Insomnia

Adam Hajduk

Important facts
Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed

OBJECTIVE
Physiology

Definition and classification

Prevalence Pathogenesis Impact Pharmacologic treatment Cognitive-behavioral therapy

Sleep Stages

Wake
2/3 of life

NREM Sleep
~80% of night

REM Sleep
~20% of night

Sleep among older adults

Falling asleep takes longer

Dozens of awakenings during the night

Despite the above, over a 24-hour period older adults accumulate the same amount of total sleep as younger people
Older adults more likely to nap during the day

Older adults do need the same amount of sleep as they did when they were younger

What is Insomnia?
Classified as the inability to get enough sleep despite adequate time.
Initiating (sleep latency > 30 minutes) Trouble maintaining sleep [eg. Insomnia in older people] Chronically non-restorative sleep (Poor quality) Early Morning Wake-Ups [eg. Depressia]

Causes many problems in daytime functioning

Sleep patterns in insomnia

Sleep onset insomnia
Difficulty falling asleep (longer time to sleep onset)

Sleep maintenance insomnia

Difficulty staying asleep (frequent nocturnal awakenings)

Early morning insomnia

Waking too early in the morning (short period of sleep)

Nonrestorative sleep
Fatigue despite adequate sleep duration Multiple awakenings Combination of above patterns

What is Insomnia?
Insomnia is not defined by the number of hours

of sleep, but rather, by an individuals ability to

sleep long enough to feel healthy and alert during the day. The normal requirement for sleep ranges between 4 and 10 hours

Insomnia is a symptom, not a disorder by itself

Epidemiology of insomnia
30-50% of American adults experience insomnia during a 1 year period Prevalence of chronic/severe insomnia is 10% 49% of adults surveyed were dissatified with their sleep > 5 nights per month 50% of patients presenting to primary care physicians experience insomnia

NHLBI working group on Insomnia. Bethesda, Md: NHLBI; 1998. NIH Publication 98-4088 Smith MT, et al. Am J psychiatry. 2002; 159:5-11 Hajak G et al. Eur Psychiatry. 2003; 18:201-8 Ringdahl EN et al. J Am Board Fam Pract. 2004; 17:212-219

Classifications of Insomnia
Acute (Transient) vs. Short-term vs. Chronic
This is based on how long the patient suffers from symptoms of insomnia

Primary vs. Secondary

This is based on what is causing a patient to suffer from lack of sleep

Duration of insomnia
Transient insomnia: episodic
Significant life stress; fear, anger Acute illness Jet lag

Short-term insomnia: few days to 3 weeks

Major life event Substance abuse

Chronic insomnia: longer than 3 weeks

Chronic or Psychiatric illness Primary and comorbid insomnia

Primary Insomnia

Also referred to as Idiopathic This is diagnosed when a patient has no other cause of insomnia other than the fact they cannot sleep

Secondary Insomnia
This is also more commonly referred to as Comorbid Insomnia When insomnia is being caused by some other outside factor, illness, or disorder including:
Psychiatric Disorders Drug Abuse Medical Problems Other Sleep Disorders disruptive to sleep
Restless Leg Syndrome Sleep Apnea Somnolence

Consequenses of insomnia
Daytime
Fatigue, Daytime sleepiness Lack of energy Irritability, Negative mood Difficulty concentrating Impaired performance Social or vocational dysfuncion

Nighttime
Ongoing worry about sleep Difficulty falling asleep Difficulty maintaining sleep Waking up too early Not feeling refreshed upon waking

Consequenses of insomnia
Worsens psychiatric disorders
More sadness, depression, and anxiety

Prolongs medical illnesses Reduced quality of life Increased accident risk Cognitive impairment Interpersonal difficulties
With families, friends, and at work

Diagnosing Insomnia
The diagnosis of insomnia can often be difficult and is a prolonged process
Sleep logs Watching symptoms for weeks at a time

It is often very underdiagnosed due to both patient and physician misunderstandings

Doctors dont routinely ask about it Patients dont think its important enough to bring up in a normal check up Goes overlooked

Types of Sleep Studies

1. Polysomnogram (PSG) most common study performed. This study records brain electrical activity, eye movements, heart rate, breathing, muscle activity, BP, and saturation levels. 2. Multiple sleep latency test (MSLT)- records whether you fall asleep during the test and what types/stages the patient is having. 3. Actigraphy- device that is placed on as a wristwatch, evaluates sleep habits.

Treatment of Insomnia
Insomnia is not a disorder that can necessarily be cured
Symptoms treated in order to relieve patient of distress Treated by two different methods
Non-Pharmacological Treatment Pharmacological Treatment

Pharmacological Treatment

4 Classes of Prescription Agents

Benzodiazepines Benzodiazepine Receptor Agonists Melatonin Receptor Agonists Antidepressants/Antipsychotics

Some supplements are thought to help as well

Benzodiazepines
Extremely high potential for abuse with prolonged use as well as tolerance Decreased reaction time Unsteadiness of gaitcan lead to falls Cognitive impairment & memory problems Risk of tolerance Risk of withdrawal (and rebound insomnia) Risk of abuse

Benzodiazepines in the US
DRUG
Estazolam Flurazepam

BRAND
ProSom Dalmane

HALF-LIFE DOSE (mg) (hrs) 8-24 1,2

48-120 15,30

Quazepam

Doral

48-120
8-20 2-4

7.5,15
7.5,15,22.5,30 0.125,0.25

Temazepam Restoril Triazolam Halcion

Benzodiazepines Adverse Effects

Daytime drowsiness Somnolence Dizziness GI upset Hallucinations Agitation Headache Nausea/diarrhea Fatigue Ataxia Extremely high potential for abuse with prolonged use Risk of tolerance Risk of withdrawal (and rebound insomnia) Decreased reaction time Cognitive impairment memory problems

Non Benzodiazepines
How do they help?
Decrease number of awakening, improve sleep duration and quality

Medication examples:
Zaleplon (Sonata) Zolpidem (Ambien) Ezopiclone (Lunesta)

Non Benzodiazepines in the US

DRUG
Zolpidem Zolpidem ER Zaleplon

BRAND
Ambien Ambien CR Sonata

HALF-LIFE DOSE (mg) (hrs) 1.5-2.4 5,10

2.8-2.9 1 5-7 6.25,12.5 5,10 1,2,3

Eszopiclone Lunesta

Adverse Effects (non benzo)

Headache

Dizziness
Nausea/Abdominal pain Somnolence Unpleasant dreams Habit forming with long term use

Benzodiazepines prescribing guidelines

Avoid hazardous activities after dose Allow sufficient time in bed Dose adjustments
Elderly and debilitated patients Hepatic impairment

Nightly vs. as needed dosing Middle of the night dosing?

Melatonin Agonist
How do they help?
Decrease sleep onset

FDA approved for sleep onset insomnia No limitation on duration of use Non-sedating Medication: Ramelteon (Rozerem)
Single dose: 8 mg Take about 30 minutes prior to bedtime

Antidepressants
How do they help?
Sedating due to anticholinergic and antihistaminergic activity Reduce time to sleep onset Decrease number of awakening Improve sleep duration and quality

Improve stage 4 NREM (Deep sleep) Decrease REM phase

Antidepressants

Some physicians prefer this mode of treatment over benzodiazepines because of the far less potential for dependency Can produce anticholinergic effects if used too long:
Constipation Weight Gain Dry mouth Urinary retention

Antidepressant Medications
Amitriptyline (Elavil) Trazodone (Trittico) Doxepin(Adapin) Opipramol (Pramolan) Mianserin (Lerivon) Mirtazapin (Mirtazen)

Antihistamines
Antihistamines increase sedation.

Medications:
Diphenhydramine (Benadryl) Hydroxizine

Adverse Effects:
Fatigue Dizziness Dry mouth Urinary retention

Non-Prescription Supplements Valerian

This is an herb that is thought to interact at the GABAA receptor because of its sedative properties similar to other drugs that act at that receptor Can cause some nausea, upset stomach, dizziness, and longlasting fatigue Is included on the FDAs Generally Recognized as Safe List

Most commonly used drugs for insomnia

1.

Trazodone

9.

Hydroxyzine

2.
3. 4.

Zolpidem
Amitriptyline Mirtazapine

10. Alprazolam
11. Lorazepam 12. Olanzapine

5.
6. 7. 8.

Temazepam
Quetiapine Zaleplon Clonazepam

13. Flurazepam
14. Doxepin 15. Estazolam 16. Diphenhydramine

Walsh et al, 2005