Insomnia Flashcards
What is SL?
sleep latency
-time to fall asleep following bedtime
What is WASO?
wake after sleep onset
-sum of wake times from sleep onset to final awakening
What is TIB?
time in bed
-time from bedtime to getting out of bed
What is TST?
total sleep time
-(TIB-SL-WASO)
How is sleep efficiency percent calculated?
SE=TST/TIB x 100
What are the two basic types of sleep?
rapid eye movement (REM) sleep
non-REM sleep (3 stages)-75% of sleep
What is insomnia?
difficulty falling or staying asleep
Describe the criteria of insomnia disorders from the DSM.
a. dissatisfaction with sleep quantity or quality
b. report one of the following:
-difficulty initiating sleep
-difficulty maintaining sleep
-early awakening and difficulty returning to sleep
-non restorative sleep
c. distress of daytime impairment
d. occurs at least 3 nights per week
e. present for at least 3 months
f. sleep difficulty occurs despite adequate opportunity
What are the types of insomnia?
primary
-insomnia in the absence of a causative factor
secondary
-caused by an underlying medical condition or medication
What are some other sleep disorders?
obstructive sleep apnea
-heavy snorer
restless leg syndrome
circadian rhythm disorder
-sleeping well but at wrong times
narcolepsy
-daytime sleeping without warning
parasomnias
-troubling behaviour associated with sleep
How can we assess insomnia?
Athens Insomnia Scale (sleep disorder questionnaire)
instruct patient to complete a sleep diary
assess severity of insomnia using one of the following:
-Insomnia Severity Index
-Epworth Sleepiness Scale
refer to a sleep clinic for further investigation if necessary
Describe the epidemiology of insomnia.
prevalence:
-25% of adults are dissatisfied with their sleep
-10-15% report symptoms of insomnia associated with daytime consequences
-6-10% meet criteria for an insomnia disorder
age:
-sleep complaints increase with age
-up to 50% of seniors with sleep problems
gender:
-twice as prevalent in women as in men
comorbidity:
-five times as likely to present with anxiety or depression
-more than twice as likely to present CHF
What are the risk factors for insomnia?
stress
increased age
female sex
comorbid conditions (nocturia, HF, COPD, depression/anxiety, dementia)
shift worker
lower economic status
What are some drugs that may cause sleep problems?
five most common:
-levodopa, prednisone, venlafaxine, fluvoxamine, rotigotine
others:
-antidepressants (bupropion, SSRIs, SNRIs, MAOIs)
-CV (a-blockers, B-blockers, diuretics, statins)
-decongestants
-opioids (in combo with caffeine)
-respiratory (B2 agonists, theophylline)
-stimulants
-alcohol and nicotine
Describe the health outcomes associated with insomnia.
cardiovascular
-ischemic stroke, CAD, inflammatory markers
metabolic
-obesity, T2DM
cancer
-breast, colorectal, prostate
accidents
-daytime fatigue and sleepiness=human error
What are the primary goals of therapy for insomnia?
sleep quality and or time
insomnia related daytime impairments like energy, attention or memory difficulties
What are the “other” goals of therapy for insomnia?
SL <30 mins
WASO <30mins
decreased frequency of awakenings
TST >6hrs
sleep efficiency >80%
sleep related psychological distress
formation of a positive and clear association between bed and sleeping
What sits at the top of the hierarchy for insomnia management?
CBT
What are the components of CBT?
cognitive therapy
stimulus control
sleep restriction
sleep hygiene
relaxation
Describe good sleep hygiene and stimulus control.
do not spend too much time in bed
-excessive sleep can be fragmented and unrestful
maintain a consistent sleep/wake time
-trains mind and body
get out of bed if unable to fall asleep
-do something boring and try again
exercise regularly
-tiring out the body can deepen sleep
keep bedroom comfortable
-good bed and temperature
dont take problems to bed
-disturbs sleep
avoid caffeine, tobacco and alcohol after lunch
-increased arousal
limit liquids in the evening/dont go to bed hungry
-waking from full bladder
keep bedroom dark and quiet
-less disturbance and arousal
avoid late night screen time
-stimulates the mind, blue light delays melatonin secretion
What are some relaxation techniques?
breathing exercises
progressive muscle relaxation
imagery
meditation
Describe proper sleep restriction.
dont get into bed unless you feel tired
reduce time in bed to your perceived total sleep time
use sleep logs
1. identify average total sleep time using a sleep diary
2. determine the sleep window
3. set up a waking time
4. set a bedtime
5. stick to the schedule for about 2 wks
6. calculate the average SE
7. adjust the sleep window
Describe pharmacotherapy for insomnia.
should be considered as adjunctive to CBT
CBT+pharm may produce faster improvements in sleep than CBT alone
studies that support the use of sedative hypnotics for insomnia limited to short term tx (<4wks)
What is the MOA of benzodiazepines and Z drugs for insomnia?
potentiates GABA
-inhibitory neurotransmitter
