00:00
Now, let's talk about insomnia disorders. Let's start with a
case. This is a 45-year-old
man who presents with difficulty falling asleep and staying
asleep. The problem
started after the death of his mother 2 months ago. He says
that he is unable
to fall asleep until about an hour after going to bed. So
his time in bed is an hour
until getting to sleep. He has no previous sleep problems.
He initially tried
taking over-the-counter sleep aids, but this caused daytime
drowsiness. Other than
the sleep complaints, he denies changes in his appetite, his
job, or pleasurable
activities. There is no anhedonia. He consumes 6 cups of
coffee during an average
day. He drinks a beer each night before bed to try and get
him to sleep. He has a
television in his room that he watches sometimes at night
when he can't get to sleep
or stay asleep. The patient's wife has noted that his legs
do jerk occasionally during
sleep though he was not aware of these movements. So, what's
the most likely
diagnosis for this patient? Is this depression? Excessive
coffee or caffeine intake?
Adjustment sleep disorder? Or inadequate sleep hygiene?
Well, we don't have
features that support a diagnosis of depression. The patient
does have a recent
stressor and that raises concern about the possibility of
depression, but those other
findings that would support this diagnosis. Changes in
appetite, pleasurable
activities, or impact on work are not present and don't
support that diagnosis. This
doesn't sound like excessive caffeine or coffee intake as
the contributor for his
sleep dysfunction. The patient has significant caffeine
intake that may be
contributing to his symptoms and reducing caffeine intake
will likely improve his
sleep but there is something more recent that's going on
that is contributing to his clinical symptoms.
02:00
The most likely diagnosis isn't inadequate sleep hygiene.
That may be the case for this
patient but is not the primary cause of his complaints.
02:09
This is a typical presentation of someone with adjustment
sleep
disorder. This is a self-limited disorder often resolving
once the patient comes to
terms and copes with the stressor that triggered this event.
The course is usually
transient, lasting a few days to less than a few weeks but
sometimes even up to
months after a significant life event. And the death of this
patient's close family
member likely contributed to this adjustment sleep disorder
for this patient.
03:41
So let's talk a little bit more about insomnia.
03:46
First, let's start with a definition. Insomnia is the
subjective
perception of difficulty with sleep initiation, duration,
consolidation, or quality
despite adequate opportunities for sleep resulting in
daytime functional
impairment. So there are a number of things going on there.
One, it's the patient's
perception. They don't feel like they're sleeping enough or
getting asleep or staying
asleep. The second and critically important is the
impairment in daily function. We
all have better nights of sleep and worse nights of sleep,
but we're able to function
regardless of how we then slept and the consistent
impairment in daily function is an
important aspect of a diagnosis of insomnia. When we think
about insomnia, we
can classify it as acute beginning and occurring over less
than 3 months or chronic,
persisting over more than 3 months. Acute insomnia is
transient and short term.
04:44
It's often due to a number of triggers, perhaps
environmental or a recent illness and
usually associated with a change in anxiety or life events
or social events or those
sorts of things or a physical stressor. And it can evolve
from acute insomnia into
the chronic form of this condition. Chronic insomnia
includes both primary and
comorbid insomnia and we can also often see muscular
weakness, hallucinations,
or double vision which may be present in these patients as a
result of this chronic
and longstanding reduction in sleep. When we think about
insomnia, we can
classify insomnia by how sleep is impaired. So we think
about sleep onset
insomnia. This is a difficulty with falling asleep at the
beginning of the night.
05:32
There is also sleep maintenance insomnia, which as it's
described is difficulty with
staying asleep. Patients are often able to get to sleep but
the problem is maintaining
consistent sleep throughout the night. Early morning
awakening is insomnia as a
result of early awakening, waking up too early and
difficulty with getting back to
sleep. And then finally, paradoxical insomnia, which is a
sleep state misperception.
05:59
This is disassociation between the patient's self-reported
quality of sleep and the
findings from objective polysomnography which are normal. In
terms of
epidemiology, insomnia is not uncommon. At least 30% of
patients report
symptoms of insomnia at some point in their life. It's more
common in women and
older adults and there is an increase prevalence in those
who are unemployed,
divorced, widowed, or experiencing physical or emotional
stressors. In terms of
risk factors, inadequate sleep hygiene is one of the most
important. Irregular
bedtime schedules can contribute to insomnia. Using bed for
work, eating,
watching television can also contribute to insomnia. When
the brain thinks it's
going to do other things in bed, it's not prepared to sleep
when you're there. Naps
especially those after 3 pm can contribute to insomnia. And
stimulating activities,
exercising right before bedtime are all risk factors for the
development and
continuation of insomnia. There are a number of
environmental factors that can
contribute to insomnia, noise, lights, and extreme
temperatures. Light is one of the
critical wakefulness producing stimuli and so bright lights
around bedtime or in
bed can contribute to insomnia. Underlying sleep disorders
like restless leg
syndrome can also contribute to insomnia and when treated we
can see insomnia
improve. And then behavioral insomnia. Jet lag or shift
worker's disorder can result
in insomnia as a result of abnormalities in that typical
circadian rhythm. When the
brain isn't expecting to sleep and needs to sleep, this can
contribute to insomnia.
07:45
And then finally, some medical conditions are associated
with insomnia; diabetes,
GERD, hyperthyroidism, asthma, Alzheimer's disease,
menopause, and chronic
pain. So when we think about managing insomnia and treating
patients, we walk
through things like sleep hygiene, environmental factors,
underlying sleep
disorders, behavioral changes, and medical conditions, and
managing these can be
important in our treatment and management of patients
presenting with insomnia.
08:16
In addition, mental health disorders can contribute to
insomnia; things like
depression, anxiety, and posttraumatic stress disorder.
Substance use and
medication-induced insomnia is also an important
consideration. Stimulants can
cause insomnia and benzodiazepines or particularly
withdrawal can also contribute
to changes in sleep. So let's talk briefly about the
pathophysiology. What's going
on to contribute to insomnia? Well, there are a number of
brain structures involved
and wakefulness and sleep and abnormalities in the
wakefulness centers or the
sleep centers can contribute to insomnia. There are a number
of neurotransmitters
that play a major role in insomnia. Decreased inhibitory
signals, reduced gaba in
the brainstem reduce the brain's ability to get to sleep.
Activation of the
suprachiasmatic nucleus and inhibition of melatonin that's
produced by the pineal
gland can also contribute to alterations in wakefulness and
contribute to
insomnia. And then finally, increased levels of stress
hormones like cortisol can
alter the brain's ability to go to sleep or be awake and
contribute to insomnia.
10:58
How do we diagnose insomnia? Well, we look for a number of
symptoms, difficulty
falling asleep, daytime sleepiness or excessive daytime
sleepiness, fatigue and
tiredness can be seen, problems with concentration or memory
can actually be
some of the presenting symptoms of insomnia, and memory
dysfunction or
cognitive dysfunction can indicate further evaluation of the
patient's sleep and be
the underlying cause. Irritability and increased errors or
accidents at work or other
activities may herald symptoms that are indicative of an
underlying sleep disorder.
11:34
When we think about the diagnosis of sleep, the DSM 5 has a
series of criteria that
are used to diagnose an insomnia disorder. The first is
difficulty initiating or
maintaining sleep or early morning awakening without being
able to return to
sleep. We look for social, occupational, and behavioral
impairment which is a
critical part of the diagnosis of an insomnia disorder.
Symptoms should be present
for at least 3 nights per week and symptoms should be
noticed for at least 3 months.
12:06
Sleep difficulty present despite having ample opportunity
for sleep should
be present. Sleep disturbances cannot be explained by any
other sleep-wake
disorders. We want to exclude other potential causes. And
then sleep difficulty
should not be due to physiologic effects of substance use or
mental health disorders
or other medical conditions. We want to rule out other
causes particularly those
that are treatable or reversible of these symptoms. In terms
of diagnosis, we can
use a number of diagnostic aids to help support a diagnosis
of an insomnia disorder
and the first is history. A comprehensive medical and
psychiatric history is
important in these patients. We want to take a sleep history
and really interrogate
the time of onset of sleep, the maintenance and adequacy of
sleep, and symptoms
around awakening. And we can also interview not just the
patient but a bed partner
about the quality and quantity of sleep. In terms of
physical exam, this can help
evaluate comorbid conditions and rule out other potential
explanations. Self-reported
screening tools can also be helpful and evaluate problems
with sleep, sleep
quality or sleep duration. And then a sleep diary can be
helpful. It's typically
kept over the course of 2-4 weeks where the patient records
the time of onset of
sleep, when they get in the bed, when they tend to fall
asleep, their sleep
maintenance or awakenings during the night, and when they
get up for their
daytime. The Epworth Sleepiness Scale is one of the most
pervasive scales used to
evaluate patients with symptoms of excessive daytime
sleepiness. A series of
questions evaluates the patient''s sleepiness during the day
and can be used to
stratify potential causes of sleep dysfunction and the
presence of sleep dysfunction.
13:55
And then lastly, polysomnography or evaluation of sleep is,
it can be helpful in the
diagnosis of an insomnia disorder but is not required. This
is utilized really to
evaluate alternative explanations for the insomnia as
opposed to confirm a
diagnosis of insomnia disorder. Here, we see the Epworth
Sleepiness Scale, which
is a really important self-administered scale to evaluate
the degree of excessive
daytime sleepiness. One of the most prominent symptoms of an
insomnia disorder
is excessive daytime sleepiness and this is how we evaluate
and stratify those
symptoms. Patients are asked a series of questions about how
likely they are to
sleep in a number of different settings such as sitting and
reading or watching
television or sitting in a public place or sitting in a car
as a passenger lying down to
rest, sitting and talking to someone, sitting quietly after
lunch without alcohol, or
being in a car when stopped for a few minutes in traffic.
Patients rate each of these
questions on a scale 0 that this would never happen or they
would never doze off.
15:00
One, there is a slight chance of dozing during this
activity, 2 a moderate chance,
and 3 a high chance of dozing off or sleeping with this
activity. A score of 10 or
more suggest the presence of excessive daytime sleepiness
and should warrant
evaluation of an underlying sleep disorder. What other
diagnostic tools can be used
to evaluate patient's sleep, sleep onset, sleep quality, or
sleep quantity? The Pittsburg
Sleep Quality Index is an important self-administered,
self-reported scale to
evaluate sleep quality. And actigraphy watches can evaluate
the quantity, onset, and
duration of sleep and be helpful in objectively evaluating
what's happening in a patient's home.
17:11
Let's talk about the approach to managing patients with
insomnia.
17:17
And here, I want you to think about the 3 P model. There are
3 Ps that we evaluate
when managing patients with insomnia. The first is we want
to think about and
look for predisposing conditions. Things like anxiety that
may predispose the
patient to developing insomnia. The second is we want to
look for precipitating
factors, a recent illness, bereavement, death, a physical or
mental stressor that may
have precipitated this episode of insomnia. And then the
last are perpetuating
factors, things that keep the insomnia going. And we think
about patient's sleep
hygiene, sleep-wake cycle schedules, daytime behaviors. When
we manage
patients, we want to intervene, treat predisposing
conditions, avoid and resolve
precipitating factors, treat and improve perpetuating
events, and the combination of
all 3 of these management strategies is most successful when
treating patients
with insomnia. Let's talk about some of the
non-pharmacologic management for
short-term acute insomnia. First, we want to identify the
stressor and address it
accordingly and this is the most beneficial way to manage
acute insomnia. We can
use medications particularly if the insomnia is interfering
with daytime function,
but we want this to be temporary. Treating any underlying
comorbidity, pain,
depression, and other comorbidities before intensive sleep
treatment can be
important for these patients. what about non-pharmacologic
management of
chronic insomnia? Here, we have a number of goals. We want
to improve sleep
hygiene by avoiding alcohol, caffeinated drinks, or large
meals within 4 hours of
bedtime. Regular exercise patterns are important but we want
to avoid vigorous
exercise too close to bedtime within 3 hours of going to
sleep. We want to avoid
napping during the day or daytime sleeping, we counsel
patients to use the bed
only for sleep and other related activities. No eating,
telephone, or other
stimulation within bed. And reduce light exposure around
bedtime. Cognitive
behavioral therapy is an important intervention for patients
with chronic insomnia.
19:35
It's a first line treatment. We have a number of goals
including the increased sleep
efficiency, address maladaptive thoughts, and promote a
stable routine of sleep and
wake times. We can conduct this in a number of ways, we can
set a time for sleep
each day, and encourage the patient to follow a sleep
schedule and that regular
schedule helps to change melatonin secretion and the
circadian rhythm to promote
sleep. Sleep restriction or reducing the amount of time that
the patient is in bed,
delaying this further and further to limit time in bed
without sleeping can be a
helpful strategy. Stimulus control. Patient is anxious and
cannot sleep, getting out
of bed, doing another activity, and then returning to bed to
sleep can be helpful.
20:21
And then we think about interventions to improve sleep
hygiene. What about
pharmacotherapy? What medications are available to treat
sleep? We typically
think about these for a temporary course. The first category
are the hypnotic
benzodiazepines. These act on gaba receptors and you can see
some examples.
20:40
Temazepam, clonazepam, being 2 common examples. There are
the non-
benzodiazepine agents. These are benzodiazepine agonists and
they also act on
gaba receptors and some examples include zolpidem. Melatonin
agonist can be used.
20:58
Melatonin is the natural hormone that promotes sleep. We ask
patients to take
naturally occurring melatonin about an hour before bed to
promote that boost of
melatonin that encourages the brain to sleep and can reset
the circadian rhythm and
sleep-wake cycle. Dual orexin receptor antagonist can also
be used. Orexin or
hypocretin is important in the control of sleep and wake
cycles and you can see
several agents that act on these receptors. Histamine
receptor antagonist can be
used. The H1 receptor antagonist produces sedation and can
help promote sleep.
21:39
There is the potential for tolerance and withdrawal from
this agent and these are
not commonly used except in very short circumstances
temporarily. And
antidepressants with sedating properties also can improve
the ability to get to sleep
and can be helpful in treating both comorbid conditions as
well as insomnia in
off-label use.