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Sleep and Christopher Okiishi, MD

Significant contribuons from: Schue-Rodin S; Broch L; Buysse D; Dorsey C; Sateia M. Clinical guideline for the evaluaon and management of chronic insomnia in adults. J Clin Sleep Med 2008;4(5):487-504.

Sleep

• Seen in most living creatures • Seems to have a restorave funcon • Physical • Mental / Emoonal • Learning • Some variability in need for sleep across populaon by age • Sleep needs gradually lessen as me goes by • Young children – 10 – 14 hours of sleep / night • Adolescents – 8.5 – 10 hours of sleep / night • Adults – 7.5 – 9 hours of sleep / night

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Dangers of Too Lile Sleep

• Poor concentraon • Grades suffer with even ½ less sleep than needed • Work performance • Loss of energy • Worse coordinaon • Decreased ability to fight infecons • Increased risk of Cardiac Disease, Diabetes • Weight Gain • Mood / implicaons • Special risk in families with BiPolar Disorder

Normal Sleep

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Normal Sleep

Sleep Disorders

• Insomnia • Due to Mental Illness • Due to Physical Illness (including medicaon side effect) • Due to Other • Primary Insomnia • • Sleep Related Movement Disorders / Breathing Disorders • Circadian Rhythm Disorders

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Mental Illnesses with Sleep Disturbance

• Mood disorders: Major depressive disorder, bipolar mood disorder, dysthymia • Anxiety disorders: Generalized anxiety disorder, , posraumac stress disorder, obsessive compulsive disorder • Psychoc disorders: Schizophrenia, schizoaffecve disorder • Amnesc disorders: Alzheimer disease, other demenas • Neurodevelopmental Disorders: Aenon deficit disorder • Other disorders and symptoms: Adjustment disorders, personality disorders, bereavement, stress

Physical Illnesses with Sleep Disturbance

• Neurological: Stroke, demena, Parkinson disease, seizure disorders, headache disorders, traumac brain injury, peripheral neuropathy, chronic pain disorders, neuromuscular disorders • Cardiovascular: Angina, congesve heart failure, dyspnea, dysrhythmias • Pulmonary: COPD, emphysema, asthma, laryngospasm • Digesve: Reflux, pepc ulcer disease, cholelithiasis, colis, irritable bowel syndrome • Genitourinary: Inconnence, benign prostac hypertrophy, nocturia, enuresis, intersal cyss

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Physical Illnesses with Sleep Disturbance

• Endocrine: Hypothyroidism, hyperthyroidism, diabetes mellitus • Musculoskeletal: Rheumatoid arthris, osteoarthris, fibromyalgia, Sjögren syndrome, kyphosis • Reproducve: Pregnancy, menopause, menstrual cycle variaons • Other: Allergies, rhinis, sinusis, bruxism, and other substance use/dependence/withdrawal

Treatment of Insomnia with Associated Mental / Physical Illness • Treat / stabilize mental condion aggressively • Where sleep loss / sleep disturbance is aggravang recovery / causing severe impairment, treat simultaneously, but ween treatment rapidly • Choose agents that will not worsen primary illness (e.g. depress breathing, trigger mania, prolong QTc, etc.)

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Medicaons with Insomnia as Side Effect

• Andepressants: SSRIs, venlafaxine, duloxene, monoamine oxidase inhibitors, bupropion • Smulants: Caffeine, methylphenidate, amphetamine derivaves, ephedrine and derivaves, cocaine • Decongestants: Pseudoephedrine, phenylephrine, phenylpropanolamine • Narcoc analgesics: Oxycodone, codeine, propoxyphene • Cardiovascular: β-Blockers, α-receptor agonists and antagonists, diurecs, lipid-lowering agents • Pulmonary: Theophylline, albuterol • Alcohol

Parasomnias

• Non-rapid eye movement (NREM) • Confusional • (somnambulism) • Sleep terrors (night terrors) • Teeth grinding (bruxism) • Sleep sex • Sleep related eang disorder (SRED) • REM parasomnias • REM sleep behavior disorder • Recurrent isolated sleep paralysis

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Treatment of Parasomnias

• Non-REM • GET MORE SLEEP (especially in children) • Relavely benign illnesses for the most part • Behavioral / environmental intervenons • are treatment of choice in severe cases • Referral to sleep specialist • REM Sleep Disorders • REM Sleep Behavior Disorder can be deadly • Benzodiazepines, physical restraints • Refer to sleep specialist • Recurrent Isolated Sleep Paralysis • Rarely dangerous, but quite alarming • Sign of underlying illness?

Evaluang Primary Insomnia

• Good history, including sleep hygiene • Paern of sleep—insomnia v. sleep phase • Contribung factors • Sleep diary

• Epworth Sleepiness Scale • Rate on scale of 1 – 4 for each situaon

• 0 = would never doze • 1 = slight chance of dozing • 2 = moderate chance of dozing • 3 = high chance of dozing

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Evaluang Primary Insomnia • Epworth Sleepiness Scale Situaon Chance of dozing (0 = low, 3 = high) Sing and reading Watching TV Sing sll in a public place (e.g. a

theatre, a cinema or a meeng) As a passenger in a car for an hour

without a break Lying down to rest in the aernoon

when the circumstances allow Sing and talking to someone Sing quietly aer lunch without

having drunk alcohol In a car or bus while stopped for a few minutes in traffic

Evaluaon of Primary Insomnia

• Epworth Sleepiness Scale • Scoring: • 0-5 Lower Normal Dayme Sleepiness

• 6-10 Higher Normal Dayme Sleepiness

• 11-12 Mild Excessive Dayme Sleepiness

• 13-15 Moderate Excessive Dayme Sleepiness

• 16-24 Severe Excessive Dayme Sleepiness

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Treatment

• Educaon • Sleep phase • Sleep expectaons • Basic Sleep Hygiene • Avoidance of triggers / impairments • Screens • Exercise (might be good for some!) • Cognive Behavioral Therapy • Relaxaon Techniques

Medical Treatment

• Receptor Agonisc Modulators • Sonata, Ambien, Belsomra, Lunesta • Mimic normal sleep • Can be addicve if used to get high • Must go to sleep aer taking • Benzodiazepines • All can have effect • Restoril, Halcion have specific use • Mimic normal sleep—but may disrupt sleep architecture • Can be addicve if used to get high • Must go to sleep aer taking

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Andepressants

• NSRIs • Remeron • Serotonin, Norepinephrine • Sedaon, but less sexual side effects, increased appete • Trazodone • Serotonin • Not a great andepressant, now used mostly for sleep

• Tricyclics • Amitriptyline • Doxipin • Check EKG to assess prolonged QTc • Can cause conspaon, dry mouth, sexual dysfuncon

Others

• Anhistamines • Quickly tolerant • Delirium • Rozarem • Prescripon strength melatonin • Sleep phase disorders

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