The Effect of the Short Term Use of Zolpidem MR on Poor Sleep, Daily Pain and Depression in Arthritis Patients
Total Page：16
File Type：pdf, Size：1020Kb
View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Wits Institutional Repository on DSPACE The effect of the short term use of Zolpidem MR on poor sleep, daily pain and depression in arthritis patients By Daniela Benjamin Supervisors Dr Alison Bentley Dr Karine Scheuermaier A dissertation submitted to the Faculty of Health Science, University of the Witwatersrand, Johannesburg, in fulfillment of the requirements for the degree of Master of Science in medicine. Johannesburg 2014 i DECLARATION I declare that this dissertation is my own, unaided work. It is being submitted for the degree of Master of Science in medicine in the University of the Witwatersrand, Johannesburg. It has not been submitted before for any degree or examination in any other University. ________________________________ Daniela Benjamin ____ th day of_________October___________2014 ii ABSTRACT Introduction: The presence of pain during sleep causes patients with chronic daily pain, such as in Rheumatoid and Osteoarthritis, to experience insomnia, fragmented sleep and an increased number of night-time awakenings. This poor sleep results in an increased sensitivity to pain during the day. The effect of improving sleep on pain, sleep and mood after taking Zolpidem MR was the aim of this study. Methods: 11 patients from Chris Hani Baragwanath Hospital in Soweto South Africa who reported insomnia and daily pain spent 4 weeks in this crossover design, double blinded, placebo controlled study. Week 1- baseline, week 2 and 4 were Intervention weeks – either placebo or Zolpidem MR, week 3 was a Washout week. Data collected included actigraphy, McGill Pain Questionnaire, PSQI, BDI, physical activity questionnaire and daily sleep and pain diaries containing VAS scales for sleep and pain. Results: No significant changes were found in the pain or physical activity levels in any of the patients. Sleep quality, as measured by an isolated PSQI question, was improved by Zolpidem MR (p=0.0075). PSQI was decreased in the final week of the study compared to baseline (8.7 vs. 11.3, p=0.0106) and BDI was lower in week 4 than baseline (7.7 vs. 15.85, p=0.0003), BDI was also lower in week 4 compared to week 2 (7.7 vs. 12.8, p<0.05). However the changes in PSQI and BDI were a result of the order of the weeks, with patients interacting with the researcher and were not due to either Zolpidem MR or placebo. Anecdotal reports include feeling more energised and capable of living life. Conclusion: This study has shown that human interaction is an important component of treatment for insomnia and chronic pain as there is a positive effect on sleep disruption and depression. iii ACKNOWLEDGEMENTS I would like to thank my supervisors Dr Alison Bentley and Dr Karine Scheuermaier for teaching me, encouraging me and guiding me through this Masters. Without their continued support I would not have been able to do this project. I would like to thank Professor Mohammed Tikly and the entire Arthritis department at Chris Hani Baragwanath Hospital. I especially want to thank the patients without whom this study would not have been possible. Thank you to the Sleep Laboratory at Wits University for their financial support, to the members of the sleep lab for all their help and particular thanks go to my lab partner Ryan Inkley for being in the trenches with me. My gratitude goes out to my friends for their emotional support and encouragement throughout this project. Lastly and most importantly I would like to thank my parents who have been my rock throughout this Masters, who have been there for me through all the blood, sweat and tears and without whom I would never have managed to do anything in life, especially this Masters. iv TABLE OF CONTENTS DECLARATION ii ABSTRACT iii ACKNOWLEDGEMENTS iv LIST OF FIGURES vii LIST OF TABLES viii LIST OF ABBREVIATIONS ix CHAPTER ONE – LITERATURE REVIEW 1.1 Introduction 2 1.2 Sleep physiology 2 1.2.1 Sleep and wake promoting systems 2 1.2.2 Measurement of sleep - Objective 3 1.2.3 Measurement of sleep - Subjective 6 1.2.4.3 Insomnia 7 1.2.4.3.1 Definition/ diagnosis of insomnia 7 1.2.4.3.2 3P Model of primary insomnia 9 16 1.2.4.3.4 Epidemiology 10 1.3 Pain physiology 11 1.3.1 Definition 11 1.3.2 Measurement of pain 12 1.3.3 The effect of pain on sleep 12 1.3.4 Impact of sleep deprivation on physiological function 14 1.3.5 The effect of sleep deprivation on pain 16 1.4. Arthritis 17 1.4.1 Osteoarthritis 17 1.4.2 Rheumatoid arthritis 18 1.4.3 Epidemiology 18 1.4.4 Arthritis pain and sleep 19 1.5 Confounders-depression 21 1.5.1 Depression and sleep 21 1.5.2 Depression and pain 22 1.6 Physical activity 24 1.7 Treatment 26 1.7.1 Treating pain 26 1.7.2 Treating pain and insomnia in arthritis 27 1.7.3 Non – pharmacological treatment of insomnia 30 1.7.4 Pharmacological treatment of insomnia 31 1.7.4.1 Benzodiazepines 31 v 1.7.4.2 Non – benzodiazepines 32 1.7.4.2.1 Zolpidem 33 1.8 Literature review conclusion and objectives of this study 36 CHAPTER TWO – MATERIALS AND METHODS 2.1 Materials and methods 39 2.1.1 Participants 39 2.1.2 Study design 40 2.1.2.1 First meeting with Doctor 40 2.1.2.2 Baseline week 41 2.1.2.3 Washout week 41 2.1.2.4 Intervention 1/ intervention 2 41 2.1.2.5 Fifth meeting 42 2.1.3 Weekly Questionnaires 42 2.1.4 Actigraphy 44 2.1.5 Daily sleep diary 45 2.1.6 Medication 45 2.1.7 Data analysis 46 2.1.7.1 Weekly measurements 46 2.1.7.2 Daily measurements 48 2.1.7.3 Actigraphy measurements 48 2.1.8 Ethics 49 CHAPTER THREE - RESULTS 3.1 Results 51 3.1.1 Weekly measurements 52 3.1.2 Daily measurements 57 3.1.3 Actigraphy 58 3.1.4 Anecdotal report back from participants 59 CHAPTER FOUR – DISCUSSION 4.1 Discussion 62 REFERENCES 74 vi LIST OF FIGURES Figure 1. A diagram of the study design shown along a timeline 40 Figure 2. The BDI score before and after testing for the ‘hands on’ effect 54 Figure 3. The McGill, PPI and PSQI scores after testing for the ‘hands on’ effect 55 Figure 4. Total minutes of physical activity of all intensities during baseline and washout weeks 55 Figure 5. A comparison between baseline week, placebo week and Zolpidem MR week for the combined number of minutes for the week 56 Figure 6. A comparison between baseline week, placebo week and Zolpidem MR week for the number of minutes spent in sedentary activities 56 Figure 7. A comparison between baseline week, placebo week and Zolpidem MR week for the number of minutes spent in light to moderate intensity activities 56 Figure 8. A comparison between baseline week, placebo week and Zolpidem MR week for the number of minutes spent in high intensity activities 56 Figure 9. Sum vector data taken from actigraphy represented as units of gravity (g). Figure 7a represents the sum vectors for the morning i.e. from wake time to midday; figure 7b represents the sum vectors for the afternoon i.e. from midday to bedtime and figure 7c represents the sum vectors for the night-time i.e. from bedtime to wake time 58 vii LIST OF TABLES Table 1. Table showing the effects of hypnotics on pain and sleep in painful disorders 34 Table 2. Demographic, anthropometric and baseline data for all study participants 51 Table 3. Values for the weekly McGill (PRI) and PPI tests; PSQI total test, BDI and physical activity questionnaire score during baseline and washout weeks 52 Table 4. Values for the weekly McGill (PRI) and PPI tests; PSQI total test and physical activity questionnaire score during baseline and intervention weeks 52 Table 5. Values for selected individual PSQI questions during baseline and washout weeks 53 Table 6. Values for selected individual PSQI questions during baseline and intervention weeks 53 Table 7. Values for the daily VAS scores of combined sleepiness and fatigue; morning pain and evening pain during baseline and washout weeks 57 Table 8. Values for the daily VAS scores of combined sleepiness and fatigue; morning pain and evening pain during baseline and intervention weeks 57 viii LIST OF ABBREVIATIONS ACL Anterior Cruciate Ligament CBT-I Cognitive Behavioural Therapy for Insomnia DSM IV-TR Diagnostic and Statistic Manual version 4 Text Revised EEG Electroencephalogram EMG Electromyogram EOG Electrooculogram ESS Epworth Sleepiness Scale GABA Gamma Aminobutyric Acid GH Growth Hormone HPA Hypothalamic-Pituitary-Adrenal ICD-10 International Classification of Disease version 10 ICSD-2 International Classification of Sleep Disorders version 2 ISI Insomnia Severity Index MOA Monoaminergic Neurons MSLT Multiple Sleep Latency Test MWT Maintenance of Wakefulness Test NREM Non Rapid Eye movement ix NSAID Non Steroidal Anti Inflammatory Drugs OA Osteoarthritis OSA Obstructive Sleep Apnea PAG Periaquaductal Gray PLMS Periodic Limb Movements PPI Present Pain Intensity PRI Pain Rating Index PSG Polysomnogram PSQI Pittsburgh Sleep Quality Index RA Rheumatoid arthritis REM Rapid Eye Movement RLS Restless Leg Syndrome SCN Suprachiasmatic Nucleus SNS Sensory Nervous System SWS Slow Wave Sleep VAS Visual Analogue Scale VLPO Ventrolateral Preoptic Area of the Hypothalamus x CHAPTER ONE Literature review 1 1.1 Introduction This dissertation is based on chronic arthritis and investigates how the pain of arthritis interferes with sleep, as well as how an intervention to improve sleep can impact pain levels.