PRACTICAL MANAGEMENT OF INSOMNIA IN THE OFFICE NORAH VINCENT, PHD., C. PSYCH. PSYCHOLOGIST, WINNIPEG REGIONAL HEALTH AUTHORITY PROFESSOR, DEPARTMENT OF CLINICAL HEALTH PSYCHOLOGY, UNIVERSITY OF MANITOBA
Faculty: Norah Vincent Relationships with commercial interests: Cerebra Health
This presentation has received no financial or in-kind support from Cerebra Health Potential for conflict(s) of interest: Norah Vincent has received no payment/funding from Cerebra Health Cerebra Health does not distribute or benefit from a sale of a product that will be discussed in this program
Insomnia Disorder DSM V Poor sleep quantity/quality Daytime impairments >3 nights per week/ >3 months in duration Not entirely explained by another disorder Not due to lack of opportunity to sleep
Insomnia Common problem 1 in 3 Disorder status with DSM V 69 000 Manitobans full blown disorder
Reasons why you Should Treat Insomnia Persists in 90% Sleep deprived are 60% more reactive to upsetting situations Lose 9 hours of productive work time per week with moderate-severe insomnia 37% of drivers admit to falling asleep behind wheel in past year
Reasons why you Should Treat Insomnia Increases morbidity (type 2 diabetes, stroke, obesity) by 2-3 fold Increases mortality (suicide, accidents) by 2 fold Improves remission rate in Major Depressive Disorder
Choosing Wisely Canada Campaign Don't use benzodiazepines and/or other sedative hypnotics in older adults as a first choice for insomnia The drugs can cause confusion and memory problems that: Double the risk of falls and hip fractures Increase the risk of car accidents 1/3 older people takes a sleep medication
Schutte-Rodin et al. 2008, Jn Clin Sleep Med, 4, 487-504 Cognitive behavioral therapy should be front line treatment American College of Physicians NIH Consensus ad State of the Science Statement American Academy of Sleep Medicine Qaseem et al., 2016, Annals of Internal Medicine NIH Consens and State Sci Statements, 2005, 22(2), 1-30
Cognitive Behavioral Therapy 7 evidence-based techniques Time-limited Involves multiple follow-ups It is not same as sleep hygiene
Cognitive Behavioral Therapy Targets 3 Critical Maintaining Factors Hyperarousal Conditioning of wakefulness Circadian rhythm misalignment More Time Awake in Bed Conditioning of wakefulness Hyper arousal Light exposure in nocturnal period, more sleeping in Delayed rhythm
Best In-Office Cognitive Behavioral Techniques Reduce Hyperarousal Breathing technique Don t monitor time at night Think realistically about next day Don t pressure yourself to sleep More Time Awake in Bed Hyper arousal Conditioning of wakefulness Light exposure in nocturnal period, more sleeping in Delayed rhythm
Best In-Office Cognitive Behavioral Techniques Conditioning of sleepiness to bedroom Go to bed only when very sleepy Use bedroom only for sleep/sex Don t bring technology into bedroom More Time Awake in Bed Hyper arousal Conditioning of wakefulness Light exposure in nocturnal period, more sleeping in Delayed rhythm
Best Technique to Combat Conditioning of Wakefulness: Sleep Restriction 1. Decide on fixed wake up time 2. Determine average total sleep time (diary) 3. Prescribe a sleep window 4. Gradually open the window in 3 day increments
Sleep Restriction example Bob: wake up time 6:00am Current total sleep time: 5 hours Calculate Sleep Window Days 1-3 Days 4-6 Days 7-10 Bedtime 1:00am 12:30am 12:00am
Sleep Restriction Schedule Day Bedtime Wakeup Time Result Days 1-3 Days 4-6 Days 7-9 Days 10-12 * hand-out
Sleep Restriction contraindicated for bipolar disorder untreated sleep apnea parasomnias seizure disorder
Best In-Office Cognitive Behavioral Techniques Entrain Circadian Rhythm Eliminate light exposure during night Encourage light exposure during day Get up at same time each day Don t encourage daytime napping More Time Awake in Bed Hyper arousal Conditioning of wakefulness Light exposure in nocturnal period, more sleeping in Delayed rhythm
How to Motivate Hypnotic-Dependent Patients to Drug Taper Memory Unsafe driving Expense Interactions with alcohol, caffeine, and other drugs
How to Motivate Hypnotic-Dependent Patients to Drug Taper Placebo effects Amnesia/memory loss Daytime misattribution of fatigue Reduced confidence
Local Resources Sleep Disorders Center, Misericordia Health Center Evaluation of sleep complaints, polysomnography HSC Sleep Clinic (fax: 787-3755) Consultation and group treatment- Restful Nights Workbook 6 week online CBT-I (return2sleep.com) Newly developed online Sleeping without Pills (SWOP) program
Upcoming Study of Sleeping without Pills (SWOP) Aim: Reduce dependency on sleep medication RCT: 6 week online program (Sleeping without Pills) 6 week self-monitoring Eligibility Adults with Internet access Awake at least 30 minutes during night Use of sleeping agent >+ 3 nights per week Either.5 clonazepam, 1 mg lorazepam, 7.5 mg zopiclone
Study starts June 2017 Fax referrals for SWOP to Drs. Vincent/Quintana at 787-3755
Local Resources Contd. Self-help resources Sink into Sleep: A step by step workbook, Dr. Judith Davidson Say Goodnight to Insomnia Dr. Gregg Jacobs Quiet your Mind and Get to Sleep, Drs. Carney and Manber