Professor Bruce Arroll Greenstone Family Clinic Auckland 14:00 - 14:55 WS #107: Insomnia in Primary Care 15:05 - 16:00 WS #118: Insomnia in Primary Care (Repeated)
I am having difficulty sleeping! a practical approach Bruce Arroll dept of general practice and primary health care school of population health
conflicts of interest • None • Not receiving any payment for webinar talk
disclaimer • not a sleep scientist • a clinician with an interest in sleep
Bruce Arroll • trained in Auckland 1973 to 79 • family Medicine McMaster in Ontario 1981-2 • dept of GP 1991 and GP Manurewa • director of the goodfellow unit 2014- • interested in knowledge translation/refineries • Research that can be used tomorrow
print • Sleep Screening tool • AASM sleep diary
goodfellow uni t.or g
goodfellow uni t.or g
goodfellow uni t.or g
goodfellow uni t.or g
goodfellow uni t.or g
• what is insomnia • what type of insomnia • what can I/we do about it
what is insomnia • do you have trouble with your sleeping (on at least 3 nights per week) such that it interferes with your activities the following day (eg unrefreshed in the morning, fatigued, poor concentration or irritability- lasting for more than one month • 41% in Auckland GP Study – Arroll et al Br J Gen Pract 2102; Feb:e99-e103
range of definitions • major current insomnia (taking at least two hours to fall asleep nearly every night 1 0% in Seattle Study – Simon GE, et Am j Psychiatr 1997;154(10):1417-23.
patient # 1 • 50 year old • BMI 35 • snores loudly at night • not feeling rested the next day • falls asleep at work
patient # 2 • 75 year old woman • Bed at 2100 wakes for 2 hours • gets up at 0600 • does not feel rested when she wakes
patient # 3 1.28 year old acoustic engineer 2.bed at 2 am 3.weekend wakes at 1000 hrs 4.during up at 6 am to go to work – tired all day
return to patients later
dr tony fernando
dr karen falloon
an interest in insomnia • tony fernando’s story • primary insomnia • “ all ” better with bed time restriction • BA skeptical → need an RCT
an interest in insomnia • primary insomnia • insomnia with no other cause • needed to know other causes • ?other causes in primary care *
causes of insomnia • depression 50% • anxiety 48% • sleep apnea 9% • general health 43% • parasomnias (Sleep walk 1%, restless legs bruxism 2% in reality about 5% Br J Gen Pract 2012; 62:e99-e103. •
causes of insomnia alcohol problem 8% other substance 4% *delayed sleep phase disorder 2% *primary insomnia 12% * mutually exclusive of other conditions
weird conditions • REM disorder • sleep eating
interest in insomnia • conducted RCT 1 0 insomnia * 75% intervention got a better sleep * 35% control group got a better sleep • sleep hygiene “effective” ?CBT • J Prim Health Care 2013;5(1):5-10.
time in bed restriction effective -?compression • More on time in bed restriction later
patient # 1 • 50 year old • BMI 35 • very tired in in daytime-asleep at work!!!!!! • wife notices that stops breathing for up to 15 seconds • snores loudly at night • wakes with dry mouth • morning headache
patient # 1 • Meets criteria for sleep apnoea • Very tired during day • Stops breathing and gasping episodes • Minor criteria – snores loudly at night – wakes with dry mouth – morning headache
patient # 1 • Needs assessment for CPAP • Pulse oximetry at night • Polysomnography (sleep lab) Treatment • CPAP (continuous positive airways pressure) • weight loss ?? • mandibular advancement splints (MAS) • surgery ???
patient # 2 • 75 year old woman • goes to bed a 2100 wakes for 2 hours in middle of night • gets up at 0600 • does not feel rested when she wakes • bored, cold lonely • use screening tool
patient # 2 • Looking at the screening tool • Will tick yes to first 2 questions → insomnia • Will tick no to all after bottom two questions • i.e. no other cause for insomnia • Hence she has primary insomnia
patient # 2 what to do • Sleep hygiene • Check on naps ( 1200 to 1500) – ~ 30 minutes mx • Exercise • Time in bed restriction • Medication
sleep hygiene • bed only for sleep or intimacy • don’t watch TV or computer screen in bed • if not asleep within 20 minutes get up • avoid caffeine before bed time • avoid energetic activity before bed time • avoid naps the during the day or else before 3 pm • make sure environment is comfortable – quiet – correct temperature – comfortable bed
sleep advice • slow down breathing • make your eyes half closed eyes • app- mysleepbutton- nonsense words • listen to podcasts • sleep routine
Exercise Cochrane review 2002 These reviewers report that evidence from one small trial is encouraging, and further research is needed.
treatment * bed time restriction * ask how long in bed ~ 9 hours * estimate time asleep approximately -or use sleep diary AASM
treatment * usually 5 to 6 hours * advise spend 5 to 6 hours in bed
treatment * if wake at 0600 hrs - go to bed 2400 * difficult to keep occupied -reading, light house work
treatment * if drowsy next day- increase by (15)30” * all changes need 1 week * may resist – consider compression
treatment * notice that getting deeper sleep * professional drivers do in vacation
treatment – other/meds 1. CBTi if you can find it- sleep restriction 2. Melatonin 3. tricyclic in low doses?? -amitriptyline 10 mg - nortriptyline
treatment – other 4. mirtazapine 15mg 6. quetiapine 7. all else fails low dose hypnotic -tolerance ? fall
other conditions- meds 1. depression and anxiety 1. TCAs 2. Mirtazapine (weight issues) 3. Add benzodiazepines 2. stop SSRIS, SNRI, buproprion
treatment- supplements good evidence -acupressure, tai chi, yoga mixed evidence -L tryptophan, mindfulness Sleep Med Rev. 2015 Dec;24C:1-12
treatment- supplements unsupportive -valerian, valerian, chamomile, kava, wuling -AEs more with valerian than placebo Sleep Med Rev. 2015 Dec;24C:1-12
treatment- supplements good evidence 1. 500 mg magnesium in elderly J res med sci 2012 Dec;17(12):1161-9 2. five mg melatonin, 225 mg magnesium, and 11.25 mg zinc – in the elderly J am geriatr soc 2011 Jan;59(1):82-90.
patient # 3 1. 28 year old acoustic engineer 2. goes to bed at 2 am and in weekend wakes at 1000 hrs 3. during the week gets up at 6 am to go to work – tired all day 4. diagnosis ??
patient # 3 1. Delayed sleep phase disorder (teenage pattern) 2. a dysregulation of a person's circadian rhythm (biological clock), compared to the general population and societal norms generally fall asleep some hours after midnight and have difficulty waking up in the morning. 3. Treat: melatonin at night and light box in am 4. Often get night jobs
take home message • insomnia is common • need to make a specific diagnosis • primary insomnia when no other cause • sleep hygiene first • time in bed restriction for primary insomnia
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