Modern Management of Case Sleep Disorders 58 yr. old WF with - PowerPoint PPT Presentation

Modern Management of Case Sleep Disorders • 58 yr. old WF with >4 yr. of “poor sleep” Douglas C. Bauer, MD • Sound asleep by 9-10 PM, but difficulty with University of California, maintenance of sleep, often awake at 3 AM. San Francisco • Few daytime symptoms. No naps. • Denies depression, anxiety, bad habits • Previous MD prescribed ambien 5-10 mg 3-5 times per week. No Disclosures • What else would want to know and what do you want to do? Barker Pass to Alpine Meadows Topics Covered • Prevalence and potential consequences • Sleep physiology • Insomnia evaluation and treatment • Sleep disordered breathing and parasomnias

Percent Reporting Symptoms Sleep Disorders of Insomnia 35% • Sleep per night: 9 hr in 1910, 6.9 hr now 30% • 40 million in US suffer from sleep disorders 25% • 95% are undiagnosed and untreated 20% 15% • Prevalence of sleep disorders higher in women and increases with age 10% • Frequent complaint in primary care… 5% 0% Almost Every Night Few times/week Few times/month Rarely/Never 2002 ‘Sleep in America’ poll, National Sleep Foundation Definitions Sleep Architecture • REM (Rapid Eye Movement) • Insomnia (insufficient or poor quality sleep) - Characteristic eye movement – Latency (time to fall asleep) - EEG resembles wakefulness – Efficiency (proportion of time in bed asleep) • Non REM • Hypersomnia (excessive daytime sleepiness) - 75% of sleep - Sleep disordered breathing/sleep apnea - Four stages: correlate with depth of sleep - Narcolepsy - Progressive cortical inactivity • Parasomnia (coordinated motor activity) -Restless leg syndrome • Sleep architecture changes over age 65 - Reduced stage 3 and 4, phase advancement -  total time,  latency,  efficiency

Special Populations: Insomnia Special Populations: in the Elderly and in Women Perimenopausal Women • Elderly • Prospective study of >3000 women 42-52 followed for 7 yr (SWAN) – High prevalence (> 50%) • Sleep complaints worse in peri and – Secondary sleep disorder more common postmenopausal women (40% vs. 22%) – Commonly associated with psychiatric – Both initiation and maintenance of sleep impaired disorders or depression – Partly attributable to hot flushes • Women – Improved but not fully reversed with HRT – Other neurocognitive effects? – 50% more common than in men – Increases dramatically after menopause Kravitz et al, Sleep, 2008 Presentation and Screening for Name Date Sleep Quality Assessment (PSQI) What is PSQI, and what is it measuring? Insomnia The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument used to measure the quality and patterns of sleep in adults. It differentiates “ poor ” from “ good ” sleep quality by measuring seven areas (components): subjective sleep quality, sleep latency, slee duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunction over the last month. INSTRUCTIONS: The following questions relate to your usual sleep habits during the past month only. Your answers should indicate the most accurate reply for the majority of days • Typical presentation and nights in the past month. Please answer all questions. During the past month, – Difficulty initiating or maintaining sleep 1. When have you usually gone to bed? 2. How long (in minutes) has it taken you to fall asleep each night? 3. What time have you usually gotten up in the morning? 4. A. How many hours of actual sleep did you get at night? B. How many hours were you in bed? – Wake after sleep onset 5. During the past month, how often have you had trouble sleeping because you Not during the past Less than once a Once or twice a Three or more times a month (0) week (1) week (2) week (3) – Early morning awakening A. Cannot get to sleep within 30 minutes B. Wake up in the middle of the night or early morning C. Have to get up to use the bathroom D. Cannot breathe comfortably – Awakening not rested E. Cough or snore loudly F. Feel too cold G. Feel too hot • Recommended screening question: “Do you H. Have bad dreams I. Have pain have trouble falling asleep or staying asleep?” J. Other reason (s), please describe, including how often you have had trouble sleeping because of this reason (s): 6. During the past month, how often have you taken medicine (prescribed or “ over the counter ” ) to help you sleep? • If positive, consider full sleep questionnaire 7. During the past month, how often have you had trouble staying awake while driving, eating meals, or engaging in social activity? 8. During the past month, how much of a problem has it been for you to keep up enthusiasm to get things done? Very good (0) Fairly good (1) Fairly bad (2) 9. During the past month, how would you rate your sleep quality overall? Very bad (3)

Medical Conditions That Drugs That Cause Insomnia Cause Insomnia • Alcohol • Decongestants • CNS stimulants • Hyperthyroidism • Heart failure • Stimulating antidepressants • Beta-blockers • Arthritis • Neurological disorders • Chronic renal failure • Bronchodilators • Thyroid hormones • Dementia/AD • Chronic lung disease • Calcium channel • Nicotine • Parkinson’s disease blockers • Corticosteroids Evaluation of Insomnia: Insomnia Therapies History, Exam and Labs Which of following is known to be superior • General history and exam to benzodiazepine receptor agonists for • Sleep pattern (patient and bedroom partner) primary insomnia? 54% - Insufficient sleep time A. sleep hygiene instruction - Delayed onset vs. frequent/early awakening 30% B. cognitive behavioral therapy - Associated nocturnal symptoms and 12% daytime symptoms C. anti-histamines 4% D. anti-depressants (TCA, SSRI, • Lab testing: thyroid function, glucose, UA s n e . o . and trazadone) . . n S . t i . i h m S c • Formal sleep study rarely indicated u t a , r l A t a t s s C r i T n o h ( i i - v i s e a t t n n n h e e a a i s g b y s e e h r v p p i t e e n i d e g - s l i o t c n a

Treatment of Insomnia: Cognitive Behavioral Therapy Non-Pharmacologic for Insomnia (CBTi) • Cognitive therapy • Treat underlying disorders – Change maladaptive thought processes • Document sleep patterns with Sleep Diary • Behavioral therapy • Begin with non-pharmacologic treatment – Stimulus control, sleep restriction, relaxation, - Sleep education (changes with aging) good sleep hygiene - Sleep hygiene: diet, exercise, habits, • RCT of 46 adults with chronic insomnia environment (e.g. computer screens) – Superior short and long-term (6 mo) - Establish optimal sleep pattern outcomes with CBT compared to zopiclone or placebo Buysse et al, Arch Intern Med, 2011 Trauer et al, Annal Int Med, 2015 CBTi: Face-to-face Vs. SHUTi vs. Face-to-face CBT Internet-based • Insufficient CBTi-trained therapists and may not be covered by insurance • Internet-base CBTi – More convenient, less expensive – Multiple vendors/programs – SHUTi Self Help extensively studied • 6 weekly 40 minute sessions, sleep diary feedback, Fitbit integration ($150 for 26 wk access) • Not easy but if motivated…

Treatment of Insomnia: Pharmacologic • Depression (use PHQ9) - TCA, trazadone, SSRI, combinations - Not recommended if not depressed • Anxiety, panic (use GAD-7) - Benzodiazepines, SRRI - Not recommended if not anxious • Primary insomnia: what to use? Treatment of Insomnia: Pharmacologic • Problems with anti-histamines: anti- cholinergic, sedation, cognitive dysfunction • Problems with benzodiazepines: habit forming, tachyphylaxis, suppression of REM sleep, cognitive dysfunction, falls • Short-term benzodiazepine use (<2 wk) may be helpful in some patients • Alternatives to benzodiazepines?

Benzodiazepine Receptor Agonists An unexpected • Zolpidem (generic), zaleplon (Sonata), eszopiclone (Lunesta) side effect… - Activate 1 of 3 benzodiazepine receptors - No anxiolytic or muscle relaxing effects - Preserves REM, less tolerance and withdrawal - Rapid onset, half life 2-3 hours • Zolpidem dosing: limit to 3-4 times per wk, use 5 mg in women and >65 – CR zolpidem if awakens too early with generic – Sublingual zolpidem (Intermezzo) for middle of the night awakening. Note women 1.75 mg, men 3.5 mg Suggested Approach to Insomnia In Primary Care Other Drugs • Melatonin (OTC) Insomnia Chronic - From pineal gland, receptors in hypothalamus Acute >4 wks - Poor evidence for insomnia, maybe for jet lag <4 wks or phase delay. Not regulated • Ramelteon (Rozerem) Primary? Assess trigger – Melatonin receptor agonist for sleep onset Consider brief tx Secondary – FDA approved but no long-term safety data cause? Sleep hygiene • Suvorexant (Belsomra) Hypersomia or CBTi parasomnia? – Orexin receptor antagonist for sleep maintenance Treat and Buysse Jama 2017 Refer if persists reassess Evaluate and treat