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© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. in the clinic Insomnia
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Which patient populations have the highest prevalence of insomnia? Women Especially in 3 rd trimester and after menopause Elderly Up to 65% Those with coexisting medical disorders Pulmonary disease, HF, and pain syndromes Neurologic disease and psychiatric disorders Others Those taking specific medications or withdrawing from hypnotics or alcohol
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Should clinicians screen for insomnia, and if so, how? Consider screening as part of regular patient care Ask patients if they have Difficulty initiating or maintaining sleep Early morning waking Nonrestorative sleep Insomnia screening instruments Sleep Condition Index questionnaire (2 questions) Pittsburgh Sleep Quality Index Insomnia Severity Index
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. CLINICAL BOTTOM LINE: Screening.. Incorporate screening as a regular part of patient care High prevalence Potential impact on health and quality of life Screening is relatively straightforward and quick Ask if initiating or maintaining sleep is difficult Ask about early morning waking Ask about nonrestorative sleep
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. When do activities occur Going to bed, waking up, getting out of bed What are the components of a comprehensive sleep history? How much sleep Sleep latency, frequency of awakening, duration awake after awakening, total sleep time Quality of sleep How well rested do you feel after awakening? Environmental factors Light, sound, temperature, telephone, TV Behaviors that might affect sleep Sleep habits, daytime napping, exercise, stimulant use
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Which conditions should clinicians consider in the diagnosis and treatment of insomnia? Sleep-related breathing disorders Obstructive / central sleep apnea syndrome Sleep-related movement disorders Restless leg syndrome, periodic limb movement disorder, nocturnal leg cramps Circadian rhythm sleep-wake disorders Jet lag or shift work The delayed or advanced sleep-phase syndrome Parasomnias related to non-rapid eye movement
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Identify signs of specific disorder contributing to sleep disruption Thyroid dysfunction Cardiopulmonary or neurologic disease Obstructive sleep apnea syndrome What is the role of physical examination in the evaluation of patients with insomnia?
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. When a possible underlying sleep disorder is suspected When insomnia may be linked to concomitant disease When should clinicians consider lab testing in the evaluation of insomnia? Possible tests Polysomnography Multiple Sleep Latency Test Sleep Actigraphy Tests for disorders contributing to insomnia Urine drug screening (to check for substance use)
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. CLINICAL BOTTOM LINE: Diagnosis... Can be associated with: Poor sleep environment Medications or other substances that interfere with sleep Underlying medical or psychological condition Perform detailed sleep and medical history and physical exam Potentially useful tools Sleep questionnaires Sleep diaries Lab testing only if underlying conditions are suspected
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What is sleep hygiene, and what is its role in the treatment of patients with insomnia? Good sleep hygiene behaviors Maintain constant bed times and rising times Allow adequate time for sleep (7 h to 8 h for adults) Do not force sleep, and avoid clock watching Maintain a quiet, dark bedroom Remove potential disruptors of sleep (tv, phone) Avoid sleep-fragmenting substances near bedtime Exercise regularly but avoid exercise just before bedtime Resolve stressful situations and relax before bedtime Avoid daytime naps
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Behavioral therapy is the primary therapy, particularly in chronic insomnia Cognitive behavioral therapy Sleep restriction Stimulus control therapy Relaxation techniques Add other therapies only if behavioral therapy fails Are behavioral therapies useful in the treatment of patients with insomnia?
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Alcohol Reduces sleep latency + may improve early sleep But highly disruptive of other sleep parameters Antihistamines Can cause mental & cognitive changes, motor impairment Sedation may carry over until daytime Melatonin May improve sleep onset + maintenance Regular structured exercise Acupuncture/-pressure, tai-chi, yoga How should clinicians advise patients about the use of nonprescription agents in the treatment of insomnia?
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. When should clinicians consider prescription drug therapy for insomnia? When other approaches prove inadequate Considerations The nature of the sleep disturbance Whether insomnia is acute or chronic Presence of other medical or psychiatric conditions Side effects Cost continued
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. FDA-approved prescription drug treatments for insomnia Benzodiazepines (flurazepam, temazepam, triazolam) Nonbenzodiazepine (zolpidem, eszopiclone, zaleplon) Orexin-receptor antagonist (suvorexant) Melatonin Receptor Agonists (ramelteon) Antidepressants (doxepin) Others options Barbituates Antipsychotics Anticonvulsants continued
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. Things to consider when prescribing drugs to treat insomnia Use the minimal effective dose Avoid medications with a long half-life Be aware of potential drug-drug interactions Caution patients about interaction with alcohol Review potential side effects, especially daytime sleepiness Agree on an appropriate duration of use Start with a GABA agonist for acute or short-term insomnia Look for rebound insomnia after discontinuation Consider intermittent use of hypnotic medications when long- term therapy is required Consider consultation with a sleep specialist before starting continuous, long-term therapy with hypnotic medication
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What is the appropriate duration of prescription drug therapy for insomnia? Avoid prolonged or excessive therapy Discuss risks and benefits of drug therapy Continuous therapy Limit to 1 month Conduct periodic tapering and discontinuation trials to determine when continuous therapy can be stopped As-needed therapy Limit to 6 months Reserve for patients who can assess when drug treatment will be helpful
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What are contraindications to drug therapy? Sedating antihistamines Cardiopulmonary disease, glaucoma, problems w/ urination Sedative-hypnotics If pregnant or breastfeeding Underlying medical disorders in which sedation detrimental Any sedating mediation Alcohol or another sedating medication Driving or using hazardous equipment All medications History of alcohol or drug abuse Use more cautiously in elderly Beware potential interaction with complementary and alternative medications
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. When should clinicians consider specialty referral for patients with insomnia? Suspicion of an underlying sleep disorder Poor response to behavioral interventions / drug therapy Psychiatrist: possible psychiatric disorder Pulmonologist: suspected sleep disordered Otolaryngologist, oral surgeon, or dentist: excessive snoring or other oropharyngeal or airway issues Neurologist: possible Parkinson disease, cerebrovascular disease, or dementia
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. How should clinicians manage insomnia in hospitalized patients? Interventions in the hospital Address sleep hygiene Address hospital environmental issues Consider discontinuing medications that may disrupt sleep Treat pain and other medical conditions that impair sleep Consider the effect of underlying medical conditions
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. What type of follow-up care should clinicians provide for patients with insomnia? Provide ongoing assessment of comorbidities Educate about sleep hygiene and behavioral techniques Monitor response and adjust therapy if medications used Schedule more frequent visits for patients with psychophysiologic insomnia Ensures patient understands and carries out behavioral recommendations
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (4): ITC4-1. CLINICAL BOTTOM LINE: Treatment... Initial therapy: address sleep hygiene factors + include CBT Cognitive training Sleep restriction Stimulus control guidelines Relaxation techniques Refer to clinician trained in these techniques If CBT unsuccessful, pharmacologic therapy may be warranted Nonprescription treatments (antihistamines) GABA agonists (nonbenzodiazepines preferred) Antidepressants only if underlying depression present Other medication classes lack evidence of effectiveness Limit continuous use of sedative-hypnotics to 1 month Longer use or intermittent use may be appropriate
© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View.
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