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
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for the Developing World
420 U.S. Hospitals recovered
> $50,000,000 worth of
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Remedy Lite - unwanted new
supplies
Individuals: 2 ways to help
Donate at www.REMEDYInc.org
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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