Insomnia, poor sleep or difficulty sleeping

Insomnia or poor sleeping pattern is a serious health issue which affects individuals’ quality of life. It is common in general population and has been reported in higher rates among individuals’ with substance use problems. Zhabenko et al (2012) reviewed nine published studies of clients with alcohol dependence and reported a mean prevalence of insomnia in as high as 56% of the participants.

Insomnia can be chronic (ongoing) or acute (short-term). Chronic insomnia means having symptoms at least 3 nights a week for more than a month. Acute insomnia lasts for less time.

Some people who have insomnia may have trouble falling asleep. Other people may fall asleep easily but wake up too soon. Others may have trouble with both falling asleep and staying asleep.

As a result, insomnia may cause you to get too little sleep or have poor-quality sleep. You may not feel refreshed when you wake up.

Mechanism of insomnia among alcohol dependent individuals may include depression, alcohol associated impairments of sleep regulation and lifestyle changes. (Conroy et al. 2012; Armitage et al. 20102).

Primary Insomnia:

Primary insomnia isn’t a symptom or side effect of another medical condition. This type of insomnia usually occurs for periods of at least 1 month.

A number of life changes can trigger primary insomnia. It may be due to major or long-lasting stress or emotional upset. Travel or other factors, such as work schedules that disrupt your sleep routine, also may trigger primary insomnia.

Even if these issues are resolved, the insomnia may not go away. Trouble sleeping may persist because of habits formed to deal with the lack of sleep. These habits may include taking naps, worrying about sleep, and going to bed early.

Researchers continue to try to find out whether some people are born with a greater chance of having primary insomnia.

Secondary Insomnia:

Secondary insomnia is the symptom or side effect of another problem. This type of insomnia often is a symptom of an emotional, neurological, or other medical or sleep disorder.

Emotional disorders that can cause insomnia include depression, anxiety, and posttraumatic stress disorder. Alzheimer’s disease and Parkinson’s disease are examples of common neurological disorders that can cause insomnia.

A number of other conditions also can cause insomnia, such as:

• Conditions that cause chronic pain, such as arthritis and headache disorders
• Conditions that make it hard to breathe, such as asthma and heart failure
• An overactive thyroid
• Gastrointestinal disorders, such as heartburn
• Stroke
• Sleep disorders, such as restless legs syndrome and sleep-related breathing problems
• Menopause and hot flashes

Secondary insomnia also may be a side effect of certain medicines. For example, certain asthma medicines, such as theophylline, and some allergy and cold medicines can cause insomnia. Beta blockers also may cause the condition. These medicines are used to treat heart conditions.

Commonly used substances also may cause insomnia. Examples include caffeine and other stimulants, tobacco or other nicotine products, and alcohol or other sedatives.

More than 8 out of 10 people who have insomnia are believed to have secondary insomnia.

Patient can complain of:

1. Difficulty falling sleep
2. Difficulty staying asleep
3. Waking up too early
4. Waking up in the morning without feeling refreshed
5. Inadequate sleep quality or duration

• Insomnia is a common disorder. One in 3 adults has insomnia sometimes. One in 10 adults has chronic insomnia.
• Insomnia affects women more often than men. The condition can occur at any age. However, older adults are more likely to have insomnia than younger people.
• People who may be at higher risk for insomnia include those who:
  • Have a lot of stress.
  • Are depressed or who have other emotional distress, such as divorce or death of a spouse.
  • Have lower incomes.
  • Work at night or have frequent major shifts in their work hours.
  • Travel long distances with time changes.
  • Have certain medical conditions or sleep disorders that can disrupt sleep.
  • Have an inactive lifestyle.

Drugs:

• Nicotine abuse
• Caffeine abuse
• Stimulant use
• Beta agonists
• Theophylline
• Bupropion
• Citalopram
• Escitalopram
• Fluoxetine
• Fluvoxamine
• MAOi
• Paroxetine
• Srteraline
• Venlafaxine
• Amphetamines
• Modafinil
• Pamoline
• OCPs
• Steroids
• Thyroid hormones
• Thiazides

Infection/Inflammation:

• Active infection

Medical/Mental:

• Asthma/COPD
• Chronic renal failure
• CHF
• Chronic pain
• CAD
• Depression
• Diabetes mellitus
• Fibromyalgia
• GERD
• Hyperthyroidism
• Mania
• Parkinson’s diseases
• RA
• Stroke

Structural:

• Acute injuries

1. Difficulty initiating or maintaining sleep for at least 1 month
2. Sleep disturbance causes significant impairment of social, occupational or other important areas of functioning
3. The sleep disturbance does not occur during the course of another mental disorder
4. The disturbance is not due to the direct physiological effects of a substance or a general medical condition

Current illness:

1. Nature
2. Severity
3. Frequency
4. Time course
5. Exacerbating factors
6. Reliving factors
7. Effect on daily life and function
8. Activities prior to bedtime
9. Night time awake (dumber, duration, timing)
10. Snoring
11. Limb movement
12. Daytime nap
13. Difficulty staying awake during the day
14. Daytime Confusion
15. Bed partner complaints

Social history:

1. Shift work
2. Substance use
3. Stimulant use
4. Physical activity
5. Smoking

Medical history:

1. Medications
2. Previous treatments
3. Sleep diary

1. General appearance
   1. Nasal septum deviation
   2. Pupil size
   3. Sweating
   4. Cardiac murmur or signs of heart failure
   5. Breathing, Cyanosis
   6. Signs of intoxication
   7. Signs of drug withdrawal
2. Vital signs
3. Neuropsychiatric
   1. Agitation
   2. Tremor
   3. Pressure speech
   4. Drowsiness
   5. Confusion
   6. Memory

1. CBC
2. Fasting blood sugar
3. Urine drug screen
4. TSH
5. Kidney and liver function
6. ECG and other Cardiac investigations as indicated by history and physical examination

Secondary insomnia often resolves or improves without treatment if you can stop its cause—especially if you can correct the problem soon after it starts. For example, if caffeine is causing your insomnia, stopping or limiting your intake of the substance may cause your insomnia to go away.

Lifestyle changes, including better sleep habits, often help relieve acute insomnia. For chronic insomnia, your doctor may recommend a type of counseling called cognitive-behavioral therapy or medicines.

Behaviour modification:

1. Avoid coffee
2. Avoid stimulant use
3. Avoid cocaine
4. Regular sleep schedule
5. Medications for 4-6 weeks and then taper

Cognitive-Behavioral Therapy

CBT for insomnia targets the thoughts and actions that can disrupt sleep. For example, relaxation training and biofeedback at bedtime are used to reduce anxiety. These strategies help you better control your breathing, heart rate, muscles, and mood. CBT also works on replacing sleep anxiety with more positive thinking that links being in bed with being asleep.

CBT also focuses on limiting the time you spend in bed while awake. This method involves setting a sleep schedule. At first, you will limit your total time in bed to the typical short length of time you’re usually asleep.

For people who have insomnia and major depressive disorder, CBT combined with antidepression medicines has shown promise in relieving both conditions.

Medical approach:

1. Atypical antipsychotics:
   1. Seroquel in low doses
2. Antidepressants:
   1. Trazodone 50-100 mg po hs
3. Benzodiazepines:
   1. Temazepam (restoril)
      1. Most preferred for elderly and ill patients because of easy metabolism
   2. Clonazepam:
      1. Has long half-life so increases the risk of hangover and daytime dizziness
      2. In low dose (0.25-2) can be used or restless leg syndrome too
   3. Estazolam (ProSom)
   4. Flurazepam
   5. Quazepam
   6. Triazolam
4. Benzodiazepine like agents:
   1. Zoplidem (Ambien) 5-10 mg hs up to 20 mg
      1. Adverse effects: palpitations, amnesia, drowsiness, dizziness, lethargy, diplopia, vertigo, dry mouth, depression, lightheadedness, flu-like symptoms
      2.  Interactions:
         1. Food reduces it’s absorption
         2. Ritonavir concomitant use causes severe sedation and respiratory depression
   2. Zaleplon (Sonata):
      1. Adults: Tablets 5 to 20 mg hs
      2. Elderly/Debilitated: tablets 5-10 mg hs
      3. Adverse reactions: migraine, depression, nervousness, abnormal thinking, anxiety, amnesia, dizziness, paresthesia, somnolence, tremor, pruritus, back pain, chest pain, malaise
      4.  Interactions:
         1. Potentiate CNS depressants
         2. Cimetidine increases Zoleplon’s level
         3. Rifampin may reduce its level
      5.  Eszopiclone:
         1. Dose: 2-3 mg hs (1-2 mg for elderly)
5. Seizure medications:
   1. Gabapentin:
      1. Increases GABA neurotransmitter activity
      2. Good for those with history of substance abuse
      3. Dose: start 300 mg po hs and titrate up to 600-1500
      4. It also can help to treat anxiety disorders, bipolar disorder and epilepsy
      5. Because it is secreted in urine, it is safe to be used in those with liver diseases
6. CPAP: For those with sleep apnea