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 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 life, nitrazepam Med life temazepam Short 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.Ts May occur up to 3/52 from stopping
Z drugs Act at the benzodiazepine receptor Less risk of dependence Zaleplon short life Zolipidem, Zopiclone slightly longer 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.) Cant 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