Insomnia by Dr Sarma

8/9/2019 Insomnia by Dr Sarma

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http://www.drsarma.in/


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Sleep disorders arecommon

Sleep disorders are serious

Sleep disorders are treatable

Sleep disorders areunder diagnosed

Important facts

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Sleep complaints are usually not due to

psychiatric conditions or character flaws

Most sleep disorders are readily

diagnosable and treatable

The studies include

Polysomnography (PSG) Multiple sleep latency test (MSLT)

Actigraphy

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Important facts

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Wake System

___________________________


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Sleep System

___________________________


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Sleep Wake Cycle

___________________________


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Changes in sleep with age___________________________


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Stages of sleep

___________________________1. NREM Sleep

A. Stage 1

B. Stage 2

C. Stage 3

D. Stage 4

2. REM Sleep


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REM Sleep

~20% of night

NREM Sleep

~80% of night

Wake

2/3 of life

Sleep Stages___________________________


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Sleep disorders (ICSD 2)___________________________

1. Insomnia.

2. Sleep Related Breathing Disorders.

3. Hypersomnia.

4. Cicadian Rhythm Sleep Disorder.

5. Parasomnia.

6. Sleep related Movement Disorder.


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Insomnia and excessive daytime sleepiness

are primary complaints regardless of the

stage of the disease

Insomnia includes difficulty falling asleep,

difficulty staying asleep, and early morning

awakening

Insomnia - definition

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Insomnia is not defined by the number of

hours of sleep, but rather, by an individuals

ability to sleep long enough to feel healthy

and alert during the day.

The normal requirement for sleep rangesbetween 4 and 10 hours

Insomnia is a symptom, not a disorder byitself

Insomnia - definition

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Determine the pattern of sleep problem (frequency,

associated events, how long it takes to go to sleep,

and how long the patient can stay asleep)

Include a full history of alcohol and caffeine intake

and other factors that might affect sleep

Review current medications that patient is taking to

eliminate these as possible causes

Take a history to rule out physical cause and/or

psychosocial cause

Insomnia - assessment

___________________________


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Cognitive Model of Insomnia

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Evolution of Insomnia

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Headache

Bad or vivid dreams

Problems of breathing

Chest pain/heartburn

Need to pass urine ormove bowels

Abdominal pains

Fever/night sweats

Leg cramps

Fear/anxiety

Depression

Possible causes of insomnia

___________________________


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Insomnia

___________________________1. A complaint of difficulty in initiating,

maintaining or waking up too early orsleep that is non-restorative or poor inquality.

2. The above sleep difficulty occurs despiteadequate opportunity and circumstance

for sleep.

3. Insomnia is a symptom not a diseaseper se


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Insomnia associated features

___________________________At least one (or more) of the following

Fatigue or malaise

Attention, concentration impairment

Social/ vocational dysfunction/ poor work

Mood disturbance or irritability

Daytime sleepiness


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Insomnia resultant problems

___________________________ Reduction in motivation, energy or initiative

Proneness for errors or accidents at work

or while driving

Tension, headaches or gastrointestinalsymptoms in response to sleep loss

Concerns or worries about sleep

Secondary psychiatric problems


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Sleep onset insomnia

Sleep maintenance insomnia

Sleep offset insomnia

Non restorative sleep

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Insomnia - subdivisions___________________________


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Types of insomnia________________________

Transient insomnia

< 4 weeks triggered by excitement or stress,

occurs when away from home Short-term

4 wks to 6 mons , ongoing stress at home or

work, medical problems, psychiatric illness Chronic

Poor sleep every night or most nights for > 6

months, psychological factors (prevalence 9%)


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Medical problems

__________________________ Depression Hyperthyroidism

Arthritis, chronic pain

Benign prostatic hypertrophy

Headaches; Sleep apnoea

Periodic leg movement,

Restless leg syndrome (RLS)


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Other problems

__________________________ Caffeine

Nicotine

Alcohol

Exercise

Noise

Light

Hunger


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Management of insomnia

____________________________ Good Sleep History

Rule out primary psychiatric disorders

Rule out adverse effects of medications

Sleep Diary

Good Sleep Hygiene Measures

Interventions CB therapy, medications


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Treat underlying causes whenever possible

Advise patient to avoid exercise, heavy

meals, alcohol, or conflict situations justbefore bed

Plain aspirin or paracetamol in low doses

may be helpful; or give short-actinghypnotics or a sedative

Treat underlying depression

Management of insomnia___________________________


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Treat underlying Medical Condition

Treat underlying Psychiatric Condition

Improve sleep hygiene

Change environment

CBT: primary insomnias, transient insomnia

Pharmacological

Light, melatonin, or chronotherapy for

circadian disorders

Management of insomnia___________________________


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Type of medication Example

CNS stimulants D-amphetamine, Methyphenindrate

Blood pressure drugs - blockers, - blockers

Respiratory medicines Albuterol, Theophylline

Decongestants Phenylephine, Pseudoephedrine

Hormones Thyroxin, Corticosteroids

Other substances Alcohol, Nocotine, Caffeine

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Medications and insomnia___________________________


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Cognitive Behaviour Therapy (CBT)____________________________


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Non pharmacological treatments

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Bed room__________________________

Temperature

Fresh air

S&S

Comfortable bed


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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 occurin 20 min, and go to another room

No daytime napping


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Sleep hygiene__________________________

Behaviours that interfere with sleep

Caffeine

Alcohol

Nicotine

Daytime napping

Exercise < 4hrs before bed


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Relaxation training__________________________

Progressive muscle relaxation

Diaphragmatic breathing

Autogenic training

Biofeedback

Meditation, Yoga

Hypnosis to anxiety & tension at bedtime


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Thought stopping__________________________

Interrupt unwanted pre-sleep cognitive

activity by instructing patient to repeat

sub-vocally the every 3 sec

(articulatory suppression)

To yell sub-vocally stop

(thought stopping)


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Behavioural therapies__________________________

Explicit instruction to stay awake when they go to bed;

Aim is to reduce anxiety associated with trying to fall

asleepParadoxical intention

Alter irrational beliefs about sleep, provide accurate

information that counteracts false beliefsCognitive

restructuring

Patient imagines 6 common objects (candle, kite, fruit,

hourglass, blackboard, light bulb) emphasis on

imagining shape, colour, textureImagery training


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Benzodiazepines

Lorazepam

Clonezepam Temazepam

Flurazepam

Quazepam

Alprazolam

Triazolam

Estazolam

Non Benzodiazepines

Zolpidem

Zolpidem CR Zeleplon

Eszopiclone

Both these classes acton the GABAA receptors(BzRA) in PCN

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Benzodiazepine receptor agonists__________________________


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Antidepressants

Trazadone

Mirtazapine Doxepin

Amitryptyline

Antipsychotics Olanzapine

Quitiepine

Melatonin Receptor Agonists

Melatonin

Ramelteon

Miscellaneous

Valerian

Diphenhydramine

Cyclobenzaprine

Hydroxyzine

Alcohol

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Other classes of medications__________________________


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Anterograde amnesia

Residual sedation longer acting BzRAs

Rebound Insomnia?

Abuse and dependence?

Mostly used short term (2 weeks)

When used as a sleeping aid dose escalation rare

No physical dependence with night time use

Low psychological dependence with night time use

Increased fall risk, cognitive effects in the elderly

BzRAs side effects and safety__________________________


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Benzodiazepines (GABA receptor agonist)

Transient insomnia, (max 2 wks, ideally 2-3/wk)

Long life - nitrazepam

Medium life - temazepam

Short life - diazepam

Poor functional day time status, cognitive impairment,

daytime sleepiness, falls and accidents, depression

Acute withdrawal, confusion, psychosis, fits - may

occur up to 3/52 from stopping

Benzodiazepines____________________________


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Benzodiazepines are the drugs of choice for the

treatment of insomnia.

Flurazepam can be used for up to one monthwith little tolerance.

Temazepam can be used for up to three

months with little tolerance.

Intermittent use recommended (every three

days). Use for no longer than 3 6 months.

Benzodiazepine use____________________________


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Half-life is an important factor

Benzodiazepines with long half lives (e.g.,

flurazepam) produce sustained sleep, butincreased risk of daytime somnolence

Benzodiazepines with short half lives may be

best for patients with difficulty falling asleep, but

can produce rebound insomnia

Development of tolerance can produce rebound

insomnia in compounds with short half lives

Benzodiazepine use____________________________


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Benzodiazepines have relatively low

abuse potential.

Prolonged use can lead to withdrawal

symptoms: headache, irritability,

dizziness, abnormal sleep

Rebound insomnia - triazolam

Benzodiazepine abuse____________________________


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Low toxicity when taken alone

In combination can be fatal

Flumanzenil is a benzodiazepine

antagonist that can be used to block

adverse effects of benzodiazepines

Stomach pump, charcoal, hemodialysis

Benzodiazepine toxicity____________________________


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Act at the benzodiazepine receptor

Less risk of dependence

Zaleplon short life Zolipidem, Zopiclone slightly longer life

No difference in effectiveness & safety

More expensive

Only to be used if adverse effects to BZP

Non benzodiazepines____________________________


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Short half life

Does not produce rebound insomnia

Low abuse potential

Less likely to produce withdrawal symptoms

Rebound insomnia after first night of

withdrawal, but soon resolves

Zolpidem____________________________


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Drug Duration of action Half-life

Phenobarbital Long 24 140 hrs.

Butabarbital Intermediate 34 42 hrs.

Amobarbital Short-intermediate 8 42 hrs.

Pentobarbital Short-intermediate 15 48 hrs.

Secobarbital Short-intermediate 19 34 hrs.

Barbiturates____________________________


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TCA - Amitriptyline, if depression also an issue

Antihistamines Promethazine

Melatonin

Hormone secreted by pineal gland, effectscircadian rhythm, synthesised at night

Use to counteract jet lag (2-5mg @ bedtime forFour nights after arrival);

Synthetic analogue of malatonin - Remelteon

Used in paediatric sleep disorders

Other drugs____________________________


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Hypersomnia___________________________

1. Narcolepsy with Cataplexy

2. Narcolepsy without Cataplexy

3. Narcolepsy due to Medical Condition4. Idiopathic Hypersomnia with Long Sleep Time

5. Idiopathic Hypersomnia without Long Sl. Time

6. Behaviorally Induced Insufficient Sleep Syn

7. Hypersomnia due to Medical Condition

8. Hypersomnia due to Drug/ Substance


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Sleep related movement disorders____________________________

1. Restless Leg Syndrome

2. Periodic Limb Movement Disorder

3. Sleep Related Leg Cramps

4. Sleep Related Bruxism


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THANK YOU ALL

HAVE GOOD SLEEP

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Insomnia by Dr Sarma