Transcript Insomnia - Tiffany Lemanski Introduction

INSOMNIA
Jennifer Gray
Anita Isabel Graham
Tiffany Lemanski
Cindy MacQuarrie
Health Promotion 809
Spring 2012
Part 1: Case Study
Helen Young is a 42 y/o Caucasian
female presenting with complaint of
insomnia and irritability, which has
gotten worse in the last six months.
She feels that her work performance
has declined over the last year. She
works as an administrative assistant
at a local university
2
Social History and
Family History
Helen is married with 2 children
ages 14 and 17. Her husband lost
his job 2 years ago and has not
been able to find meaningful work
since; finances have been tight
 Her father used to suffer from
insomnia, hypertension and
ischemic heart disease. Her mother
was a diabetic.
3
Medical History
The patient has high blood pressure,
but no other health problems.
 She currently takes Lisinopril 10 mg
daily; no other medications.
She states she doesn’t like taking
medications.
No history of any significant illness in
her past.
She has no known allergies.
4
Discussion of Problem
Helen relates she is having
trouble sleeping - states that
she has a lot on her mind.
 She retires at 11 PM and arises
at 5:30 AM daily. She wakes up
intermittently throughout the
night, and her sleep is disturbed
at the slightest sound. She does
not feel rested when awakening.
5
Discussion of Problem,
continued
Patient eats three meals a day and
consumes a glass of wine at dinner.
She often will have another glass of
wine at 10 PM to help her with
sleep.
 She denies use of recreational
drugs, although admits to using
marijuana when she was in college.
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Discussion of Problem,
continued
Helen is not involved in any exercise
program, as she says she is too
busy at work, caring for the children
and the house. Her children and
husband help out some around the
house, but Helen does not feel they
cannot properly complete the tasks
that need to be done.
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Physical Exam
On exam, Helen maintains eye contact
during interview, but seems restless
and distracted. Her speech is mildly
pressured.
VS: BP-146/88; HR-86, RRR; R-20;
Ht-5’4”; Wt-157#; BMI-26.9
Thyroid not enlarged; lungs CTA;
2+ DTRs; skin is warm and dry
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Part 2
Complementary Therapy
Recommended: Acupuncture
9
Justification
Key points
 Acupuncture appears to be effective in
treating insomnia
 Acupuncture is safe and has minimal side
effects
 Some insurance companies will cover
acupuncture. Treatments can be as low
as $39 a session in Kansas.
 Acupuncture can treat symptoms of
depression and anxiety, and can induce
relaxation
10
Meta-Analysis of 878 Papers
on Auricular Acupuncture (AA)
Findings
 Subjects preferred AA to treat
insomnia over other control treatments
such as Diazepam and Magnetic Pearls
 AA increased nocturnal sleeping hours
and subjects felt refreshed upon
awakening.
 More quality evidence is needed
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Chen, H. Y., Shi, Y., Ng, C. S., Chai, S. M., Yung, K. K., & Zhang, Q.
L. (2007). Auricular Acupuncture Treatment for Insomnia: A
systematic Review. Journal of Alternative and Complementary
Medicine , 669-676.
Systematic Review of 46
Randomized Trials
Findings
 Acupuncture is better than no treatment for
insomnia
 Real Acupressure is superior to sham acupressure
to treat insomnia
 Patient experienced longer sleep duration with
acupuncture than medication.
 Acupuncture concurrently used with medications or
herbs is superior than medication or herbals alone.
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Cow, H., Pan, X., Li, H., & Liu, J. (2209). Acupuncture for Treatment
of Insomnia: A Systematic Review of Controlled Trials. The Journal
of Alternative and Complementary Medicine. , 1171-1186.
Autonomic Activation in Insomnia:
The Case for Acupuncture
Findings
 Three separate case studies of patients with
insomnia showed increased sleep duration
and sleep efficiency after acupuncture.
 Acupuncture has effects on neurotransmitters
known to effect sleep: serotonin,
norepinepherine, endorphins, cortisol, ACTH,
Melatonin substance P, GABA, Acetylcholine,
and nitric oxide.
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Huang, W., Kutner, N., & Bliwise, D. (2011). Autonomic Activation in
Insomnia: The Case for Acupuncture. Journal of Clinical Sleep
Medicine , 95-102.
Other Studies
Findings
 Acupuncture is effective in treating insomnia in
Pregnancy (Guerreiro da Silva, Nakamura, Cordeiro, &
Lulay, 2005)
 Acupuncture is effective in treating insomnia after a
stroke (Kim, et al., 2004)
 Acupuncture is effective in treating insomnia in patients
with major depression (Yeung, Chung, Tso, Zhang,
Zhang, & Ho, 2011)
 Acupuncture is effective in treating insomnia in cancer
patients (Lu, Dean-Clower, Doherty-Gilman, &
Rosenthal, 2008)
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Part 3
Suggestions for how the client
should implement the therapy:
Specifics of prescription therapy
dosing, including how much, how
often, and for how long
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How to implement therapy?
 Identify local licensed therapists
 American Academy of Medical
Acupuncture has a website that allows
an individual to find licensed
acupuncturist in a specific location.
Licensed providers are identified by
state and area code
http://www.medicalacupuncture.org/fi
ndadoc/index.html
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Assist with appointment coordination.
Goals of therapy
Use a measurement tool to
determine outcome of therapy.
Use before and after therapy.
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Dosing
The issue of number of treatments,
type of acupuncture, number of
sessions, and patients' ages and
range of co-morbidities all remain to
be clarified (Huang et al, 2011).
Much research is still needed to
develop concise prescribing
information. Huang et al notes the
use of acupuncture for insomnia in
several case studies.
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Acupuncture Treatment Dosing
The provider and subject interaction
time was 45–60 minutes each
session, including a brief history and
exam and acupuncture treatment.
 A total of 12 sessions were
conducted twice a week for 4
weeks, followed by once a week for
4 weeks
19
Huang, et al, 2011
Other Recommendations:
Exercise
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Add a gentle exercise routine such
as walking for thirty minutes per
day, four to five days per week.
In a study conducted by
Northwestern, 23 sedentary adults,
primarily women, 55 and older who
had difficulty falling sleep and/or
staying asleep and impaired daytime
functioning were studied (Paul,
2010).
Recommendation of exercise
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After a conditioning period, the
aerobic physical activity group
exercised for two 20-minute sessions
four times per week or one 30-to-40minute session four times per week,
both for 16 weeks (Paul, 2010).
Exercise improved the participants’
self-reported sleep quality, elevating
them from a diagnosis of poor
sleeper to good sleeper (Paul, 2010).
Other Recommendations:
Alcohol Intake
Limit alcohol intake daily, especially
in the hour prior to going to bed.
According to Mayo Clinic (2011),
alcohol is a sedative that may help
you fall asleep, but it prevents
deeper stages of sleep and often
causes you to awaken in the middle
of the night.
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Recommendation re: Alcohol
Alcohol consumed within an hour of
bedtime appears to disrupt the
second half of the sleep period
(NIAAA, n.d.).
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Other Recommendations: Diet
Diet modification to decrease BMI to
25 or less.
Short sleep durations were also
associated with increased likelihood
of obesity.
Women sleeping less than 5 hours
were 2.3 times more likely to be
obese
24
Sanjay et al, 2008
Part 4
Outcomes and Evaluation
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Part 5
Recommendations for
Additional Research
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References
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Huang, W., Kutner, N., and Bliwise, D. L. (February 2011). Autonomic activation in
insomnia: The case for acupuncture. Journal of Clinical Sleep Medicine; 15; 7(1): 95102. PMCID: PMC3041619
Mayo Clinic. (January 2011). Insomnia: Causes. Retrieved from
http://www.mayoclinic.com/health/insomnia/DS00187/DSECTION=causes
NIAAA. (n.d.). Alcohol and sleep. Retrieved from
http://alcoholism.about.com/cs/alerts/l/blnaa41.htm
Paul, M. (September 2010). Aerobic exercise relieves insomnia: Boosting
cardiovascular fitness improves sleep, vitality and mood for insomniacs. Northwestern
University [Website]. Retrieved from
http://www.northwestern.edu/newscenter/stories/2010/09/aerobic-exercise-relievesinsomnia.html
Guerreiro da Silva, J. B., Nakamura, U. M., Cordeiro, J. A., & Lulay, L. J. (2005).
Acupuncture for insomnia in pregnancy. Acupuncture in Medicine , 47-51.
Kim, Y. S., Lee, S. H., Jung, W. S., Park, S. U., Moon, S. K., Ko, C. N., et al. (2004).
Intradermal Acupuncture on Shen-Men and Nei-Kuan Acupoints in Patients With
Insomnia After Stroke. The American Journal of Chinese Medicine , 771-778.
Lu, W., Dean-Clower, E., Doherty-Gilman, A., & Rosenthal, D. S. (2008). The Value of
Acupuncture in Cancer Care. Hematology Oncology Clinics of North America , 631648.
Yeung, W., Chung, K., Tso, K., Zhang, S., Zhang, Z., & Ho, L. (2011).
Electroacupuncture for residual insomnia associated with major depressive disorder:
a randomized controlled trial. Sleep , 807-15.
References
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 Sanjay R. P., Blackwell, T., Redline, S., Ancoli-Israel, S., Cauley,
J. A., Hillier, T. A., Lewis, C. E., Orwoll, E. S., Stefanick, M. L.,
Taylor, B. C., Yaffe, K., & Stone, K. L. (December 2008). The
association between sleep duration and obesity in older adults.
International Journal on Obesity, 32(12), 1825-34. doi:
10.1038/ijo.2008.198
 Cow, H., Pan, X., Li, H., & Liu, J. (2209). Acupuncture for
Treatment of Insomnia: A Systematic Review of Controlled
Trials. The Journal of Alternative and Complementary Medicine.
, 1171-1186.
 Chen, H. Y., Shi, Y., Ng, C. S., Chai, S. M., Yung, K. K., &
Zhang, Q. L. (2007). Auricular Acupuncture Treatment for
Insomnia: A systematic Review. Journal of Alternative and
Complementary Medicine , 669-676.
 Huang, W., Kutner, N., & Bliwise, D. (2011). Autonomic
Activation in Insomnia: The Case for Acupuncture. Journal of
Clinical Sleep Medicine , 95-102.