SLEEP-WAKE DISORDERS: INSOMNIA. Prof. Paz Gía-Portilla

SLEEP-WAKE DISORDERS: INSOMNIA Prof. Paz Gía-Portilla

SLEEP-WAKE DISORDERS AND ICD-10 Chapter V: Mental and Behavioural Disorders F51. Non-organic sleep disorders Chapter VI: Nervous System Illnesses G47. Non-psychogenic disomnias, sleep apnea, narcolepsy and cataplexy, and Kleine-Levin syndrome Chapter IV: Endocrine and Metabolic Illnesses E66.2. Pickwick syndrome

SLEEP-WAKE DISORDERS (SD) AND DSM-5 Insomnia disorder Hypersomnolence disorder Narcolepsy Breathing-related SD Obstructive sleep apnea / hypopnea Central sleep apnea Sleep-related hypoventilation Circadian rhythm sleep-wake disorders Non-rapid eye movement (NREM) sleep arousal disorders Nightmare disorder Rapid ella movement (REM) sleep behavior disorder Restless legs syndrome Substance-/medication- induced SD

ICD-10TH: F51. NON-ORGANIC SLEEP DISORDERS Sleep disorders in which emotional causes are a primary factor Disomnias: primary psychogenic disorders in which the main complaint is related to amount, quality, or timing due to emotional causes Non-organic insomnia Non-organic hypersomnia Sleep-wake rhythm disorders

ICD-10TH: F51. NON-ORGANIC SLEEP DISORDERS Parasomnias: episodic disorders during sleep. In the childhood are due to the neurodevelopmental process while in adulthood are related to emotional problems Sonanbulism Nocturnal terrors Nightmares

INSOMNIA: EPIDEMIOLOGY The most prevalent sleep disorder: 19-35% In adulthood: Chronic insomnia: 9-15% Transient insomnia: 25-35% (studies report up to 50-60%) Risk factors: Women: 1.5 more likehood Older than 65 yrs of age: 1.5 more likehood Up to 33% of older adults: continous insomnia Mental disorder: present in 30-50% of persons with insomnia

INSOMNIA: DIAGNOSTIC CRITERIA Insomnia (780.52) DSM-5 Unhappiness with the quality or quantity of sleep (trouble falling asleep, staying asleep or waking up early and being unable to get back to sleep) Difficulty sleeping occurs at least 3 times / week for at least 3 months Non-Organic Insomnia (F51.0) ICD-10th a) Difficulty for initiating or maintaining sleep or sleep of poor quality b) At least 3 times / week during at least 1 month

INSOMNIA: DIAGNOSTIC CRITERIA Insomnia (780.52) DSM-5 Non-Organic Insomnia (F51.0) ICD-10th c) Excessive worrying about the sleep problems and their consequences The sleep disturbance causes significant distress or impairment in functioning d) General discomfort or interference with work and social functioning The problem occurs despite ample opportunity to sleep

INSOMNIA: MAIN COMPLAINT Initiation sleep Maintaining sleep: awakenings after sleep onset Early awakening: last awakening at least 2 hours before than desired by the patient Non-restorative sleep Most patients shows more than 1 subtype Young adults: falling asleep Older adults: mainteining sleep

INSOMNIA: DURATION Transient Less than 1 week Triggered by acute stressful events New environment Situational stress Acute somatic illnesses Jet lag Side-effects of caffeine, nicotine, OH or other substances

INSOMNIA: DURATION Short-duratino Between 1 nad 3 weeks Related to more severe or longer lasting stressful factors Hospitalization Emotional trauma Pain Marriage / divorce Bereavement

INSOMNIA: DURATION Chronic More than 3 weeks No clear cause (multi-causality) Represents around the 50% of cases of insomnia Worst prognosis A good diagnosis of this type of insomnia is the best treatment strategy

INSOMNIA: CLINICAL CONSEQUENCES Somatic and psychological symptoms Fatigue, discomfort Decreased energy, abulia, loss of interest, depressive mood Irritability Tensional headache Loss of attention/concentration and memory Daytime somnolence Worry about sleep Edinger et al, 2004

INSOMNIA: CLINICAL CONSEQUENCES Negative impact on Physical health: associated with diabetes, obesity, and cardiovascular illness Functioning (social, work, ) Quality of life Greater risk of Mental disorders (depression, memory problems) Accidents (motor vehicle, working) Greater health expenditure

INSOMNIA: DIAGNOSIS Comprehensive assessment Sleep history: core element Physical exam (thyroid dysfunction, ) Psychometric evaluation and sleep diaries Sleep Lab measures To select the best treatment for each person we need information on ethiology, main compliant, and duration of the sleep disorder

INSOMNIA: SLEEP HISTORY the patient s sleep-related behaviors and use of substances that might affect sleep; the times at which the patient goes to bed, actually attempts to go to sleep, wakes up, and gets out of bed; the quantity of sleep the patient obtains; variations in the patient s sleep schedule due to weekends or time off; any daytime symptoms, including fatigue, mood symptoms, and cognitive or functional impairments, as well as napping behaviors; social, economic, or occupational stressors that may be creating anxiety that contributes to sleep difficulties; the duration and chronology of the patient s sleep difficulties, as well as response to any previous treatment trials; and assessment for other sleep symptoms and disorders, including sleep apnea, restless legs syndrome, parasomnias, and circadian rhythm disorders. It is important to emphasize that the patient evaluation should be based on a 24-hour history and the focus should be on daytime functioning as well as the amount of sleep obtained during the night.

INSOMNIA: TREATMENT Progressive management Non-pharmacological interventions Psychoeducation Sleep hygiene Psychotherapeutic interventions Pharmacological treatment Hypnotics Other drugs with hypnotic capacity

INSOMNIA: PSYCHOEDUCATION Give the patient and its family specific information on sleep and its disorders Essential information for patients and families (WHO- GP, 1996) Sleep disorders are common under stress or somatic illnesses Total sleep time varies across people. Generally, is shorter in older adults

INSOMNIA: SLEEP HYGIENE Sleep hygiene is the habits and practices that contribute to getting a good night s sleep Include factors like diet and exercise, as well an environmental elements like light and sound levels at bedtime.

INSOMNIA: SLEEP HYGIENE #1 Avoid Caffeine, Alcohol, Nicotine, and Other Chemicals that Interfere with Sleep #2 Turn Your Bedroom into a Sleep-Inducing Environment #3 Establish a Soothing Pre-Sleep Routine #4 Go to Sleep When You re Truly Tired #5 Don t Be a Nighttime Clock-Watcher #6 Use Light to Your Advantage #7 Keep Your Internal Clock Set with a Consistent Sleep Schedule #8 Nap Early Or Not at All #9 Lighten Up on Evening Meals #10 Balance Fluid Intake #11 Exercise Early #12 Follow Through

INSOMNIA: PSYCHOTHERAPY TX Cognitive behavioral therapy (CBT) A person s attitudes and beliefs about sleep may be contributing to the insomnia - CBT challenges sufferers to rethink their beliefs and behaviors in order to bring about positive change. Relaxation therapy Sufferers of insomnia disorder are often highly aroused. Relaxation therapy may help deactivate the arousal system through techniques like imagery training and progressive muscle relaxation. Stimulus control therapy This type of treatment encourages the patient to associate their bedroom with sleeping and establish a sleep/wake pattern.

PHARMACOLOGICAL TREATMENT FOR INSOMNIA: PRIMARY HYPNOTICS Hypnotics are defined as substances included in the Anatomical Therapeutic Chemical group (ATC-group) N05C According to the chemical structure of its components the N05C group is subdivided into 1. N05CD or Benzodiazepines derivates 2. N05CF or Benzodiazepine related drugs a. Zopiclone b. Zolpidem c. Zaleplon d. Eszopiclone 3. N05CH or Melatonin receptor agonists a. Melatonin b. Ramelteon c. Tasimelteon Dual Orexin receptor antagonists (Suvorexant)

PHARMACOLOGICAL TREATMENT OF INSOMNIA: OTHER DRUGS USED IN EUROPE Antidepressants Agomelatine, amitriptyline, doxepin, mianserin, mirtazapine, trazodone, trimipramine Antipsychotics Chlorprothixene, levomepromazine, melperone, olanzapina, pipamperone, prothipendyl, quetiapine Antihistamines Diphenhydramine, doxylamine, hydroxyzine, promethazine Phytotherapeutics Melissa, passiflora, valerian Riemann et al, 2017

PHARMACOLOGICAL TREATMENT FOR INSOMNIA: PRIMARY HYPNOTICS American Academy of Sleep Medicine recommendations for the treatment of insomnia in older adults. Class Chemical name Indication Geriatric dose (mg) Benzodiazepines Triazolam Temazepam SOI SOI & SMI 0.125-0.5 7.5-15 Cost / 30 days ($)* 472 / 298 120 / 71 Non-benzodiazepine receptor agonists Zolpidem Zaleplon Eszopiclone SOI & SMI SOI SOI & SMI 5 5-10 1-2 447 / 350 222 / 109 475 / 139 Melatonin receptor agonist Dual orexin receptor antagonist Ramelteon SOI 8 334 Suvorexant SMI 10-20 316 *brand/generics; SOI: Sleep-onset insomnia; SMI: Sleep-maintenance insomnia Suzuki et al, 2017; Lam and Macina, 2017

PRIMARY HYPNOTICS: ADVERSE EVENTS BCZDs Short- Long-acting Non-BZDs RA Zs Melatonin receptor agonists Dual Orexin RAnt Potential abuse +++ / ++ - - - Rebound insomnia +++ / ++ - - - Withdrawal symptoms +++ / ++ + - - Delirium ++ ++ / - Cognitive decline +++ ++ / - Anterograde amnesia +++ / ++ ++ / - General CNS sedation ++/ +++ + / - + Impaired motor coordination: Risk of falls and fractures Increased risk of motor vehicle accidents ++ / +++ ++ / - + ++ / +++ ++ / - +

PRIMARY HYPNOTICS: ADVERSE EVENTS Non-Benzodiazepine receptor agonists (non-bzdras) Zolpidem Dose-related Headache, dizziness, myalgia, nausea, and vomiting Case reports of hallucinations and increased risk for hazardous sleep-related activities (sleep driving, preparing and eating food, making telephone calls, of having sex while asleep) Zaleplon No adverse events compared to placebo Contraindicated in patients with sleep apnea syndrome, miastenia gravis, and severe respiratory dysfunction Zopiclone Headache, unpleasant taste, somnolence and dyspepsia Use in caution in patients with depression, hepatic impairment, and respiratory dysfunction

PRIMARY HYPNOTICS: ADVERSE EVENTS Melatonin receptor agonists (Ramelteon) No adverse events compared to placebo Dual Orexin receptor antagonists (Suvorexant) Dose-dependent Mild: fatigue, headache, dry mouth Serious: sleep paralysis and complex sleep-related behaviours