FMF 2019

Managing Insomnia and Other Sleep Problems in Your Practice

Nick Kates MB.BS FRCPC MCFP(hon)Professor and Chair

Dept. of Psychiatry & Behavioural NeurosciencesMember, Dept. of Family Medicine

McMaster University

Faculty/Presenter Disclosure

• Faculty: Nick Kates

• Relationships with financial sponsors:

– Grants/Research Support: Labarge Community Foundation

– Speakers Bureau/Honoraria: None

– Consulting Fees: None

– Patents: None

– Other: None

Plan

• Why sleep matters

• The sleep cycle

• Different sleep problems

• Assessing Insomnia

• Treating Insomnia

Scientists have discovered a revolutionary new treatment that makes you live longer. It enhances your memory and makes you more creative. It makes you look more attractive. It keeps you slim and lowers food cravings. It protects you from cancer and dementia. It wards off colds and the flu. It lowers your risk of heart attacks and stroke, not to mention diabetes. You’ll even feel happier, less depressed and less anxious. Are you interested?

What is sleep?Sleep is a dynamic and regulated set of

behavioral and physiological states during which many

processes vital to health and well-being take place.

• Learning and memory consolidation

• Balance ghrelin and leptin production

• Promotes healing of some body structures

• Boosts the immune system

• Reduces cortisol levels

• Cleansing of beta-amyloid proteins associated with Alzheimer’s

• Healthy brain development

Sleep is an active and essential process

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How much sleep do we need• Average is 7-9 hours – Great variation – Minimum 6 hours

• Almost 45% of adults report not getting enough sleep.

• 10-15% report chronic insomnia

• 40% report daytime drowsiness

• 85% of teens get less than the minimum (8 hours)

• Getting less sleep by the year (were once biphasic)

Consequences of insufficient sleep

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Health Consequences of Inadequate or Poor Sleep

• Diabetes• Obesity• GI problems – especially reflux• Cardiovascular Problems• Memory impairment• Mood changes• Inattention and decreased reaction

time

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Safety is compromised• 51% of adults report driving drowsy; • 17% dozed off at the wheel• 2013 - 10,000 sleep-related crashes

– 150 fatalities – 4,000 injuries

• 27% report being sleepy at work at least 2 days / week• 19% report making errors at work • 2% report being injured

• Hypnotic Drug Dependence

Sleep Cycle

Stage 1 Light sleep, drift in and out, awaken easily Eyes move slowly, muscle activity slows May experience a sense of falling followed by sudden muscle contractions

Stage 2 Eye movement stops Brain waves are slower, occasional bursts of rapid waves

Stage 3 Extremely slow waves-Delta waves Interspersed with smaller faster waves Considered deep sleep

No eye or muscle movement, difficult to awaken Time when sleepwalking, bedwetting, or terrors occur

Stage 4 Almost exclusively Delta waves Considered deep sleep

Stages of Sleep

Rapid Eye Movement (REM) Sleep Brain waves increase to the awake level

Most dreams occur during this stage If awoken in this stage, most people remember their dreams

Physical changes during REM Increase in H.R., B.P., and breathing rate Breathing more shallow and irregular Eyes jerk rapidly Limb muscles temporarily paralyzed Some loss of temperature regulation Men may experience erections

Most people have 3-5 intervals of REM each night Infants spend 50% of time in REM Adults spend nearly half of time in Stage 2 20% in REM, other 30% divided among other stages Progressively spend less time in REM as we age

Sleep Stages• Stage 1- Transition to sleep, 5% of total time

• Stage 2- Light non REM sleep 50% of total time

• Stage 3 & 4- Deep, slow wave Non-REM sleep, Most restorative sleep 20-25% of total sleep time

• REM - Rapid eye movement – When we dream 20-25% of total sleep time

Sleep Stages• Stage 1 & 2

• Stage 3 & 4 – Storing memories– Trimming synapses– Moving memories within

• REM – Within the pre-frontal cortex– Cognitive functioning– Emotional intelligence– Memory integration– Creativity– Insight and problem solving

Comparison of Sleep Cycles in Young Adults and the Elderly

The elderly tend to have less stage 3 and 4 sleep and develop advanced phase sleep syndrome (go to bed early, wake up early), while the young tend to have delayed phase shift syndrome (go to bed late, wake up late).

.

Hours of Sleep

Young Adults

Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

1 2 3 4 5 6 7 8

Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

1 2 3 4 5 6 7 8Hours of Sleep

Elderly

Sleep and Brain Development

• Evolution of the circadian rhythm (Suprachiasmatic nucleus)

– 2 months

– Through the teenage years

– Aging

• Impact on brain development with disrupted REM sleep

– ADHD

– ASD

– Effects of alcohol

• Changes in Non-REM sleep precede all cognitive developmental milestones

Sleep and the older patient

• Fragmented

• Less deep sleep

• Decreased sleep efficiency

• Circadian rhythm moves (back) earlier

• Decreased cognitive performance with less sleep

• Harder to store, integrate and recall memories

• Areas that drive deep sleep are also the areas that are most likely to show degeneration (ie Alzheimers)

© Copyright 2003 National Sleep Foundation 20

Sleep needs vary over the life cycle.

Newborns/Infants0 - 2 months:

2 - 12 months:

10.5-18 hours14-15 hours

Toddlers/Children

12 mo - 18 mo:

18 mo - 3 years:

3 - 5 years:

5 - 12 years:

13-15 hours12-14 hours

11-13 hours10-11 hours

Adolescents On Average: 9.25 hours

Adults/Older Persons On Average: 7-9 hours

© Copyright 2003 National Sleep Foundation 21

Sleep patterns and characteristics change

over the life cycle.

Newborns/Infants More active in sleep; 50% REM; several periods of sleep; need naps

Toddlers Sleep begins to resemble adult patterns

Children Experience more deep sleep

Adolescents Shift to later sleep-wake cycle; experience daytime sleepiness

Adults Need regular sleep schedule to obtain sufficient, quality sleep

Older AdultsMore likely to have medical problems; sleep disrupters & disorders;

sleep less efficiently

Process that control our sleep cycle

1 Sleep homeostasis or sleep pressure – role of adenosine

• Pressure to sleep increases during the day until an internal threshold is crossed causing sleep to occur

• Waking occurs when homeostatic drive decreases sufficiently to cross opposite threshold

Sleep is regulated by two body systems:

1 Sleep homeostasis or sleep pressure – role of adenosine

• Pressure to sleep increases during the day until an internal threshold is crossed causing sleep to occur

• Waking occurs when homeostatic drive decreases sufficiently to cross opposite threshold

2 Circadian rhythms• Cyclical changes driven by an internal

“biological clock” located in the

suprachiasmatic nucleus (SCN)

• Synchronised to external environment

Sleep is regulated by two body systems:

1 Sleep homeostasis or internal drive, exact mechanism unknown

• Pressure to sleep increases throughout the day until an internal threshold is crossed causing sleep to occur

• Waking occurs when homeostatic drive decreases sufficiently to cross opposite threshold

2 Circadian rhythms

• Refers to cyclical changes that

occur over a 24 hour period driven

by an internal “biological clock”

located in the brain in the

suprachiasmatic nucleus (SCN)

• Synchronized to external physical

environment

Teens Experience a Shift

to a Later Sleep-Wake Cycle

• The biological clocks of children shift during adolescence,

which drives them to a later bed time schedule (around

11:00 pm) and a natural tendency to wake later in the

morning.

• This delayed phase syndrome can place them in conflict

with their schedules – particularly early school start times.

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Common Circadian Disruptions

Shift Work Jet Lag

Working evening, night, irregular

or rotating shifts

Traveling across time zones

disrupts sleep

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Quality of Sleep• Sleep patterns

• Sleep habits

• Environmental factors

• Sleep consequences

• Other potential causes (psychosocial factors)

Measuring Sleep Quality

• Sleep latency

• Number of awakenings

• Wake after sleep onset

• Total sleep time

• Time in Bed

• Sleep efficiency (85%)

• Nap times

Types of sleep problems

Types of Sleep Problems Insomnia

Sleep-related breathing disorders

Obstructive / central sleep apnea syndrome

Sleep-related movement disorders

Restless leg syndrome, periodic limb movement disorder,

Circadian rhythm sleep-wake disorders

Jet lag or shift work

Delayed or advanced sleep-phase syndrome

Hypersomnias

Narcolepsy

Parasomnias related to non-rapid eye movement

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Sleep Apnea• 3-5 % of adults – Male, obese, over 50, family Hx

– Central or Obstructive

– Snoring

– Restless

– Wake with panic symptoms

– Day-time sleepiness

• Can contribute to obesity, cognitive changes, hypertension, MI

• 2% of children – Snoring

– Tonsils

• Polysomnography – Measures apnoeic episodes an hour– 5 – 14 = mild

– 14 – 29 = Moderate

– >30 = Severe

Treatmentof sleep apnoea

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Sleep Apnea

• Behavioral Therapy– Avoid alcohol, nicotine

and sleep medications– Lose weight if overweight

• CPAP (Continuous Positive Airway Pressure)

• Dental appliance

• Surgery

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Restless Leg Syndrome• Unpleasant, tingling, creeping feelings or

nervousness in legs during inactivity and sleep with an irresistible urge to move; 80% may have involuntary jerking of limbs

• 4-14%; can be genetic

• A neurological movement disorder leading to daytime sleepiness; can be associated with other medical conditions/problems

• Periodic Limb Movement Disorder

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Restless Leg Syndrome• Check Iron levels

• Dopamine agonists – Ropinirole (Requip) 0.25mgm – 2mgm

– Pramipexole (Mirapex) 0.125 mgm – 0.5mgm

• Gabapentin

• Pregabalin

• Clonazepam

Insomnia

• Inadequate or poor quality sleep:

• Difficulty falling asleep

• Frequent awakenings during the night

• Waking too early and being unable to go back to sleep

• Unrefreshed or non-restorative sleep

• Daytime fatigue or deficits in

functioning

What is Insomnia

Types of InsomniaPrimary – Transient, Short-term or Long-term

Psychophysiological

Adjustment

Paradoxical

Sleep hygiene

Idiopathic

Secondary

Drugs

Medical conditions

Psychiatric Disorders

Approach to assessing insomnia• Screening questions / ask

• Rule out

– Medical condition

– Medication effects

– Psychiatric disorder

– Stressors / changes that may be interfering with sleep

• Assess quality of sleep and sleep habits

• Ask what someone does to try to get to sleep

• Sleep log / Rating scale

• Refer if help is needed with a diagnosis

Screening for Sleep Disorders

• Are you content with your sleep? Do you feel refreshed on waking (insomnia)

• Are you excessively sleepy during the day? (May suggest narcolepsy, primary hypersomnia and obstructive apnea )

• Does your bedpartner (or parent) complain about your sleep? (parasomnias, sleep apnoea and RLS)

• B - bedtime problems?

• E - excessive sleepiness during the day?

• A - awakenings at night?

• R - regularity of sleep (number of hours)?

• S - sleep disorders…including sleep apneaand snoring

• Also, may inquire about lifestyle factors impacting sleep such as work schedule, alcohol use, illness, medications, bed sharing arrangements, etc….

B E A R S

Medical Conditions Contributing to Insomnia

• Hyperthyroidism

• Arthritis or any other chronic painful condition

• Chronic lung or kidney disease

• Cardiovascular disease (heart failure, CAD)

• Heartburn (GERD)

• Neurological disorders (epilepsy, Alzheimer’s, headaches, stroke, tumors, Parkinson’s Disease)

• Diabetes

• Menopause/Menstrual disorders

• Autism Spectrum Disorders

• Depression, Anxiety, BAD, Psychotic disorders

• Alcohol

• Caffeine/chocolate

• Nicotine/nicotine patch

• Beta blockers

• Calcium channel blockers

• Bronchodilators

• Corticosteroids

• Decongestants

• Antidepressants

• Thyroid hormones

• Anticonvulsants

• Anti-hypertensives

Medications Contributing to Insomnia

Common Investigations

• Epworth Sleepiness Scale

• Sleep Log

• Polysomnography (referral)

Treatment of Sleep Problems

• Education about sleep

• Sleep hygeine

• Cognitive and Behavior Therapy (CBTI)

• Self-prescribed over the counter sleep aids

• Prescription medications

Sleep Education

• Importance of sleep

– Mental health

– Physical health

– Other consequences

• Sleep cycle

• Dispel sleep myths

• Making it a priority

• Benefits or otherwise of sleep medication

• Alternatives to sleep medication

False beliefs about insomnia

• Misconceptions about causes of insomnia– “Insomnia is a normal part of aging.”

• Unrealistic expectations re: sleep needs– “I must have 8 hours of sleep each night.”

• Faulty beliefs about insomnia consequences– “Insomnia can make me sick or cause a mental breakdown.”

• Misattributions of daytime impairments– “I’ve had a bad day because of my insomnia.” – I can’t have a normal day after a sleepless night.”

• Myths about what behaviors lead to good sleep– “When I have trouble getting to sleep, I should stay in bed and

try harder.”

• Having good sleep hygiene knowledge is weakly associated with good sleep hygiene but is not related to overall sleep quality.

• Practicing good sleep hygiene is strongly related to good sleep quality.

Sleep Hygiene

Sleep Hygeine• Fix a bedtime and an awakening time • Avoid napping during the day • Avoid alcohol, nicotine, chocolate before bed• Avoid caffeinated beverages 4 – 6 hours before bedtime• Avoid heavy, spicy, acidic or sugary foods before bed• Avoid screen time before and after going to bed• Exposure to bright light in the morning• Regular exercise is helpful, but not too close to bedtime• Comfortable bedding• Bedroom cool, dark, quiet• White noise, blackout curtains, ear plugs, humidifiers• The bedroom is NOT a work room – sleep & sex

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Bed Time Routine• Hot herbal tea or warm milk

• Read or listen to books on tape

• Crossword puzzle, Sudoku or knitting

• Relaxing music

• Comfortable sleep wear

• Use the bathroom

• Scents (lavender, vanilla)

• Deal with your worries before bedtime

– Plan for the next day before bedtime

– Set a worry time earlier in the evening

– Keep a journal

• Journaling

– Writing down things you can’t get out of your head.– Make a list of things you are worried about or need to

do that might keep you up at night.

CBT for Insomnia

• Cognitive restructuring

• Stimulus Control

• Sleep restriction

• Relaxation

• Paradoxical intention

Cognitive Restructuring

• Identify thought processes to reduce anxiety

• Includes self-talk, distraction, rationalization

• Helpful in altering dysfunctional sleep beliefs

• Postponing worry episodes

• Limited benefits if used alone Not sufficient as a stand alone treatment

• Identify beliefs about sleep that are incorrect

• Challenge their truthfulness

• Substitute realistic thoughts

Cognitive Restructuring

Stimulus Control

• Insomnia is a conditioned response to temporal and

environmental cues

• Promote consistent sleep / wake cycle

• Re-associate the bedroom with sleeping

• Well established stand alone treatment

Stimulus control therapy– Assumes that there is a learned associated between

wakefulness and the bedroom

– To break the cycle, the patient must not spend time wide awake in the bedroom

– Go to bed only when sleepy

– Do not use the bedroom for sleep-incompatible activities

– Leave the bedroom if awake for more than 20 minutes

– Return to bed only when sleepy

– Repeat if necessary

– Do not nap during the day

– Arise at the same time every morning

Sleep Restriction

• Reducing time in bed to match sleep obtained

• To increase sleep efficiency

• Adherence is problematic

• Probably efficacious treatment

Sleep Restriction

• Cut bedtime to the actual amount of time you spend asleep (not in bed), but no less than 4 hours per night

• No additional sleep is allowed outside these hours

• Record on your daily sleep log the actual amount of sleep obtained

• Compute sleep efficiency (total time asleep divided by total time in bed)

• Based on average of 5 nights’ sleep efficiency, increase sleep time by 15 minutes if efficiency is >85-90%

• With elderly, increase sleep time if efficiency >80% and allow 30 minute nap.

Sleep Restriction

• If sleep efficiency falls to less than 80%, decrease time in bed by 15 minutes

• Have set, daytime hours (whenever possible).

• As sleep consolidation improves, time in bed (and asleep) increases.

• Creates a mild state of sleep deprivation, and thus promotes more rapid sleep onset and more efficient sleep

Sleep Restriction

Relaxation

• To deactivate arousal system

• Various types - muscular, imaging, hypnosis, etc.

• Well established treatment

• Worry postponement

Relaxation• Plan a relaxation period before bed, develop a

bedtime routine.• Relaxation Therapy:

– Progressive muscle relaxation* best– EMG Biofeedback* best– Meditation– Imagery training– Self-hypnosis– Diaphragmatic breathing

Paradoxical Intention

• Engage in the feared outcome (not sleeping)

• Break cycle of performance anxiety

• Large variance in response

Efficacy Of CBT For Insomnia

Benefits of CBTI

Benefits are long-lasting, even after therapy is over

Relatively free of medical risks

No significant interactions with other medical treatments

Can be used in conjunction with medications

Challenges with CBTIMonetary cost (repeated visits to a provider)

Improvement may not occur for several weeks

Requires time and motivation

Daytime sleepiness during sleep restriction

Lack of access to a trained therapist

Lack of therapist expertise

• Antihistamines (Diphenhydramine 25 – 50 mgm)

– Can cause mental & cognitive changes, motor impairment

– Sedation may carry over until daytime

• Melatonin

– May improve sleep onset + maintenance

• Regular structured exercise

• Herbal – L-Tryptophan, Valerian Root, Kava Kava

Non-prescription agents

Mostly: L-Tryptophan, Valerian, & Kava-kava

• L-Tryptophan: precursor of Serotonin, a substrate for Melatonin – in milk (doesn’t need to be warmed) & turkey – FDA has limited availability after > 1,500 cases of Eosinophilia Myalgia Syndrome with at least 37 deaths in 1989

• BZD agonists– Zolpidem 5-15 mgm– Zopiclone 2.5 – 10 mgm

• (Melatonin agonists)– Ramelteon 8mgm

• Anti-depressants– Doxepin 3-6 mgm– Trazodone 25-100 mgm– Amitriptyline 25 – 100mgm– Mirtazapine 7.5 - 15 mgm

• Benzodiazepines– Temazepam 7.5 – 30 mgm– Lorazepam 0.5 – 1.0 mgm– Alprazolam 0.25 – 1.0 mgm

• Neuroleptics– Quetiapine 25-100 mgm– Loxapine 10 – 20 mgm

• Orexin-Receptor Antagonists– Suvorexant 10 – 20mgm

• Gabapentin 600 – 1800 mgm

• Prazosin 1-3 mgm

• Pregabalin 75 – 300 mgm

• Clonidine 0.1 – 0.3 mgm

Medications to consider

• Low‐dose cannabis use appears to decrease sleep onset latency and decreases REM sleep.

• Chronic use leads to suppression of slow wave sleep.

• No dreams due to REM suppression

• Slow wave sleep most restorative so decrease correlates with poor quality of sleep

Sleep Onset Insomnia

• Zolpidem

• Ramelteon

• Temazepam

• Zopiclone

• (Lorazepam)

Sleep Maintenance Insomnia

• Doxepin

• Zopiclone

• Temazepam

• Zolpidem

• Suvorexant

• (Lorazepam)

Choice of Agent 2017 AASM Guidelines

Seniors• Doxepin

• Zolpidem / Zopiclone

• Trazodone

• Temazepam / Lorazepam

Pain• Gabapentin

• Nortriptylene

• Duloxitene

• Temazepam / Lorazepam

• Zolpidem / Zopiclone

• Topirimate

• Trazodone

• Paragabalin

Choice of Agent

Guidelines when using medication Manage the relationship

Don’t feel pressured into doing ”something”

Education ie re tolerance / psychological dependency

Clear contract ie duration

Sleep hygiene and CBTI first or in combination

Use the minimum effective dose

Limit to less than 30 days if continuous, 6 months if intermittent (longer if

not BZD)

Watch for psychological dependency

Review potential side effects, especially daytime sleepiness

Look for rebound insomnia after discontinuation

Consider intermittent use if long-term therapy is required

Consider consultation with a sleep specialist before starting continuous,

long-term therapy with hypnotic medication

When Prescribing Medication

Use the minimum 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

• 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

Contraindications to drug therapy

• Sedating anti-histamines– Cardiopulmonary disease and urinary retention

• 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 interactions with complementary and alternative

medications

• On-Line Self Help Resources

• www.sleepfoundation.org

• www.aasmnet.org

• www.bettersleep.org

• www.sleepresearchsociety.org

• www.sleepandhealth.com

• www.kidzzzsleep.org

References

• Thorpy M, Classification of sleep disorders Neurotherapeutics 2012 Oct; 9(4): 687–701. Published online 2012 Sep 14. doi: 10.1007/s13311-012-0145-6

• Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307–349