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					        Insomnia

        Simon Tucker
Swindon/Bath GP Registrar DRC
       September 2005
             What is it?

• Trouble falling asleep, staying asleep, waking too
  early, or not feel rested after sleep.

• Most adults need about 7-8 hrs a night, as we age,
  sleep patterns change, sleep less at night and take
  naps in the day.
            Types of insomnia
• Transient insomnia
    • <4/52, triggered by excitement or stress, occurs
      when away from home
• Short-term
    • 4/52-6/12, ongoing stress at home or work,
      medical problems, psychiatric illness
• Chronic
    • Poor sleep every night or most nights for > 6/12,
      psychological factors (prevalence 9%)
           Medical problems
• Depression
• Hyperthyroidism
• Arthritis, chronic pain
• Benign prostatic hypertrophy
• Headaches
• Sleep apnoea
• Sleep related periodic leg movement, Restless
  legs
• GOR
               Other factors
•   Caffeine
•   Nicotine
•   Alcohol
•   Exercise
•   Noise
•   Light
•   Hunger
             The bedroom
• Temperature, fresh air

• S&S

• Comfortable bed
          C.B.T. & insomnia
• Over 40yrs research has shown C.B.T is
  effective in treatment insomnia but effect is
  not as great then when applied to other
  psychological disorders.
         Stimulus control
• Go to bed when sleepy
• Only S & S in bedroom
• Get up the same time every morning
• Get up when sleep onset does not occur in 10 min,
  and go to another room
• No daytime napping

    – Rational is that insomnia in the result of maladaptive
      conditioning between the environment (bedroom) and
      sleep incompatible behaviours. Aim is to reverse this –ve
      association by limiting the sleep incompatible behaviours
      engaged within the bedroom environment.
        » Richard Bootzin 1972
               Sleep hygiene
– Education about behaviours that interfere with
  sleep
  •   Caffiene
  •   Alcohol
  •   Nicotine
  •   Day time napping
  •   Exercise < 4hrs before bed
       – “education” is followed by monitoring of “sleep-unfriendly”
         behaviours to improve compatibility of patients lifestyle
         with sleep.
        Relaxation training

•   Progressive muscle relaxation
•   Diaphragmatic breathing
•   Autogenic training
•   Biofeedback
•   Meditation
•   Yoga
•   Hypnosis
        » Reduce anxiety and tension at bedtime
        Sleep restriction
• Sleep record for 2/52, calculate the average total
  asleep time (ATST)
• Time in bed (TIB) = ATST + 30 min
• TIB increased every few weeks by 15 min if
  sleeping well but still having daytime sleepiness

   – Grew out of observation that insomniacs stay in bed
     hoping this will produce more sleep time, instead it
     breaks up sleep over a longer time period and increases
     frustration
        » Arthur Spielman.1987
           Thought stopping
• Interrupt unwanted pre-sleep cognitive
  activity by instructing patient to repeat sub-
  vocally “the” every 3 sec (articulatory
  suppression)
• or to yell sub-vocally “stop” (thought
  stopping)
      Paradoxical intention

– Explicit instruction to stay awake when they
  go to bed

     – Aim is to reduce anxiety associated with trying to fall
       asleep
       Cognitive restructuring

• Alter irrational beliefs about sleep, provide
  accurate information that counteracts false
  beliefs.
           Imagery training


– Patient imagines 6 common objects (candle,
  hourglass, blackboard, kite, light bulb, fruit)

      – Emphasis on imagining shape, colour, texture
                    Drugs
• Benzodiazepines (GABA rec. agonist)

   – Transient insomnia, (max 2/52, ideally 2-3/7)
       » Long ½ life, nitrazepam
       » Med ½ life temazepam
       » Short ½ life diazepam

   – Poor functional day time status, cognitive impairment,
     daytime sleepiness, falls and accidents, depression,
     dependence (DTB Dec 04)

   – Acute withdrawal, confusion, psychosis, fits, D.T’s
      » May occur up to 3/52 from stopping
                    Z drugs
– Act at the benzodiazepine receptor

  • Less risk of dependence
     – Zaleplon short ½ life
     – Zolipidem, Zopiclone slightly longer ½ life

     – NICE 2004
         » No consistant difference found for effectiveness and
           safety
         » More expensive
         » Only use if adverse effects to BZP
                 Other drugs
• TCA
     • Amitriptyline, if depression also an issue


• Antihistamines
     • Promethazine OTC


• Chloral hydrate
               melatonin
• Hormone secreted by pineal gland, effects
  circadian rhythm, synthesised at night

• Use to counteract jet lag (2-5mg @ bedtime for 4
  night nights after arrival, Cochrane)

• Used in paediatric sleep disorders (severe learning
  difficulties, visually handicapped.)

   – Can’t be prescribed
What about kids?
         Controlled crying
•   From 9/12
•   Bedtime routine
•   Regular bedtime, say goodnight
•   Leave to cry, checking every 5 – 10 – 15 min, (may
    also need a graded withdrawal phase)
•   Works for bed time and middle night waking
•   during checks, minimal stimulation
•   can work in 3/7
•   Maternal instinct is main barrier to effectiveness
           bibliography
• Americaninsomniaassociation.org
• Familydoctor.org
• Gpnotebook.co.uk
• Cognitive behavioural therapy for primary
  insomnia: can we rest yet? Harvey A, Tang N.
  Sleep medicine reviews Vol 7, No3, 237-262, 2003
• BNF

				
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posted:7/16/2012
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