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Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia

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Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia 1 Learning Objectives • Screen patients for insomnia according to current diagnostic criteria • Identify the cause of insomnia, including psychosocial and lifestyle issues and comorbidities, to determine treatment and reduce risk factors • Individualize treatment with approved insomnia medications, including dual orexin receptor antagonists 2 2 Insomnia: Definition and Types Desired • Patient report of difficulty: wake time Sleep-maintenance ‒ Initiating sleep insomnia ‒ Maintaining sleep • Adequate opportunity and circumstances for sleep Sleep-onset • Daytime impairment insomnia Bedtime Sateia MJ. Chest. 2014;146:1387-1394; Sateia MJ, et al. J Clin Sleep Med. 2017;13:307-349. 3 3 2020 PCE Symposia Series 3 1 Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia Epidemiology of Insomnia Prevalence of Insomnia Symptoms* in the US Proportion of Patients With Insomnia† Who Discuss Symptoms with HCP 2% 5% Never Never discuss 19% Rarely 33% Mention during discussion 26% of a different problem A few nights per month Specifically seek evaluation 69% A few nights per week 25% for insomnia Every night or almost 21% every night *Insomnia symptoms defined as trouble falling asleep, waking frequently at night, †Insomnia defined as having any history of difficulty sleeping waking too early and unable to fall back asleep, or waking feeling unrefreshed Ancoli-Israel S, et al. Sleep. 1999;22(suppl 2):S347-S353; Bailes S, et al. Fam Pract. 2009;26:294-300; National Sleep Foundation. www.sleepfoundation.org/professionals/sleep-america-polls/2005-adult-sleep-habits-and-styles. Accessed October 19, 2020. 4 4 Pathophysiology of Insomnia Increased brain & body metabolism Cognitive arousal Hyperarousal EEG arousal Sympathetic nervous HPA axis activation system activation Insomnia EEG = electroencephalogram; HPA = hypothalamic-pituitary-adrenal axis. Bonnet MH, et al. Sleep Med Rev. 2010;14:9-15; Buysse D. JAMA. 2013;309:706-716. 5 5 Case Study: Kylie, a 58-Year-Old Business Manager • Primary reason for telehealth visit: wakes up around 3 AM every night and rarely gets back to sleep ‒ Symptoms began 6 months ago along with stress about working from home and maintaining company productivity due to quarantine measures • Works at small construction firm ‒ Worries about not being able to function during accepted work hours ‒ Falls asleep at computer most afternoons despite drinking coffee ‒ Complains of more time sitting, less exercise; has gained 7 pounds ‒ 1 to 2 alcoholic drinks nightly at home with partner—an increase from pre-pandemic days • Wants something to help her sleep through the night 6 6 6 2020 PCE Symposia Series 3 2 Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia Case Study (cont’d): Kylie’s History and Physical Findings • Medical history • Physical exam at her last visit ‒ Generally healthy; last in-person visit ‒ Blood pressure: 140/80 mm Hg was February 2020 ‒ Heart rate: 83 beats/min ‒ Nonsmoker ‒ Respiration rate: 16 breaths/min ‒ Postmenopausal ‒ 5 ft 9 in; 145 lb (BMI: 21.4 kg/m2) ‒ Hypertension (controlled with • Testing at last visit amlodipine) ‒ CBC, CMP, TFT: all within normal • Anxious affect apparent during telehealth ranges consult 7 CBC = complete blood count; CMP = complete metabolic panel; TFT = thyroid function test. 7 7 Risk Factors for Insomnia • Age ≥65 years • Female • Shift work • Stressors (eg, unemployment, divorce) • Lower socioeconomic status • Comorbid conditions Matheson E, et al. Am Fam Physician. 2017;96:29-35; Schutte-Rodin S, et al. J Clin Sleep Med. 2008;4:487-504. 8 8 What To Ask About When Taking a Thorough Insomnia History Include history from bed partners or caregivers whenever possible • Frequency and quality of snoring • Activities before bed • Trouble falling sleep (eg, time to fall asleep) • Bedroom environment • Awakenings (eg, number, duration) • Daytime symptoms and activities (fatigue, naps, • Quality of sleep (poor or unrefreshing) work, quality of life) • When symptoms first started • Disturbance in mood or cognitive function • Frequency and severity of symptoms • Associated symptoms and behaviors surrounding and during sleep • Duration of sleep • Contributing comorbid conditions, medications, • Contributing and perpetuating factors and substances • Prior treatments and responses Riemann D, et al. J Sleep Res. 2017;26:675-700; Schutte-Rodin S, et al. J Clin Sleep Med. 2008;4:487-504. 9 9 2020 PCE Symposia Series 3 3 Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia Effects of COVID-19 Measures on Sleep • Higher rates of insomnia, depression, anxiety reported in essential workers and general population • Disruption of regular schedules contributes to sleep disorders ‒ Effects of confinement/social isolation and limited outdoor activity ‒ Loss of sleep-wake cues due to atypical work, social, and exercise schedules • Depression and/or anxiety related to finances, social isolation, worries about childcare or infection • Changes in work schedules add to concerns about exposure and family time Altena E, et al. J Sleep Res. 2020;29:e13052; Morin CM, et al. Can J Public Health. 2020;July 22:1-4. 10 10 Impact of Insomnia • Impaired daytime functioning • Risk factor for: – Drowsy driving and fatal crashes – Coronary artery disease – Injuries and accidents – Depression – Decreased quality of life – Hypertension – Increased presenteeism and – Diabetes absenteeism – Obesity – Stroke – Suicide attempts – Overall mortality Daley M, et al. Sleep. 2009;32:55-64; Liu Y, et al. MMWR. 2016;65:137-141; National Center for Statistics and Analysis. crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812446. Accessed October 19, 2020; Winkelman JW. N Engl J Med. 2015;373:1437-1444. 11 11 Increased Prevalence of Medical Disorders in People With Insomnia 100 90 No Insomnia (n = 401) P <.001 80 Insomnia (n = 137) 70 60 P <.001 50 P <.001 40 P <.001 Patients (%) 30 P <.01 P <.05 P <.01 20 P <.05 10 0 Heart Cancer Hyper- Neurologic Breathing Urinary Diabetes Chronic GI Any Disease tension Disease Problems Problems Pain Problems Medical Problems Taylor DJ, et al. Sleep. 2007;30:213-218. 12 12 2020 PCE Symposia Series 3 4 Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia Contributing Medications and Substances Category Medications or Substances Stimulants Caffeine, amphetamines, methylphenidate, ephedrine, cocaine Antidepressants SSRIs (eg, sertraline, citalopram), duloxetine, venlafaxine, MAOIs Decongestants Pseudoephedrine, phenylephrine, phenylpropanolamine Opioids Codeine, oxycodone, propoxyphene, hydrocodone, meperidine, morphine, heroin Cardiovascular Diuretics Corticosteroids Hydrocortisone, cortisone, prednisolone, prednisone, methylprednisolone, dexamethasone (oral, IV, IM) Pulmonary Albuterol, theophylline Alcohol Alcohol MAOI = monoamine oxidase inhibitor; SSRI = selective serotonin reuptake inhibitor. Schutte-Rodin S, et al. J Clin Sleep Med. 2008;4:487-504; Serdarevic M, et al. Sleep Health. 2017;3:368-372; Warrington TP, et al. Mayo Clin Proc. 2006;81:1361-1367. 13 13 Multiple Factors Contribute to Insomnia • Sleep history provides clues to patient’s symptoms and environment • Medical history can identify comorbidities that may contribute to, or result from, insomnia • Medications, foods, alcohol, and recreational substances often contribute to insomnia • Identify modifiable triggers as a first step in management 14 14 Case Study (cont’d): Kylie’s Sleep History • Goes to bed by midnight and falls asleep quickly (confirmed by partner) • Wakes up around 3:00 AM every night, followed by no or fitful sleep until final awakening at 7:00 AM (desired wake-up time) • Partner confirms no snoring, breathing pauses, or limb movements during sleep • Forgetful, fatigued, slower than normal at work tasks despite six cups of coffee daily • Feels that symptoms are worsening over time (confirmed by partner) 15 15 2020 PCE Symposia Series 3 5 Beyond Counting Sheep: New Strategies for Sleep Maintenance Insomnia DSM-5 Diagnostic Criteria for Insomnia A. Dissatisfaction with sleep quantity or quality with one or more of the following: 1. Difficulty initiating sleep 2. Difficulty maintaining sleep • Poor sleep maintenance 3. Early morning awakening with inability to return to sleep is the most prevalent B. Significant distress or impairment in social, occupational, educational, academic, symptom, reported by behavioral, or other important areas of function 50% to 70% of adults C. ≥3 nights per week with insomnia D. ≥3 months • However, multiple sleep E. Adequate opportunity for sleep symptoms are more F. Not better explained by or solely due to another sleep-wake disorder common than single symptoms G. Not attributable to medication or substance use H. Not adequately explained by comorbid medical or mental disorders 16 Buysse D. JAMA. 2013;309:706-716; Center for Behavioral Health Statistics and Quality. www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t36/. Accessed October 19, 2020. 16 16 Assessing Severity of Symptoms • Sleep diary ‒ Helps identify patterns or behaviors that contribute to insomnia • Insomnia Severity Index (ISI) ‒ 7-item ISI is a validated, patient-completed tool ‒ Helps identify sleep onset from sleep maintenance insomnia • Other useful instruments ‒ Epworth Sleepiness Scale (ESS): Assesses daytime sleepiness ‒ Sleep Hygiene Self Test (SHST): Assesses behaviors contributing to insomnia ‒ Simple
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