Professor Bruce Arroll Greenstone Family Clinic Auckland 14:00 - - - PowerPoint PPT Presentation

Professor Bruce Arroll

Greenstone Family Clinic Auckland 14:00 - 14:55 WS #107: Insomnia in Primary Care 15:05 - 16:00 WS #118: Insomnia in Primary Care (Repeated)

I am having difficulty sleeping!

a practical approach

Bruce Arroll dept of general practice and primary health care school of population health

conflicts of interest

• None
• Not receiving any payment for webinar talk

disclaimer

• not a sleep scientist
• a clinician with an interest in sleep

Bruce Arroll

• trained in Auckland 1973 to 79
• family Medicine McMaster in Ontario 1981-2
• dept of GP 1991 and GP Manurewa
• director of the goodfellow unit 2014-
• interested in knowledge translation/refineries
• Research that can be used tomorrow

print

• Sleep Screening tool
• AASM sleep diary

goodfellow uni t.or g

goodfellow uni t.or g

goodfellow uni t.or g

goodfellow uni t.or g

goodfellow uni t.or g

• what is insomnia
• what type of insomnia
• what can I/we do about it

what is insomnia

• do you have trouble with your sleeping (on at least 3

nights per week) such that it interferes with your activities the following day (eg unrefreshed in the morning, fatigued, poor concentration or irritability- lasting for more than one month

• 41% in Auckland GP Study

– Arroll et al Br J Gen Pract 2102; Feb:e99-e103

range of definitions

• major current insomnia (taking at least two

hours to fall asleep nearly every night 10% in Seattle Study – Simon GE, et Am j Psychiatr 1997;154(10):1417-23.

patient # 1

• 50 year old
• BMI 35
• snores loudly at night
• not feeling rested the next day
• falls asleep at work

patient # 2

• 75 year old woman
• Bed at 2100 wakes for 2 hours
• gets up at 0600
• does not feel rested when she wakes

patient # 3

1.28 year old acoustic engineer 2.bed at 2 am 3.weekend wakes at 1000 hrs 4.during up at 6 am to go to work – tired all day

return to patients later

dr tony fernando

dr karen falloon

an interest in insomnia

• tony fernando’s story
• primary insomnia
• “all” better with bed time restriction
• BA skeptical →need an RCT

an interest in insomnia

• primary insomnia
• insomnia with no other cause
• needed to know other causes
• ?other causes in primary care

*

causes of insomnia

• depression 50%
• anxiety 48%
• sleep apnea 9%
• general health 43%
• parasomnias (Sleep walk 1%, restless legs

bruxism 2% in reality about 5%

• Br J Gen Pract 2012; 62:e99-e103.

causes of insomnia

alcohol problem 8%

• ther substance 4%

*delayed sleep phase disorder 2% *primary insomnia 12% * mutually exclusive of other conditions

weird conditions

• REM disorder
• sleep eating

interest in insomnia

• conducted RCT 10 insomnia

* 75% intervention got a better sleep * 35% control group got a better sleep

• sleep hygiene “effective” ?CBT
• J Prim Health Care 2013;5(1):5-10.

time in bed restriction effective

• ?compression
• More on time in bed restriction later

patient # 1

• 50 year old
• BMI 35
• very tired in in daytime-asleep at work!!!!!!
• wife notices that stops breathing for up to 15 seconds
• snores loudly at night
• wakes with dry mouth
• morning headache

patient # 1

• Meets criteria for sleep apnoea
• Very tired during day
• Stops breathing and gasping episodes
• Minor criteria

– snores loudly at night – wakes with dry mouth – morning headache

patient # 1

• Needs assessment for CPAP
• Pulse oximetry at night
• Polysomnography (sleep lab)

Treatment

• CPAP (continuous positive airways pressure)
• weight loss ??
• mandibular advancement splints (MAS)
• surgery ???

patient # 2

• 75 year old woman
• goes to bed a 2100 wakes for 2 hours in middle of night
• gets up at 0600
• does not feel rested when she wakes
• bored, cold lonely
• use screening tool

patient # 2

• Looking at the screening tool
• Will tick yes to first 2 questions → insomnia
• Will tick no to all after bottom two questions
• i.e. no other cause for insomnia
• Hence she has primary insomnia

patient # 2 what to do

• Sleep hygiene
• Check on naps ( 1200 to 1500)

– ~ 30 minutes mx

• Exercise
• Time in bed restriction
• Medication

sleep hygiene

• bed only for sleep or intimacy
• don’t watch TV or computer screen in bed
• if not asleep within 20 minutes get up
• avoid caffeine before bed time
• avoid energetic activity before bed time
• avoid naps the during the day or else before 3 pm
• make sure environment is comfortable

– quiet – correct temperature – comfortable bed

sleep advice

• slow down breathing
• make your eyes half closed eyes
• app- mysleepbutton- nonsense words
• listen to podcasts
• sleep routine

Exercise Cochrane review 2002

These reviewers report that evidence from one small trial is encouraging, and further research is needed.

treatment

* bed time restriction

* ask how long in bed ~ 9 hours * estimate time asleep approximately

• or use sleep diary AASM

treatment

* usually 5 to 6 hours

* advise spend 5 to 6 hours in bed

treatment

* if wake at 0600 hrs - go to bed 2400

* difficult to keep occupied

• reading, light house work

treatment

* if drowsy next day-increase by (15)30”

* all changes need 1 week * may resist – consider compression

treatment

* notice that getting deeper sleep * professional drivers do in vacation

treatment –other/meds

• 1. CBTi if you can find it- sleep restriction
• 2. Melatonin
• 3. tricyclic in low doses??
• amitriptyline 10 mg
• nortriptyline

treatment –other

• 4. mirtazapine 15mg
• 6. quetiapine
• 7. all else fails low dose hypnotic
• tolerance ? fall

• ther conditions- meds
• 1. depression and anxiety

1. TCAs 2. Mirtazapine (weight issues) 3. Add benzodiazepines

• 2. stop SSRIS, SNRI, buproprion

treatment- supplements

good evidence

• acupressure, tai chi, yoga

mixed evidence

• L tryptophan, mindfulness

Sleep Med Rev. 2015 Dec;24C:1-12

treatment- supplements

unsupportive

• valerian, valerian, chamomile, kava, wuling
• AEs more with valerian than placebo

Sleep Med Rev. 2015 Dec;24C:1-12

treatment- supplements

good evidence

• 1. 500 mg magnesium in elderly

J res med sci 2012 Dec;17(12):1161-9

• 2. five mg melatonin, 225 mg magnesium,

and 11.25 mg zinc – in the elderly

J am geriatr soc 2011 Jan;59(1):82-90.

patient # 3

• 1. 28 year old acoustic engineer
• 2. goes to bed at 2 am and in

weekend wakes at 1000 hrs

• 3. during the week gets up

at 6 am to go to work –tired all day

• 4. diagnosis ??

patient # 3

• 1. Delayed sleep phase disorder (teenage pattern)
• 2. a dysregulation of a person's circadian rhythm

(biological clock), compared to the general population and societal norms generally fall asleep some hours after midnight and have difficulty waking up in the morning.

• 3. Treat: melatonin at night and light box in am
• 4. Often get night jobs

take home message

• insomnia is common
• need to make a specific diagnosis
• primary insomnia when no other cause
• sleep hygiene first
• time in bed restriction for primary insomnia