INSOMNIAINSOMNIA

Jennifer GrayAnita Isabel Graham

Tiffany LemanskiCindy MacQuarrie

Health Promotion 809Spring 2012

Jennifer GrayAnita Isabel Graham

Tiffany LemanskiCindy MacQuarrie

Health Promotion 809Spring 2012

Part 1: Case StudyPart 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

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

22

Social History and Family History

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.

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.33

Medical HistoryMedical 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.

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.44

Discussion of ProblemDiscussion 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.

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.

55

Discussion of Problem, continued

Discussion of Problem, continued

66

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.

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.

Discussion of Problem, continued

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.

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.

77

Physical Exam 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

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

88

Part 2Part 2

Complementary Therapy Recommended: Acupuncture

Complementary Therapy Recommended: Acupuncture

99

JustificationKey points

JustificationKey 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

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 relaxation1010

Meta-Analysis of 878 Papers on Auricular Acupuncture (AA)

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

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 neededChen, 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. 

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. 

1111

Systematic Review of 46 Randomized Trials

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.

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.

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.

 

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.

 

1212

Autonomic Activation in Insomnia: The Case for

Acupuncture

Autonomic Activation in Insomnia: The Case for

AcupunctureFindings 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.

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.

Huang, W., Kutner, N., & Bliwise, D. (2011). Autonomic Activation in Insomnia: The Case for Acupuncture. Journal of

Clinical Sleep Medicine , 95-102. 

Huang, W., Kutner, N., & Bliwise, D. (2011). Autonomic Activation in Insomnia: The Case for Acupuncture. Journal of

Clinical Sleep Medicine , 95-102. 

1313

Other StudiesOther 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)

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)

1414

Part 3Part 3

Suggestions for how the client should implement the therapy: Specifics of prescription therapy dosing, including how much, how often, and for how long

Suggestions for how the client should implement the therapy: Specifics of prescription therapy dosing, including how much, how often, and for how long

1515

How to implement therapy?

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 codehttp://www.medicalacupuncture.org/findadoc/index.html

Assist with appointment coordination.

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 codehttp://www.medicalacupuncture.org/findadoc/index.html

Assist with appointment coordination.

1616

Goals of therapyGoals of therapy

Use a measurement tool to determine outcome of therapy.

Use before and after therapy.

Use a measurement tool to determine outcome of therapy.

Use before and after therapy.

1717

DosingDosing

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.

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.

1818

Acupuncture Treatment Dosing

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

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

1919 Huang, et al, 2011Huang, et al, 2011

Other Recommendations: Exercise

Other Recommendations: Exercise

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).

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).

2020

Recommendation of exercise

Recommendation of exercise

After a conditioning period, the aerobic physical activity group exercised for two 20-minute sessions four times per week or one 30-to-40-minute 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).

After a conditioning period, the aerobic physical activity group exercised for two 20-minute sessions four times per week or one 30-to-40-minute 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).

2121

Other Recommendations: Alcohol Intake

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.

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.

2222

Recommendation re: Alcohol

Recommendation re: Alcohol

Alcohol consumed within an hour of bedtime appears to disrupt the second half of the sleep period (NIAAA, n.d.).

Alcohol consumed within an hour of bedtime appears to disrupt the second half of the sleep period (NIAAA, n.d.).

2323

Other Recommendations: Diet

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

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

Sanjay et al, 2008Sanjay et al, 20082424

Part 4Part 4

Outcomes and EvaluationOutcomes and Evaluation

2525

2626

Part 5Part 5

Recommendations for Additional Research

Recommendations for Additional Research

2727

2828

ReferencesReferences

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): 95-102. 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-relieves-insomnia.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 , 631-648.

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.

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): 95-102. 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-relieves-insomnia.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 , 631-648.

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.

2929

ReferencesReferences

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.

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 , 95-102.3030