Week 09 - Insomnia - Student Version PDF

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Canadian College of Naturopathic Medicine

Dr. Poonam Patel, ND

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insomnia sleep disorders learning outcomes medical education

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This document provides learning outcomes and case studies related to insomnia in an instructional format. It covers definitions, types of insomnia, prevalence, and diagnostic aspects, along with potential treatment and management approaches for insomnia.

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Insomnia CMS200 Dr. Poonam Patel, ND Learning Outcomes 1.Analyze the definition, classification, prevalence, and etiology of insomnia, short-term insomnia, primary insomnia in older people, and chronic insomnia according to DSM-5, ICSD- III, and the American Sleep Disorder Association. 2.Interp...

Insomnia CMS200 Dr. Poonam Patel, ND Learning Outcomes 1.Analyze the definition, classification, prevalence, and etiology of insomnia, short-term insomnia, primary insomnia in older people, and chronic insomnia according to DSM-5, ICSD- III, and the American Sleep Disorder Association. 2.Interpret age-related changes in sleep patterns, variations in sleep patterns, and the impact of sleep loss on physical and mental health. 3.Investigate the association between insomnia and psychiatric disorders, medical conditions, substance use (alcohol, caffeine, nicotine, and other stimulants), and sleep disorders (obstructive sleep apnea, parasomnias, and hypersomnias). 4.Conduct the diagnostic process for insomnia and other sleep disorders, including taking a detailed sleep history, performing physical examinations, using diagnostic tests (e.g., polysomnography, actigraphy), and interpreting their results. 5.Distinguish common factors, symptoms, and comorbidities associated with various types of insomnia and their potential consequences. Learning Outcomes 6.Evaluate the importance of persistent sleep disorders being assessed by a sleep specialist and the role of the interprofessional team in managing patients with sleep disorders. 7.Investigate the role of self-evaluating questionnaires, sleep diaries, and monitoring tools in diagnosing insomnia and sleep disorders. 8.Assess the impact of sleeplessness on health, quality of life, work performance, and other aspects of life, as well as the importance of proper sleep in maintaining overall well-being. 9.Examine circadian rhythm sleep-wake disorders, their diagnosis, and the role of the interprofessional team in managing patients with these disorders. 10.Understand the prevalence and impact of sleep loss as a treatable health problem and its association with serious medical conditions. 11.Address underlying factors and adopt an interprofessional approach to ensure patients get adequate sleep to maintain physical and psychiatric health. Case Study – 52-year-old Female A 52-year-old woman comes to your office complaining of persistent insomnia and requests a prescription for a natural sleeping pill that she saw on a television advertisement List 10-15 questions to further explore her concern of insomnia List 5 differential diagnoses for this patient with insomnia Are there any red flags to explore to determine if the insomnia is related to a serious condition? Sleep Disorders International Classification of Sleep Disorders (ICSD-III) (American Academy of Sleep Medicine) groups sleep disorders into seven categories 1. Insomnia (Primary) 2. Circadian rhythm sleep-wake disorders 3. Central disorders of hypersomnolence – idiopathic hypersomnia, narcolepsy, Klein—Levin syndrome 4. Parasomnias 5. Sleep-related movement disorders 6. Sleep-related breathing disorders 7. “Other sleep disorders” - not captured above Insomnia – Prevalence Up to one-third of the world’s population reports dissatisfaction with their sleep – higher in the elderly and women 35–50% of adults have insomnia symptoms 12–20% of adults have insomnia disorders As high as 50% of older adults Women are two times as likely to have insomnia than age-matched men Insomnia (Primary)- Definition “A repeated difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate time and opportunity for sleep and results in some form of daytime impairment” (The American Sleep Disorder Association, ICSD-III, DSM-V) Includes: difficulty falling asleep, difficulty maintaining sleep (frequent or prolonged awakenings), waking up too early in the morning, or nonrestorative sleep Distress and impairment in daytime functioning - fatigue/low energy, daytime sleepiness, impaired attention/concentration, mood disturbances, etc. These disturbances with sleep are not related to any other medical disorder, substance use, or prescription use Insomnia (Primary) Classification According to the International Classification of Sleep Disorder (ICSD-3): Chronic Insomnia Disorder Sleep disturbances at least 3x/week, present for at least 3 months Short-Term Insomnia Disorder Sleep disturbances at least 1 month, but < 3 months “Acute” or “Adjustment” Insomnia Other Insomnia Disorder Difficulty in initiating or maintaining sleep that does not meet the criteria of chronic insomnia or short-term insomnia disorder Chronic Insomnia ICSD-3 Diagnostic criteria (A-F must be met): A. Difficulty initiating sleep/maintaining sleep, early waking, resistance to going to bed on appropriate schedule, difficulty sleeping without intervention B. As related to the nighttime sleep difficulty: fatigue/malaise, attention/concentration/memory impairment, impaired social/ family/ occupational/academic performance, mood disturbance/irritability, daytime sleepiness, behavioural problems (e.g. hyperactivity, impulsivity, aggression), reduced motivation/energy/initiative, prone to errors/accidents, concerns about or dissatisfaction with sleep C. Complaints not explained only by inadequate opportunity for sleep (i.e. enough time is allotted for sleep) or inadequate circumstances (i.e. the environment is safe, dark, quiet and comfortable) D. Sleep disturbance and associated daytime symptoms occur at least three times per week E. Sleep disturbance and associated daytime symptoms have been present for at least 3 months F. Sleep/wake difficulty is not explained by another sleep disorder 3 3 Image: https://www.osmosis.org/learn/Insomnia Short-Term Insomnia Note: Four of the five criteria for short-term insomnia overlap with criteria A, B, C and F of chronic insomnia Criterion (D) is specific - ‘the sleep disturbance and associated daytime symptoms have been present for < 3 months’ Features that distinguish short-term insomnia from chronic insomnia: Shorter duration Presence of an identifiable cause (such as stressful life event) triggering or precipitating insomnia is common Also includes insomnia occurring episodically, possibly in connection with particular daytime stressors Evaluation of both chronic/short-term insomnia based on history and use of sleep diaries/logs Also known as “Acute” or “Adjustment” Insomnia Insomnia – Epidemiology Risk factors for insomnia include the following: Depression, anxiety or other psychiatric conditions Female sex Older age - women of peri-menopausal and post-menopausal transitions Lower socioeconomic status Concurrent medical and mental disorders Marital status (divorced/separated more often than married) Race (blacks more often than whites) Obesity Comorbid conditions: can be both the cause and effect of chronic sleep loss Insomnia – Risk Factors Short-term insomnia (“Acute” or “Adjustment” Insomnia): Acute events, including changes in sleep environment, jet lag, changes in a work shift, environmental issues (excessive noise or extremes of temperature), stressful life events, acute medical or surgical illnesses, use of stimulant medications (i.e. corticosteroids, decongestants, bronchodilators, amphetamines, or cocaine), or withdrawal from central nervous system depressant substances (i.e. alcohol or benzodiazepines) Chronic insomnia: Genetics – Apolipoprotein (Apo) E4, clock genes, etc. Molecular factors - orexin, catecholamine, histamine and sleep promoting chemicals like GABA, serotonin, adenosine, melatonin, and prostaglandin D2 Impacts of Insomnia Negative impacts on daytime social and/or occupational functioning are present in 20-60% of insomnia patients adverse effects on health, quality of life, academic performance, decrease productivity at work, cause irritability and increase daytime sleepiness A contributing risk factor for cardiovascular diseases, chronic pain syndrome, depression, anxiety, diabetes, obesity, and asthma Insomnia precedes the development of mood disorders in 50% of cases and anxiety disorders in 20% of cases The risk of developing depression over 1 to 3 years is approximately 5-fold in patients with insomnia Patients with insomnia have an increased risk of industrial accidents (3- to 4-fold risk), road accidents (2- to 3-fold risk) and falls and hip fracture in the elderly population Creativity and rapidity of response to unfamiliar situations are impaired by loss of sleep Sleep Changes - Development and Aging REM latency tends to decrease, and the length of the first REM period tends to increase Sleep-Wake States (SWS): The amount of time in childhood is high, peaks in early adolescence, and gradually declines with age until it nearly disappears around the sixth decade of life Men lose SWS at an earlier age Young adults typically spend about 15–20% of total sleep time (TST) in SWS In middle-aged and elderly adults sleep is shallower, more fragmented, shorter in duration with an increase in wakeful periods [Wakefulness after sleep onset (WASO)], and daytime sleepiness increases Decrease "deeper" (delta wave) stages 3 and 4 Sleep Change - Aging Image: https://sleeponitcanada.ca/all-about-sleep/what-is-sleep/ Sleep Changes - Development and Aging After 65 years of age - one in three women and one in five men report taking > 30 minutes to fall asleep Due to: normal changes in circadian rhythm à daytime fatigue à daytime naps à poor nocturnal sleep WASO and number of arousals increase with age à may be due to increased incidence of sleep-related breathing disorders, PLMs, and other physical conditions in elderly easier arousal by internal and external stimuli Related to a phase-advanced temperature rhythm, elders tend to retire and arise earlier than younger adults Psychosocial alterations can disrupt zeitgebers and light exposure. Napping also increases with age, but the TST per 24 hours does not change with age Primary Insomnia in Older People Primary insomnia in older people = chronic insomnia without specific underlying medical, psychiatric, or other sleep disorders 60 years and older Up to 40 percent of older adults have insomnia, with difficulty falling asleep, early awakening, or feeling tired on awakening Prevalence: increases with age 31-38% in persons 18 to 64 years of age, up to 45% in persons 65 to 79 years of age U.S. prospective cohort study – 23-34% of persons > 65 years had insomnia, and 7-15% had chronic insomnia Primary Insomnia in Older People – Risk Factors Image: https://www.consultant360.com/articles/sleep- disruptions-and-insomnia-older-adults Sleep Disorders International Classification of Sleep Disorders (ICSD-3) (American Academy of Sleep Medicine) groups sleep disorders into seven categories 1. Insomnia 2. Circadian rhythm sleep-wake disorders 3. Central disorders of hypersomnolence – idiopathic hypersomnia, narcolepsy, Klein—Levin syndrome 4. Parasomnias 5. Sleep-related movement disorders 6. Sleep-related breathing disorders 7. “Other sleep disorders” - not captured above Circadian Rhythm Regulates sleep consolidation and other physiologic parameters necessary for health and optimal functioning Sleep and wakefulness rhythm is an endogenous cycle governed by: internal biological "clocks” environmental stimuli à known as zeitgebers (social activities and meals, light-dark cycle) processes that promote or inhibit arousal Can be measured by evaluating melatonin levels, cortisol levels, and core body temperature Structurally, these biological ‘clocks’ exists within the suprachiasmatic nuclei (SCN) of the hypothalamus ganglion cells in the retina illuminate and send information to SCN SCN process this information and stimulate the pineal gland to release melatonin melatonin increases in the evening in response to dim light and peaks around 3 hours before waking this feedback mechanism onto the SCN supports the circadian rhythm Circadian Rhythms and Zeitgebers Normally, the circadian oscillator has an intrinsic cycle which is on average just over 24 hours It is entrained to the 24-hour environment by zeitgebers which force the system to undergo phase shifts - of which the light-dark cycle is the most effective In the absence of zeitgebers humans tend to self-select a sleep–wake cycle of about 25 hours from wake time to wake time The circadian rhythm system works in harmony with the sleep homeostatic system to ensure proper sleep Circadian rhythm system disorders result from intrinsic dysfunction or environmental factors Prevalence of various circadian rhythm sleep disorders is unknown Circadian Rhythm Disorders Image: https://upload.wikimedia.org/wikipedia/commons/9/92/CRSD_Types.jpg Circadian Rhythm Disorders – Sleep-Wake Disorders Delayed Sleep-Wake Phase Disorder Delayed sleep and wake times relative to what is desired or expected à inadequate sleep and resultant daytime functional impairment lose at least 2 hours of sleep/night relative to the optimal amount of sleep Sx - difficulty waking up, sleep inertia à confusion/frustration upon waking, remains even with sufficient quantity and quality of sleep Incidence - peaks in adolescents, often accompanied by depression Diagnosis - history of persistent delayed sleep-wake cycles that interfere with desired daytime functioning Sleep logs - screen for other causes i.e., caffeine use, excessive evening light exposure Treatment - behavioral modification, including good sleep hygiene and gradually moving sleep and wake times earlier, avoid caffeine, alcohol, nicotine, and daytime naps, melatonin supplementation and circadian rhythm-light training Circadian Rhythm Disorders – Sleep-Wake Disorders Advanced Sleep-Wake Phase Disorder Excessive evening sleepiness and early morning awakening Sleep deprivation from staying awake longer due to societal obligations à but will wake at the same early time leading to sleep deprivation and daytime sleepiness Hypothesis - results from an intrinsic circadian cycle that is less than 24 hours Prevalence - older adults and males Diagnosis - history and sleep logs Treatment - evening bright light therapy, pharmacotherapy is not indicated Circadian Rhythm Disorders – Sleep-Wake Disorders Irregular Sleep-Wake Rhythm Disorder Failure of the circadian rhythm system to consolidate sleep à multiple short periods of sleep and wakefulness Diagnosis - no clear circadian rhythm pattern can be identified and at least 3 periods of wakefulness lasting at least one hour occur during an average 24- hour period Prevalence - generally found in older and dementia patients and is attributed to dysfunction of the SCN Due to lack of exposure to external time cues (zeitgebers) à less likely to have consistent commitments and schedules. Treatment - Behavioral modification and melatonin supplementation Circadian Rhythm Disorders – Sleep-Wake Disorders Jet Lag Disorder With air travel across time zones in a short amount of time à intrinsic circadian rhythm becomes descynchronized with external light cues Occurs when traveling through at least two time zones Sx - inability to sleep when desired, daytime sleepiness, and decreased alertness and cognitive performance usually most prevalent on the day after arrival at a destination The intrinsic circadian rhythm will adjust to destination cues at a rate of 1 to 1.5 time zones per day Eastward travel is more difficult to adjust to than westward travel Treatment - timed light exposure, melatonin supplementation Circadian Rhythm Disorders – Sleep-Wake Disorders Shift Work Disorder Approximately one-third of night shift or swing shift workers Insomnia occurs despite sleep debt when the circadian rhythm promotes alertness and prevents sleep Workers who consistently work the night shift do better than those with rotating schedules Workers on rotating schedules do better when shifts are grouped, and the swings progress later in the day instead of earlier Treatment - practice sleep hygiene, keep sleep schedules consistent even when not working, prefer dark, cool, quiet environment, short naps, caffeine, melatonin/sleep aids, bright lights Aim for at least 3 to 4 hours of "anchor" sleep at the same time every day Circadian Rhythm Disorders – Sleep-Wake Disorders Non-24 Sleep-Wake Rhythm Disorder Results from a circadian rhythm system not entrained or running without apparent regulation May result from blindness, where light-dark cues cannot be received but can also occur in those with normal vision Diagnosis - history of intermittent insomnia and daytime sleepiness alternating with asymptomatic periods when the circadian rhythm happens to fall in line with desired schedules Treatment - entrainment of the circadian rhythm system, Rx Tasimelteon (melatonin-receptor agonist) Recall Case Study – 52-year-old Female What additional questions can you add to your list of questions? What additional differential diagnoses can you consider for this patient with insomnia? Are there any red flags to explore to determine if the insomnia is related to a serious condition? What is Mr. Bean Suffering From? https://www.youtube.com/watch?v=6B1V1PFsyho Image: https://www.imdb.com/title/tt0096657/episodes/?season=1 Sleep Disorders International Classification of Sleep Disorders (ICSD-III) (American Academy of Sleep Medicine) groups sleep disorders into seven categories 1. Insomnia 2. Circadian rhythm sleep-wake disorders 3. Central disorders of hypersomnolence Disorders of Excessive Daytime Sleepiness (EDS) 4. Parasomnias 5. Sleep-related movement disorders 6. Sleep-related breathing disorders 7. “Other sleep disorders” - not captured above Central Disorders of Hypersomnolence Disorders of Excessive Daytime Sleepiness (EDS) related to the central nervous system Sleepiness is not caused by other disorders related to problems with night sleep (i.e., sleep apnea or circadian rhythm disorder) ICSD-3 classification of central disorders of hypersomnolence: Narcolepsy Type 1 (with cataplexy) Narcolepsy Type 2 Idiopathic hypersomnia Klein-Levin syndrome Hypersomnia due to medical conditions Hypersomnia due to medications or substances Hypersomnia associated with psychiatric conditions Insufficient sleep syndrome Central Disorders of Hypersomnolence Narcolepsy Syndrome A chronic neurological disorder which consists of: EDS with sudden, brief (about 15 minutes) sleep attacks Cataplexy—sudden loss of muscle tone or generalized muscle weakness Sleep paralysis—a generalized flaccidity of muscles with full consciousness Hypnagogic or hypnopompic hallucinations, visual or auditory *abrupt transition into REM sleep Image: https://www.verywellhealth.com/what-is-narcolepsy-3014795 Central Disorders of Hypersomnolence Narcolepsy Syndrome Additional symptoms include fragmented sleep and insomnia, and automatic behaviors Generally feel refreshed after taking a nap (unlike idiopathic hypersomnia) Begins in early adult life, levels off by 30 yoa Affects both sexes equally Two types of narcolepsy: Narcolepsy Type 1 – characterized by low levels hypocretin (orexin) or episodes of cataplexy Narcolepsy Type 2 – normal levels of hypocretin (orexin) and no episodes of cataplexy Central Disorders of Hypersomnolence Idiopathic Hypersomnia ICSD-3 - The following 6 criteria must be met for a diagnosis of idiopathic hypersomnia: 1. Daytime lapses into sleep or an irrepressible need to sleep on a daily basis, for at least 3 months. NOTE additional supporting features are: a) sleep drunkenness; and/or b) naps that are unrefreshing and long (greater than 1 hour) 2. Insufficient sleep syndrome is confirmed absent, preferably with a week of wrist actigraphy 3. MSLT (Multiple Sleep Latency Test) shows one of the following: Fewer than 2 sleep onset REM periods (SOREMPs); Or No SOREMPs, if the REM latency on the preceding overnight sleep study was less than or equal to 15 minutes Central Disorders of Hypersomnolence Idiopathic Hypersomnia 4. The presence of one or both of the following: Average sleep latency of less than or equal to 8 minutes on MSLT Total 24-hour sleep time is greater than or equal to 660 minutes (more typically 12-14 hours) when measured by: a) a 24-hour sleep study performed after correcting any chronic sleep deprivation; or b) wrist actigraphy recorded along with a sleep log and averaged over at least 7 days of unrestricted sleep 5. No cataplexy 6. Not explained by another condition - i.e., sleep disorder, medical or psychiatric disorder, or drug/medication use Central Disorders of Hypersomnolence Kleine-Levin Syndrome Rare disorder, occurs mostly in young men Characterized by hypersomnic attacks 3-4 times a year lasting up to 2 days Symptoms include hyperphagia, hypersexuality/disinhibition, irritability, and confusion on awakening Between episodes alertness, behaviour and thinking are normal No known cause Central Disorders of Hypersomnolence Forms of central disorders of hypersomnolence caused by or intimately related to a different condition include: Hypersomnia due to a medical condition caused by a head injury, a neurodegenerative disease such as Parkinson’s disease, or a neuromuscular disorder such as myotonic dystrophy, or rare conditions such as Ehlers-Danlos syndrome, POTS (postural tachycardia syndrome) Hypersomnia due to a medication or substance sleepiness caused by a prescription or non-prescription medication or drug Insufficient sleep syndrome Not sleeping enough hours per night on a regular basis—i.e., 7-9 hours in adults, with individual variation in duration of sleep needed within that range Hypersomnia associated with a psychiatric disorder Comorbid diagnosis of depression, psychosis, bipolar disorder, etc. Sleep Disorders International Classification of Sleep Disorders (ICSD-III) (American Academy of Sleep Medicine) groups sleep disorders into seven categories 1. Insomnia 2. Circadian rhythm sleep-wake disorders 3. Central disorders of hypersomnolence Disorders of Excessive Daytime Sleepiness (EDS) 4. Parasomnias 5. Sleep-related movement disorders 6. Sleep-related breathing disorders 7. “Other sleep disorders” - not captured above Parasomnias (Abnormal Behaviours During Sleep) Common in children and less so in adults ICSD-3 – defines parasomnias as undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousals from sleep May occur during any sleep stage: NREM, REM or during transitions to and from sleep Characterized by the occurrence of complex motor or behavioural events or experiences at sleep onset, within sleep or during arousal from sleep abnormal sleep-related complex movements, behaviours, emotions, perceptions, dreams and autonomic nervous system activity - potentially harmful and can cause injuries (also to the bed partner), sleep disruption, adverse health consequences and undesirable psychosocial effects Kazaglis, L., Bornemann, M.A.C. Classification of Parasomnias. Curr Sleep Medicine Rep 2, 45–52 (2016). https://doi.org/10.1007/s40675-016-0039-y Image: Avidan et al. (2010) Parasomnias (Abnormal Behaviours During Sleep) NEM Related Parasomnias: Sleep Terrors an abrupt, terrifying arousal from sleep, usually in preadolescent boys although it may occur in adults as well Occur in stage 3 or stage 4 sleep distinct from sleep panic attacks Sx: fear, sweating, tachycardia, and confusion for several minutes, with amnesia for the event Sleepwalking (somnambulism) includes ambulation or other behaviors while asleep, with amnesia for the event affects mostly children aged 6–12 years Occur during stage 3 or stage 4 sleep in the first third of the night and in REM sleep in the later sleep hours In adults: may be a feature of dementia in older adults May be due to Idiosyncratic reactions to drugs (eg, marijuana, alcohol) and medical conditions (eg, partial complex seizures) Parasomnias (Abnormal Behaviours During Sleep) REM Related Parasomnia: Nightmares occur during REM sleep Other Parasomnias: Enuresis involuntary micturition during sleep in a person who usually has voluntary control more common in children, usually in the 3–4 hours after bedtime not limited to a specific stage of sleep confusion during the episode and amnesia for the event are common Sleep Disorders International Classification of Sleep Disorders (ICSD-III) (American Academy of Sleep Medicine) groups sleep disorders into seven categories 1. Insomnia 2. Circadian rhythm sleep-wake disorders 3. Central disorders of hypersomnolence Disorders of Excessive Daytime Sleepiness (EDS) 4. Parasomnias 5. Sleep-related movement disorders 6. Sleep-related breathing disorders 7. “Other sleep disorders” - not captured above Sleep Related Movement Disorders Diagnosis: Movements that occur during sleep or at its onset AND Disturbed night sleep or daytime sleepiness/fatigue Sleep-related movement disorders include: 1. Restless legs syndrome 2. Periodic limb movement disorder 3. Sleep-related leg cramps 4. Sleep-related bruxism 5. Sleep-related rhythmic movement disorder 6. Benign sleep myoclonus of infancy 7. Propriospinal myoclonus at sleep onset 8. Sleep-related movement disorder due to a medical disorder 9. Sleep-related movement disorder due to a medication or substance 10.Sleep-related movement disorder, unspecified 11.Isolated symptoms and normal variants (a) Excessive fragmentary myoclonus (b) Hypnagogic foot tremor and alternating leg muscle activation (c) Sleep starts (hypnic jerks) Sleep Related Movement Disorders Periodic Limb Movements During Sleep (PLMS) Occur only during sleep with subsequent daytime sleepiness, anxiety, depression, and cognitive impairment ICSD-3: Diagnostic criteria– meets criteria A–D A. Polysomnography demonstrates PLMS B. Frequency is AHI >5/h in children or >15/h in adults C. PLMS cause clinically significant sleep disturbance or impairment in mental, physical, social, occupational, educational, behavioural or other important areas of functioning D. PLMS and the symptoms are not explained more clearly by another current sleep disorder, medical or neurological disorder or mental disorder (e.g. PLMS occurring with apneas or hypopneas should not be scored) Sleep Related Movement Disorders Restless leg syndrome (RLS) includes movements while awake as well ICSD-3: Diagnostic criteria – meets criteria A–C A. An urge to move the legs, usually accompanied by or thought to be caused by uncomfortable and unpleasant sensations in the legs. These symptoms must: 1. Begin/worsen during periods of rest or inactivity; 2. Be partially or totally relieved by movement; and 3. Occur exclusively/predominantly in the evening/night B. Not related to another medical or a behavioural condition (e.g. leg cramps, positional discomfort, myalgia, venous stasis, leg edema, arthritis, habitual foot- tapping) C. Symptoms cause concern, distress, sleep disturbance or impairment in mental, physical, social, occupational, educational, behavioural or other important areas of functioning Differential Diagnoses for Insomnia (Conditions that Mimic Sleep Loss) Mental health disorders 30-40% Depressive disorders, anxiety disorders (PTSD, GAD, panic disorder), bipolar disorder, other disorders Medical or Neurologic disorders: 4-11% Chronic pain, CHF, IHD, COPD/asthma, respiratory distress syndromes, PUD, GERD, perimenopause, CFS/FM/RA/MSK disorders, uremia, end stage kidney disease, nocturia due to BPH, urinary incontinence, thyroid disorders (hyperparathyroidism, hyperthyroidism, hypothyroidism, etc.), DM/DI, allergic rhinitis, stroke, dementia, neurodegenerative and movement disorders, brain tumors, posttraumatic insomnia due to brain injury, epilepsy, headache syndromes, fatal familial insomnia Differential Diagnoses for Insomnia (Conditions that Mimic Sleep Loss) Medications and Substances: 3-7% Side effects of OTC and Rx drugs, substance abuse (marijuana)/illicit drug use, opioid use, alcohol use disorder, caffeine, nicotine, withdrawal from CNS depressants, Lifestyle Shift work (10%), poor sleep hygiene/environmental factors (i.e. noise, temperature), jet lag, stressful life events, Other sleep disorders: 12-16% Sleep apnea syndromes (OSA), sleep state misperception (15%), RLS/PMLD, circadian rhythm disorders (delayed sleep phase syndromes), altitude insomnia Effects of Substances on Insomnia Alcohol use disorder - may cause or be secondary to the sleep disturbance Acute alcohol intake à a decreased sleep latency with reduced REM sleep during first half of the night while REM sleep is increased in the second half of the night, with an increase in total amount of slow wave sleep (stages 3 and 4) Vivid dreams and frequent awakenings are common Chronic alcohol abuse increases stage 1 and decreases REM sleep, with symptoms persisting for many months after the individual has stopped drinking Acute alcohol or other sedative withdrawal causes delayed onset of sleep and REM rebound with intermittent awakening during the night Nicotine - heavy smoking (more than a pack a day) causes difficulty falling asleep often independently associated with an increase in coffee drinking Caffeine (excess intake), cocaine, and other stimulants (eg, over-the-counter cold remedies) near bedtime causes decreased total sleep time Mostly affects NREM sleep - with some increased sleep latency Medications Case Study: 52-year-old Female A 52-year-old woman comes to your office complaining of persistent insomnia and requests a prescription for a sleeping pill that she saw on a television advertisement. Additional History The patient has had difficulty falling asleep most nights as well as early awakening for the past 6 months. She states that she falls asleep at her job due to this, and she feels fatigued much of the time. Her sleep habits are that she goes to bed at 11 pm every night but does not fall asleep until 12:30 or 1 am. She does not nap on purpose during the day and uses her bedroom only for sleep or sex. She does drink caffeinated sodas throughout the day and evening but does not drink alcohol. She denies heavy snoring, leg symptoms, or waking with any medical symptoms, and she is not obese. Her past history is notable only for hypertension, and the only medication she takes is hydrochlorothiazide. She does admit that she has been feeling depressed over the past 6 months after the death of her mother and with current financial problems at home. She denies suicidal ideation. Case Study 52-year-old Female What Is the Most Likely Cause of Her Insomnia? A. Depression B. Multifactorial C. Poor sleep hygiene D. Primary insomnia E. PLMD Case Study: 63-year-old Male A 63-year-old man comes to see you with his wife because she is concerned about his snoring – it keeps her awake during the night! She has noticed he will gasp for air or occasionally choke at night during his sleep. He is not concerned about the snoring and does not feel sleepy during the day, though he likes to take naps. He has a history of hypertension, which is medicated with hydrochlorothiazide 25mg/day. What are your initial Differential Diagnoses? List the signs/symptoms presented that may help you in your assessment. List additional signs/symptoms you would like to know. Sleep Disorders International Classification of Sleep Disorders (ICSD-III) (American Academy of Sleep Medicine) groups sleep disorders into seven categories 1. Insomnia 2. Circadian rhythm sleep-wake disorders 3. Central disorders of hypersomnolence Disorders of Excessive Daytime Sleepiness (EDS) 4. Parasomnias 5. Sleep-related movement disorders 6. Sleep-related breathing disorders Obstructive sleep apnea 7. “Other sleep disorders” - not captured above Obstructive sleep apnea (OSA) Prevalence: 2-14% and up to 21-90% for patients referred for sleep evaluation OSA/Obstructive sleep apnea-hypopnea syndrome (OSAHS) characterized by repetitive collapse of upper airway which may be either partial or total resulting in reduction of airflow (hypopnea) or nighttime breathing cessation (apnea), respectively causes excessive daytime sleepiness associated with significant morbidity - including hypertension, heart failure, arrhythmia, and diabetes, and mortality Treated effectively with weight loss, nocturnal continuous positive airway pressure (CPAP), and some surgical procedures CPAP improves hypertension control and quality of life and reduces depression and motor vehicle crashes Obstructive sleep apnea - OSA AHI > 5 times per hour during sleep Prevalence of OSA varies based on: the AHI threshold used for the evaluation 5 events/h, prevalence 14% 15/h, prevalence 6% and whether the disease definition requires symptoms in addition to an abnormal AHI 5/h with symptoms, prevalence 2%-4% Image: Myers et al (2013) OSA Risk Factors Male sex, older age (40-70 years, mean age 50yo), AHI > 10 Postmenopausal women Family history of sleep apnea may be related to craniofacial structures and upper airway abnormalities (e.g. enlarged tonsils or long upper airway) Obesity (higher BMI 31.4 (95% CI, 30-5-32.2) & lifestyle factors leading to obesity Black, Hispanic/Latino, and Native American/Alaska Native persons have a higher prevalence of OSA compared with White persons Hypertension May be risk as well as consequence However minimal impact on likelihood or OSA at AHI >10 or >15 Normotensive patients have lower likelihood (LR- 0.60, 95% CI, 0.51-0.72) Tobacco, Alcohol, Sedative use History of motor vehicle crashes –moderate or severe OSA (AHI 15/h) Obstructive sleep apnea - OSA Image: Myers et al (2013) Sleep Apnea - Symptoms Finding AHI Threshold Sensitivity, % Specificity, % LR+ LR- (Events/hour) (95% CI) (95% CI) (95% CI) (95% CI) Risk factors Hypertension >10 or >15 74 (65-81) 45 (34-55) 1.3 (1.2-1.5) 0.60 (0.51-0.72) Symptoms Nocturnal >10 or >15 52 (34-70) 84 (77-92) 3.3 (2.1-4.6) 0.57 (0.38-0.76) choking/gasping Morning headache >5 12-34 91-95 2.6-3.8 0.73-0.93 >10 or >15 22 (12-32) 85 (82-88) 1.5 (0.98-2.0) 0.92 (0.82-1.0) Reported apnea >10 or >15 80 (73-87) 42 (33-51) 1.4 (1.2-1.5) 0.47 (0.38-0.56) Excessive daytime >5 46 (38-53) 68 (59-78) 1.4 (1.0-1.9) 0.80 (0.67-0.92) sleepiness >10 or >15 50 (41-60) 61 (52-71) 1.3 (1.1-1.4) 0.81 (0.74-0.88) Snoring >5 79-97 27-46 1.3-1.5 0.12-0.45 >10 or >15 90 (77-96) 19 (9.7-35) 0.60 (1.0-1.1) 0.60 (0.49-0.73) OSA Signs Anthropometric measurements from examination of oropharyngeal and craniofacial structure Anthropometric Measurements Obesity – BMI Neck circumference - performed with the patient in the upright position Craniofacial Structure Cricomental space and the thyromental angle and distance Malocclusions - associated with retrognathia Overjet Oropharyngeal Examination - Enlargement of the tonsils, tongue, and uvula Mallampati airway class 3-4 OSA - Signs Image: Myers et al (2013) OSA – Mallampati Classification System Image: Myers et al (2013) Sleep Apnea - Signs Finding AHI Threshold Sensitivity, % Specificity, % LR+ LR- (Events/hour) (95% CI) (95% CI) (95% CI) (95% CI) Mallampati Class (3 or 4) >5 65 (54-75) 60 (47-72) 1.6 (1.1-2.3) 0.60 (0.41-0.85) >15 55 (40-69) 65 (57-72) 1.6 (1.1-2.2) 0.68 (0.47-0.98) Pharyngeal narrowing >10 or >15 67 (38-95) 53 (25-80) 1.4 (1.1-1.7) 0.63 (0.39-0.87) Combination of Findings Overall clinical impression >10 or >15 58 (49-67) 67 (60-73) 1.7 (1.5-2.0) 0.67 (0.60-0.74) STOP-Bang Questionnaire >5 88 (83-92) 53 (43-62) 1.8 (1.5-2.3) 0.23 (0.15-0.35) >15 93 (91-94) 35 (27-44) 1.4 (1.2-1.6) 0.20 (0.16-0.25) Snoring Severity Scale > 4 >15 97 (92-99) 38 (27-51) 1.6 (1.3-2.0) 0.07 (0.03-0.19) and BMI >26 Sleep Apnea Clinical Score (SACS) As neck circumference increases, fewer of the other 3 variables are required to increase the likelihood of OSA On its own, neck circumference of 50 cm or higher is associated with a SACS above 15, and so even without any other features of OSA this confers modestly increased risk Image: Myers et al (2013) STOP BANG (for OSA) https://www.mdcalc.com/ calc/3992/stop-bang- score-obstructive-sleep- apnea http://www.stopbang.ca/ osa/screening.php Image: https://www.sleepmedicine.com/files/files/StopBang_Questionnaire.pdf STOP-BANG Questionnaire (Screening for OSA) Score - at least 3 has a sensitivity of 84%, 93%, and 100% to detect all OSA (apnea-hypopnea index [AHI] ≥5), moderate OSA (AHI ≥15), and severe OSA (AHI ≥30), respectively Advantages: High diagnostic accuracy (high discriminative power to exclude moderate to severe and severe OSA) Easy to use, and clear thresholds for risk stratification Case Study: 63-year-old Male What additional questions would you like to ask? What physical exams would you like to perform? Assuming a community prevalence in men of 15% for OSA (AHI 5/hour) calculate the post test probability of him having OSA What are some initial treatment recommendations you can offer? OSA Dx Bottom line What is the value of Individual signs/symptoms in diagnosing OSA? How does snoring impact the diagnosis of OSA? Do self-reported sleepiness and morning headaches help differentiate between patients with or without OSA? Insomnia – Interview Framework *history is critical to successful assessment and treatment* Sleep complaints usually fall into four general categories: Insomnia: complaints of difficulty initiating sleep or staying asleep Hypersomnia: difficulty staying awake during the day Parasomnia: abnormal movements or behavior during sleep Circadian rhythm disorders: timing of the sleep–wake cycle at undesired or inappropriate times over a 24-hour day …or a combination of the above Interview Framework Detail the nature and development of the sleep problem. Determine the chief sleep symptom difficulty initiating asleep, staying asleep or both? early awakenings? poor or unrefreshing/non-restorative sleep? Determine the chronology of the insomnia including: onset predisposing, precipitating or perpetuating factors ameliorating or exacerbating factors duration, and frequency Evaluate the patient's sleep hygiene Interview Framework Detail the nature and development of the sleep problem. Assess effects on daytime functioning and social or occupational function to gauge the severity of insomnia validated questionnaires – Pittsburgh Sleep Quality Inventory (PSQI) Epworth Sleepiness Scale (ESS) or Insomnia Severity Index (ISI) Assess excessive daytime sleepiness lack of daytime fatigue or sleepiness suggests the insomnia is not clinically significant Review previous treatments and assess their efficacy Explore Sleep-wake schedule? Cognitive attitude toward sleep? Negative expectations regarding the ability to sleep and distortions about the effects of insomnia lead to perpetuation of the insomnia. Attitudes toward previous treatments are also important. Interview Framework Expand the history to cover potentially contributing medical, psychiatric, and sleep disorders Review past medical and psychiatric history Any comorbid or psychiatric disorders present? Any pre-existing medical illnesses with nocturnal symptoms? Review medications, and substance use history Perform a review of symptoms that have not been covered by your other questions If possible, get collateral history from a bed partner For information on the quality and quantity of sleep, daytime consequences, and nocturnal events (e.g., snoring, apneas, and limb movements) Complete a sleep diary - to determine an accurate diagnosis and assess treatment response in the future Identify Alarm symptoms Heavy snoring, observed sleep apneas, daytime somnolence Consider obstructive sleep apnea or central sleep apnea Suicidal or homicidal thoughts Consider severe psychiatric disorders (depression, bipolar disorder, psychosis) Nocturnal chest pain or pressure Unstable coronary artery disease Nocturnal breathing patterns Decompensated pulmonary disease (asthma, COPD) Unstable coronary disease Undiagnosed sleep apnea syndromes Sleep Quality: Sleep Logs/Diaries Maintain logs for 2 to 4 weeks à quantifies sleep performance and variability Used to determine the total sleep time (TST), wakefulness after sleep onset (WASO), sleep efficiency (SE), and circadian rhythm disturbances Advantage – identifies behaviours or patterns that may be targeted for intervention, reliable, cost-effective Limitation - reliability and validity based on adequate documentation Sample Sleep Diary Image: Keenan (2012) Diagnostic Approach (Algorithm) Image: Henderson et. al. (2012) Sleep Quality Questionnaires Subjective tools to aid in the diagnosis of insomnia Includes questionnaires such as: Pittsburgh Sleep Quality Index (PSQI) Insomnia Severity Index (ISI) Epworth Sleepiness Scale (ESS) Pittsburgh Sleep Quality Inventory (PSQI) Measures different domains of sleep (quality, latency, duration, efficacy, medication use, daytime symptoms, and disturbances) over one month Accepted reference or gold standard Available in many languages 19 questions: Global PSQI score > 5 (sensitivity 89.6%, specificity 86.5%) helps distinguish good and poor sleepers Demonstrates good consistency, reliability and validity https://sleep.pitt.edu/instruments/ https://www.goodmedicine.org.uk/files/as sessment,%20pittsburgh%20psqi.pdf Image: https://www.yumpu.com/en/document/read/28214347/pittsburgh-sleep-quality-index-psqi-goodmedicineorguk Insomnia Severity Index (ISI) Measures perceived insomnia severity focusing on: level of disturbance to the sleep pattern consequences of insomnia degree of concern and distress related to the sleep problem 7 Questions; item with time interval of the past 2 weeks Available in three versions: patient (self- administered), significant other, and clinician https://www.healthquality.va.gov/guidelines/CD /insomnia/TrifectaInsomniaSeverityIndexFillabl e910162020.pdf Image: https://www.med.upenn.edu/cbti/assets/user-content/documents/Insomnia%20Severity%20Index%20(ISI).pdf Epworth Sleepiness Scale (ESS) Measures sleepiness/sleep tendency in eight different daily situations Convenient, standardized, and cost-effective Good internal consistency and validity Differentiates individuals with excessive daytime sleepiness (EDS) from alert people can be caused by OSA, narcolepsy, idiopathic hypersomnia, insomnia, periodic limb movement disorder https://www.merckmanuals.com/en- ca/professional/multimedia/clinical-calculator/epworth- sleepiness-scale-ess https://qxmd.com/calculate/calculator_85/epworth-sleepiness- scale Image: https://nasemso.org/wp-content/uploads/neuro-epworthsleepscale.pdf Physical Exams Evaluate Vitals Height & weight – calculate body mass index (BMI) Craniofacial morphology Oropharyngeal examination Neck circumference Cardiovascular examination Digital clubbing Neurologic examination Image: https://1md.org/health-guide/heart/symptoms/insomni Sleep Laboratory Evaluation Most sleep complaints can be managed by the non-specialist Consider referral to sleep specialist/sleep disorder centre for: sleep apnea PLMs during sleep narcolepsy parasomnias with potential for serious injury intractable insomnia Sleep Quality – Polysomnography (PSG) & Actigraphy Objective methods of measuring sleep quality Advantages: Demonstrate high reliability in obtaining information on sleep parameters Disadvantages: Not readily available to most clinicians in their daily practice, expensive and time-consuming Studies with large populations have shown an agreement between actigraphy and PSG in total sleep time (TST), wake after sleep onset (WASO), and sleep efficiency (SE) parameters Some studies have demonstrated that actigraphy consistently underestimated sleep onset latency (SOL) in comparison with PSG Actigraphy Uses non-invasive devices (3D accelerometer) - worn on the wrist, ankle or waist, for days to weeks Records the occurrence and degree of limb movement and provides a graphical summary of wakefulness and sleep patterns over time Assesses total sleep duration, wakefulness after sleep onset (WASO), sleep latency, sleep interruptions, daytime naps, sleep quality and efficiency, posture changes, lifestyle patterns Cost effective Image: https://thrive.kaiserpermanente.org/care-near-you/northern-california/sanjose/departments/sleep-medicine- services/patient-resources/actigraphy/ Actigraphy Limitations: It cannot access the periodic limb movements (PLM) or abnormal breathing patterns in insomnia à indicates need for polysomnography The recorded activity is only a proxy for sleep and is not sleep itself There are a variety of devices and scoring algorithms available that limit the comparability between different actigraphic devices AASM Suggests using actigraphy in adults and pediatric patients with insomnia disorders, circadian rhythm sleep-wake disorder, suspected central disorders of hypersomnolence, sleep-disordered breathing, insufficient sleep syndrome Strongly recommends that clinicians not use actigraphy in place of electromyography for the diagnosis of periodic limb movement disorder in adult and pediatric patients Polysomnography (PSG) Gold standard for diagnosing sleep-related breathing disorders, which include obstructive sleep apnea (OSA), central sleep apnea, sleep-related hypoventilation/hypoxia and parasomnias Also utilized to evaluate nocturnal seizures, narcolepsy, periodic limb movement disorder, and rapid eye movement sleep behavior disorder Not indicated in the initial assessment of primary insomnia unless a co-existing sleep disorder is suspected Sleep stages are constructed by monitoring electroencephalogram, chin electromyogram, and eye movements by electrooculogram Cardiorespiratory function and movement disorders during sleep assessed by continuous monitoring of respiratory effort, nasal and oral airflow during inspiration and expiration, arterial oxygen saturation, electrocardiogram, and limb electromyogram Image: https://www.sleep-apnea-guide.com/polysomnogram.html PSG Limitations Costly and inconvenient The first-night effect à underestimating OSA due to the potential for decreased REM sleep being captured Medication changes before a PSG à quality and quantity of sleep Nocturnal seizures and sleep related rapid breathing disorders may occur too infrequently Equipment issues à PSG inaccuracies Requires An adequate sleep period Highly trained technicians to administer the study, and sleep providers interpreting the study à high cost What about other devices? Image: https://www.fitbit.com/global/en-ca/products/smartwatches/versa4 Management – Interprofessional Healthcare Team Consider referral and co-management between Primary care practitioner Psychiatrist, Psychotherapist Sleep disorder specialist Pharmacist Nurse practitioner Neurologist Treatment Education – set realistic goals Sleep relaxation exercises Encourage a healthy lifestyle Address causative medical and psychiatric conditions Image: https://www.sleepfoundation.org/insomnia Treatment Behaviours approaches Sleep restriction, stimulus control, cognitive behavioral therapy (CBT), aerobic exercise Brief pharmacologic therapy – sedative-hypnotics (short acting benzodiazepines, benzodiazepine receptor agonists) Inappropriate to use side effects of other meds (i.e., antidepressants) or self- medicating with diphenhydramine Combined effects - hypnotics used with other CNS depressants, never combine hypnotics with alcohol Other hypnotics L-tryptophan, melatonin First-line treatment for OSA is PAP during sleep Includes CPAP (continuous positive airway pressure) and auto-titrating continuous positive airway pressure (APAP) Insomnia Complications Image: https://sleep.hms.harvard.edu/education-training/public-education/sleep-and-health-education-program/sleep- health-education-21 Sleep and Memory Consolidation Image: Cross et. al. (2018) Insomnia Complications Sleep disturbances are associated with neurocognitive dysfunctions, attention deficits, impaired cognitive performance, stress, and poor impulse controls Impairments in memory, executive functions, and attention over time à may develop psychiatric disorders such as depression, anxiety, psychosis and even suicide Poor sleep can severely affect daytime performance, both socially and at work Increases the risk of occupational and automobile accidents and injuries, alcohol use, poor quality of life and poor overall health Can develop dependence on medication to sleep Strong associations with diabetes mellitus & insulin resistance, asthma, obesity, obstructive sleep apnea, hypertension, vascular disease, stroke, myocardial infarct Overall lower self-reported quality of life, decreased family well-being, and increased mortality & morbidity Insomnia Prognosis Short-term insomnia - good long-term prognosis if interventions and treatments are made appropriately and promptly Chronic insomnia - usually very persistent, especially in patients with significant comorbid medical and psychiatric conditions 46% to 72% of patients with insomnia continue to have insomnia symptoms 3 years later Insomnia impacts quality of life and poses a substantial economic burden on the society Elderly persons with primary insomnia - at greater risk of dependence on hypnotic medications, depression, dementia, and falls, and may be more likely to require residential care Any Questions? 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