Transcript Clinical Slide Set. Insomnia - Annals of Internal Medicine

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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (4): ITC4-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (4): ITC4-1.
in the clinic
Insomnia
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 161 (4): ITC4-1.
What are the components of a comprehensive
sleep history?
 When do activities occur
 Going to bed, waking up, getting out of bed
 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, 2014
Ann 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, 2014
Ann Int Med. 161 (4): ITC4-1.
What is the role of physical examination in
the evaluation of patients with insomnia?
 Identify signs of specific disorder contributing to sleep
disruption
 Thyroid dysfunction
 Cardiopulmonary or neurologic disease
 Obstructive sleep apnea syndrome
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (4): ITC4-1.
When should clinicians consider lab
testing in the evaluation of insomnia?
 When a possible underlying sleep disorder is suspected
 When insomnia may be linked to concomitant disease
 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 161 (4): ITC4-1.
Are behavioral therapies useful in the
treatment of patients with insomnia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (4): ITC4-1.
How should clinicians advise patients about
the use of nonprescription agents in the
treatment of insomnia?
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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 longterm therapy is required
 Consider consultation with a sleep specialist before starting
continuous, long-term therapy with hypnotic medication
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (4): ITC4-1.
What is the appropriate duration of
prescription drug therapy for insomnia?
 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
 Avoid prolonged or excessive therapy
 Discuss risks and benefits of drug therapy
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (4): ITC4-1.