Sleep Medicine Quiz

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Questions and Answers

What is the primary purpose of polysomnography (PSG) Type I?

To conduct a basic overnight test for sleep apnea

To monitor patient sleep patterns in a home environment

To provide a comprehensive in-lab study of sleep disorders (correct)

To assess a patient's blood oxygen levels

Which sleep study is most commonly used as a home sleep apnea test (HSAT)?

Type I PSG

Type IV PSG

Type II-III PSG (correct)

Type II PSG

What does excessive daytime sleepiness (EDS) need to be accompanied by to indicate a potential sleep disorder?

Lack of sleep for more than 24 hours

Witnessed apnea/choking and hypertension (correct)

Only loud snoring

Documented irregular sleep-wake cycles

In the case of a negative result from a Type II or III sleep study, what is the recommended next step?

Perform a Type I PSG for comprehensive analysis Signup and view all the answers

Which statement accurately reflects the nature of Type IV sleep studies?

They measure only one or two signals and are unattended. Signup and view all the answers

What is SDB an acronym for in sleep medicine?

Sleep disordered breathing Signup and view all the answers

What does the acronym CPAP stand for?

Continuous positive airway pressure Signup and view all the answers

What indicates a higher risk of moderate to severe obstructive sleep apnea (OSA)?

Clinical symptoms in adults Signup and view all the answers

What is the potential result of a misalignment between the circadian rhythm and sleep-wake schedule?

Excess sleepiness or insomnia Signup and view all the answers

Which sleep phase type is commonly associated with adolescents and young adults?

Delayed sleep phase type Signup and view all the answers

What is the maximum melatonin level reached after administration of melatonin supplements?

45 minutes post-administration Signup and view all the answers

Which of the following groups is likely to experience the irregular sleep-wake type of circadian rhythm sleep-wake disorder?

Individuals with neurocognitive disorders Signup and view all the answers

What aspect of melatonin administration is supported by many studies?

Timing is more important than dosage Signup and view all the answers

Which sleep pattern could be characterized as having three sleep episodes within a 24-hour period?

Irregular sleep-wake type Signup and view all the answers

What is the primary hormone involved in regulating circadian rhythms?

Melatonin Signup and view all the answers

Which population may experience the Non-24 hour sleep-wake type most significantly?

Blind individuals Signup and view all the answers

What body mass index (BMI) is identified as a risk factor in the BANG criteria for OSA?

≥35 kg/m2 Signup and view all the answers

What is the sensitivity of the STOP screening tool for an AHI greater than 30?

80% Signup and view all the answers

Which condition is NOT commonly associated with obstructive sleep apnea (OSA)?

Asthma Signup and view all the answers

What treatment for OSA involves providing continuous positive airway pressure?

CPAP Signup and view all the answers

Which of the following treatments may be classified as a surgical option for OSA?

Inspire Therapy Signup and view all the answers

According to the STOPBANG criteria, how many points suggest an AHI greater than 30?

3 points Signup and view all the answers

What occurs during REM sleep that makes sleep apnea more severe?

Increased airway obstruction Signup and view all the answers

Which of the following contributes to impaired glucose control related to OSA?

Alcohol consumption Signup and view all the answers

What is the overall prevalence of obstructive sleep apnea (OSA) in individuals with serious mental illness (SMI)?

25.7% Signup and view all the answers

Which mental health condition has the highest reported prevalence of OSA?

Major depressive disorder Signup and view all the answers

How much more likely are patients with depressive disorder to have OSA compared to non-depressed patients?

5 times more likely Signup and view all the answers

In children, undiagnosed OSA may be mistaken for which condition in 20-50% of cases?

ADHD Signup and view all the answers

What mental health condition is associated with nightmares due to OSA?

PTSD Signup and view all the answers

Which percentage reflects the overall side effects of patients taking 3 mg of Doxepin after 5 weeks?

32% Signup and view all the answers

Which of the following factors is a predictor for OSA?

Older age Signup and view all the answers

What is the reported percentage of headache side effects for patients taking 6 mg of Doxepin?

14% Signup and view all the answers

What distinguishes the symptoms of sleep deprivation in children from those in adults?

Children may appear more cranky and fidgety Signup and view all the answers

How does the sedation rate for 3 mg of Doxepin compare to that for the placebo after 5 weeks?

Lower for Doxepin Signup and view all the answers

What characterizes periodic limb movements (PLMs) during sleep?

Repetitive leg movements 20-40 seconds apart Signup and view all the answers

Which side effect showed the highest percentage in patients taking the placebo during the 12-week period?

Headache Signup and view all the answers

What side effect percentage remained consistent at 0% across both dosages of Doxepin?

Memory Signup and view all the answers

What is the recommended ferritin level threshold for starting iron supplementation?

75 μg/L Signup and view all the answers

Which factor is NOT associated with iron absorption difficulties?

Iron supplements Signup and view all the answers

What is the maximum recommended dose of Eszopiclone for individuals over 65 years old?

2 mg Signup and view all the answers

According to the Beers criteria (2023), what type of medication should be avoided in older adults?

Z drugs Signup and view all the answers

What is a potential adverse consequence of benzodiazepine (BDZ) use in older adults?

Rebound insomnia Signup and view all the answers

What is the onset time for sleep induction when using Eszopiclone?

15-30 minutes Signup and view all the answers

What condition is associated with the chronic use of benzodiazepines in older adults?

Neurocognitive disorders Signup and view all the answers

Which of the following is a recommended action for individuals who have a transferrin saturation below 20%?

Start iron supplementation Signup and view all the answers

Study Notes

Sleep Disorders Medicine: Ottawa Review Course

The course was presented by Elliott Kyung Lee MD, FRCP(C), D. ABSM, a sleep specialist, medical director of the Sleep Disorders Clinic at the Royal Ottawa Mental Health Center, and an Associate Professor at the Department of Psychiatry, UOttawa.
The course was held on January 6, 2025.

Presenter Disclosure

Presenter: Elliott K. Lee MD, FRCPC, D. ABSM, F. APA, F. AASM
Relationships with commercial interests: none
Contract work with CADTH (Canada Drug and Health Technology Agency)
Some slide graphics provided by Eisai medical, modified by Elliott Lee
Royal College Examiner

Learning Objectives

Describe the stages of sleep and normal homeostatic and circadian influences
Describe polysomnography, including the electrical and physiologic variables monitored and illustrate its clinical utility in psychiatry
Discuss the epidemiology, clinical features, diagnosis, and treatments of breathing-related sleep disorders, restless legs syndrome (Willis Ekbom Disease), periodic limb movement disorder, parasomnias, insomnia, and hypersomnolence disorders
Illustrate the bidirectional relationship of sleep difficulties and psychiatric illnesses, including mood disorders, PTSD, and drug use disorder

Sleep Architecture

NREM and REM
NREM = N1, N2, N3 (N1 and N2 are light sleep)
REM increases as the night progresses
Sleep cycle changes across the lifespan

Stages of Sleep

NREM & REM
NREM = N1, N2, N3 (N1 and N2 are light sleep)
Sleep Cycle
REM increases as the night progresses
Changes across the lifespan

Sleep Hypnogram

Blueprint of what our sleep should look like.
1st half – more SWS; 2nd half, more REM sleep, cycles in the night
REM length increases throughout the night
Average of 3 to 5 REM cycles throughout the night

Wakefulness

Alpha – awake, eyes closed
Stage N1 (5%), theta
Stage N2 (50%) - Sleep spindles, K-complex
Stage N3 (20-25%) - (Slow Wave Sleep - SWS), Delta Sleep (A) - Physically restorative, Declarative memory (facts), Most difficult to arouse
REM (25%) - (Paradoxical Sleep) - Theta, sawtooth waves, Metabolically irregular,Emotional memory?

Assessment of Sleep

Sleep history
Polysomnography (PSG)
- Type/Level I, III most common
- Type/Level IV
Actigraphy
Technologies
- Wearables, nearables

Sleep-Wake History

Overview of typical night's sleep
- Initiation, maintenance, termination
- Work vs. vacation, weekends, travel, shifts
Nocturnal symptoms
- Snoring/sleep disordered breathing (SDB)
- Movements/behaviors (dreams, parasomnias etc.)
Daytime symptoms
- Sleepiness, driving
- Cataplexy, hypnagogic hallucinations, sleep paralysis
Substances - caffeine, nicotine, alcohol, other

Measuring Sleep (Polysomnography)

EEG - brainwaves (Central & Occipital Leads)
EOG – eye movements
EMG – muscle tone -chin, legs
ECG - heart
Breathing:
- Airflow: (nose/mouth)
- Effort: Thoracic & Abdominal
Blood oxygen saturation (SaO2)
Snore Microphone
Digital AV recording

Polysomnography (PSG)

Most comprehensive, objective evaluation of sleep
Indications
- Suspicion of
  - Breathing related sleep disorder (SDB)
  - Parasomnia (e.g. RBD)
  - Movement disorder (e.g. PLMD)
  - Other (seizure etc.)
- Objectively quantify sleep
  - e.g. before MSLT
- Titration (CPAP, BiPAP)
- Therapy evaluation
- Oral appliance, provent etc.

Type I-IV PSG

Type I - Most comprehensive
- In lab study [attended] (most leads)
Type II/III - "Home sleep study" (HSAT) - Recommended in uncomplicated adult patients with clinical symptoms suggesting higher risk of moderate to severe OSA.
Type IV - Overnight Oximetry (OVOX). Unattended -1-2 signals. Positive results help rule in SDB. Negative results do not rule out SDB.

Type IV Data

Data storage rate of 4 seconds every sample.
Contains detailed tables on desaturation events, pulse data, and overall graphic summaries for sleep quality

Actigraphy

Accelerometer – days-wks activity
Indications: Insomnia, CRSWD, insufficient sleep syndrome
Assess TST prior to MSLT with Type III (home sleep) tests
Not for assessment of PLMD

Sleep Technologies

"Wearables," "Nearables"
Pillows, Mattresses
Activity monitors (Fitbit, Jawbone etc,)
Apps (1000s+++)
Rings (Oura, etc)
Challenges: Accuracy and generalizability, predominantly on healthy populations.

Orthosomnia

Seeking treatment for concerns about sleep tracker data related to sleep duration and/or quality
Spending excess time in bed for "8 hours sleep/night"

Sleep Stages % by Age

Graphs of the percentage of total daily sleep and the distribution of sleep stages (REM and NREM) across various age groups (newborn to older)

REM Sleep

Rapid Eye Movements (REM)
Muscle atonia (paralysis)
Dream recall
90-minute latency, "Paradoxical Sleep": EEG mimics wakefulness, breathing irregular, heart rate fluctuates

What do we need for sleep to be restorative?

Sleep quantity, sleep quality, Sleep Timing

Sleep Factors Impacting Restoration

Sleep Quantity
Sleep Quality
Sleep Timing

Sleep Duration Recommendations

Charts presenting recommended sleep duration in hours for different age groups (newborn to older adults).

Sleep Quantity

Too little sleep is equivalent to functioning with a low blood alcohol level (<6 hours) and can negatively impact performance and cognitive function. Less sleep correlates with increased risk of cardiovascular disease and other health problems.

Are Canadian Adults Getting Enough Sleep?

Statistics on sleep adequacy among Canadian adults across age groups, with considerations of sedentary time, chronic stress and mental health.

Quality

General discussion about the quality of sleep; what is required for a refreshing and productive sleep.

Timing

Impact of sleep timing on circadian rhythm and consequences of misalignment (e.g., jet lag, shift work).

Sleep Control

Processes S(leep) and C(ircadian) coordinate sleep
Homeostatic control and circadian rhythmicity are regulated independently by the brain, while both are necessary for proper coordination of sleep.

Process S(leep)

Homeostatic control (accumulation of sleep debt with wakefulness)
More wakefulness= more sleep debt accumulated
Lack of restorative sleep can lead to sleep disorders or mental health concerns

Circadian Rhythms

Intrinsic rhythmicity, typically with a slightly longer 24.2-hour cycle and daily resynchronization (entrainment) is needed from daily cues ("zeitgebers")
Light (melatonin)
Dark (melatonin)
Exercise
Food/meals
Job/work
Social demands

Suprachiasmatic Nucleus and Pineal gland

Light & pineal gland send signals to pacemaker, pacemaker regulates circadian rhythmicity
Suprachiasmatic nucleus ("pacemaker")
Pineal (Melatonin)

Photoreceptors

Photoreceptors (melanopsin) are sensitive to light (450-480 nm - blue light).
Light exposure in late evenings disrupts/delays sleep by reducing melatonin secretion.

Asynchronous Sleep Consequences

Poor sleep continuity
Decreased alertness, cognitive errors
Mood disturbances
Inefficient sleep
Jet lag, shift work
Difficulty shifting sleep timing and circadian rhythm, leading to consequences like jet lag, shift work difficulties.

Circadian Typology

Delayed sleep onset (commonly during puberty, peak delay at 20 years)
Greater time differences in onset and wake compared to sleep.
Phase tolerance and responsiveness to zeitgebers decrease with age
Chronic misalignment between the preferred sleep schedule and the sleep/wake schedule imposed by social/occupational factors, most often in evening preferences.
This often applies to individuals with evening preferences.

Sleep Duration is Dependent On Circadian Timing

Sleep duration can be influenced by circadian timing.

Melatonin Rhythm

Fluctuation in melatonin levels over a 24-hour period
Melatonin levels peak in the middle of the night (higher), decline to low daytime amounts.
Pineal gland produces melatonin in the evening.

Melatonin Secretion Profiles Change with Age

Charts/graphs demonstrating how melatonin secretion patterns change as humans age.

Circadian Rhythm Sleep Disorders

Normal sleep-wake rhythm
Delayed Sleep Phase Syndrome
Advanced Sleep Phase Syndrome
Irregular sleep-wake rhythm

Circadian Rhythm Sleep-Wake Disorders (DSM-5)

Persistent/recurrent sleep disruption due to alterations in circadian system.
Misalignment of circadian rhythm to sleep schedule results in disruption leading to excessive sleepiness or insomnia.
Clinically significant distress is a key component of the disorder.

Circadian Rhythm Sleep-Wake Disorders - Types

Delayed sleep phase type
Advanced sleep phase type
Irregular sleep-wake type
Non-24-hour type
Shift work type

Circadian System Regulation

General description and overview of circadian system regulation.

Phase Response Curve: Light and Melatonin

Graphic/graph demonstrating the phase response curve of light and the changes in melatonin levels across different times of the day, highlighting the link between light exposure and circadian rhythms.

Melatonin

0.1-0.3 mg produces physiologic levels of melatonin.
1 mg produces supraphysiologic levels (e.g., 500-600 pg/mL).
Maximum level reached 45 min after administration.
T1/2= 90 min.
Metabolized by cytochrome P4501A2.

To achieve phase advances vs. delays

Instruction on adjusting sleep timing (more or less time in bed).

Sleep Disorders

General overview of different sleep disorders

Sleep Disorders Symptoms

Insomnia,
Excessive Daytime Sleepiness,
Nocturnal Spells (episodic sleep issues).

Predisposing, Precipitating, Perpetuating Factors to Insomnia

Factors that contribute to insomnia include age, medical disorders, psychiatric disorders, acute/chronic stressors, behavioral/psychological factors, circadian rhythm and zeitgebers, medications and substances.

Excessive Daytime Sleepiness

Lack of sleep (inadequate quantity of sleep).
Insufficient time in bed,
Inadequate quality of sleep,
Intrinsic sleepiness,
Medical/psychiatric disorder (e.g., mood disorder),
Medications, medical conditions(e.g., thyroid, anemia, etc.)
Circadian Rhythm Disturbance (e.g., shift work, delayed sleep phase,etc.)

Nocturnal "Spells"

NREM Sleep Arousal Disorder (parasomnia
- Night terrors, sleepwalking
REM Sleep Arousal Disorder (parasomnia)
Nightmares/REM behavior disorder, etc.
Seizure disorder, Psychiatric issues such as panic attacks

Sleep Disorders

Obstructive Sleep Apnea/hypopnea (OSA)
Restless Legs Syndrome (RLS)
Periodic Limb Movement Disorder (PLMD)
Narcolepsy
REM behavior disorder (RBD)

OSA (Obstructive Sleep Apnea)

Definition: abnormal breathing (apnea/hypopnea) during sleep due to the tongue and throat relaxing, resulting in the closing of the airway. Frequency relates to severity
Disrupted sleep leading to recall-less periods of sleep deprivation coupled, or resulting in daytime sleepiness.

Epidemiology of OSA

Prevalence up to 22% males and 17% females across all ages
Ratio between males and females is fairly consistent until menopause, then reverses.
Approximately 90% with moderate/severe OSA are likely undiagnosed.
Risk factors include being overweight/obese.

STOP BANG Screening for OSA

Screening tool for obstructive sleep apnea focusing on physical attributes and symptoms (snoring, daytime tiredness etc). 2-4 positives suggests OSA

Global Heat Map of OSA Prevalence

Maps showing global prevalence of OSA

Other Diseases and OSA

Link between OSA and major medical conditions (hypertension, atheroscleroclerosis, atrial fibrillation/CHF, stroke, Impaired Glucose Control, Gastroesophageal reflux disease, depression, ADHD, neurocognitive dysfunction

Treatments for OSA

CPAP (Continuous Positive Airway Pressure): Use this to maintain a positive airway pressure to keep the airway open
Weight Loss
Avoiding alcohol, sedatives
Oral appliance therapy (OAT)/ Mandibular repositioning device
Provent/Bongo devices (a type of EPAP – the use of which is debatable) – now considered obsolete.
Upper Airway Surgery [tonsillectomy, Uvulopalatopharyngoplasty (UPPP)], Inspire therapy, Maxillomandibular Advancement (MMA)
Tracheostomy – last resort when other measures have not worked.

OSA and Mental Illness

Obstructive Sleep Apnea worsens in REM sleep
OSA can exacerbate mental illnesses
Aggression/cognition in schizophrenia
Mood disorders (MDD, bipolar)
Nightmares in PTSD
Cognitive dysfunction in neurocognitive disorders
Relapse to substance abuse
ADHD
Bidirectional relationship of OSA and mental health problems; both worsen the other.

Prevalence of OSA in SMI (Serious Mental Illness)

Meta-analysis and systematic review of sleep apnea prevalence
Objectively assessed OSA (AHI >5) prevalence among patients with SMI (Serious Mental Illness). Prevalence is higher.
Factors: older age, increasing BMI, etc.
Other disorders (PTSD, Neurocognitive) are also highlighted with high frequency of OSA in studies.

Obstructive Sleep Apnea

Approximately 1/5 of Obstructive Sleep Apnea (OSA) patients have a depressive disorder.
Patients with depressive disorders are approximately 5 times more likely to have OSA compared to non-depressed patients.

Sleep Deprivation and Children

Symptoms of sleep deprivation may manifest as hyperactivity, poor attention, and crankiness in children.

Periodic Limb Movements (PLMS) & Restless Legs Syndrome (RLS)

Repetitive leg (limb) movements during sleep, typically 20-40 seconds apart
Cause awakenings and fragmentation
Patients often unaware; bed partners often report “kicking”
Commonly accompanied by frequent awakenings and light sleep; Nocturnal Myoclonus

Restless Legs Syndrome (RLS) – DSM-5

Urge to move legs, worsened at rest, better with movement, typically worse in the evening.
3 times per week for over 3 months.
Significant distress
Not due to other medical conditions/substances

Epidemiology/Pathology – RLS/PLMD

Primarily affects women compared to men
Involves dopamine dysfunction
Deficiencies (e.g., iron) may play a role
Key diagnostic questions focus on leg discomfort at night

RLS and Psychiatric Comorbidity

Comorbidity of RLS with several psychiatric conditions (panic, generalized anxiety disorder, and major depressive disorder.
Significant increase in risk overall).

RLS/PLMD Treatment

Address exacerbating factors (e.g., caffeine, tobacco, alcohol, medications that block dopamine)
Iron replacement or supplementation
First-line treatments (e.g., gabapentin, pregabalin, dipyramide, extended-release oxycodone, peroneal nerve stimulation)
Dopamine-increase causing medications (dopamine agonists) should be avoided

Hypersomnolence Disorders

Hypersomnolence disorder
- Idiopathic Hypersomnia
- Kleine Levin Syndrome
- Kluver-Bucy Syndrome
Narcolepsy
- Type I (with cataplexy or hypocretin deficiency)
- Type II (without cataplexy or with or without hypocretin deficiency)

Narcolepsy – DSM-5

Recurrent periods of irrepressible need to sleep (>3x weekly)
Cataplexy (muscle paralysis with heightened emotion)
Hypocretin deficiency (<110 pg/mL)
REM sleep latency ≤ 15 min on PSG, or MSLT ≤ 8 min with 2 or more SOREMPS

Cataplexy

Sudden onset of full or partial skeletal muscle weakness/paralysis
Preceded by heightened emotion (e.g., laughter, anger, or excitement)
Duration: seconds to minutes
Results from REM sleep system abnormality

Narcolepsy Pentad

Excessive daytime sleepiness
Cataplexy
Hypnagogic/hypnopompic hallucinations
Sleep paralysis
Disturbed nocturnal sleep

Narcolepsy: Age of onset

Chart depicting the incidence of narcolepsy across different age groups during adolescence/early adulthood

Markers of Narcolepsy

Hypocretin/Orexin deficiency,
HLA DQB1*0602 strongly associated with hypocretin deficiency.
Other markers (HLA DQA10102 and DRB11503) may also be associated with hypocretin deficiency

Narcolepsy Treatment

Stimulant medications (Modafinil, Methylphenidate)
REM suppressant medications for cataplexy (e.g., SSRIs, TCAs);
Sodium oxybate (Xyrem, Na-GHB), now replaced by calcium/magnesium/potassium/sodium oxybate (Xywav)

Psychiatry and Sleep

General overview linking psychiatry and sleep

Functions of Sleep

REM sleep functions (mood regulatory role, emotional memories)
Slow Wave Sleep functions (declarative memory, cerebral restoration, waste clearance) / Glymphatic system

Major Depressive Disorder (MDD)

80-90% MDD pts report sleep problems.
Key findings include decreased slow-wave sleep, increased REM density, shorter REM latency, and poor sleep continuity (sleep fragmentation).
Sleep abnormalities in patients with MDD

Alcohol

Acute: reduced sleep latency and increased slow wave sleep (SWS), but REM sleep decreased in first half of sleep cycle
Chronic: increased sleep latency, reduced sleep efficiency, and less total sleep time.
Tolerance: one week for chronic effects.

Pain and Sleep

Pain and sleep quality are bi-directionally linked. Impaired sleep is a consistent pain predictor

Opioids and Sleep

Opioids may have benefits by reducing pain, promoting sleep, but negatively impact REM sleep.
Many patients report SDB (sleep disordered breathing) and are at higher risk for moderate/severe SDB, when taking opioids.

Cannabis and Cannabinoids

Intoxication (THC) can: decrease sleep latency, increase slow wave sleep
Chronic use (THC): can have long latency, reduced total sleep time, reduced sleep efficiency, and disturbed REM sleep.
Possible association with PTSD, nightmare symptoms. possible role in chronic pain and RLS/PLMD.

Insomnia Disorder

Insomnia Disorder in DSM-5: Now viewed as a primary or comorbid disorder and not solely secondary to a psychiatric condition.
Factors that contribute to chronic insomnia include age, medical disorders, psychiatric disorders, acute/chronic stressors, behavioral/psychological factors, circadian rhythm, and zeitgebers, medications, substances.
Insomnia progression factors: Precipitating, perpetuating.

Insomnia

Sleep deprivation (hypoarousal): decreased metabolism, temperature, lethargy, and reduced sleep onset time
Insomnia (hyper arousal): increased metabolism, temperature, anxiety, and agitation.

Caffeine

Table presenting caffeine content for different beverages and foods

Canadian Treatment Guidelines for Insomnia Disorder

CBTi (Cognitive Behavioral Therapy for Insomnia) is the first-line treatment for chronic insomnia, and both benzodiazepines (BDZs) and z-drugs are short-term effective.
Other medications (e.g., melatonin, antipsychotics, or sedating antidepressants) are limited due to insufficient evidence or potential risks.

Psychological Therapies for Insomnia

Sleep Hygiene, Stimulus Control Therapy (SCT), Sleep Restriction Therapy (SRT), Cognitive Behavioral Therapy for Insomnia (CBT-I): CBT-I is considered the most effective and recommended method for treatment outside of immediate and acute crises.

Sleep Restriction Therapy (SRT)

Step 1: Sleep log for 2-3 weeks.
Step 2: Calculate average total sleep time (TST).
Step 3: Calculate initial time in bed (TIB) = TST+30 min.
Step 4: Increase in 15-20 min increments whenever sleep efficiency is greater than 85%.
Note: Wake-up time must remain fixed overall.

CBT-Insomnia

Components: Cognitive therapy, sleep hygiene, relaxation training, SCT and SRT.
Cognitive Therapy: focus on sleep-related maladaptive beliefs identified via thought recording,
Self-help apps, books, and resources available.

Primary Care for (Chronic) Insomnia

CBTi is the initial recommendation for chronic treatment
Only 5% of patients get referred to CBTi for treatment by family doctors. Most are prescribed medication as a first line.
Access to support and expertise: cost is an additional barrier to successful treatment.

CBT-I Workbooks

Available workbooks provide self-help resources for insomnia treatment; useful for both practitioners and private individuals.

Books

Recommended books for insomnia management (titles)

CBTI for Insomnia Disorder

Insomnia Disorder with normal sleep duration (INS) - (>6 hrs) has 30% higher response rate in acute cases than short sleep disorder insomnia, and 20% higher remission rate.
Insomnia disorder with short sleep duration (<6 hrs) has a less pronounced effect with CBT-I.
PSG and Actigraphy are the standard method of evaluating sleep.

Medications

-General questions to ask about medications (how it works, which patient populations may benefit, common & serious effects).

FDA Approved Medications

FDA-approved medications for insomnia (non-benzo, benzodiazepines, melatonin and dual orexin receptor antagonist).

Other Medications for Insomnia Treatment

Alpha 2 delta drugs, Sedating antidepressants (e.g., Trazodone, TCAs, Mirtazapine), Antihistamines, Melatonin, cannabis, Serotonin Dopamine antagonists (Atypical antipsychotics).

Z-Drugs

Zolpidem (Sublinox), Zopiclone (Imovane), Eszopiclone (Lunesta)
Sleep induction within 15-30 minutes.
Beers Criteria (2023) strongly suggests avoiding Z-drugs in older adults.

Benzodiazepines

Sleep induction within 30 minutes
Adverse consequences: fall risk, MVAs, daytime sedation, anterograde amnesia, rebound insomnia, dependence.
BDZ use → potential developmental delay in cognitive function.
Beers criteria (2023); Strongly suggest avoiding chronic use in older adults.

Take Home Messages

Short-term use may be necessary in some cases, but the use of Z-drugs and BDZs is not recommended as a chronic treatment. Doxepin, DORAs may be considered.

Sedating Antidepressants

Trazodone, Mirtazapine, Doxepin
Limited data on efficacy for primary insomnia
Helpful for comorbid depression, PTSD, medical issues
Downregulates physiologic (HPA) arousal
Doxepin has some advantages due to its selective H1 antagonist action (minimal effect on other receptors)
2023 Beers Criteria – avoid >6 mg/day doxepin (anticholinergic effects).

Receptor Occupancy - Drugs

Comparison of receptor occupancy (efficacy) for different medications (e.g., Doxepin, Trazodone)

Selective H1 Antagonism

Doxepin (low doses): Helpful for sleep onset and maintenance
Minimal cognitive and motor impairment; minimal abuse potential.
Mirtazapine (also helpful for WASO)
No changes in arousal threshold.

Doxepin Side Effect Profile

Safety information for adverse effects are separated by short-term and long-term (12-week) use.

Trazodone for Insomnia Disorder (<6 hrs)

Randomized controlled trial of a low dose trazodone
Improves sleep efficiency
Reduces levels of stress-induced cortisol
No dropouts.

Take Home Messages – Doxepin

Helpful in sleep maintenance
Low doses are very selective as H1 antagonist
Minimal cognitive/motor impairments

Dual Orexin Receptor Antagonists (DORAs)

Overview of the Doras. Mechanism of action: acting as antagonists toward specific receptors, suppressing REM and NREM sleep
Approved medications for clinical use (suvorexant, lemborexant).

DORAs (Background)

Suvorexant, lemborexant are examples of clinically approved DRAs
Increased sleep latency by suppressing REM cycles/ sleep
Less daytime fatigue
Improved sleep quality

Sleep Onset Improved by Lemborexant

Randomized, controlled trial on older adults with insomnia.
Lemborexant improved sleep onset latency (time to fall asleep) by around 20 minutes
Tolerance to other sleep medications (zolpidem) was observed.

Sustained Improvements in TST with Lemborexant

Shows long-term improvements in total sleep time (TST)
Positive results for Lemborexant

Adverse Effects (AE) – Lemborexant

Well tolerated (safe to use)
Reduced night-time sway compared to zolpidem
Less driving impairment compared to zopiclone
Commonest adverse effects are headache, URT disturbance, fatigue, sedation, anxiety, complex sleep disturbances, and REM intrusion phenomena, troubling dreams, sleep paralysis, and hypnopompic/hypnagogic hallucinations.

Take Home messages (DORA)

Lemborexant is helpful in sleep initiation and maintenance
No noticeable changes in arousal threshold
Minimial daytime side effects , reduced risks for falls, driving, abuse.

Insomnia Summary

Insomnia is common with multifactorial etiology
Associated with pain, emotional/cognitive impairment including depression
Psychological therapies should be assessed before prescription medications
Z-drugs, BDZs, Doxepin, DORAs are helpful for initial and maintenance sleep

Insomnia Disorder in DSM-5

Now viewed as a primary disorder, or comorbid disorder, not solely secondary to other conditions
Psychological Therapies and other behavioral factors should be evaluated and addressed before a medical solution is considered

Insomnia Progression

Conceptual illustration of risk factors (predisposing, precipitating, perpetuating) in stages of insomnia (acute, early, chronic)