CMS200 - Week 9

Insomnia Overview

• A good laugh and a long sleep are the two best cures for anything. (Irish Proverb)
• Insomnia is defined as repeated difficulty with sleep initiation, duration, consolidation, or quality, occurring despite adequate time and opportunity for sleep.
• This results in daytime impairment.
• Short-term insomnia ("Adjustment" or "Acute") is insomnia lasting less than 3 months.
• Chronic insomnia disorder involves sleep disturbance at least 3 times per week for at least 3 months.
• Prevalence of insomnia increases with age.
• Women are twice as likely to experience insomnia as men.
• Risk factors for insomnia include depression, anxiety, other psychiatric conditions, female sex, older age, lower socioeconomic status, concurrent medical and mental disorders, marital status (divorced/separated more often than married), race (blacks more often than whites), and obesity.

Learning Outcomes

• Analyze the definition, classification, prevalence, and etiology of insomnia types (short-term, primary in older people, chronic) according to different classifications (DSM-5, ICSD-III, American Sleep Disorder Association).
• Interpret age-related changes in sleep patterns, sleep pattern variations, and the impact of sleep loss on physical and mental health.
• Investigate the association between insomnia and psychiatric disorders, medical conditions, substance use, and other sleep disorders.
• Conduct the diagnostic process for insomnia and other sleep disorders (e.g., sleep history, physical exams, diagnostic tests such as polysomnography, actigraphy, result interpretation).
• Distinguish common factors, symptoms, and comorbidities associated with various types of insomnia and their potential consequences.
• Evaluate the importance of persistent sleep disorders, the role of the interprofessional team, and self-evaluating tools (questionnaires, sleep diaries, monitoring tools) in managing sleep disorders.
• Assess the impact of sleeplessness on health, quality of life, work performance, and other aspects of life.

Normal Sleep Architecture

• A sleep cycle is approximately 90-120 minutes.
• Stages of sleep: - Wake - REM - N1 - N2 - N3
• Stage N3 (slow-wave sleep) predominates in the first half of sleep.
• REM sleep predominates in the second half of sleep.
• Wake after sleep onset (WASO) is another factor in evaluating sleep architecture.

Case Study: 52-year-old Female

• A 52-year-old woman reports persistent insomnia and seeks a prescription for a natural sleeping pill.
• Further analysis through 10-15 questions should explore her insomnia concerns.
• 5 different insomnia diagnoses should be listed.
• Examine red flags indicating potentially serious underlying causes.

Classification of Sleep Disorders

• Insomnia (primary)
• Circadian rhythm sleep-wake disorders
• Central disorders of hypersomnolence
• Parasomnias
• Sleep-related movement disorders
• Sleep-related breathing disorders
• Other sleep disorders

Insomnia - Prevalence

• Up to one-third of the global population reports dissatisfaction with their sleep.
• Higher prevalence in elderly and women.
• 35-50% of adults experience insomnia symptoms.
• 12-20% of adults have insomnia as a disorder.
• Up to 50% of older adults experience insomnia disorders.
• Women are twice as likely as comparable men.

Insomnia (Primary) - Definition

• Repeated difficulty with sleep initiation, duration, consolidation, or quality, despite adequate time and opportunity.
• Results in daytime impairment.
• Includes: difficulty falling asleep; difficulty maintaining sleep (frequent/prolonged awakenings); waking up too early in the morning; non-restorative sleep.
• Distress/impairment in daytime functioning (fatigue, sleepiness, attention/concentration problems, mood disturbances).
• Not attributed to another medical disorder, substance use, or prescription medication.

Insomnia (Primary) - Classification

• Chronic insomnia disorder: sleep disturbances for at least 3 months, 3 or more times a week.
• Short-term insomnia disorder: sleep disturbances for at least 1 month, but less than 3, 3 or more times a week.
• Acute or adjustment insomnia.
• Other insomnia disorders

Chronic Insomnia (ICSD-3 Criteria)

• Difficulty initiating sleep/maintaining sleep, early waking, resistance to appropriate sleep schedule.
• Related to nighttime sleep difficulty: fatigue/malaise, attention/concentration problems, memory impairment, mood disturbances, irritability, daytime sleepiness, behavioural problems.
• Concerns about or dissatisfaction with sleep.
• Complaints not solely due to inadequate sleep opportunity or circumstances.
• Sleep disturbance and associated daytime symptoms occur at least 3 times per week, for at least 3 months.
• Sleep/wake difficulty is not explained by another sleep disorder.

Short-Term Insomnia

• Four of the five criteria for short-term insomnia overlap with criteria A, B, C, and F of chronic insomnia.
• Sleep disturbance and associated daytime symptoms are present for less than 3 months.
• Identifiable cause, such as stress, a common trigger.

Insomnia - Epidemiology

• Risk factors include depression, anxiety, psychiatric conditions, female sex, older age, lower socioeconomic status, concurrent medical and mental disorders, marital status (divorced/separated more often than married), race (blacks more often than whites), and obesity.

Insomnia - Risk Factors

• Short-term insomnia (acute/adjustment): acute events (environmental changes, jet lag, work shifts, stressful life events, acute illness, medications), use of stimulants (steroids, decongestants, amphetamines).
• Chronic insomnia: genetics (Apo E4 genes, clock genes), molecular factors (orexin, catecholamines, histamine, GABA, serotonin, adenosine, melatonin, prostaglandin D2).

Impacts of Insomnia

• Negative impacts on daytime social/occupational functioning (20-60% of patients).
• Adverse effects on health, quality of life, academic/work performance; increased risk for diseases.
• Risk factor for cardiovascular disease, chronic pain syndrome, depression, anxiety, diabetes, obesity, and asthma.
• Precedes mood and anxiety disorders.
• Increased risk for industrial and road accidents, falls, hip fractures in the elderly.
• Impairs creativity and responsiveness.

Sleep Changes - Development and Aging

• REM latency decreases and length of the first REM period increases with age.
• Early childhood sleep-wake states amount is high, declining gradually with age, especially around the sixth decade.
• Loss of slow-wave sleep in men occurs earlier.
• Middle-aged and elderly adults have shallower, fragmented sleep with increased periods of wakefulness (WASO).
• Daytime sleepiness increases.

Primary Insomnia in Older Adults

• Chronic insomnia without underlying medical, psychiatric, or other sleep disorders.
• Affecting up to 40% of older adults—often characterized by difficulty falling asleep, early awakening, or feeling tired on awakening.
• Prevalence increases with age (31-38% in 18-64 year olds, up to 45% in 65-79 year olds)

Primary Insomnia in Older People - Risk Factors

• Host factors (age, cognitive impairment, response to stress, sleep habits/sleep/activity cycle, napping).
• Health conditions (sleep related, pain, depression, nocturia, anxiety, dyspnea, heartburn, cough).
• Environment factors (light/noise exposure, temperature, disruptive schedules, limited social interactions).
• Medications.

Circadian Rhythm

• Regulates sleep consolidation and physiologic parameters.
• Controlled by: internal biological clocks, environmental stimuli (zeitgebers).
• Measured by melatonin levels, cortisol, core body temperature.
• Sleep/wakefulness rhythm is an endogenous cycle.
• In the absence of zeitgebers, humans tend toward a 25-hour sleep-wake cycle.

Circadian Rhythm Disorders

• Delayed sleep-wake phase disorder, advanced sleep phase disorder, irregular sleep-wake rhythm.
• Shift work sleep disorder
• Jet lag

Sleep-Wake Disorders (Circadian Rhythm)

• Delayed sleep-wake phase disorder: delayed sleep onset with daytime sleepiness, difficulty waking up, problematic for adolescents, frequently associated with depression.
• Advanced sleep-wake phase disorder: excessive evening sleepiness and early morning awakening, intrinsic circadian cycle that is less than 24 hours (usually in older adults and males), bright light therapy is beneficial.
• Irregular sleep-wake disorder: failure of the circadian rhythm to consolidate sleep—multiple short periods of sleep and wakefulness, often found in older adults or dementia sufferers, behavioral modification is useful.
• Jet lag disorder: Desynchronization during short periods of long travel (crossing time zones), marked by sleep/wake disturbance.
• Shift work disorder: problems consistently working non-standard sleep schedules.

Case Study: 63-year-old Male

• A 63-year-old man seeks help due to his wife's concern about his snoring and periods of daytime sleepiness.
• Differential diagnoses should be considered (obstructive sleep apnea, potentially other sleep/respiratory disorders).
• Analyze signs/symptoms (snoring, sleep-disrupting gasping/choking sounds during sleep, tendency for daytime naps), alongside further questions to be asked.
• Initial treatment recommendations should also be listed.

Obstructive Sleep Apnea (OSA)

• Defined as repetitive collapse of the upper airway during sleep, either partial or full, causing disturbance to airflow.
• Results as apnea or hypopnea/breathing cessation
• Causes excessive daytime sleepiness, hypertension, heart failure, arrhythmia, diabetes (morbidity/mortality).
• Treated with weight loss, CPAP (continuous positive airway pressure), or surgical procedures.
• Often associated with increased risk of depression, motor vehicle accidents, and worse quality of life.

OSA Clinical Definitions

• Apnea: breathing cessation >10 seconds.
• Hypopnea: reduced airflow (30%), decrease in oxygen saturation (4%).
• AHI: apnea/hypopnea index (events recorded per hour of sleep).
• Mild OSA: AHI 5-15.
• Moderate OSA: AHI 15-30.
• Severe OSA: AHI >30

OSA Risk Factors

• Male sex
• Older age (40-70 years).
• Family history of sleep apnea.
• Postmenopausal women (risk of sleep apnea).
• Obesity (higher BMI).
• Craniofacial abnormalities (enlarged tonsils/long airway).
• Black, Hispanic/Latino, and Native American/Alaska Native people have increased prevalence compared to white people.
• Hypertension is a factor and a possible consequence of OSA.

OSA Symptoms

• Primary: Snoring without sleep apnea/excessive daytime sleepiness.
• Habitual: snoring nightly.
• Severe: audible snoring throughout night.
• Apnea/choking/gasping (patient may awaken).
• Excessive daytime sleepiness (during activities like driving).
• Morning headache; potential link to increased CO2 during apneic episodes.

OSA Signs (Craniofacial Structures)

• Anthropometric measurements (height, weight, BMI, neck circumference).
• Craniofacial structure (cricomental space, thyromental angle, distance, malocclusions).
• Oropharyngeal examination (tonsil enlargement, tongue size, uvula).
• Mallampati airway class 3 or 4.

STOP-BANG Questionnaire

• Screening tool for OSA.
• Based on 8 questions; scores 0 to 8.
• Advantages: high sensitivity/accuracy to rule out moderate/severe OSA.
• Convenient to use.

Insomnia - Interview Framework

• Detail the nature and development of the sleep problem.
• Determine the chief sleep symptom (difficulty initiating sleep, staying asleep, both, early awakening, poor/non-restorative sleep)
• Determine the chronology (onset, duration, and frequency of the sleep problem).
• Assess contributory, exacerbating, and ameliorating factors.
• Evaluate sleep hygiene.
• Review past medical and psychiatric history, medications, substances use, comorbid conditions.
• Review of symptoms not covered by initial questions; getting collateral history from a bed partner.
• Develop a sleep diary.

Identify Alarm Symptoms

• Heavy snoring, observed sleep apnea, daytime somnolence.
• Suicidal or homicidal thoughts.
• Severe psychiatric disorders.
• Nocturnal chest pain/pressure; unstable coronary artery disease.
• Nocturnal breathing patterns/decompensated pulmonary disorders (asthma, COPD), unstable coronary disease, undiagnosed sleep disorders.

Sleep Quality: Sleep Logs/Diaries

• Maintain logs 2-4 weeks to quantify sleep patterns.
• Evaluate sleep time (TST), wakefulness after sleep onset (WASO), and sleep efficiency (SE), and circadian rhythm disturbances.
• Identify behaviors and patterns for targeted intervention (reliable, cost-effective).
• Limitation: reliability and validity depend on documentation quality.

Sleep Quality Questionnaires (Subjective Tools)

• Pittsburgh Sleep Quality Index (PSQI).
• Insomnia Severity Index (ISI).
• Epworth Sleepiness Scale (ESS).

Physical Exams

• Evaluate vitals, height, weight (BMI).
• Craniofacial morphology (neck circumference).
• Oropharyngeal examination (tonsil size, tongue size, airway).
• Cardiovascular examination.
• Digital clubbing, neurologic examination

Sleep Laboratory Evaluation

• Non-specialist can manage sleep complaints, but referral to sleep specialists is recommended for specific cases: sleep apnea, PLMs during sleep, narcolepsy, serious injury risk parasomnias, Intractable insomnia.

Sleep Quality - Polysomnography (PSG) & Actigraphy

• PSG: Gold standard to diagnose sleep apnea, sleep-related breathing disorders, to evaluate for nocturnal seizures and sleep-related rapid breathing disorders, nocturnal limb movements disorders. Not suited for initial assessment of insomnia unless a coexisting sleep disorder is suspected.
• Actigraphy: an objective measure of sleep using a 3D accelerometer, worn on the wrist/ankle for days or weeks, to identify sleep patterns, sleep-wake cycles and sleep efficiency.

PSG Limitations

• Expensive, time-consuming; impractical for everyday routine.
• First-night effect: Sleep quality and quantity might not be accurate due to the different behaviors on the first night.
• Medications can alter quality and quantity of sleep.
• Equipment issues can lead to questionable results.
• Requires trained staff, sufficient duration of sleep, sleep professionals to interpret results.

What about other devices?

• Wearable devices (e.g., smartwatches) are increasingly available to track and measure metrics related to sleep quality. However, are not considered as a replacement for clinical diagnosis.

Management – Interprofessional Healthcare Team

• Collaboration among healthcare providers (primary care, psychiatrist, psychotherapist, sleep disorder specialist, pharmacist, nurse practitioner, neurologist).

Treatment for Insomnia

• Education (realistic goals, relaxation exercises): Provide guidance and encouragement towards desired changes.
• Lifestyle approaches: Healthy lifestyle to combat insomnia, including avoiding naps, limiting screen time, and maintaining a regular sleep schedule.
• Address underlying medical/psychiatric conditions: Identify and treat/manage any contributing medical or psychiatric factors (e.g., depression, anxiety).
• Behavioral approaches: sleep restriction, stimulus control, cognitive behavioral therapy (CBT), aerobic exercise.
• Pharmacologic therapy (brief): sedative-hypnotics (short-acting benzodiazepines, benzodiazepine receptor agonists).
• Medication cautions: inappropriate to use medication for side effects of other meds; not recommended to combine hypnotics with alcohol since this can exacerbate sleep issues.

Insomnia Complications

• Sleep deficiency, and or poor insomnia quality can lead to many potential negative situations over time, including but not limited to: - Impaired cognitive performance, executive functioning, impulse control. - Memory problems - Increased risk for psychiatric disorders (depression, anxiety, psychosis). - Work-related issues or safety concerns - Increased risk of injuries and even road accidents - Negative changes to overall quality of life.

Insomnia Prognosis

• Short-term insomnia has a good prognosis with prompt treatments.
• Chronic insomnia is typically persistent, especially with significant comorbid conditions (anxiety, depression, medical conditions).
• Symptoms can persist over 3 years in 46-72% of affected patients.
• Insomnia negatively impacts quality of life and has a substantial economic burden on society.
• Elderly individuals with primary insomnia show an increased risk for dependencies on hypnotics, and for conditions like depression, falls, dementia.

Sleep Quality Questionnaires

• Pittsburgh Sleep Quality Index (PSQI): Measure sleep quality in 8 domains.
• Insomnia Severity Index (ISI): Measures severity of insomnia symptoms.
• Epworth Sleepiness Scale (ESS): Measures tendency toward sleep in different daily situations.

Physical Exams

• Evaluate vitals, weight/height (BMI calculation)
• Craniofacial morphology
• Oropharyngeal examination (oral cavity for enlargement of tonsils, neck).
• Neck circumference
• Cardiovascular examination
• Digital clubbing
• Neurologic examination

Sleep Laboratory Evaluation

• Most sleep issues can be addressed by a primary care physician.
• Sleep specialists are best for complex issues like sleep apnea, periodic limb movements (PLMs), narcolepsy and potentially serious parasomnias, and intractable insomnia.

Sleep Quality – Polysomnography (PSG) and Actigraphy

• Polysomnography (PSG): The gold standard for diagnosis of sleep-related breathing disorders (OSA, etc.)
• Detects and tracks sleep stages; useful to identify sleep apnea and other sleep-related issues.
• Actigraphy: A cost-effective method using a 3D accelerometer to measure sleep patterns and movements (provides visual results).

Actigraphy Limitations

• Cannot identify periodic limb movements (PLM) or breathing issues.
• The recorded activity is not a direct measure of sleep itself.
• Variations in devices and scoring systems reduce comparability.
• The AASM recommends against using actigraphy to diagnose periodic limb movement disorder.

Polysomnography (PSG):

• Gold standard method to diagnose sleep-related breathing disorders (OSA, CSA, sleep-related hypoventilation/hypoxia and parasomnias).
• Used to evaluate nocturnal seizures and sleep-related behaviors (including narcolepsy, periodic limb movements disorder, and rapid eye movement sleep behavior disorder).

PSG Limitations

• Costly and inconvenient, which can lead to inaccuracies due to issues such as first night effect, medication changes before a PSG, nocturnal seizures, etc.
• Requires trained technicians and staff for correct procedure and interpretation of results.

Case Study: 52-year-old Female - Additional Questions

• What other questions might help assess potential causes for the patient's sleep difficulties?

Case Study: 63-year-old Male - Additional Questions

• What additional questions might help assess potential causes for the patient's sleep difficulties?