines: Prescription Medicines: Other Drugs (antidepressants)Other Drugs (antidepressants)

Antidepressants only work well if patient is Antidepressants only work well if patient is depressed; otherwise, trazadone and elavil depressed; otherwise, trazadone and elavil work, but not as well as Ambien (Benzo-Like).work, but not as well as Ambien (Benzo-Like).

Should not be used in combination as a sleep Should not be used in combination as a sleep aid if the patient is taking some other form of aid if the patient is taking some other form of antidepressant.antidepressant.

Antidepressants used as sleep aids are not Antidepressants used as sleep aids are not addicting.addicting.

Antipsychotics should only be used in psychotic Antipsychotics should only be used in psychotic patients or occasionally the elderly in an patients or occasionally the elderly in an institutional setting, if they cannot tolerate other institutional setting, if they cannot tolerate other medicinesmedicines

If all else failsIf all else fails

If your bed partner sleeps well, but keeps If your bed partner sleeps well, but keeps you up by snoring, moving, coughing, etc., you up by snoring, moving, coughing, etc., sleep in a different bed or in a different sleep in a different bed or in a different room. room.

SummarySummary

Be alert for symptoms of insomnia and Be alert for symptoms of insomnia and depressiondepression

Determine specific type of sleep problemDetermine specific type of sleep problemMake a differential diagnosisMake a differential diagnosisDon’t neglect behavioral therapiesDon’t neglect behavioral therapiesPay attention to onset of action/duration of Pay attention to onset of action/duration of

effect of all medicines usedeffect of all medicines usedTeach ALL insomniacs proper sleep Teach ALL insomniacs proper sleep

hygienehygiene

ReferencesReferences 1) AAFP and American Academy of Sleep Medicine 1) AAFP and American Academy of Sleep Medicine

Monograph “Strategies for Managing Insomnia” 1999Monograph “Strategies for Managing Insomnia” 1999 2) Roth T, Roehrs T. Insomnia: Epidemiology, 2) Roth T, Roehrs T. Insomnia: Epidemiology,

characteristics, and consequences. characteristics, and consequences. Clin CornerstoneClin Cornerstone 2003;5(3):5-152003;5(3):5-15

3) Neubauer DN. Pharmacologic approaches to the 3) Neubauer DN. Pharmacologic approaches to the treatment of chronic insomnia. treatment of chronic insomnia. Clin CornerstoneClin Cornerstone 2003;5(3):16-272003;5(3):16-27

4) Smith MT, Neubauer DN. Cognitive behavior therapy 4) Smith MT, Neubauer DN. Cognitive behavior therapy for chronic insomnia. for chronic insomnia. Clin CornerstoneClin Cornerstone 2003;5(3):28-40 2003;5(3):28-40

5) Kupfer DJ, Reynolds CF. Management of Insomnia. 5) Kupfer DJ, Reynolds CF. Management of Insomnia. NEJM 1997;336:341-46NEJM 1997;336:341-46

ReferencesReferences 6) National Center on Sleep Disorders Research… 6) National Center on Sleep Disorders Research…

Insomnia: Assessment and Management in Primary Care. Insomnia: Assessment and Management in Primary Care. NIH/NHLBI, 1998: 1-16NIH/NHLBI, 1998: 1-16

7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine. 7) Hauri PJ. Sleep Disorders. Clinics in Chest Medicine. 1998;19:157-681998;19:157-68

8) Simon GE, VonKorff M. Prevalence, burden, and 8) Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. treatment of insomnia in primary care. Am J PsychiatryAm J Psychiatry 1997;154:1417-14231997;154:1417-1423

9) Krystal AD. Insomnia in women. 9) Krystal AD. Insomnia in women. Clin CornerstoneClin Cornerstone 2003;5(3):41-502003;5(3):41-50

10) Ward SH, Ward LD. The evaluation and management 10) Ward SH, Ward LD. The evaluation and management of insomnia in primary care. of insomnia in primary care. Patient CarePatient Care. July 2006;40:46-. July 2006;40:46-55.55.

11) Gritz BF. “Overview of Insomnia” CME-TAFP Primary 11) Gritz BF. “Overview of Insomnia” CME-TAFP Primary Care Lecture Series. Dec 6, 2006.Care Lecture Series. Dec 6, 2006.

insomnia presentation

Health & Medicine