Sometimes insomnia is a perception. Some people need less sleep. Many need only seven hours and feel fine; but feel they have insomnia because they

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1 Insomnia Purpose: The purpose of this course is to provide an overview of insomnia including its definition, assessment and treatment options. Objectives 1. Differentiate between chronic and acute insomnia 2. List five causes of insomnia 3. List five consequences of insomnia 4. Discuss the evaluation of patients with insomnia 5. List five sleep hygiene measures Not being able to sleep also known as insomnia is a common problem where an individual has a difficult time falling or staying asleep. For insomnia to be present, difficulty sleeping is not the only factor that must be present. The sleep disturbance needs to be associated with non-restorative sleep. If someone does not sleep like they feel they should have but do not have poor functioning, decreased concentration or irritability, they are not plagued with insomnia. Insomnia can be chronic or acute. Acute insomnia is insomnia that is short lived and lasts less than three to four weeks and usually less than one week. Most patients with acute insomnia have primary insomnia (insomnia with no other diagnosis), but the majority of those with chronic insomnia have another diagnosis. Chronic insomnia is symptoms that last beyond four weeks. When insomnia is a chronic problem, the negative consequences of insomnia become normal for that person. It often requires the input of someone who knows this person well to determine if they are suffering from insomnia. Insomnia is more common in those who are anxious, chronically worried or depressed. These types of people are predisposed to sleep problems and when a major factor such as a sudden stress or change in medication affects these individuals they are at high risk for sleep disorders. When these precipitating factors persist, chronic insomnia may ensue. About 50% of primary care patients present to their doctor s office with insomnia. Unfortunately, few discuss it with their doctor. Only 5% of those with chronic insomnia will make an appointment with their primary doctor to discuss insomnia. To make matters worse doctors often overlook this problem and neglect to ask about it.

2 Sometimes insomnia is a perception. Some people need less sleep. Many need only seven hours and feel fine; but feel they have insomnia because they feel they need eight or nine hours of sleep. Sleep can be broken down into two states: nonrapid eye movement (NREM) and rapid eye movement (REM) sleep. Most sleep is made up of NREM sleep. NREM sleep is made up of four stages - stage I-IV. Each stage is a little deeper. Stage one is drowsiness eyes are closed but the person is easily arousable. Stage two is light sleep and sets the body up for the deeper stages of three and four. REM is made up of one stage and follows NREM sleep. REM sleep is when there is an increase in respirations, eye movement and brain activity. This is the stage when most dreams occur - it occurs 5-6 times a night. Causes Many things can cause insomnia. Among the most common are medical illnesses, psychiatric illnesses, mediations, stress and environmental problems. Many times it is easy to determine what causes the insomnia, other times it is not. Many times an identifiable stress can be linked to insomnia - a new job, a divorce, the death of a loved one or financial concerns. Sleeplessness can run in the family. Some people are more susceptible to certain factors that influence sleep. There is genetic variability in people s response to caffeine, stress and light in its effect on sleep. In addition, genes can be passed on that affect the circadian rhythm. Some people are more prone to developing a circadian rhythm disorder. These are disruptions in the body s internal clock. Some people are more prone to disease states that can affect sleep, such as depression. Depression is associated with problems with the neurotransmitter serotonin, which has been linked to sleep problems. Many chronic disease states are associated with insomnia. Almost any chronic disease can cause sleep problems. Those with poorly controlled chronic diseases are more often afflicted with insomnia. Common medical problems linked to insomnia include: Arthritis Chronic lung disease Cancer

3 Any disease with chronic pain Heart failure Hyperthyroidism Enlarged prostate (increased nighttime urination) Acid reflux Stroke Acute infectious illnesses such as a cold or an asthma exacerbation Medications are a common cause of sleep disorders. Common medications that may cause sleep problems include: Antihistamines (Benadryl) Corticosteroids Oral contraceptives Some anti-depressants, particularly bupropion (Wellbutrin) Thyroid medications Drugs for Parkinson's Disease Nicotine or nicotine replacement Alcohol Decongestants (pseudoephedrine [Sudafed]) Diuretics Beta-blockers Alpha-antagonists Theophylline Albuterol Dextroamphetamine Decongestants Stimulants Some over the counter herbal remedies Central nervous system stimulants Many lifestyle factors are associated with insomnia. Poor sleep habits such as an irregular sleep schedule, eating a lot before bed, poor sleep environment and participating in stimulating activities before bed may lead to insomnia. The job can cause insomnia. Those

4 who travel or participate in shift work can have disturbances in the body s circadian rhythm disrupting sleep. Obstructive sleep apnea (OSA) is a problem that usually presents with the complaint of waking up many times at night, snoring, and the bed partner complaining that there are interruptions in breathing at night. OSA is beyond the scope of this course and will not be discussed further here. Race, Sex and Age There is no evidence to link race to insomnia. Women are more commonly affected by chronic insomnia than men. Women with menstrual problems are more likely to have sleep problems then those without. Insomnia incidence is increased in the elderly. Many reasons have been proposed for this including medical illnesses are more common and there is more psychological stress. Aging is associated with changes in sleeping habits. Changes in the circadian rhythm often occur as one ages. Some people are afflicted with circadian rhythm problems which change with aging. The normal body has a typically pattern where it gets tired at around PM and wakes up around 7-8 in the morning. This rhythm correlates with the core body temperature. Core body temperature often dips around the time that one gets tired and rises around the time that one wakes up. Teenagers often have a modification in their circadian rhythm. Their core temperature dips later often at 1-2 AM and rises later in the morning. Therefore, there is a physiological reason that teenagers want to stay up late and sleep in. As teenagers get into there twenties this often reverts back to normal. Older adults have the opposite situation. Their temperature drops earlier and rises earlier. Therefore, the older adult often wants to go to bed earlier and rise earlier. Circadian rhythm disorders, another cause of insomnia, are diseases of sleep. There are four major ones. Advanced sleep phase syndrome This is when the patient feels sleepy before 8 pm and wake up early (4-5 am). This is more common in older adults Delayed sleep phase syndrome This is where the patient does not feel sleepy until later and then wakes up late. Irregular sleep-wake rhythm This is common in those with poor sleep hygiene

5 Shift work sleep disorder This is related to those who work varied or abnormal shifts. This can occur because the patient is worried about waking up for an early shift or a rotating shift. Individuals who work until late in the night often need time to relax after work. This makes it hard to sleep. Negative Consequences of Not Sleeping Insomnia reduces quality of life. Many people are unaware that their lack of sleep is the cause of their reduction in their quality of life. Studies have shown that insomnia reduces quality of life comparable to diseases such as arthritis, diabetes and heart disease. Insomnia is a common problem that needs to be addressed. Without adequate sleep you can suffer from: Poor general health Poor concentration Poor judgment Missing work Increased risk of catching a cold Poor cognitive function Poor memory Increased risk of falls Poor job performance Increased risk of accidents Increased health care costs Some people make repeated doctor appointments for a problem that is related to sleep. Neither doctor nor patient comes to the conclusion that a sleep problem is the underlying cause of the problem. Poor sleep is associated with many health problems. It is often difficult to determine if the sleep problem was the cause or contributing factor to the disease; or if the disease came first and contributed to the sleep problem. Because of this fact, doctors now consider insomnia a factor on equal ground with other diseases. This is important because this means that both disease and insomnia should be addressed. In years past, doctors used to treat the underlying disease and assume that the sleep disturbance would get better.

6 One of the major reasons that his came to fruition was when it was determined that depression was much more successfully treated when insomnia was treated at the same time. Common co-morbid health problems include: depression, anxiety, Parkinson's disease, stroke, lung problems, dementia, heart disease, any disease that causes discomfort (such as arthritis) and sleep apnea. Who needs medical help Most people with insomnia do not need to get immediate medical care. The following are situations that require immediate medical evaluations. Those with insomnia and A recent stroke Sleep walking that may put the person at risk for danger such as walking into the street. Falling asleep suddenly for example, while driving Periods of not breathing associated with gasping Unstable lung or heart disease Violent behavior during sleep In addition, those individuals who cannot manage their insomnia on their own should consider seeking medical attention. Seeking medical attention does not necessarily mean that the person is seeking sleeping pills. The doctor appointment can be used for teaching, assessment of other disease states to assure they are not causing the problem or setting up referral to a sleep expert. When all else fails a doctor s appointment can be set up for pharmacological management of insomnia. Although sleep medications are not recommended as an initial step, they are at times needed. Each patient should engage in sleep hygiene before resorting to medication. How to evaluate insomnia The first step in the evaluation of a medical problem is to understand the problem. The person with insomnia needs to take an inventory of his symptoms. This can be best accomplished with a sleep diary. Important things to document include: Normal sleep schedule. When do you go to bed? When do you wake up? Timing Does the patient have difficulty falling asleep, staying asleep? Is there any early morning awakening?

7 What is the sleep environment like? Is the bed comfortable? Do you sleep in a bed or chair? Is the room dark? Is there a lot of nose? Evaluate the sleep habits. What do you do before bed (read, exercise, eat, watch TV (what shows)? Are there any other symptoms? Is there any snoring? Has the bed partner witnessed you stop breathing during sleep (apnea)? Do the legs move a lot at night (periodic limb movement disorder)? How do you feel during the day? Are you tired, fatigued, have low energy, poor concentration or feel irritable? Are there any known medical problems? Many medial problems that are not controlled well can lead to sleep problems. Each medical problem should be evaluated to assure they are managed properly. A review of medications must ensue to help assure they are not leading to sleep problems. Many medications can lead to sleep problems. Review the list above and consider any of those medications as possible contributing factors to the sleep disturbance. Evaluate social problems Many social problems can lead to short term insomnia. Changes or things that lead to stress are most to blame. Questions to consider include: Has there been any change in personal relationships? Has there been any change in jobs or a major change at work? Is there increased stress at work? Has there been any recent loss? Physical exam A physical exam can pick up on some causes of sleep problems. What is the body weight? When the body mass index is greater than 30 there is increased risk of sleep apnea. Neck circumference greater than 18 inches is also a risk factor of sleep apnea. If there are enlarged tonsils or a large tongue there may be sleep apnea present. Diagnostic tests Most people with insomnia do not need medical testing. If there is a suspected disease such as sleep apnea or restless leg syndrome than a referral to a sleep lab may help confirm this diagnosis.

8 Individuals who have a disease state that is not well controlled may be referred for diagnostic testing or lab work to assure that these conditions are well controlled. For example, those with a history of night cough and asthma may be having problems with control of asthma. A referral for spirometry or even stepping up asthma therapy may be indicated. Another example includes; those individuals with a history of chronic obstructive pulmonary disease may need arterial blood gases to see if they have enough oxygen in the blood. The Patient's Role Because this is a rarely discussed disease in the doctor's office, the responsibility to manage this condition often falls on the patient. Often the first step a patient will take is to go the drug store and get a medication with the word PM in it. This is not the best option. It should certainly not be the first choice for longterm management of sleep problems. The first initial step should be to take an inventory of the sleep habits. Assess your sleep habits In order to treat a sleep problem, it must first be defined. The first step is to determine if there is any condition that would require immediate medical attention. The next step is to take a sleep inventory as outlined in the above section. Are there any medical problems that may be interfering with sleep? Evaluate for any: Pain treating pain may help in the management of sleep. Are there any breathing problems such as asthma, bronchitis or emphysema? Uncontrolled lung disease can lead to problems with sleep. Heartburn can cause discomfort at night Heart disease may present with nocturnal pain or difficulty breathing Snoring, obesity, and large neck suggest obstructive sleep apnea. The use of a dairy can be helpful in determining the sleep pattern. Many sleep diaries are available on the web. One diary is available through the American Academy of Sleep Medicine at: Maintaining this diary will assist the patient in determining the significance of the problem. Next, determine if there is a problem. How much sleep is the patient getting in a day (is it within the normal range)? Are there any negative consequences of not sleeping? Is there difficulty falling asleep? Is a there problem staying asleep?

9 Third, determine which interventions would be most appropriate for improving sleep. While sleep medications are certainly a viable option, they should not be first line treatments. While they can be effective they are laced with side effects and problems. Prescription sleep medicines may be associated with dependency, falls, rebound insomnia and sedation the next day. Below is a list of tips for improving sleep. 1. Develop a regular sleep schedule. Go to bed and wake up at the same time every day. This includes weekends. 2. Have a bedtime routine. This helps set the mood for sleep. 3. Maintaining a consistent sleep/wake routine. 4. Do not spend excessive time in bed. If you can't fall asleep in 20 minutes get out of bed and come back when you are sleepy. 5. Use the bed for only sex and sleep. 6. Relaxation therapy is helpful especially right before bed. This may include taking a hot bath or practicing progressive muscle relaxation, breathing or guided visual imagery. 7. Set up a worry time. Many people worry at night. It is the first time in the day that they have had time to quiet their mind and many negative thoughts can pop into the mind. If you set up minutes every day to worry about things and plan for future events, this may help quiet the mind at night because you will have a time set up for worry in the daytime so you do not have to burden yourself with worry at night. 8. Exercise. Individuals who are more fit sleep better. Do not exercise too late in the evening as this can charge the body up making it harder to go to sleep. 9. Avoid bright light at night. A dark environment is needed for best sleep. 10. Get plenty of bright light during the day. This may help regulate the circadian rhythm. 11. Avoid naps. It is common to want to take a nap in the mid afternoon. The core body temperature decreases, but this will generally throw off your nighttime sleep schedule. Another physiological mechanism that drives sleep in the afternoon is physiological shifts after lunch; blood flow is diverted from the brain to the stomach. Naps may be appropriate in those with shift work, those who are narcoleptic or the older adult. Naps should be no longer than 30 minutes. 12. Set an appropriate room temperature. 13. Assure appropriate room darkness. Have heavy curtains. Some people benefit from a sleep mask.

10 14. Set a quiet sleep environment. The use of earplugs may be helpful in some people. Others prefer to use fans or white noise machines. 15. Have a nice pillow. Properly placed pillows can promote comfort. Those with back pain may benefit form a large pillow under the knees. 16. Don't eat a heavy meal within three hours of bed. For many people this will aggravate heartburn or just cause generalized discomfort when trying to sleep. 17. Don't drink large quantities of fluid with in three hours of bed. Those who drink large quantities of liquid before bed are more likely to need to get up in the middle of the night to go to the bathroom. 18. Don't open your eyes when you wake up. 19. Don't look at the clock. When you look at the clock, you have to process what time it is. This will drive you out of a state of deep sleep into a state of less deep sleep. 20. Use night-lights in the bathroom. If you have to get up to go to the bathroom, truing on the bright overhead lights has the potential to wake you up even further. Night-lights will provide enough light to see, but not enough to blast you out of deep sleep cycle. 21. Avoid alcohol before bed. While this may help you initially get to sleep it is associated with early awakening and unrest sleep. 22. Avoid other stimulants before bed such as caffeine, nicotine and decongestants. 23. Sound machines can be purchased to aid with sleep. If all of the above strategies are implemented and there are still sleep issues the addition of cognitive behavioral therapy should be considered before medications are tried. Cognitive behavioral therapy (CBT) works on the negative thoughts that interrupt sleep. This type of treatment works on poor sleep habits, irregular sleep schedules, poor sleep hygiene and misconceptions about sleep. CBT works on many of the lifestyle changes implemented above and is most effective when the patient suffers from primary insomnia. Some people need to attain professional help (with a therapist) for successful implementation of CBT. CBT is tremendously beneficial for sleep improvement. The National Institute of Health says that there is immediate improvement with CBT that can be maintained for up to two years. CBT is more effective than medications. What does it entail? 1. Cognitive therapy. Cognitive therapy is educating the patient about sleep. It works on faulty thinking and anxiety about insomnia and what will happen if you do not get enough sleep.

11 2. Sleep hygiene. CBT will help teach the patient about many of the hygiene factors discussed above. 3. Stimulus control. Therapy will educate the person about many things related to stimulus of sleep such as: using the bed for sleep and sex only, going to bed only when sleepy, don't nap during the day and if unable to sleep in minutes get up. 4. Relaxation therapy. Relaxation therapy is taught to help reduced tension. It typically involves certain exercises such as guided imagery, meditation or biofeedback. 5. Sleep restriction therapy. This technique teaches the person not to spent too much time in bed. Medications When all of the above interventions have failed medications can be considered There are many medications used to treat insomnia. They range from over the counter to controlled substances. Sometimes treatment of insomnia starts with medications, but it should not. Medications are not without risk and starting with many of the lifestyle interventions is a better first line option than drugs. Medications are an easy fix for Americans. It is much easier to pop a pill than take the time and effort to implement lifestyle changes. Twenty-four million prescriptions are written for sleeping pills each year (1). Advertising executives do not help. Lunesta and Ambien CR spend almost 500 million dollars on direct to consumer advertising a year (1). Drugs are often taken much longer than they are supposed to be. Most drugs are indicated for short-term use, but many people take them for years on end. This misuse of sleeping aids can lead to many problems including dependency, memory problems sleepwalking, hallucinations and daytime drowsiness. In addition to approved sleeping pills, there are many drugs indicated for other purposes, used for insomnia. This includes anti-anxiety drugs such as alprazolam (Xanax), antidepressants such as trazodone and pain medications such as Vicodin or Darvocet. The most common over the counter medication is some form of antihistamine. They often contain diphenhydramine (Benadryl) or doxylamine succinate. Many people do not realize that they are taking an antihistamine to sleep. They assume it is a specific sleeping

12 pill. Popular over the counter products includes Tylenol PM, Sominex, Simply Sleep and Unisom. Antihistamines are used to treat allergies, they are not sleep aids. They do have the side effect of drowsiness and therefore can help promote sleep. They are also associated with other side effects such as dry mouth, constipation, confusion and difficulty urinating. Side effects are more common in the older population. One problematic side effect in the older population is confusion. These drugs can lead to significant confusion in the hospitalized older adult. According to Consumer Reports (1) over the counter drugs and supplements help over 50% of the people that took them. This survey found sound machines to be more effective than over the counter sleeping pills. Over the counter medications are popular because they are cheap and convenient. The problem is that there are many problems with these medications. They have not been proven effective in inducing sleep on a consistent basis. For healthy people they are quite effective and safe to use for one to two nights. If used for longer than a couple nights tolerance may develop. Tolerance is when the body gets used to the drug and it is no longer effective. These drugs are not encouraged for long-term use because they are not proven effective in the long-term, reduce the quality of sleep and are associated with many side effects. Sedating anti-depressants The effectiveness of the sedating anti-depressants has not been shown to be effective in patients who are not depressed. They are not approved for use in sleep, but are often prescribed. Sometimes they are prescribed as agents solely for sleep, but more often they are prescribed to the depressed individual who need help sleeping. Common drugs in this class are included on the table below. Medication Side effects Trazodone Dry mouth, constipation, daytime sleepiness Doxepine Dry mouth, drowsiness, constipation, GI upset, photosensitivity Amitriptyline Dry mouth, constipation,

13 Mirtazapine daytime sleepiness Drowsiness, weight gain, sore throat, neutropenia Hypnotics Hypnotics are agents meant to induce sleep. Most of these should not be used if there is a history of drug abuse, untreated sleep apnea, alcohol abuse or pregnancy particularly the benzodiazepine class. Those who have used these drugs for an extended period of time need to be tapered off slowly and not abruptly discontinued. Hypnotics include: Benzodiazepines Nonbenzodiazepines Melatonin receptor agonists The first two classes work on a receptor in the brain called the gamma-aminobutyric acid (GABA) receptor. The benzodiazepines are the older class of drugs and generally have a longer half-life. This means that the drug stays in the system much longer. Sedation often carries over to the next day. The most commonly used benzodiazepine for sleep problems is Temazepam (Restoril). Its half-life is about 9-12 hours. Benzodiazepines are often used in the treatment of anxiety. Drugs such as alprazolam (Xanax) and lorazepam (Ativan), are indicted for anxiety, but due to their sedating properties are often used for sleep. When used in this way it is an off label use. Other medications in the benzodiazepines class are older drugs and are not used as often today. They include: flurazepam (Dalmane) and Triazolam (Halcion). Dependency is a major risk with this class; this is especially problematic in those who use them for more than a few weeks. Withdrawal from these medications can be bad and lead to anxiety, nausea, rebound insomnia, depression, nightmares and memory problems. Gradual reduction in dose is needed when these drugs are used. The nonbenzodiazepines were more recent additions to the insomnia armamentarium. These medications work differently and do not affect the sleep stages and do not cause REM sleep rebound. This class is associated with fewer side effects than the benzodiazepines. There are three drugs in this class: Zolpidem (Ambien), Zaleplon (Sonata) and Eszopiclone (Lunesta).

14 Eszopiclone (Lunesta) works though unknown mechanisms but is thought to interact with the GABA receptor. Its half-life is about 6 hours. It is most effective in higher doses for sleep maintenance and lower doses are more effective in sleep initiation. Zolpidem (Ambien) is most helpful in the initiation of sleep. Half-life is about 2.5 hours. The extended release product (Ambien CR) helps with sleep initiation and/or maintaining sleep. Zaleplon (Sonata) is useful in helping those fall asleep with a half-life of about.5 to 1 hour. Benzodiazepines and nonbenzodiazepines should be used with extreme caution in older adults and those with lung disease. It can lead to confusion, restlessness or excitement. Some sleeping agents (Ambien) are associated with bizarre nighttime behavior such as sleep walking or doing things at night in which there is no memory of in the morning. Many of the drugs need to be tapered as some can lead to rebound insomnia and in some severe cases, seizures, tremor or anxiety. Melatonin receptor agonists There is one drug in this class Ramelteon (Rozerem). It speeds up the time it takes to fall asleep and increases the length of time one sleeps. The melatonin receptor agonist is a unique drug that is not associated with abuse. It is taken within 30 minutes of bedtime and is contraindicated in those with severe hepatic impairment. It is not recommended in those with severe chronic obstructive pulmonary disease or sleep apnea. Side effects include daytime sleepiness, fatigue, nausea, headache and dizziness. Drug Note Temazepam (Restoril) Benzodiazepine Half-life 9-12 hours. Less effective for sleep onset, may lead to daytime sleepiness. Eszopiclone (Lunesta) Longest half-life of the nonbenzodiazepine class and is useful for sleep onset and the maintainable of sleep. Higher doses are more effective for sleep onset and maintenance, lower doses are effective for sleep onset. Zolpidem ER (Ambien CR) Used for sleep onset and sleep maintenance insomnia. There is no tolerance when used 3-7 nights a week for 6 months. Zolpidem Used for sleep onset insomnia NOT sleep maintenance, can lead to rebound insomnia. Side effects are more problematic when doses are greater than 20 mg a day.

15 Zaleplon (Sonata) Ramelteon (Rozerem) Very short half-life. Useful for sleep onset insomnia or when waking up in the middle of the night as long as there is four or more hours of sleep remaining. Least commonly associated with daytime drowsiness. Melatonin receptor agonist. No abuse risk. Likely safe to use long-term. Adding medications together has not been shown to be effective. The combination of CBT and benzodiazepines is better than the drug alone. Supplements Supplements are commonly used to treat insomnia. The two most popular are melatonin and valerian root. These medications are not well studied. Results from studies are not consistent. A problem with all herbal mediations is that they are not regulated. This means that products may contain variable amounts active ingredients. Melatonin is an over the counter product that is widely recognized as helping with sleep. Scientific research suggests that it does not. It is helpful for those with circadian rhythm disturbances, jet lag and those who are shift workers, but not typical insomnia. Melatonin is a hormone secreted in the brain by darkness. When it is light, the hormone is inhibited. If it is to be used it should be used in the early evening. Side effects common with melatonin include dizziness, irritability, fatigue, sleep disruption, daytime fatigue and headache. Valerian root has minimal evidence that proves its effectiveness. It has been associated with daytime sedation. On a rare occasion it can lead to liver problems. It should not be used by those who are breast-feeding or are pregnant and not by those who are going to have surgery in the next two weeks. Conclusion To sum up, below is a list of steps health care providers can move through to evaluate and manage insomnia. 1. Determine if the insomnia acute or chronic? 2. Determine if the insomnia associated with daytime impairment (is there sleepiness, fatigue or poor function during the day)? 3. Identify any problems that may be contributing to the sleep problem. 4. Encourage the patient to maintain a sleep diary.

16 5. Evaluate for any underlying problem medical disorders, psychiatric disorders or medications that can interfere with sleep. 6. Implement sleep hygiene measures. 7. Encourage exercise in all patients 8. Implement non-drug treatments 9. Drug treatment can be used after the above steps have been implemented and are not effective. References 1. Consumer Reports. (2008). The Trouble with Drugs. (cited 2009 October 19). Available form: URL: 2. Kelso CM & Gentilli A. (2009) Primary Insomnia. (cited 2009 October 22). Available from: URL:

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