Download Meeting the Challenge of Chronic Insomnia

presented by
Teresa D. Valerio, D.N.P. APN, FNP-BC
Illinois State University
Normal, Illinois
Presentation 12.3.54
5/25/2017
1
At the end of this presentation, the learner will be
able to:
1. Identify key components of a diagnosis of
chronic insomnia in adults
2. Describe effective behavioral management of
chronic insomnia
3. Describe effective pharmacologic management
of chronic insomnia
Presentation 11.5.22
5/25/2017
2

Teresa D. Valerio has no financial relationship or
interests to disclose related to this topic.
Presentation 11.5.22
5/25/2017
3
1. Complaint (> 3 times a week, > 1 month)




Difficulty falling (initiating) asleep
Difficulty staying (maintaining) asleep
Waking too early
Poor quality (non-restorative) of sleep
2. Above occurs despite adequate sleep opportunity
3. One or more daytime impairments




Sleepiness, fatigue
Attention, concentration, memory, mood, motivation,
energy
Work/school or social performance
Worry about sleep, headaches or GI distress
INSOMNIA=symptom
Presentation 11.5.22
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30% of general population, 10% chronic
problem, 50% in clinical setting1
 ↑ in chronic illness2
◦ 75-90% with insomnia have comorbid medical
disorder (hypoxemia, dyspnea, pain syndromes,
gastroesophageal reflux, neurodegenerative disease)
◦ 40% with insomnia have psychiatric condition

↑ in primary sleep disorders2 (restless leg
syndrome, periodic limb movement disorder, snoring,
obstructive sleep apnea, circadian rhythm disorders, shift
work disorder)
Presentation 11.5.22
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
↑ in women (onset of menses & menopause)

↑ older adults

Divorced, separated, or widowed

Lower education and income

Cigarette smoking

Alcohol and caffeine consumption

Certain prescription drugs
Presentation 11.5.22
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Frequency of Sleep Problem in Past Month
(N=1000)
Net: Any
44%
Woke up
feeling unrefreshed
28%
Awake a lot
during the night
25%
Woke up too early and
couldn’t get back to sleep 11%
Difficulty falling asleep
14%
18%
12%
21%
21%
17%
20%
16%
19%
14%
Every night/Almost every night
A few nights a week
A few nights a month
12%
26%
26%
28%
20%
<1%
16%
26%
32%
1%
<1%
<1%
Rarely
Never
Don’t know/Refused
Presentation 11.5.22
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Sleep Problem in Past Month
At Least a Few Nights/Week
26%
Difficulty Falling Asleep
65%
35%
29%
Early Awakenings
42%
Frequent Awakenings
49%
Woke Unrefreshed
Rarely, Never, Don't Know/Refused
Any Sleep Problem
4% diagnosed (told by physician that they had a sleep problem)
2% currently receiving treatment for sleep problem
Presentation 11.5.22
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• ↓ Quality of life
• Greater dysfunction than CHF (pain, emotional & mental
health)4
• Health problems; developing evidence of increased
hypertension, AMI17, diabetes and obesity
• Psychiatric disorders; depression, anxiety
• ↑Health care expenditures5
• + $1,253 for 6 months; age 18-64
• + $1,143 for 6 months; age 65 and older
• Risk of accidents; motor vehicle crashes
Presentation 11.5.22
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
How much sleep do you get at night?
◦ <6h, >8 h are “red flags”

Do you have trouble falling or staying asleep?

Do you have uncomfortable leg feelings in the evening?

Do you feel unrefreshed after a night’s sleep?

Do you feel tired or sleepy during the day?

Do you snore (does your partner say you snore)? Do
you have breathing pauses (gasp, snort)?

Do you have any unwanted behaviors in your sleep?
Presentation 11.5.22
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
Identify the sleep complaints
◦
◦
◦
◦


Difficulty initiating sleep (onset)
Difficulty maintaining sleep (maintenance)
Early morning awakenings
Non-restorative sleep
Adequate sleep opportunity?
What are the associated impairments?
◦
◦
◦
◦
◦
Excessive sleepiness, fatigue
Reduced attention, concentration, memory, motivation, mood
Errors/accidents
Concerns/worries about sleep
Symptoms in response to sleep loss – tension, headaches,
gastrointestinal distress
Presentation 11.5.22
5/25/2017
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
Routine physical examination
vital signs
heart
lungs
oropharynx
neurological screening


Consider screening for anxiety and
depression
If memory concerns, Mini Mental Exam
Presentation 11.5.22
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
Determined primarily by physical exam
◦ Chem 20
◦ Thyroid panel
◦ CBC

If indicated
◦ polysomnogram if other sleep disorders are
suspected
◦ FE/TIBC/Ferritin/B12/Folate
Presentation 11.5.22
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Presentation 11.5.22
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5/25/2017
1. Use ↓ to mark the time you get in bed and ↑ to mark the time you get
out of bed.
2. Mark any time you sleep (including naps) by filling the spaces with a line
or shade. The hour starts at the beginning of each square.
3. Place a "C" any time you consume caffeine
4. Fill in this log after you get up. Don't look at the clock during the night.
Just estimate the time.
MONTH/YEAR:_June__2012
Time
6/ 20
6/21
1
PM
2
3
4
5
6
7
8
c
c
↓ - ↑
c
c c
↓ ↑ c c
9
10
11
12
AM
1
2
3
4
10
11
-- - ↑ ↓ - - ↑ ↓ -
-
-↑ ↓
↓
↓
5
6
7
8
9
12
PM
↑ c c
c
↑
15
Presentation 11.5.22

Look for:
◦
◦
◦
◦
◦
◦
◦
◦
◦

Patterns (differences between weekend/weekdays)
How patient rates sleep quality
Time patient goes to bed and awakens
Time in bed awake
Total sleep time
Number of awakenings/why
How patient feels in the morning/day
Caffeine/alcohol intake and medication schedule
Napping patterns
Use to determine if treatment is helping patient’s
insomnia or to refer
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Situation
Chance of dozing (0-3)
Sitting and reading
0
1
2
3
Watching television
0
1
2
3
Sitting inactive in a public place for example, a theater or 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
0
1
2
3
Sitting and talking to someone
0
1
2
3
Sitting quietly after lunch (when you’ve had no
alcohol)
0
1
2
3
In a car, while stopped in traffic
0
1
2
3
Total Score
0 = would never doze
1 = slight chance of dozing
5/25/2017
2 = moderate chance of dozing
3 = high chance of dozing
Presentation 11.5.22
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Primary insomnia is a DSM-IV-TR® classification:
•



>1 month duration
Impaired next-day functioning
Independent of another sleep or mental disorder
Not due to a substance, medication, or medical
condition
Cormorbid insomnia is described by DSM-IV-TR®
as insomnia:
• psychiatric disorder
• medical condition
• substance use
Presentation 11.5.22
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
Primary insomnias
◦
◦
◦
◦
◦

Adjustment (acute)
Psychophysiological
Inadequate sleep hygiene
Idiopathic
Paradoxical
Comorbid insomnia
◦ Mental disorder
◦ Medical condition
◦ Drug or substance
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





Psychosocial stressors – work, family, home
Mental disorders – anxiety, somatoform,
depression, dysthymia, bipolar, cyclothymic
Prescription drugs – antidepressants,
antihypertensives, hypolipidemics, corticosteroids,
antiparkinsonian, theophylline, anorectic,
decongestants, stimulants
Drug or substance abuse – nicotine, alcohol,
caffeine, food allergen
Medical disorders – pain, fibromyalgia, COPD,
asthma, Parkinson’s, dementia, “hot flashes”,
pregnancy, gastroesophageal reflux,
hyperthyroidism, anemia
Other sleep disorders – circadian rhythm, restless
legs syndrome, periodic leg movements,
obstructive sleep
apnea
Presentation 11.5.22
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Behavioral techniques




Effective, particularly in chronic insomnia; time consuming
and some require specialists
Adherence
Patient preference
Time limitations (provider and patient)
Pharmacological therapy







Sleep maintenance problems with generic drugs
Side effects; residual sleepiness, amnesia, sleep behaviors
Tolerance
Dependence concern and issues in discontinuation
Scheduled drugs; limited NPs prescribing in some states
Costs
Health insurer coverage issues; short-term vs. long-term use
Presentation 11.5.22
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

Viable treatment options for the management
Most are compatible with one another and
can be combined to optimize outcome

Benefits are sustained over time

Adverse effects are minimal

Require more clinical time and patient
motivation than using pharmacologic
therapies
Presentation 11.5.22
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Therapy
Description
Stimulus control
Set of instructions designed to reassociate the bedbedroom with sleep and to re-establish a consistent
sleep-wake schedule
Sleep restriction
Method designed to curtail time in bed to the actual
amount of sleep time
Relaxation training
Clinical procedures aimed at reducing somatic tension
Cognitive therapy
Psychological methods aimed at challenging and
changing misconceptions about sleep and insomnia
Sleep hygiene education
Guidelines about health practices such as diet,
exercise, and substance abuse and environmental
factors such as light, noise and temperature related to
sleep
Cognitive-behavior therapy
(CBT)
Combination of any of the above. Addresses behavioral
mechanisms underlying insomnia. Refer to psychologist
or professional trained in CBT.
Presentation 11.5.22
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
Definition: education for patients about
behaviors that will help them sleep
◦ Limit use of stimulants (caffeine, decongestants, tobacco,
some SSRIs)
◦ No checking the time
◦ Do not use alcohol as a sleep aid
◦ Do not exercise 3 hours before bedtime
◦ Establish a conducive sleep environment (quiet, cool,
dark)
◦ Reduce napping and time in bed not sleeping
Insufficient evidence for use as monotherapy
Presentation 11.5.22
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





Go to bed when
sleepy
Get up at the same
time every day
Sleep only in bed
Use the bedroom
only for sleeping and
sex
If you cannot fall
asleep, do not lie in
bed and “try harder”
No nap







Cover the clock or
turn it around
No caffeine use
Don’t take worries to
bed
Limit sounds
Moderate room
temperature
Limit light exposure
Tobacco and alcohol
use disturbs sleep
Presentation 11.5.22
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
Caution – Consider other sleep disorders first
Determine usual total hours of sleep
◦ Example; 5-6 hours by patient history

Set regular wake up time – 7 days a week
◦ Example; 0530 for work at 0700, and 0700 on days off!

Determine the usual time sleep begins
◦ Example; often asleep by 0000 (in bed at 2200)

Set an initial sleep schedule = to total hours
◦ Example; 0000 to 0530, daily for 1 week

Advance bedtime 30 minutes/week if insomnia
improved up to 7-8 hours total
◦ Example; after 1 week of falling asleep easily at 0000
with 1-2 brief awakenings then progress to 2 nd week
2330-0530, 3rd week 2300-0530, etc.
Presentation 11.5.22
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




Nonbenzodiazepines (nonBZD)
Benzodiazepines (BZD)
Melatonin receptor agonist
Selective H1 antagonist
“Off-label” (Not FDA approved)
◦ Sedating antidepressants
◦ Atypical antipsychotics


Under study for fibromyalgia – Sodium Oxybate
Over-the-counter (OTC)
◦ Antihistamines
◦ Herbals
◦ Alcohol
Presentation 11.5.22
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Thalamus
Cortical activation
Sleep spindles
EEG synchronization
Cortex
Hypothalamus
Pineal gland
Sleep-wake switch
SCN
Circadian clock
Brain Stem
Ascending cortical activation
REM/SWS switch
EEG=electroencephalography; REM=rapid eye movement; SCN=suprachiasmatic
nucleus; SWS=slow-wave sleep.
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Acetylcholine
(BF)
Acetylcholine
(PPT; LDT)
Norepinephrine
(LC)
Histamine
(TMN)
Dopamine
(VTA)
Serotonin
(raphe)
Motor
neurons
Reticular
formation
BF=basal forebrain; LC=locus coeruleus; LDT=laterodorsal tegmental nucleus;
PPT=pedunculopontine nucleus; TMN=tuberomammillary nucleus; VTA=ventral tegmental
area.
Presentation 11.5.22
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GABA
Sleep
GABA
(ventrolateral
preoptic
area)
–
–
–
Norepinephrine
Histamine
Dopamine
Serotonin
Acetylcholine
Wake
Norepinephrine, Serotonin
Presentation 11.5.22
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Process S:
Homeostatic
sleep drive
Work
Sleep
propensity
Sleep
Process C:
Circadian drive
for wakefulness
09.00
15.00
21.00
03.00
09.00
Time of day
Presentation 11.5.22
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

Nearly all agents promote sleep by broadly
enhancing inhibition of brain regions
Clinical effects of neural inhibition
◦ Sleep promotion, reduction of anxiety, amnesia,
muscle relaxation, incoordination, antiseizure
effect

Effects proportional to blood level
◦ Independent of time of day, activity level, other
neural systems
Presentation 11.5.22
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Generic
Name
Adult
Dose
Geriatric
Dose
t1/2
Eszopiclone
2-3 mg
1-2 mg
~6h/9h
Zaleplon
10-20 mg
5 mg
~1h
Zolpidem
10 mg
5 mg
~2.5h/2.9h
Zolpidem
Extendedrelease
12.5 mg
6.25 mg
~2.8h
Act on GABA receptors, nonselective depressants
Side effects: Residual next-day sedation, cognitive impairment, motor
incoordination, dependence, rebound insomnia
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Generic
Name
Adult
Dose
Geriatric
Dose
T1/2
Estazolam
0.5-2 mg
0.5 mg
~8-25h
Flurazepam
15-30 mg
15 mg
~47-100h
Quazepam
15-50 mg
7.5 mg
~39-73h
Temazepam
7.5-30 mg
7.5 mg
~3.5-18h
0.125-0.25 mg
0.125 mg
~1.5-5.5h
Triazolam
Act on GABA receptors, nonselective depressants
Side effects: Residual next-day sedation, cognitive impairment, motor
incoordination, dependence, rebound insomnia
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Ramelteon (Rozerem®) 9
 Melatonin Receptor Agonist
 FDA approved; nonscheduled, onset insomnia
indication


Dose: 8 mg
Side effects - headache, somnolence, dizziness, and
fatigue; no abuse or rebound insomnia
Doxepin (Silenor®)15


Selective H1 antagonist that decreases wakefulness
FDA approved; nonscheduled, maintenance insomnia
indication - efficacy throughout the night, no next day
sedation


Dose; 3 mg, 6 mg
Side effects - headache, sedation, GI; no sleep behaviors,
amnesia, anticholinergic effects
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Sedating Antidepressants10
 No established dose-response relationship


Significant adverse effects, risk-benefit ratio?
Trazodone
◦ Widely used; sedating, risk of serious adverse effects
◦ limited research; use for 2 weeks studied in treating insomnia
Amitriptyline and others – lacking data for insomnia use
Atypical Antipsychotics10
◦ Quetiapine (Seroquel®), Risperidone (Risperdal®),
Olanzapine (Zyprexa®)

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Sodium Oxybate (Xyrem) AKA GHB
 Currently FDA-approved for treatment of cataplexy
and sleepiness in Narcolepsy
 Controlled substance schedule III; made in 1 pharmacy in
the U.S. and shipped to patients home
 CNS depressant
 ↑ Slow Wave Sleep (Stage IV)

Trials reported reduces insomnia, fatigue and myalgias in
fibromyalgia patients
Dosed 2 times a night; bedtime and 2-4 hours later
 Salt added to provide taste

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
Antihistamines
◦ No systematic evidence for efficacy
◦ May be effective for mild, transient insomnia for
3-4 days
◦ Side effects: Next-day sedation, cognitive
impairment, anticholinergic effects

Herbals – melatonin, valerian
◦ Variability in quality of preparations
◦ Little to no evidence of efficacy and safety
◦ Side effects: Next-day sedation, headache,
excitability

Alcohol
Presentation 11.5.22
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Medication
Indication
Sleep Maint
Sleep Onset
Flurazepam
X
Quazepam
X
Estazolam
X
Temazepam
X
Triazolam
X
Doxepin (low-dose)
X
Eszopiclone
X
X
Ramelteon
X
Zaleplon
X
Zolpidem Ext-Rel
X
X
Zolpidem
X
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

With BZDs and nonBZD medications,
discontinuation effects are minimal
and transient
Gradually decrease the dose when concerns
about dependence
◦ To minimize any discontinuation symptoms
◦ To minimize the potential for recurrence
of insomnia

Ensure stimulus control and sleep hygiene
measures are in place and continue
Presentation 11.5.22
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Plan for regular follow-up until improved and
then periodically
Insomnia is often a chronic problem
 See patient in 1 month
 If improved, then schedule for 2-3 months
 After 3 months of improved sleep, consider
discontinuing or long-term therapy
Treatment improves perceived health, qualityof-life and function16

Presentation 11.5.22
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5/25/2017





Discuss “normal” sleep patterns
Completing sleep logs/diary
Completing Epworth Sleepiness Scale
Behavioral therapy implementation:
◦
◦
◦
◦
Stimulus control
Good sleep hygiene
Sleep restriction
Relaxation techniques
◦
◦
◦
◦
When to take
Frequency; nightly for 2-3 months, then . . .
Side effects
Discontinuation plan
Drug therapy
Presentation 11.5.22
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5/25/2017



Uncomfortable with diagnosing and
managing insomnia
Do not have the time to manage insomnia
Suspect other sleep disorders
Obstructive Sleep Apnea
Restless leg syndrome
Narcolepsy or hypersomnia
Unusual behaviors in sleep

Patient not improving with treatment or
dangerous symptoms (excessive sleepiness)
43
Presentation 11.5.22







Insomnia is a symptom, not a diagnosis
Diagnosis is made by history
Significant health and safety issues
Behavioral therapy is most effective;
adherence issues
Pharmacologic therapy alone less effective
than behavioral therapy
Combination therapy most effective
NPs in any setting can effectively evaluate and
manage insomnia
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