Activity Description Target Audience This continuing medical education activity is planned to meet the needs of primary care providers including internists, family physicians, doctors of osteopathy, physician assistants, and nurse practitioners, who can contribute to early detection and assessment of insomnia as well as participate in management of these patients. Learning Objectives At the conclusion of the educational activity, the learner should be able to: • Describe the impact of insomnia on a patient’s quality of life and overall well-being. • Identify communication strategies aimed to improve the assessment of patient sleep quality to support earlier detection of potential sleep disorders. • Compare and contrast the benefits and risks of newer sleep medications, such as dual orexin receptor antagonists (DORAs), with traditional pharmacotherapeutic agents in the treatment of insomnia.
Faculty and Disclosure Paul P. Doghramji, MD, FAAFP Medical Director Wellness Center Ursinus College Family Physician Collegeville Family Practice Collegeville, PA Dr. Paul Doghramji, MD has the following relevant financial relationships to disclose: Advisory Board: Eisai, Inc., Jazz Pharmaceuticals, Harmony Shareholder: Pfizer Inc. Dr. Doghramji intends to discuss the off-label uses of the following products: Trazodone, doxepin, mirtazapine, paroxetine, quetiapine, and olanzapine. No (other) speakers, authors, planners or content reviewers have any relevant financial relationships to disclose. Content review confirmed that the content was developed in a fair, balanced manner free from commercial bias. Disclosure of a relationship is not intended to suggest or condone commercial bias in any presentation, but it is made to provide participants with information that might be of potential importance to their evaluation of a presentation.
Why Should PCPs be Proactive in Evaluating SLEEP? Sleep Problems… • …are very prevalent in primary care – But patients don’t tell you • …have serious consequences – Day-to-day life – Poor outcome on mental and physical health • …are a clue to other medical conditions – Most insomnias are co-morbid • …are easy to identify Effective management may improve outcomes • Majority is done by PCPs
Prevalence of Sleep Problems in America Poll of 1503 individuals (age range of 13‒64 years) reveals 87% report at least 1 sleep problem for at least a few nights/week. National Sleep Foundation. 2011 Sleep in America Poll. Available at: https://sleepfoundation.org/sites/default/files/sleepinamericapoll/SIAP_2011_ Summary_of_Findings.pdf
Epidemiology of Insomnia Prevalence of insomnia • 40‒70 million adults in the United States have insomnia (approximately up to 30% of general population) • 10% of population has associated symptoms of daytime functional impairment • Up to 50% prevalence in clinical practices • Greater prevalence in postmenopausal women NIH. NIH Consens State Sci Statements . 2005;22(2):1-30. Qaseem A, et al. Ann Intern Med . 2016;165:125-133. Buscemi N, et al. Evidence report/technology assessment number 125. Rockville, MD: AHRQ. Publication 05-E021-2. June 2005. https://archive.ahrq.gov/clinic/epcsums/insomnsum.htm.
Where do Patients with Insomnia Go for Management? Primary Reason for Consultation 6% • 62% Family Physician/ “Has your doctor ever asked Internist you about sleep issues?” • 8% Psychiatrist 80% 70% • 4% OB/GYN No one Secondary • 4% Sleep Specialist Reason for 60% 70% Consultation • 22% Other 24% 40% 29% 20% 0% Yes No Ancoli-Israel S, Roth T. Sleep. 1999;22:S347-S353. The Gallup Organization for the National Sleep Foundation, 1995. National Sleep Foundation. “Sleep in America” Poll. March 2005. Available at: https://sleepfoundation.org/sleep-polls-data/sleep-in-america-poll/2005-adult-sleep-habits-and-styles.
Insomnia Disorder: DSM-5 Definition A. Dissatisfaction with sleep quantity and quality “Insomnia is insomnia is insomnia”* with one or more of the following: Eliminates concept and differentiation A. Difficulty initiating sleep of primary and secondary insomnia B. Difficulty maintaining sleep Emphasizes that insomnia is often C. Early morning awakening with inability to return to sleep comorbid with other disorders and B. Significant distress or impairment should be diagnosed and managed as a distinct disorder C. ≥3 nights per week *Michael Sateia, editor of ICSD-3 D. ≥3 months E. Adequate opportunity for sleep F. Not better explained by or solely due to another sleep-wake disorder G. Not attributable to medication/substance use H. Not adequately explained by comorbid medical or mental disorders Reynolds CF 3 rd , et al. J Clin Sleep Med . 2010;15:6:9-10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5 th Edition. 2013.
How Frequent are Comorbidities Among Insomnia Patients? Medical Conditions in Primary Care Insomnia in Patients with Medical Conditions Patients with Insomnia 50 50 47 50 42 39 38 Prevalence % 40 37 40 35 30 28 30 30 25 22 19 17 20 20 15 17 14 15 11 12 10 10 10 6 0 0 Insomnia Severe insomnia Terzano MG, et al. Sleep Med. 2004;5:67-75. Katz DA, McHorney CA. Arch Intern Med. 1998;158:1099-1107.
Insomnia Increases Risk for Diabetes and Hypertension Analysis of 1741 random adults from Central Pennsylvania who were studied in a sleep laboratory Insomnia defined as complaint of insomnia with duration of at least 1 year Compared to normal sleeping, insomnia with a sleep duration of <5 hours was associated with: ~3-fold higher risk of diabetes 5-fold higher risk of hypertension Adjusted OR of diabetes associated with Adjusted OR of hypertension associated insomnia and sleep duration with insomnia and sleep duration 3.5 6 3 Adjusted Odds Ratio >6 hours 5-6 hours <5 hours Adjusted Odds Ratio >6 hours 5-6 hours <5 hours 5 2.5 4 2 3 1.5 2 1 1 0.5 0 0 Normal Sleeping Insomnia Normal Sleeping Insomnia Vgontzas AN, et al. Diabetes Care . 2009;32:1980-5. Vgontzas AN, et al. SLEEP . 2009;32:491-497.
Insomnia is a Causal Risk Factor for Type 2 Diabetes Mendelian randomization study to identify risk factors for type 2 diabetes (T2D) • Included 74,124 T2D patients and 824,000 controls Insomnia identified as a causal risk factor (OR 1.17; 95% CI 1.11 to 1.23) Though prior observational studies indicated insomnia as a possible risk factor for T2D, this is the first study to identify a causal association between insomnia and T2D Yuan S, Larsson SC. Diabetologia . 2020;63:2359-71.
Does Insomnia Increase Risk for Psychiatric Disorders? Incidence (%) over 3.5 years 40 Insomnia (n=240) 35.9 35 No Insomnia (n=739) 31.1 30 30 Patients (%) 25 21 18 20 14.4 15 10 10 5 5 0 Breslau N, et al. Biol Psychiatry . 1996;39:411-8.
Does Treating Insomnia Improve Comorbidities? 2-hour group sessions weekly over 4 months with a 16-month evaluation Cognitive Behavioral Therapy (CBT), Tai Chi chih (TCC), Sleep Seminar control (SS) 4 months OR=.08 CBT OR=.21 (.03-1.47), p<.10 TCC NS 16 months CBT OR=.06 (.005-.669), p<.01 TCC OR=.10 (.008-1.29), p<.05 Risk score based on 8 biomarkers: • High-density lipoprotein, low-density lipoprotein, triglycerides, C-reactive protein, fibrinogen • Hemoglobin A1c, glucose, insulin • High risk = 4 or more abnormal biomarkers Carroll, JE, et al. Psychoneuroendocrinology. 2015;55:184-92.
When Do You Ask About Sleep Problems? • When applicable Risk Factors During Acute Visit • Age (↑ in older individuals) o During Follow-up Visit • Female gender (especially post- and peri- o • During Periodic Health Assessment Visit menopausal females) • During Review of Systems • Divorce/separation/widowhood Case Finding Initial Questions • Psychiatric illness o • Sleep Schedule: • Medical conditions Do you have trouble getting to sleep, • Cigarette smoking o staying asleep, or waking up too early? • Alcohol and coffee consumption • Daytime consequences: • Certain prescription drugs Do you feel like you have slept well o throughout the day? NIH Consens State Sci Statements . 2005;22:1-30. Young T, et al. Sleep . 2003;26:667-672. Sateia MJ, et al. Sleep . 2000;23:1-66. Erman MK. In: Sleep Disorders: Diagnosis and Treatment. Totowa, NY: Humana Press; 1998; pp. 21-51.
Follow-Up Questions • Sleep timing: – When do you go to bed? …Wake up? …Middle of the night awakening? …How long does it take you to fall back to sleep? • Duration, frequency, prior such: – How long has this been going on?...How often have you had this sleep problem?...Have you had it before?... • Any sleep hygiene/lifestyle issues? – Sleep environment? Alcohol? Smoking? Exercise? Medications? • Medical/psychiatric associations • Treatments: – What remedies have you tried? Any previous Rx’s? • Other sleep disorders – Snoring, daytime sleepiness, restless legs • Family History of sleep difficulties
Approaches to Improve Sleep Quality • Education • Sleep hygiene measures • Behavioral and cognitive therapy techniques • Neurofeedback • Pharmacotherapy • Sleep medicine specialist consultation and sleep laboratory testing
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