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Managing Sleep Health in Primary Care
1
Managing Sleep Health in Primary Care
Paul P. Doghramji, MD, FAAFP
Family Practice Physician
Collegeville Family Practice & Pottstown Medical Specialists, Inc.
Medical Director of Health Services, Ursinus College – Collegeville, PA
Attending Family Practice Physician, Pottstown Memorial Medical Center – Pottstown, PA
Learning Objectives
▪ Communicate risk factors associated with not getting
enough sleep
▪ Explain the sleep/wake cycle and circadian rhythms
▪ Identify common sleep disorders in primary care
▪ Use appropriate diagnostic tools to assess patients’
sleep health
Managing Sleep Health in Primary Care
2
Agenda
▪ What is sleep?
▪ Sleep stages
▪ Sleep physiology
▪ Dreaming
▪ Sleepiness
▪ Sleep disorders
▪ Insomnia and comorbidities
Sleep Perspectives
▪ Behavioral
▪ Reversible
▪ Perceptual disengagement from, and unresponsiveness to, the environment
▪ Neurophysiological
▪ Two distinct states: REM sleep and NREM
▪ Actively produced, not a result of passive inactivity
▪ Highly regulated by homeostatic and circadian processes
▪ Produces changes in the entire organism, not just the CNS
▪ Teleological
▪ Necessary for survival; deprivation leads to functional impairments and eventual death
▪ Important for clearance of neurotoxic waste products (e.g., beta amyloid) that accumulate in
the brain during wakefulness
NREM = non-rapid eye movement
Carskadon MA, Dement WC (2005), Normal human sleep: an overview. In: Principles and Practice of Sleep Medicine, 4th ed., Kryger MH et al., eds. Philadelphia: Elsevier/Saunders, pp13-23. Science vol 342, 18 Oct 2013.
Managing Sleep Health in Primary Care
3
Why is sleep important?
▪ Cognition and performance
▪ Mood regulation
▪ Mental health
▪ Physical health
▪ Safety
Fig. 4 Aβ plaque deposition after chronic sleep restriction and chronic orexin receptor blockade in transgenic mice (A) Mice that underwent chronic sleep restriction for 21 days showed significantly greater Aβ plaque deposition in multiple subregions of the cortex compared to age-matched control mice.
The glymphatic system supports interstitial solute and fluid clearance from the brain.
Sci Transl Med 2012;4:147ra111
Managing Sleep Health in Primary Care
4
Sleep Stages
SLEEP REST
Managing Sleep Health in Primary Care
5
Two States of Sleep
Rapid eye movement (REM) sleep
▪ When dreaming occurs
▪ “Active brain in a paralyzed body”
Hours 1
N 1
& REM
N 2
N3
2 3 4 5 6 7 8
Non-REM sleep
▪ 3 stages
▪ Based primarily on EEG
Typical Sleep Architectural Pattern of a Young Human Adult
Adapted from Hauri P. The Sleep Disorders. Kalamazoo, Mich: Upjohn;1982:8.
Stage I & REM sleep (red) are graphed on the same level because their EEG patterns are very similar
Sleep Architecture
▪ Sleep is entered through stage N1
▪ Orderly progression from stage N1 to N3 and, typically within 90
minutes of sleep onset, to the 1st REM period
▪ 90-minute cycle of REM-NREM repeats throughout sleep
▪ As the night progresses
▪ REM periods increase in duration and density of eye movements
▪ N3 sleep becomes less prominent in the 2nd half of the night
Managing Sleep Health in Primary Care
6
Sleep Stage Characteristics
NREM REM
Heart rate Steady Variable
Blood pressure Steady Labile
Respirations Regular Irregular
Skeletal muscle tone Normal Decreased
Thermoregulation Waking modes Decreased
Penile tumescence Infrequent Frequent
Mental activity Limited Dreaming
Brain O2 consumption Decreased Waking level
Lee-Chiong T, ed. Sleep: A Comprehensive Handbook. Hoboken, NJ: Wiley & Sons; 2006.
Sleep Across the Life Span
0
100
200
300
400
500
600
700
Tota
l Sle
ep
Tim
e (
min
)
Age (years)
Total Time in Bed
Awake in Bed
NREM N 1
REM
NREM N 2
NREM N 3
10 20 30 40 50 60 70 8050
Adapted from Williams RL, et al. Electroencephalography of Human Sleep: Clinical Applications. New York, NY: John Wiley & Sons; 1974.
Managing Sleep Health in Primary Care
7
Sleep Physiology
Managing Sleep Health in Primary Care
8
Brainstem Mechanisms Underlying Sleep and Arousal
Orexin = Hypocretin
▪ Hypothalamic peptides (OX1 and OX2)
▪ Localized in the dorsolateral hypothalamus
▪ Wide projections throughout brain and spinal column
▪ Peptide neurotransmitters involved in
▪ Arousal
▪ Locomotion
▪ Metabolism (energy and appetite control)
▪ Increase blood pressure & heart rate
Peyron et al. J Neurosci. 1998;18:9996. Moore et al. Arch Ital Biol. 2001;139:195. Silber & Rye. Neurology. 2001;56:1616.
Managing Sleep Health in Primary Care
9
Flip Flop Switch Model of Arousal and Sleep
Awake Sleep
Modified from Saper CB, et al. Nature. 2005;437(7063):1257-1263.
Dreaming
Managing Sleep Health in Primary Care
10
When do we dream?
▪ Dreaming occurs in all stages of sleep
▪ 80% of persons who are awakened during REM sleep and
sleep onset (N1 & N2)
▪ 40% of persons who are awakened from a deep sleep
Foulkes D. Dreaming: a cognitive-psychological analysis. Hillsdale, N.J.: Erlbaum, 1985.
N1 & N2 N3 REM
Simpler, shorter
and have fewer
associations
than REM sleep
dreams
More diffuse
(e.g., about a
color or an
emotion)
Tend to be
bizarre and
detailed, with
storyline plot
associations
Highest recall during sleep stages with EEG patterns
most like those in the waking state
D
R
E
A
M
S
REM and Non-REM Dreams
Managing Sleep Health in Primary Care
11
Frightening Dreams
TYPE OF
DREAMINCIDENCE SYMPTOMS SLEEP STAGE
ASSOCIATED
FACTORSFrequent
nightmares in
children
20% to 30%,
declines with age
Frightening, detailed plots
Difficult return to sleep
REM sleep, usually
late in sleep (4 - 6
a.m.)
Usually no pathology
Frequent
nightmares in
adults
5% to 8%
Increased awakenings
Daytime memory
impairment and anxiety
REM sleep
“Thin-boundary” / creative
personality
May have associated
psychopathology
PTSD
8% - 68% of
veterans
>25% of trauma
victims
Stereotypic dreams of the
trauma
Intense rage, fear, grief
REM sleep and sleep
onset
Significant trauma
Daytime hyper-
arousability & anxiety
REM sleep
behavior
disorder
Most common in
late middle age and
in men
Acting out of dreams
Nocturnal injuries
REM sleep
REM EMG tone
Degenerative neurologic
illness in 50%
Night terrors
1% to 4% of
children
Declines with age
Rare in adults
Blood-curdling screams
Autonomic discharge
Limited recall
Deep sleep, early
(1- 3 a.m.)
Stages 3 & 4
arousals on PSG
No pathology in children
Psychiatric & neurologic
disorders in adults
PAGEL JF, Nightmares and Disorders of Dreaming. Am Fam Physician. 2000 Apr 1;61(7):2037-2042.
REM = rapid eye movement; EMG = electromyography
Sleepiness
Managing Sleep Health in Primary Care
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Sleepiness: How do patients describe it?
▪ “I’m tired all the time”
▪ “I have no energy”
▪ “I feel fatigued”
▪ “I feel depressed”
▪ “I don’t feel rested”
▪ “I don’t sleep well”
The International Classification of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005.
Chervin RD. Chest 2000;118:372-379. Shen J, et al. Sleep Med Rev 2006;10:63-76.
Patients Also Mean Other Things“TIRED”
Sleepiness FatigueLack of
motivation
Tendency to fall
asleep or inability
to stay awake
Sensation of
weariness,
tiredness,
exhaustion,
loss of energy;
the desire to rest
“I don’t feel like
doing anything…”
Improved by sleep Improved by rest,
exertion makes it
worse
Managing Sleep Health in Primary Care
13
Sleepiness in America
37%
16%
0%
10%
20%
30%
40%
At least a few days per month At least a few days per week
% of US Adults Reporting that They Are So Sleepyit Interferes with Their Daily Activities
National Sleep Foundation. “Sleep in America” Poll. March 2002.
Assessment Options: Sleep Parameters
▪ Subjective: based on self-report
▪Epworth
▪ Insomnia Severity Scale
▪Diaries
▪Often do not reflect objective sleep measures
▪ Objective: Sleep lab or home sleep monitor
▪ Wearable technology (eg, Fitbit) increasingly capable of more
objective sleep assessment: eg, total sleep time, slow wave sleep,
REM sleep
▪Not reimbursable, not validated in clinical practice
Managing Sleep Health in Primary Care
14
Epworth Sleepiness Scale
Johns MW. Sleep. 1991;14:540-545.
Rate the chances of dozing in sedentary situations
Never Slight Moderate High
Sitting and reading 0 1 2 3
Watching television 0 1 2 3
Sitting, inactive in a public place (eg, a movie theater or a meeting)
0 1 2 3
As a passenger in a car for an hour without a break
0 1 2 3
Lying down to rest in the afternoon when circumstances permit
0 1 2 3
Sitting and talking to someone 0 1 2 3
Sitting quietly after lunch without alcohol
0 1 2 3
In a car, while stopped for a few minutes in the traffic
0 1 2 3
Score >=10 Prompts Further Evaluation
US women 20.8%,US men 29.7%2
South Africa1 24.5%
Japan1 12.4%
China1 6.2%
Austria1 17.5%
Belgium1 17.5%
Brazil1 14.3%
Germany1 7.2%
Portugal1 18.3%
Slovakia1 13.7%
Spain1 12.7%
Norway3 17.7%
N=35,327 survey respondents aged 39 ± 15.3 years.1
ESS, Epworth Sleepiness Scale
1. Soldatos CR, et al. Sleep Med. 2005;6:5-13; 2. Baldwin CM, et al. Sleep. 2004;27:305-311; 3. Pallesen S, et al. Sleep. 2007;30:619-624.
Worldwide Prevalence of ESS Scores >10
Managing Sleep Health in Primary Care
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Categories of Sleepiness
▪ Insufficient sleep
▪ Factitious
▪ Insomnia
▪ Poor quality sleep
▪ Obstructive sleep apnea
▪ Restless Legs Syndrome
▪ Disturbed timing of sleep
▪ Circadian rhythm disorders
▪ Medications and substances
▪ Rx, OTC, herbals
▪ Illicit drugs, alcohol
▪ Brain “damage”
▪ MS, Parkinson’s, TBI, stroke,
Alzheimer's
▪ Narcolepsy
Sleep Disorders
Managing Sleep Health in Primary Care
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Restless Legs Syndrome6
10%-15%
Comorbid Insomnias4
6%
Narcolepsy5
0.06%†
Obstructive Sleep Apnea1
3%-28%
Sleep-Wake Disorders: Prevalence in Adults
*Among night and rotating shift workers; †Prevalence of hypersomnias such as narcolepsy without cataplexy may be higher.
1. Young T, et al. Am J Respir Crit Care Med. 2002;165:1217-1239. 4. Ohayon MM. Sleep Med Rev. 2002;6:97-111.2. Drake CL, et al. Sleep. 2004;27:1453-1462. 5. Silber MH, et al. Sleep. 2002;25:197-202.3. Strine DP, et al. Sleep Med. 2005;6:23-27. 6. Merlino G et al. Neurol Sci. 2007;28:S37-S46. †Mignot E, et al. Brain. 2006;129:1609-1623. †Singh M, et al. Sleep. 2006;29:890-895.
Shift Work Disorder2
8%-32%* Insufficient Sleep
Syndrome3
26%
How to Diagnose the Cause of Sleepiness
▪ Get detailed sleep/wake history
▪ Determine whether sleepy, fatigue, or depression
▪ Quantify degree of sleepiness: ESS
▪ Start probing for the causes, looking for clues
▪ Insufficient Sleep Syndrome: doesn’t get enough sleep
▪ OSA: loud snoring, waking up choking, witnesses apneas, waking with
sore throat, headache, enuresis, nocturia
▪ RLS: uncomfortable feelings in legs prevent sleep, need to move them to
relieve symptoms
▪ PLMD: no clues except excessive sleepiness
▪ Narcolepsy: hypnogogic/hypnopompic hallucinations, sleep paralysis,
cataplexy
Managing Sleep Health in Primary Care
17
Obstructive Sleep Apnea
Symptoms
▪ Loud Snoring
▪ Gasping, choking
▪ Witnessed apneas
▪ Morning headaches, sore throat
▪ Enuresis/nocturia
Physical Findings
▪ Large neck
▪ Crowded pharynx
▪ Obesity
▪ Micrognathia, short chin
Treatment
▪ CPAP/BiPAP/Auto-AP
▪ Oral appliance
▪ Surgery
▪ Weight loss
▪ Positioning
▪ “Provent”
▪ “Inspire”
Screening for OSA: STOP-BANG Method
STOP Questionnaire*
▪ Snoring
▪ Tiredness (daytime)
▪ Observed you stop
breathing during sleep
▪ High blood Pressure
BANG†
▪ BMI > 35
▪ Age > 50 years
▪ Neck circumference
> 40 cm (~ 16 in)
▪ Gender: Male
* High risk = Yes to > 2 of 4 STOP items
† High risk = Yes to > 3 of 8 STOP-BANG items
Chung F, et al. Anesthesiology 2008;108:812-821.
Managing Sleep Health in Primary Care
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Airway Assessment: OSA Mallampati Scale
Nuckton TJ, et al. Sleep. 2006;29:903-908.
Odds of OSA increase >2-fold for every 1-point increase
Class I Class II Class III Class IV
Restless Leg Syndrome (RLS)
Symptoms
▪ Irresistible urge to move legs usually with unpleasant sensations
▪ Relief with movement
▪ Worse at night
▪ Worse with rest
Etiology
▪ Dopaminergic dysfunction
▪ Iron deficiency
▪ Renal insufficiencies
▪ Peripheral neuropathies
▪ 25% secondary
Treatment
▪ Dopaminergic agents
▪ Iron if deficient
▪ Sedative hypnotics
▪ Anticonvulsants
▪ Opiates
▪ Sleep hygiene
Allen RP, Sleep Med, 2003.
Managing Sleep Health in Primary Care
19
Periodic Limb Movement Disorder (PLMD) vs. RLS
▪ Substantial overlap
▪ Up to 85% of RLS patients have PLMD
▪ 30% of PLMD patients have RLS
▪ RLS diagnosis is made clinically
▪ PLMD diagnosis is made via PSG
▪ No other daytime clues, just sleepiness
▪ Treatments are the same
Insomnia and Comorbidities
Managing Sleep Health in Primary Care
20
Insomnia
As a disorder:
▪ Trouble getting to sleep and/or
▪ Trouble staying asleep and/or
▪ Waking up too early and/or
▪ Occurring more days of the week than not
▪ Ongoing for over 3 months
Why Should PCP’s be Proactive about Insomnia?
▪ Very prevalent in primary care
▪ But patients don’t tell you
▪ Serious consequences
▪ Day to day life
▪ Poor outcome on mental and
physical health
▪ Insomnia is a clue
▪ Most insomnia is co-morbid
▪ Easy to identify
Treatment
▪ Relieves an upsetting symptom
▪ Improves next day
consequences
▪ Improves outcome of
co-morbidity
▪ Psychiatric
▪ Medical
▪ Majority is done by PCP
Managing Sleep Health in Primary Care
21
Insomnia Risk Factors
▪ Age (older)
▪ Sex (especially post-1 and perimenopausal2 females)
▪ Divorce / separation / widowhood
▪ Psychiatric illness (mood and anxiety disorders)
▪ Medical conditions
▪ Cigarette smoking
▪ Alcohol and coffee consumption
▪ Certain prescription drugs
1. NIH Consens State Sci Statements. 2005;22:1-30.
2. Young T, et al. Sleep. 2003;26:667-672.
Insomnia Screening and Follow-up
▪ Sleep Schedule: Do you have trouble getting to sleep, staying asleep, or waking
up too early?
▪ Daytime consequences: Do you feel like you have slept well throughout the day?
▪ Sleep timing: When do you go to bed? …Wake up? …Middle of the night
awakening? …How long does it take you to fall back to sleep?
▪ Treatments: What remedies have you tried? Any previous Rx’s?
▪ Sleep hygiene/lifestyle issues: Alcohol? Smoking? Exercise? Medications that
cause insomnia?
▪ Duration, frequency, prior: How long has this been going on?...How often?...
Have you had it before?...
Sateia MJ, Doghramji K, Hauri PJ, Morin MM. Sleep. 2000;23:1-66.
Erman MK. In: Sleep Disorders: Diagnosis and Treatment. Totowa, NY: Humana Press; 1998:21-51.
Managing Sleep Health in Primary Care
22
How Frequent are Comorbidities?
Terzano MG, et al. Sleep Med. 2004;5:67-75. Katz DA, McHorney CA. (1998).
Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med 158(10):1099-1107.
35
28
19 17 15 1411
0
10
20
30
40
50
30
47
37 39
50
3842
106
17
2522
1215
0
10
20
30
40
50
InsomniaSevere insomnia
Pre
vale
nce
%
Medical Conditions in Primary
Care Patients with InsomniaInsomnia with Medical Conditions
How Does Inadequate Sleep Increase CVD?
▪ Total sleep time (TST) < 5 hours compared to TST > 5 hours
▪ Higher glucose & cortisol levels
▪ HPA-associated endocrine & metabolic imbalances
▪ Hypercholesterolemia even after controlling for other risk factors
▪ Night time BP: Nighttime SBP higher and day-to-night SBP dipping was lower
(-8% vs -15%, P < 0.01) in insomniacs
▪ Atherosclerosis: Total sleep time (P = 0.005), and sleep quality (P = 0.05)
contributed to increased carotid intima-media thickness
▪ Inflammation: Serum CRP levels higher and increased at a steeper rate
Lanfranchi, PA, et al. (2009). Nighttime blood pressure in normotensive subjects with chronic insomnia: implications for cardiovascular risk. Sleep 32(6): 760-766.
Nakazaki, C, et al. (2012). Association of insomnia and short sleep duration with atherosclerosis risk in the elderly."Am J Hypertens 25(11): 1149-1155. Parthasarathy,
S, et al. (2015). Persistent insomnia is associated with mortality risk. Am J Med 128(3): 268-275 e262. Lin, CL, et al. (2016). The relationship between insomnia with short
sleep duration is associated with hypercholesterolemia: a cross-sectional study. J Adv Nurs 72(2): 339-347. Farina, B., et al. (2014). Heart rate and heart rate variability
modification in chronic insomnia patients. Behav Sleep Med 12(4): 290-306. de Zambotti, M., et al. (2011). Sleep onset and cardiovascular activity in primary insomnia.
J Sleep Res 20(2): 318-325.
Managing Sleep Health in Primary Care
23
Does insomnia contribute to development of hypertension?
Lewis, P. E., et al. (2014). Risk of type II diabetes and hypertension associated with chronic insomnia among active component, U.S. Armed Forces,
1998-2013. MSMR 21(10): 6-13.
Prospective Follow-up
▪ Active duty in US Military
▪ Excluded: Chronic
insomnia prior to
1/1/1998
▪ Without hypertension at
baseline
▪ Chronic insomnia led to
higher risk of
hypertension (aHR 2.00)
Rate of Developing
Hypertension(per 10,000 person-years)
46.2
95.6
0
20
40
60
80
100
Controls Insomnia
Does Insomnia Increase Risk of CVDs?
1.681.85
1.4 1.3
0
0.5
1
1.5
2
aOR of CV Event
0.961.35
4.53
0
1
2
3
4
5
1 2 3
aOR for CHF
1st CV Event
# Insomnia Symptoms
Hsu, CY, et al. (2015). The Association Between Insomnia and Increased Future Cardiovascular Events: A Nationwide Population-Based Study.
Psychosom Med 77(7): 743-751. Laugsand, LE, et al. (2014). Insomnia and the risk of incident heart failure: a population study. Eur Heart J 35(21):
1382-1393. Canivet, C, et al. (2014). Insomnia increases risk for cardiovascular events in women and in men with low SES: a longitudinal, register-
based study. J Psychosom Res 76(4): 292-299.
Managing Sleep Health in Primary Care
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How Much Does Insomnia Contribute to CV Mortality?
Health Professionals Follow-Up Study
▪ US men free of cancer
▪ Insomnia symptoms in 2004, followed through 2010
▪ Adjusted for age, lifestyle factors, and common chronic conditions
Metaanalysis of 13 Prospective Studies
▪ 122,501 subjects followed for 3-20 yrs
▪ Insomnia increased risk by 45% of developing or dying from CVD ▪ (RR 1.45, 1.29-1.62; p < 0.00001)
Li, Y, et al. (2014). "Association between insomnia symptoms and mortality: a prospective
study of U.S. men." Circulation 129(7): 737-746. Sofi, F, et al. (2014). Insomnia and risk of
cardiovascular disease: a meta-analysis. Eur J Prev Cardiol 21(1): 57-64.
1.25
1.091.04
1
1.25
1.5
Total Mortality CVD MortalityDifficulty Initiating & Nonrestorative
Difficulty initiatingDifficulty maintainingEarly-morning awakenings
1.55 (1.19-2.04)
1.32 (1.02-1.72)
Health Professionals Follow-Up Study
Adjusted Hazards Ratio
How Does Insomnia Contribute to Diabetes Risk?
Insulin Resistance Associated with
Subjective Sleep Complaints In
Those without Diabetes
ORs
Adjusted
for
InsomniaDaytime
Sleepiness
Sex and age1.68
(1.09–2.58)
1.80
(1.22–2.66)
Fully*1.24
(0.74–2.09)
1.75
(1.10–2.77)
*Adjusting for sex, age, alcohol consumption,
smoking, exercise, occupational status, BMI,
and family history of diabetes
Pykkönen A-J, et al. (2012) Subjective Sleep Complaints Are
Associated With Insulin Resistance in Individuals Without Diabetes.
Diabetes Care 35:2271–8.
aORs for HbA1c >= 6.0%
6.79
3.96
2.33
0
2
4
6
8
Kachi, Y., et al. (2011). Association between insomnia symptoms and
hemoglobin A1c level in Japanese men. PLoS One 6(7): e21420.
Males 22-69 years old with no hx of diabetes
Difficulty maintaining
sleep
Lasting 2+wks
Early AM
awakening
Some-times
Some-times
Japanese company annual health check-up
Managing Sleep Health in Primary Care
25
Does Treating Insomnia Lower Blood Pressure?
Standard BP treatment + estazolam
vs.
Standard BP treatment + placebo
▪ Insomnia treatment efficacy
▪ Estazolam: 67.3% (P < 0.001)
▪ Placebo: 14.0%
▪ Goal BP(< 140/90 mmHg)
▪ Estazolam: 74.8% (P < 0.001)
▪ Placebo: 50.5%
Li, Y, et al. (2017). "The impact of the improvement of insomnia on blood
pressure in hypertensive patients." J Sleep Res 26(1): 105-114.
Blood Pressure Reduction
from Baseline
-2.6 -2.8-2.5
-3.4
0
-2.3-2
-2.5 -2.7
-0.7
-2.8
-5
-7.1
0
-2.5
-3.7
-5.4
-8
-6
-4
-2
07 14 21 28 7 14 21 28
Placebo Estazolam
Systolic Diastolic
N = 202N = 200
Days of Treatment
Does Insomnia Increase Risk of Psychiatric Disorders?
31.1
35.9
30
14.4
5
21
18
10
0
5
10
15
20
25
30
35
40
Pati
en
ts (%
)
Incidence (%) over 3.5 years
Insomnia (n=240)
No Insomnia (n=739)
Breslau N, Roth T, Rosenthal L, Andreski P. Sleep disturbance and psychiatric disorders: a longitudinal epidemiological study of young adults. Biol Psychiatry. 1996;39:411-418.
Managing Sleep Health in Primary Care
26
Does Treating Insomnia Improve Comorbidities?
0
20
40
60
80
100
4 Months 16 Months
Poor Good
0
20
40
60
80
100
4 Months 16 MonthsControl Tai Chi
By Sleep Quality
%
4 months
CBT .21 (.03-1.47) p<.10
TCC NS
16 months
CBT .06 (.005-.669) p<.01
TCC .10 (.008-1.29) p<.05
ORs of Remaining
at High Risk
2-hour group sessions
weekly for 4 mo with a
16-mo evaluationRisk score based on 8 biomarkers: HDL, LDL, triglycerides,
C-reactive protein, fibrinogen, HA1c, glucose, insulin• High risk = 4 or more abnormal
By Intervention
% Remaining at High Risk
Carroll, JE, et al. (2015). Improved sleep quality in older adults with insomnia reduces biomarkers of disease risk: pilot results from a randomized controlled comparative
efficacy trial. Psychoneuroendocrinology 55: 184-192.
How is Insomnia Best Conceptualized to Guide Treatment?
▪ Genetic: heritability 42% - 57% in chronic insomnia
▪ Final common pathway: Autonomic and CNS hyperarousal
▪ Greater whole-brain metabolism during both sleep and wake periods
▪ Increased secretion of corticotropin and cortisol throughout sleep-wake cycle
▪ Sleep-wake regulation imbalance
▪ Overactivity of arousal systems
▪ Hypoactivity of sleep-inducing systems
▪ Both
▪ Failure of wake-promoting structures to deactivate during the transition
from waking to sleep states
Riemann D., et al. (2015). The neurobiology, investigation, and treatment of chronic insomnia. Lancet Neurol 14(5): 547-558. Vgontzas, AN, et al. (2013).
Insomnia with objective short sleep duration: the most biologically severe phenotype of the disorder. Sleep Med Rev 17(4): 241-254. Vgontzas et al.
Nofzinger et al. Am J of Psychiatry. 2004;161:2126-2128.
Managing Sleep Health in Primary Care
27
1. Kupfer DJ, Reynolds CF III. N Engl J Med. 1997;336:341-346.
2. Consensus Conference. JAMA. 1984;251:2410-2414.
Stepwise Approach for Managing Insomnia
Discuss With
Patient How They Sleep
Diagnosis1, 2
Education,
Including
Good Sleep
Practices1, 2
Nonpharma-
cologic
and/or
Pharma-
cologic
Therapy1, 2
Referral to
Sleep
Specialist
(In Cases of
Treatment
Failure)1
Patient Education: Most Powerful Tool
▪ Inform WHY management is so important
▪ Consequences
▪ Emphasize keeping regimented sleep schedule
▪ Wake up same time every day
▪ Naps usually not a good idea
▪ Emphasize sleeping long enough
▪ Can’t catch up on weekends
▪ Emphasize lifestyle measures
▪ Alcohol, exercise, smoking, caffeine, diet (no large meals)
Managing Sleep Health in Primary Care
28
Treatments: CBT and/or Medications?
▪ Address the co-morbid condition as well as the insomnia
▪ Discuss with patient pros and cons of meds and CBT
▪ Medications:
▪ Which are best applicable?
▪ Habit forming?
▪ How long to use?
▪ Side effects?
▪ CBT: at your discretion—ability, time, interest
▪ Allow patient to voice his/her concerns, fears, and needs
How Does Cognitive Behavioral Therapy Compare To Pharmacotherapy?
Adapted from: Jacobs GD, et al. Arch Intern Med. 2004;164:1888-1896.
Schutte-Rodin S et al. J Clin Sleep Med. 2008;4(5):487-504. Morin CM, et al. Sleep 1999;22:1134-56.
CBT-I Components
▪ Sleep hygiene education
▪ Cognitive therapy
▪ Sleep restriction therapy
▪ Stimulus control therapy
▪ Relaxation training
Sleep Hygiene
▪ Regular wake time
▪ Limit time awake and in bed
▪ Limit napping during the day
▪ Avoid clock watching if awake
▪ Avoid caffeine (after 2 PM),
alcohol after dinner, or eating
dinner just before bedtime
▪ Avoid stressful activities in
the evening
Managing Sleep Health in Primary Care
29
Treating Insomnia: Choosing the Right Pharmacotherapy
▪ Trouble with sleep initiation only: rapid and short acting
▪ Ramelteon, triazolam, zaleplon, zolpidem
▪ Trouble staying asleep with sleep initiation problems: rapid and long acting
▪ Eszopiclone, temazepam, zolpidem ER, zolpidem (if awakes early in evening), suvorexant
▪ Trouble staying asleep withOUT sleep initiation problems
▪ Doxepin (taken at sleep onset), sublingual zolpidem (taken if one awakens)
▪ Issues with controlled substances: both of these unscheduled
▪ Ramelteon, doxepin
▪ Generic medications
▪ Temazepam, triazolam, zaleplon, zolpidem, eszopiclone
When to Consider Referral to a Sleep Expert
▪ Suspected obstructive sleep apnea or narcolepsy1-3
▪ Violent behaviors or unusual parasomnias1-3
▪ Daytime tiredness (sleepiness) that you can’t figure out1
▪ Insomnia fails to respond to behavioral and/or pharmacologic
therapy after an appropriate interval1,3
▪ You don’t feel comfortable treating the condition
1. Doghramji P. J Clin Psychiatry. 2001;62(suppl 10):18-26.
2. Sateia MJ, Owens J, Dube C, Goldberg R. Sleep. 2000;23:243-308.
3. Kushida CA, Littner MR, Morgenthaler T, et al. Sleep. 2005;28:499-521.
Managing Sleep Health in Primary Care
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Additional Resources
▪ For additional resources, visit:
▪ Sleepfoundation.org
▪ Sleep.org
▪ Sleephealthjournal.org