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InsomniaWhat the Internist Needs
to Know
Sleep
Terms:
Initiation/latency (going to sleep)
 Duration (early wakening)
 Consolidation/maintenance (staying asleep
continuously)
 Quality (feeling refreshed by sleep)
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Introduction
Consequences of insomnia
 Basic sleep physiology
 Insomnia: definition and epidemiology
 Insomnia: types
 Insomnia: initial evaluation
 Insomina: treatment
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Case Study
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60 yo female with depression, anxiety, OSA presented with insomnia, with problems
initiating and maintaining. CPAP routine and problems.
PMH: depression, anxiety, OSA, glaucoma, HLP, HTN, osteopenia, migraines
Meds: zocor, fosinopril, flonase, xalatan, calcium, mvi, vit C
SH: no tob, etoh, drugs, caffeine. Exercises daily.
PE: 131/81, 72, 20, 97.9, BMI 25. unremarkable.
Previously tried:
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paxil x1 month (HA, palpitations)
trazodone (HA)
wellbutrin (never took) - felt R>B
Rozerum – didn’t tolerate
ambien CR x3 months (palpitations)-slept 6-7 hours
sonata 10mg (worked, but told only could be used short-term)
lunesta 2mg (HA)
Pamelor – never took 2/2 concerns about her glaucoma
Consequences of insomnia: why this
lecture is important
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General medical health: ↑hospitalizations, HA, stomach
discomfort, diarrhea, palpitations, non-specific pain, daytime
fatigue, weakness, cardiovascular disease (↑CNS, HTN; *OSA),
decreased immune function (↓NK cells), ↑substance abuse
Public health: car crashes, absenteeism
Behavioral health: more time shopping, watching tv, relaxing vs.
spending more time talking with people, studying, working
Psychiatric sequelae: mood disorders, other
Cognitive performance: attention, memory, reasoning, problemsolving, reaction time.
International Congress and
Symposium Series. 2006.
ICSS. 2006.
Sleep-Basic Physiology
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Sleep Cycles (q 90
minutes)
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REM (20-25%)
NON-REM
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Stage 1 (5%-transition)
Stage 2 (40-50%)
Stage 3/4 (20%-slow
delta wave sleep)
ICSS. 2006.
Sleep-Regulation
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Homeostatic: drive for sleep
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Primary centers: hypothalamus,
thalamus (gateway to activation of
cortex)
Neurotransmitters: gamma
aminobutyric acid (GABA), adenosine
(stimulated by caffeine), melatonin.
Circadian: daytime alertness
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Primary centers: hypothalamus
(suprachiasmic nucleus), brainstem
nuclei, basal forebrain
Neurotransmitters: histamine,
catecholamines, serotonin, dopamine,
hypocretin, acetylcholine.
ICSS. 2006.
Sleep (cont.)
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Normal changes over time
Age: ↓ sleep efficiency (time sleeping/time in bed)
 ↓ in stages 3 and 4 and ↑ in stages 1 and 2.
 Can lead to more night-time falls with bad sequelae
 Etiology: Inactivity, dissatisfaction with social life,
poor sleep habits, medical and psychiatric
conditions, medications, not age per se.
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Pediatrics 2003;111:302-307.
Sleep (cont.)
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Differences with women.
Have less of a decreased in slow-wave sleep (SWS) and
their circadian rhythm is more robust.
 BUT: 2/3 of sleep complaints to PCM are from women.
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Insomnia
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Definition: all 3 required
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Difficulty with initiation of sleep, maintenance of sleep, early waking,
chronically nonrestorative, or poor quality
Problems occur despite adequate opportunity for sleep.
Impaired sleep results in daytime deficits in function.
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Fatigue or malaise
Poor attention or concentration
Social or vocational dysfunction
Mood disturbance
Daytime sleepiness (not a prerequisite for diagnosis)
Reduced motivation or energy
Increased errors or accidents
Tension, headache, or gastrointestinal symptoms
Ongoing worry about sleep
International classification of sleep disorders. 2005.
Epidemiology
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Prevalence
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Depends on study design and definition of insomnia
 Review of 50 studies: 10%
 Survey of primary care patients: 69% (only 17% report problems
to PCM)
 National survey of institutionalized patients: 35% in the last year
Increases with age: 57% of elderly with chronic insomnia; only 12% had
normal sleep.
More prevalent in women: 50% more than men.
More prevalent in unemployed, divorced, widowed, separated, or of
lower socioeconomic status.
Insomnia in primary care patients. Sleep 1999.
Prevalence and correlates. Arch Gen Psychiatry 1985.
Epidemiology of insomnia. Sleep Med Rev 2002.
Sleep complaints among elderly persons. Sleep 1995; 18:425.
ICSS. 2006.
Types of Insomnia
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Classification systems
International classification of sleep disorders (ICSD)
 Diagostic classification of sleep and arousal disorders
(DCSAD)
 Diagnostic and statistical manual of mental disorders, 4th
edn (DSM-IV)
 International classification of diseases (ICD)
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Insomnia is Multifactorial
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Contributing factors (Spielman
and Glovinsky- Sleep
1999;22(2):S347-S353.)
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Predisposing factors
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Alterable: smoking
Non-alterable: genetics, sex, age
Precipitating factors: life-stressor,
acute illness
Perpetuating factors: chronic
illness
Figure 1.1 Insomnia:
principles and management
Insomnia. Principles and Management.
Szuba. Cambridge. 2003.
Insomnia of short duration: <3
months
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Acute: temporally related to stressor
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Synonyms:
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Stressors: physical, psychological, psychosocial,
interpersonal, environmental
Circadian rhythm sleep disorders
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adjustment insomnia
short-term insomnia
stress-related insomnia
transient insomnia
Jet lag
Shift work
High altitude insomnia
Types of Chronic Insomnia
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Prevalence: 10%, >80% with s/sx >/ 2-3 yr after onset
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Inadequate sleep hygiene
Psychophysiological insomnia
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Synonyms:
 Primary insomnia
 Chronic insomnia
 Learned insomnia
 Conditioned insomnia
Required physiologic activation of CNS, not just inadequate quantity or
poor quality; measurable (cardiac, metabolic, hormonal, EEG)
Symptoms: onset – racing thoughts, difficult to relax, cycle of focusing
on in ability to initiate sleep
Types of Chronic Insomnia (cont.)
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Idiopathic insomnia
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Synonyms:
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Incidence: <1% young adults and adolescents
Symptoms: difficulty initiating and maintaining
Begins in infancy or early childhood
Cause: idiopathic.
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Life-long insomnia
Childhood onset insomnia
Associated with learning disabilities and ADHD.
Neurochemical imbalance
Clustering in families
Dx only after excluded other medical, neurological, and
psychiatric disorders.
Types of Chronic Insomnia (cont.)
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Behavioral insomnia of childhood
Learned specific circumstances in order to sleep.
 Examples: parent, toy, blanket, pacifier
 Incidence: to some extent 10-30% children, starting
at 6 months.
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Types of Chronic Insomnia (cont.)
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Paradoxial insomnia
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Synonyms:
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Sleep state misperceptions
Subjective insomnia
Pseudoinsomnia
Sleep hypochondriasis
Symptoms: subjective insomnia, even when EEG shows
normal sleep stages.
Gross overestimation of sleep onset and total sleep time
Dx: requires EEG (incidence therefore unknown). High
frequency EEG, ↑metabolic rate during sleep.
DDx: psychophysiological insomnia
Types of Chronic Insomnia (cont.)
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Insomnia associated with another condition
Coexistence vs. being secondary to. When coexisting condition adequately treated, insomnia
often persists.
 Medical conditions: 10% of pts with insomnia have
chronic condition or take Rx. Conversely, 40% of pts
with medical problems have insomnia.
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Types of Chronic Insomnia (cont.) –
Co-existing Medical Conditions
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Pulmonary (>50% have insomnia).
Postural changes↑WOB,
secretions pool in aw, nocturnal
bronchoconstriction; Rx
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Cardiovascular
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Heart failure (30%): Cheyne-stokes
breathing
Ischemic heart disease
Nocturnal angina
Rheumatologic
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COPD
Bronchial asthma
Arthritis
Fibromyalgia
Musculoskeletal: Chronic pain
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Endocrinologic
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Menopause
Hyperthyroidism
Diabetes
Pheochromocytoma
Urinary: nocturia
Gastrointestinal: GERD
Other
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Lyme disease
AIDS
Chronic fatigue syndrome
Types of Chronic Insomnia (cont.)
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Psychiatric disorders:
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45% pts with insomnia have psychiatric d/o
Insomnia may precedes psychiatric dz (controversial: causal
or a marker?)
Comorbidity not simply causal
Examples:
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Depression – early awakening
Anxiety – difficulties with sleep initiation
Substance abuse – i.e. pt with insomnia are more sensitive to caffeine.
PTSD – dx includes sleep disturbances
Diagnostic Overlap
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S-sleep disturbances
I-decreased interest
G-excessive guilt
E-decreased energy
C-decreased concentration
P-psychomotor agititation
S-suicidal ideation
Diagnositic Overlap (cont.)
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Anxiety
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Sleep initiation, restless sleep (maintenance),
difficulty concentrating, irritability
PTSD
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Recurrent distressing dreams of the event (one of
the B Criteria)
ICSS. 2006.
Types of Chronic Insomnia (cont.)
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Neurological diseases
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Neurodegenerative disease
Alzheimers disease
Parkinson disease
Neuromuscular disorders: Peripheral neuropathies
Cerebral hemispheric and brain stem strokes
Brain tumors
TBI causing post-traumatic insomnia
Headache syndromes
Fatal familial insomnia – a rare prion disease; degeneration of
mediodorsal nucleus
Types of Chronic Insomnia (cont.)
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Medications
CNS stimulants
 CNS depressants
 Bronchodilators
 Antidepressants
 Beta agonist
 Glucocorticoids
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Types of Chronic Insomnia (cont.)
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Sleep disorders
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Sleep disordered breathing
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Apnea
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Obstructive sleep apnea (normal
oxygenation, snore): 10% with insomnia.
Central apnea. Cheyne-stokes breathing
 Respiratory alkalosis
 Heart failure (EF<40%)
 Stroke
Pickwickian syndrome (“obesity hypoventilation syndrome”).
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Requires daytime hypercapnea, Hypopnea/apnea, ↓O2 sat.
Leads to pHTN RHF (cor pulmonale)
Usually also have OSA.
Types of Chronic Insomnia (cont.)
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Sleep disorders (cont.)
Restless legs syndrome
 Periodic limb movements
 Circadian rhythm disorders
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Delayed sleep phase syndrome (much more common than
advanced SPS).
 Advanced sleep phase syndrome
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Review of Types with Synonyms
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Insomnia of short duration:
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Acute: adjustment insomnia, short-term insomnia, stress-related insomnia, transient
insomnia
Circadian rhythm sleep disorders
High altitude insomnia
Insomnia of longer duration:
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Inadequate sleep hygiene
Psychophysiological insomnia: Primary insomnia, Chronic insomnia, Learned
insomnia, Conditioned insomnia
Idiopathic insomnia: Life-long insomnia, Childhood onset insomnia
Behavioral insomnia of childhood
Paradoxial insomnia: Sleep state misperceptions, Subjective insomnia, Pseudoinsomnia,
Sleep hypochondriasis
Insomnia associated with another condition: medical, psychological,
neuromuscular, medications, sleep disorders
Evaluation
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History
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Medication review: current; prior sleep meds
Explore co-morbidities
Sleep hygiene
Bed-partner history
Sleep diary
Sleep study
Differential Diagnosis
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Short duration sleep: some people simply require less sleep.
Sleep deprivation: will rapidly fall asleep if given the chance.
Sleepy vs. fatigue
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Epworth sleepiness scale.
Epworth Sleepiness Scale
Sleep Journal
Name:
Complete in the
morning
Sun
Bedtime (date/time)
Rise time (date/time)
Estimated time to fall asleep
Estimated number of awakening and total
time awake
Estimated amount of sleep obtained
Complete at
bedtime
Naps (number, time, and duration)
Alcoholic drinks (number and time)
List stresses of the day
Rate how you felt today
1 = Very tired/sleepy
2 = Somewhat tired/sleepy
3 = Fairly alert
4 = Wide awake
Irritability level
1 = None
2 = Some
3 = Moderate
4 = Fairly high
5 = High
Sleep medications
Mon
Tues
When to Refer to Sleep Study?
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Paradoxical insomnia
Sleep disordered breathing
Parasomnias: d/o with abnl psyiological or
behavioral events during sleep, not changes ni
amount or timing of sleep
Movement disorders
Behavioral disturbances
Not simply for chronic insomnia
Non-pharmacologic Treatment
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Stimulus control
Sleep-restriction
Relaxation therapy
Sleep hygiene
Education
NEJM 2009;353(8):803-809.
Pharmacologic Treatment
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Terms
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Tolerance: Reduction in drug effect requiring an increase in
dosage to maintain the same response.
Physiologic dependence: The state of response to a drug
whereby removal of the drug evokes unpleasant symptoms,
usually the opposite of the drug’s effects.
Phychologic dependence: The state of response to a drug
whereby the drug taker feels compelled to use the drug and
suffers anxiety when separated from the drug.
Pharmacology. Katzung. 1998.
Pharmacologic Treatment
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Benzodiazepines/BZreceptor agonists
•Non-benzodiazepines
>Antidepressants
>Melatonin
>Antihistamines
>Atypical antipsychotics
>other herbals
GABAa receptor-chloride ion channel macromolecular complex.
http://www.mona.uwi.edu/fpas/courses/physiology/neurophysiology/GABAreceptorA.jpg
NEJM 2009;353(8):803-809
General Guidelines
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BZD
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for short-term insomnia.
If for chronic insomnia, 3-4 nights/week max 3 weeks.
BZD/BZD-receptor agonists
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Data limited by length of studies (longest is 6 months-Lunesta)
Lowest possible dose, intermittently, shortest duration possible.
Sleep initiation: short-acting (rebound)
Sleep maintenance/early wakening: intermediate (rare rebound)
Avoid in apnea, substance abuse, or pregnancy.
Caution in the elderly, especially long-acting (dose reduction).
Long-acting good only if also pt has daytime anxiety
Ambien: little or no rebound
Sonata: no rebound, can take in middle of the night
Lunesta: no tolerance after 6 months
Pharmacotherapy Handbook. 2000.
NEJM 2009;353(8):803-809
Specific Treatments for Sleep
Disordered Breathing
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OSA (briefly)
Tx for insomnia, heart failure and pulmonary HTN
 CPAP desensitization (next slide)
 CPAP interfaces
 Avoid/limit BZD like temazepam ( acute airway crisis)
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Pickwickian syndrome:
CPAP
 tracheostomy if decompensated
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CPAP Desensitization
STEP 1:
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Wear the nCPAP mask or nasal pillows at home, while awake in the evening and performing
normal evening activities, for about one hour daily. When you can do this without anxiety or
concern for five consecutive days, then go to Step 2.
STEP 2:
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Connect the pressure device and tubing to the CPAP pressurizer. The pressurizer will be set to a
pressure of 6 CN H20. Turn on the machine, and breathe through it at home and at rest, for one
hour daily. When you can do this without anxiety or concern for five consecutive days, then go to
Step 3.
STEP 3:
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Wear the entire nCPAP apparatus for a scheduled one hour nap. When you can do this without
anxiety or concern for five consecutive days, then go to Step 4.
STEP 4:
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Wear the entire nCPAP apparatus for 4-5 hours of sleep each night. When you can do this
without anxiety or concern for five consecutive days, then go to Step 5.
STEP 5:
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Use nCPAP for your entire night’s sleep.
This treatment was published by Doctors Edinger and Radtke, from Duke University, in 1993.
Conclusion
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Sleep complaints are common, and often not brought up
with doctor: ask the patient.
Evaluation is based on a good understanding of the etiologies
of insomnia.
Bed-partner history
Explore co-morbidities
Insomnia is considered to coexist with other medical and
psychiatric conditions, not necessarily to cause them.
Age: associated features, not age per se
Treatment includes both non-pharmacologic (best to try first)
and pharmacologic
Sleep hygiene
Questions?
References
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International Congress and Symposium Series 262. Update on the Science, Diagnosis, and Management of Insomnia. Richardson,
G. The royal Society of Medicine Press Ltd. 2006.
International classification of sleep disorders: diagnostic and coding manual. 2nd ed, American Academy of Sleep Medicine,
Westchester, IL 2005.
Ohayon, MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Medicine Review 2002; 6:97
Shochat, T. Insomnia in primary care patients. Sleep 1999; 22 Supplement 2:S359.
Mellinger, GD. Insomnia and its treatment. Prevalence and correlates. Arch Gen Psychiatry. 1985; 42:225.
Foley, DJ. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep 1995; 18:425.
Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of 1991 National Sleep Foundation Survey. I.
Sleep 1999;22(2):S347-S353.
Insomnia. Principles and Management. Szuba. Cambridge. 2003.
Silber, M.H. Clinical Practice: Chronic Insomnia. New England Journal of Medicine 2009 Aug 25;353(8):803-809.
Iglostein I. Sleep Duration From Infancy to Adolescence: Reference Values and Generational Trends. Pediatrics 2003;111:302307.
Bonnet. Types of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, 2009.
Bonnet. Overview of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, 2009.
Bonnet. Diagnostic Evaluation of Insomnia. UpToDate. Last updated October 16, 2008. Accessed January 13, 2009.
Pharmacotherapy Handbook. Wells, B. Second Edition. Appleton & Lange. 2000.
Pharmacology – Examination & Board Review. Katzung. McGraw Hill. 1998.
Special thanks to David Bradshaw, MD