Insomnia - Northern Valley Anesthesiology home page
Download
Report
Transcript Insomnia - Northern Valley Anesthesiology home page
Insomnia
David A. Garfunkel, M.D.
August 31, 2005
Irrelevant Fact
Sleep Physiology
Joke
Scope of the Problem
Diagnosis
Commercial Break
Non-Pharmacologic Treatment
Pharmacologic Treatment
Who was the 2004 U.S. Open
Tennis Woman’s Winner?
Svetlana Kuznetsova
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
Philagrypnia
Ability to stay alert with very
little sleep
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
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
REM sleep has both tonic and
phasic qualities
Other features include periodic
skeletal muscle twitches,
increased heart rate variability
and increased respiratory rate
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
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.
Patient’s subjective dissatisfaction
with the sleep quality and quantity
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
Poor Sleep Maintenance
Waking after sleep has been
initiated, but before desired
waking time
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 reinitiating sleep, or awakening too early without
being able to go back to sleep at all
Some patients may not meet
any of the above conditions,
but awake feeling poorly
rested.
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.
What do you call a nun
who sleep walks?
A Roamin’ Catholic
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.
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
Consequences
Mood Disturbance
Depression and/or Anxiety
Poor memory
Difficulty concentrating
Motor vehicle and other
accidents
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
There are 4-5 cycles in a
normal night’s sleep
First REM- 10 minutes, but
later REM periods may exceed
60 minutes
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
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
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
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
Parasomnias
Disoriented Arousal
Sleepwalking
Night/Sleep Terrors
Hypnagogic Hallucinations
Sleep Paralysis
Nocturnal Seizures
Parasomnias, continued
REM Behavioral Disorder
Bruxism
Rhythmic Movement Disorder
Restless Legs Syndrome
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
Medications that may
cause insomnia
Clonidine
Beta Blockers
Theophyline
Certain Antidepressants
Protriptyline, Fluoxetine
Decongestants
Stimulants
Alcohol
Exercise in morning or early
afternoon lessens insomnia
Exercise close to bedtime
worsens insomnia
Physical Exam
Anatomic features of
obstructive sleep apnea
Neurologic exam in case of
restless leg or other neurologic
syndrome
Sleep Log
Maintain for 2-4 weeks
Sleep and wake times
Awakenings
Daytime naps and activities
Correlation with bed partner
Commercial Break
Remedy
Recovered Medical Equipment
for the Developing World
420 U.S. Hospitals recovered
> $50,000,000 worth of
medical supplies in 2004
Remedy Lite - unwanted new
supplies
Individuals: 2 ways to help
Donate at www.REMEDYInc.org
Shop through
www.iGive.com/REMEDYInc
Nonpharmacalogic
Therapy
Cognitive Behavioral Therapy
Individual counseling- 6
sessions
Effective in 50% of patients
Relaxation Therapy
Recognize and control tension
through systematically tensing
and relaxing various muscle
groups
Guided imagery and
meditation
Biofeedback
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
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
Pharmacologic Therapy
Non-prescription
Prescription
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
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
What is the active
ingredient in Tylenol PM?
Diphenhydramine
hydrochloride
Main Ingredient in Tylenol PM,
Sominex, Unisom, etc.
Antihistamine and
anticholinergic agent
Non-specific and long lasting
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
Rapid Onset
Drugs
Slow Elimination
Drugs
Zoldipem
(Ambien)
Temazepam
(Restoril)
Estazolam
(Prosom)
Flurazepam
(Dalmane)
Zaleplon
(Sonata)
Triazolam
(Halcion)
Concomitant Depression
Antidepressants with sedative
properties
Trazodone (Desyrel)
Amitriptyline (Elavil)
Eszopiclone (Lunesta)
New class of nonbenzodiazepine
May affect GABA receptor
Rapid onset, medium 1/2 life
No tolerance or withdrawal
after 6 months of treatment
1,2,3 mg. dose
Rozerem (ramelteon)
Unscheduled prescription drug
Acts on Melatonin receptors
No activity on the following
receptors
GABA, neuropeptides,
cytokines,seratonin, dopamine,
noradrenaline, acetylcholine, or
opioid
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
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
The End