INSOMNIA - OVERVIEW

ASTUTI
2016
Tujuan :
Memberi pengenalan klinik kepada para peserta workshop
mengenai:
• prinsip – prinsip manajemen komprehensif pada
gangguan tidur
• tanda dan gejala, cara pemeriksaan standar, jenis – jenis,
serta kriteria diagnosis insomnia
• tatalaksana non farmakologis pada insomnia
• tatalaksana farmakologis pada insomnia
• evaluasi serta tindak lanjut pasien insomnia
Insomnia
o Suatu kondisi ketidakpuasan tidur yang berhubungan
dengan onset tidur, mempertahankan tidur, dan
bangun tidur lebih awal.
o Gangguan tersebut mempengaruhi fungsi dan
kemampuan subyektif pada siang hari sehingga dapat
dipertimbangkan sebagai gangguan 24 jam

(Wilson et al, 2010)

 Insomnia menyebabkan berbagai gangguan
seperti : mengantuk berlebihan di siang hari,
mudah capek, letih, lesu, kurang konsentrasi,
iritabel, depresi, gangguan fungsi kognitif,
kurangnya produktifitas, cedera, dan
kecelakaan.
 Insomnia berdampak pada kualitas hidup seperti
penyakit kronis lainnya.
 Insomnia temporer : sering timbul saat ada
masalah spesifik seperti kehilangan pekerjaan,
kejadiaan tidak diinginkan seperti kecelakaan, dan
saat perubahan pola tidur seperti setelah
melahirkan, atau perubahan jam kerja.
 Survey di Amerika menunjukkan bahwa setengah
responden mengalami insomnia temporer setelah
kejadian 11 September 2001.
Insomnia - epidemiologi
 Insidensi 6 - 40%
 Usia tua>muda; 5% pada usia 20 th, 25-35% pada lansia (>60 th)
 Wanita>pria (3:2)
 Unemployed, divorced,widowed, separated,low educational level
 Biaya pertahun : 30-107 miliar dollars(di Amerika)
 Menurunkan produktivitas; menyebabkan kecelakaan karena insomnia /obat
Underrepresented, underdiagnosed & poorly understood
• 2/3 patients do not discuss insomnia with their doctors
• 5% make physician visit focused mainly on insomnia

Qaseem et.al., 2016. Management of Chronic Insomnia Disorders in Adult: A Clinical Practice Guideline From the
American College of Physicians. Ann Intern Med; 165:XXX-XXX. www.annals.org
ECONOMIC IMPACT OF INSOMNIA
Direct Cost
◦ Drugs: $1.97 Billion (41% prescription)
◦ Services: $11.96 Billion
Indirect Costs
◦ Decreased productivity
◦ Higher accident rate
◦ Increased absenteeism
◦ Increased comorbidity
Total Annual Cost: $30-$107 billion
Walsh JK, Engelhardt CL. Sleep. 1999;22(suppl 2):S386-393
Stoller MK. Clin Ther. 1994;16:873-879
Chilcott LA, Shapiro CM. Pharmacoeconomics. 1996;10(suppl 1):1-14
Alarm “Its time to act”
Sudahmenjadi masalah kesehatanUtama

Prevalensi meningkat seiring dengan bertambah umur

Implikasi ringan-sedang – berat , menurunkan kualitas hidup
Risiko menjadi Insomnia kronis, rebound
Komplikasi meningkat : accident, adiksi, medical disease dll
Berbiaya mahal

Perlu Penanganan yang tepat

Qaseem et.al., 2016. Management of Chronic Insomnia Disorders in Adult: A Clinical Practice
Guideline From the American College of Physicians. Ann Intern Med; 165:XXX-XXX. www.annals.org
Kunci Asesmen: 3 “P’s”

Therapy in Sleep Medicine, Borkoukis et al., 2012

Faktor Predisposisi Insomnia
Faktor Risiko Statis Karakteristik Personal
• Umur • Predisposisi mudah
cemas, panic,
• Jenis Kelamin
khawatir
• Predisposisi genetik
• Kecenderungan
gelisah
• Circular thinking
• Generalized
hyperarousal
(increased metabolic rate/
plasma Noradrenaline/
body temperature, etc)
Faktor Risiko yang bias
dimodifikasi
• Stessor hidup
• sleep hygiene buruk
• Jadwal kelompok jam
kerja
• Komorbiditas medis
(seperti nyeri kronis)
• Komorbiditas
psikiatri(seperti cemas,
depresi)
• Substance abuse
• Riw. Insomnia
Faktor Pencetus Insomnia /
precipitating factors
• Distres emosional (paling sering)
- Kematian
- Perceraian atau putus cinta
- Kehilangan pekerjaan
- Masalah keuangan
- Stresor tertentu(ujian sekolah, proyek pekerjaan dsb)

• Perubahan dosis obat atau jenis obat

• Onset gangguan medis/psikiatri atau
gangguan tidur primer
Faktor memperburuk Insomnia /
perpetuating factors
Sleep hygiene yang buruk :
• Konsumsi kafein secara berlebih/meningkat
• Konsumsi alkohol
• Kondisi sekitar ruang tidur yang tidak mendukung
• Aktivitas lain di tempat tidur (menonton televisi,
membaca, dll)
• Tidur siang berlebihan
Penyebab Co-morbid isnomnia
Siklus insomnia persisten
MALADAPTIVE HABITS
CONSEQUENCES •Excessive time in bed
•Mood Disturbances •Irregular sleep
•Fatigue schedule
•Performance impairments •Daytime napping
•Social Discomfort •Sleep- incompatible
activities

DYSFUNCTIONAL
COGNITIONS
•Worrying over sleep AROUSAL
loss •Emotional
•Ruminating over •Cognitive
consequences •Physiologic
•Unrealistic
Expectations
Development of insomnia
Criteria diagnosis
DSM V Diagnostic criteria :
Insomnia Kronik
 Insomnia kronik : Insomnia yang terjadi minimal 3 hari
setiap minggu selama minimal 1 bulan (American Academy of
Sleep Medicine, 2005)
 Penyebab insomnia kronik terbanyak adalah penyebab
sekunder (medikasi atau gangguan medis lainnya)
 Cakupan Masalah :
– 52%–64% pasien layanan primer mengeluh gangguan tidur
– 10%–14% mengalami insomnia berat yang menyebabkan disfungsi
di siang hari (Terzano et al, 2004)
– Insidensi insomnia lebih tinggi pada wanita dan usia lanjut.
 Gejala yang muncul
Survey terbaru di Canada:

Keluhan pasien di awal Frekuensi

Kombinasi > 2 gejala 47%
Sulit masuk tidur 28%
Sulit mempertahankan tidur 15%
Terbangun lebih awal 10%
Kualitas tidur jelek/Nonrestorative sleep 37%
Concomitant insomnia symptom 71%

(Morin CM, 2011)

Insomnia - types
 Symptom, not a disease
 Many different causes
 Therefore, organization into a single topic arbitrary

Divided into several types -

By time of onset
by duration
by etiology
by severity
by age

 Effective treatment depends on Etiologic Diagnosis and

 Early detection and early treatment
 Insomnia- based on time of onset/timing
Classification based on time of onset of symptoms :
 Sleep onset insomnia - anxiety, tension
 Sleep maintenance insomnia - Medical/neurological diseases;
Parasomnias - RLS/PLMS etc; Alcohol, stimulants, hypnotic/drug
withdrawal
 Early morning awakening insomnia – depression
 Circardian rythm sleep disorder (CRSD) - Phase-shift disorder- depending
on shift
 Cyclical insomnia - drug/alcohol abuse, psych/medical disorders- bipolar
disorder, bulimia, anorexia

ICSD Classification – diagnosis, code

 Insomnia – based on duration
Categorized into : Transient, or Chronic
Transient <4weeks long and/or intermittent-COMMON
 Stress related – hyper arousal - happy or sad
 Environment induced- noise/travel, hospital
 Shift work
 Jet lag-easier with westward travel
 Altitude-(12,000 feet) - Acute mountain Sickness
 sleep disturbance usually in the setting of high altitude : Nausea, vomiting, headache, decreased
mental acuity & insomnia, poor appetite; Periodic breathing, CA-arousals, Alveolar hypoxia,
art.hypoxemia Later polycythemia, decreased stage 3 & 4; Treatmentdescent,Acetazolamide
250mg Bid 3-4 days before ascent

May not see many of these patients

Insomnia –based on duration
Chronic insomnia – daily symptoms for > a month – subacute or for
>6 months - chronic
 In reality, chronic insomniacs have variable sleep
 Symptoms may not be present every night
 Vary night to night
 Some nights better than others
 So - Chronic intermittent insomnia more pertinent description for
many patients
 Most insomnia patients in the clinic have chronic insomnia
Insomnia– based on cause, age perpetuating factor &
presenting symptoms (ICSD – international classification of Sleep
Disorders)
 Adjustment insomnia
 Psychophysiological insomnia
 Paradoxical insomnia
 Idiopathic insomnia
 Insomnia due to mental disorder
 Inadequate sleep hygiene
 Behavioral insomnia of childhood
 Insomnia due to drug or substance
 Insomnia due to medical condition
 Physiological (organic insomnia), unspecified
 Insomnia not due to substance or known physiological condition (Non-
organic insomnia, NOS)

Basically – ICSD classification separates out insomnia due to drugs/substance

use/medical/psych disorders
Referensi
Chilcott LA, Shapiro CM. Pharmacoeconomics. 1996;10(suppl 1):1-14
Edinger, J. D., Bonnet, M. H., Bootzin, R. R., Doghramji, K., Dorsey, C. M., Espie, C. A.,
... & Stepanski, E. J. (2004). Derivation of research diagnostic criteria for insomnia:
report of an American Academy of Sleep Medicine Work Group. Sleep, 27(8), 1567-
1596.
Lee Chiong; Sleep A comprehensive handbook,103-11
Sahota P. Insomnia – Evaluation and management. Powerpoint Slides
Schutte-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. 2008. Clinical guideline for
the evaluation and management of chronic in-somnia in adults. J Clin Sleep
Med;4(5):487-504
Stoller MK. Clin Ther. 1994;16:873-879
Therapy in Sleep Medicine, Borkoukis et al., 2012
Qaseem et.al., 2016. Management of Chronic Insomnia Disorders in Adult: A Clinical
Practice Guideline From the American College of Physicians. Ann Intern Med;
165:XXX-XXX. www.annals.org
Walsh JK, Engelhardt CL. Sleep. 1999;22(suppl 2):S386-393
www.sleepreviewmag.com/.../2004-05_04.
TERIMAKASIH