© 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

© Copyright Annals of Internal Medicine, 2014Ann 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


Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets constitutes copyright infringement.


in the clinic

Insomnia


Which patient populations have the highest prevalence of insomnia?

Women

Especially in 3rd 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


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


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


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


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


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?


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)


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


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


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?


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?


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


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


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


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


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


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


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


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


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

Documents

© 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