Insomnia What is it and how do you treat it by vasana


									          Insomnia: What is it and how do you treat it?

1.   Insomnia is a complaint and a symptom, not a disease
•     Liken it to other symptoms such as fever or chest pain
•     It has many causes
•     Try to establish an underlying diagnosis and treat the cause

2. Definition of insomnia
• Difficulty falling asleep and/or difficulty staying asleep and/or nonrestorative sleep
• Associated with next-day consequences including impaired concentration and
   memory, decreased ability to accomplish daily tasks and decreased quality of life

3.   Screening questions to help identify patients (modified from DSM IV)
•    Do you have difficulty falling asleep?
•    Do you wake up during the night and have trouble getting back to sleep?
•    Do you get less sleep than you think you need?
•    Do you often feel sleepy during the day?
•    Do you have difficulty completing your work or other daily activities because you are
     too tired?

4. Risk factors for insomnia
• Of course, anyone can develop insomnia
• More prevalent in: women, the elderly, divorced or widowed people, people of lower
   socioeconomic status, people who snore (probably due to sleep apnea) and people
   with concomitant health problems

5.   Prevalence of insomnia according to Gallup poll for National Sleep Foundation, 1995
•    Almost half of Americans suffer from sleep difficulties at least 1 out of 5 nights
•    74% of the sufferers have problems an average of 6 nights per month
•    26% of the sufferers have problems an average of 16 nights per month
•    70% of those frequent sufferers (the 26%) never discussed it with a health care

6.   Impact of insomnia
•    Impaired cognitive functioning
•    Negative impact on quality-of-life measures
•    Increased incidence of bodily pain, poorer general health
•    Increased risk of psychiatric disorders, especially depression
•    Decreased job performance and increased absenteeism
•    Increased risk of accidents
•    Increased overall health care costs

7. How does insomnia develop?

•    Predisposing factors: Weak sleep generating system, recurrent depression,
     predilection to stay up late
•    Acute factors that can precipitate insomnia: stress, anxiety, medical problems, drugs
•    Perpetuating factors can develop as a result of coping with the insomnia which tend to
     perpetuate it: Expecting a poor night’s sleep, maladaptive conditioning (clock
     watching, etc.), caffeine, hypnotics and spending too much time in bed
•    In chronic insomnia, the acute, precipitating factors can resolve but the perpetuating
     factors remain and become the dominant reason for continued insomnia

8.   Duration of insomnia
•    Key factor in evaluation
•    Important for diagnosis, treatment and prognosis
•    Acute insomnia: Present for less than 2-4 weeks
•    Chronic insomnia: Present for longer than 3-6 months

9. Diagnosis of insomnia
• Try to find an underlying cause
• Specific treatment can be instituted only when the etiology (cause) is known

10. Clinical evaluation: THE SLEEP HISTORY
• Medical history: Psychiatric, cardiac, pulmonary, endocrine, gastrointestinal, renal
• Sleep history: 24 hr sleep/wake schedule, when is patient sleepy, bedtime, sleep
    latency, number and reason for awakenings, daytime naps
• Completion of a sleep diary, which is a graphic representation of sleep/wake cycle
    completed by the patient day-to-day
• Nighttime activities and symptoms: evening/bedtime rituals, restless legs, anxiety
• Symptoms on arousal: dyspnea, choking, chest pain, palpitations, heartburn, hunger,
    musculoskeletal pain, anxiety, sweating
• Daytime performance: Daytime sleepiness, social/familial issues and stresses, job
    performance, use of stimulants
• Other important questions: Age of onset; how patient sleeps in a strange bed (better or
    worse); sleep pattern on weekends and vacations; use and effect of drugs; shift work
• Questions of bed partner: Confirm sleep complaint; daytime sleepiness; social/family
    stresses and problems; abnormal nocturnal movements; snoring or apneas or irregular
    breathing; parasomnias (sleep walking, night terrors, sleep talking)
• Drug history: Detailed list of timing and doses of all medications and other drugs
    including prescription, OTC, illicit, caffeine, alcohol and herbal/naturopathic

11. Disorders associated with insomnia
• Behavioral/psychophysiological insomnia
• Psychiatric
• Environmental
• Drug dependency
• Respiratory
• Movement disorders

•   Circadian timing disorders
•   Parasomnias
•   Neurological disorders
•   Other medical disorders
•   Idiopathic insomnia

12. Approach to the management of insomnia
• Diagnosis followed by
• Patient education, including good sleep practices followed by
• Nonpharmacologic and pharmacologic therapy

13. Patient education: Good sleep practices
• Standardize wake and sleep time
• Limit amount of time awake spent in bed
• No napping at all
• Avoid exercise 3 hours or more before bed
• Avoid looking at the clock (set the alarm and turn it out of line of sight)
• Reduce or eliminate nicotine, caffeine and alcohol. At very least, consume none of
    these 4-6 hours prior to bed

14. Nonpharmacologic therapy
• Behavioral therapy: Relaxation therapy, sleep restriction therapy and stimulus control
• Cognitive therapy
• Psychotherapy

15. Common prescription medications used to treat insomnia
• Short-acting benzodiazepines (triazolam) and the benzodiazepine-receptor agonists
    (zolpidem, zaleplon and eszopiclone).
• Sedating anti-depressants, such as trazodone and amitryptiline. These are generally
    not recommended unless the insomnia sufferer is depressed.

16. Take home messages
• Insomnia is a symptom and complaint, not a specific disease
• Attempt to make a specific diagnosis
• Treatment should be aimed at the underlying disorder causing the insomnia

                        SELECTED REFERENCES

1.     Diagnostic and Statistical Manual of Mental Disorders (DSM IV), 1994
2.     The Gallup Organization for the National Sleep Foundation. Sleep in America:
       1995. Princeton, NJ: The Gallup Organization; 1995.
3.     Zammit GK, Weiner J, Damato N, Sillup GP, McMillan CA. Quality of life in
       people with insomnia. Sleep. 1999; 22 (suppl 2): S379-S385.
4.     Kupfer DJ, Reynolds CF III. Management of insomnia. New England Journal of
       Medicine. 1997; 336: 341-346.
5.     Consensus Conference. Drugs and insomnia: the use of medications to promote
       sleep. JAMA. 1984; 251: 2410-2414.
6.     Bootzin RR, Perlis ML. Nonpharmacologic treatments of insomnia. Journal of
       Clinical Psychiatry. 1992; 53 (suppl 6): 37-41.
7.     Morin CM, Colecchi C, Stone J, Sood R, Brink D. Behavioral and pharmacologic
       therapies for late-life insomnia: a randomized controlled trial. JAMA. 1999; 281:
8.     Mitler MM. Nonselective and selective benzodiazepine receptor agonists---Where
       are we today? Sleep. 2000; 23 (suppl 1): S39-S46.
9.     Chesson A, Hartse K, Anderson WM, Davila D, Johnson S, Littner M, Wise M,
       Rafecas J. Practice parameters for the evaluation of chronic insomnia. Sleep.
       2000; 23 (2): 237-241.
10.    Sateia MJ, Doghramji K, Hauri PJ, Morin CM. Evaluation of chronic insomnia.
       Sleep. 2000; 23 (2): 243-308.

                               Selected Websites
American Academy of Sleep Medicine       

National Center of Sleep Disorders Research

National Sleep Foundation                

Sleep Medicine Home Page (Dr. Michael Thorpy)

Stanford (Dr. Dement)                    


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