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Insomnia

posted Jan 22, 2014, 7:20 AM by Ewa Rakowski   [ updated Jan 22, 2014, 7:22 AM ]
This Monte Minute brought to you by RAT resident Jeff Kroopnick:

What is Insomnia and is it common?
Insomnia refers to dissatisfaction with sleep quality or duration, difficulty falling asleep, waking up in the middle of the night or early morning awakenings, and non-restorative or poor quality sleep. Patients also complain of daytime sleepiness and low energy, difficulty concentrating, and irritability. And it is actually quite common. Approximately 25% of adults are dissatisfied with their sleep, 10-15% report insomnia related to daytime activities, and 6-10% have an insomnia disorder. Actually, one study found that insomnia was present in 23-64% of people 65 years and older -- a pretty staggering number!

Insomnia may be situational, recurrent, or persistent. Situational insomnia is usually related to a stressful life event (being laid off work, death of a loved one, social stressors) or change in sleep schedule due to a job or travel; this type of insomnia usually abates once the precipitating event has subsided. On the other hand, insomnia may be intermittent with recurrent periods of sleeping difficulties associated with stressful events. Persistent, or chronic, insomnia is exactly as it sounds, though these patients can have an occasional good night’s rest.

How do we screen for insomnia and why is it important?
People prone to insomnia include those who are stressed, depressed, or under emotional distress, those who work nights or work shifts, and those traveling to different time zones. People with insomnia tend to have poorer health, quality of life, and work performance. In fact, individuals with insomnia are more than five times as likely to present with anxiety or depression and more than twice as likely to present with CHF compared to those without insomnia. Furthermore, people with insomnia frequently have comorbid mood, impulse, and substance abuse disorders.

It’s recommended that all patients be screened for insomnia by asking them if they have trouble falling asleep or maintaining sleep, waking up earlier than anticipated, or if their sleep is of poor quality (i.e. non-restorative).

For those who screen positive, a more comprehensive sleep history should be conducted. Find out if their insomnia is acute or chronic and if it’s stable, worsening, or improving. Also ask what their bed and wake times typically are, their length of sleep, alcohol and caffeine intake, previous treatment for insomnia (behavioral therapy, OTC meds, prescription meds), shift work or irregular sleep hours, mood disorders, illicit drug use, and any new stressors at work or at home.

While I will not go into detail here, it is important to note that sometimes insomnia may be due to medical conditions such as OSA, central sleep apnea, restless leg syndrome, periodic limb movement disorder, and psychophysiologic insomnia (disturbed sleep from conditioned arousal, usually to the bedroom), asthma/COPD, and GERD. These are contrasted to extrinsic sleep disorders that are related to medications and alcohol, poor sleep hygiene, and abnormal circadian rhythm disorders from shift work or change in time zones, which are the sleep disorders this talk is meant to address.

What are some simple techniques to help improve sleep?
So what should we do when after our patient has screened positive for insomnia? Well, we should first assess if they practice good sleep hygiene. This could include keeping the same bed and wake-up times, making sure to get regular daytime light exposure, spending no more than 8 hours in bed, having a dark and quiet bedroom, avoiding caffeine/nicotine/alcohol before going to sleep, avoiding clock-watching, encouraging regular exercise during the day (but avoiding it within 2 hours of going to sleep), and having a 30-minute relaxation routine before sleep (i.e. reading a book).

In patients with chronic insomnia, behavioral therapy should be attempted prior to drug treatment. For instance, in Cognitive Behavioral Therapy (CBT), which has been proven to be more effective long-term than drug therapy, patients are reminded that they need 7-8 hrs sleep each night, informed about expected changes in sleep habits with age, and their exaggerated concerns about the impact and consequences of insomnia are alleviated. The goal of CBT is to change the behavioral, psychological, and physiologic factors that perpetuate insomnia. Muscle relaxation techniques may also be useful to help decrease stimulation prior to sleep.

What about medications?
If all else fails, various medications exist, including OTC agents, prescription sedative-hypnotics (GABA agonists), and herbal supplements to treat insomnia. Medications may be as effective as behavioral techniques in the short-term, but tolerance tends to set in after 30 days of use. As a matter of fact, the literature, expert consensus, and the FDA all suggest limiting use to 1 month.
antihistamines: little data to support effectiveness; concern about daytime sedation, cognitive impairment, anticholinergic effects (dry mouth, urinary retention), even if patients get more sleep it tends to be non-restorative
melatonin: hormone produced by pineal gland to help regulate circadian rhythm, may have some benefit for jet lag or circadian rhythm sleep disorders; side effects include drowsiness, dizziness, nausea, headache
benzos (temazepam, triazolam, lorazepam): GABA receptor agonists, may be helpful in short-term (< 30 days); worry about tolerance, dependence, and misuse
non-benzo GABA agonists (zolpidem, zaleplon): selective GABA agonists, fewer side effects and shorter half-lives compared to benzos, possibly less rebound insomnia once discontinued

Take home points:
- Insomnia is a common problem in the outpatient setting and particularly prevalent in people 65 years of age or older
- All patients should be screened for insomnia, and if positive, a comprehensive sleep history should be undertaken
- First assess for appropriate sleep hygiene, these are simple techniques that can really improve sleep health
- Behavioral therapy, like CBT or muscle relaxation techniques, tend to have better long-term effects
- Pharmacologic treatment (non-benzo GABA agonists are preferred) may be appropriate if initial measures are unsuccessful; ideally these should be taken for no longer than 1 month as they have many potential side effects

References:
Laine C and Goldmann D. In the Clinic: Insomnia. Annals of Internal Medicine 2008; 148(1): ITC1-16.
Morin C and Benca R. Chronic Insomnia. The Lancet 2012; 379: 1129-41.

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Ewa Rakowski,
Jan 22, 2014, 7:20 AM
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