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Insomnia
Insomnia is a
sleep disorder characterized by an inability to sleep and/or inability to remain asleep for a reasonable period. Insomniacs typically complain of being unable to
close their eyes or "rest their mind" for more than a few minutes at a time. Both organic and nonorganic insomnia constitute a
sleep disorder. It is often caused by fear, stress,
anxiety, medications, herbs, caffeine,
depression,
Bipolar disorder or sometimes for no apparent reason. An overactive mind or physical
pain may also be causes. Finding the
underlying cause of insomnia is usually necessary to cure it.
Current Research
For current research articles click
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Types of Insomnia
Three types of insomnia exist: transient, acute, and chronic
- Transient insomnia lasts from one night to a few weeks but it seems longer. Most people occasionally suffer from transient insomnia due to such causes as
jet lag or short-term anxiety. If this form of insomnia continues to occur from time to time, the insomnia is classified as intermittent.
- Acute insomnia is the inability to consistently sleep well for a period of between three weeks to six months.
- Chronic insomnia is regarded as the most serious; persists almost nightly for at least a month.
Insomnia Versus Poor Sleep Quality
Poor sleep quality can occur as a result of sleep apnea or major
depression. Poor sleep quality is caused by the individual not reaching stage 4 or delta sleep which has
restorative properties. There are, however, people who are unable to achieve stage 4 sleep due to brain damage who still lead perfectly normal lives.
- Sleep apnea is a condition that occurs when a sleeping person's breathing is interrupted, thus interrupting the normal sleep cycle. With the obstructive form of the
condition, some part of the sleeper's respiratory tract loses muscle tone and partially collapses. People with obstructive sleep apnea often do not remember
any of this, but they complain of excessive sleepiness during the day. Central sleep apnea interrupts the normal breathing stimulus of the central nervous
system, and the individual must actually wake up to resume breathing. This form of apnea is often related to a cerebral vascular condition, congestive heart
failure, and premature aging.
Major
depression leads to alterations in the function of the hypothalamus and pituitary causing excessive release of cortisol which can lead to poor sleep quality.
Nocturnal polyuria or excessive nighttime urination can be very disturbing to sleep. Urination produces strong signals to the brain to wake up. Nocturnal polyuria can be nephrogenic
(related to kidney disease) or it may be due to prostate enlargement or hormonal influences. Deficiencies in vasopressin, which is either caused by a pituitary problem or by
insensitivity of the kidney to the effects of vasopressin, can lead to nocturnal polyuria. Excessive thirst or the use of diuretics can also cause these symptoms.
How Much Sleep is Needed?
Some people get an average of 8 to 10 hours of sleep, and always feel tired, drowsy, low on energy, and complain about “poor sleep”, or “sleep deprivation”, and try to compensate
by sleeping even longer. In reality, they are sleeping too much, and decreasing the “quality” of their sleep as well as their energy levels.
The most important fact about sleep is that Quality counts, not Quantity.
Children Sleep Problems
Signs that a child has a problem with sleep might include the following:
• The parent spends too much time “helping” your child fall asleep.
• The child wakes up many times during the night.
• The child’s behavior and mood are affected by poor sleep.
• The parent loses sleep as a result of the child’s sleeping patterns.The child’s poor sleep hurts the parents relationship with the child.
• The child constantly tosses and turns during sleep.
Most sleep problems in children can be corrected quickly once detected. Talking with other parents and with the doctor will help. For more rare or severe problems, consult a
sleep specialist.
Treatment for Insomnia
In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful.
All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of
sedatives such as benzodiazepines and newer non-benzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully
titrated down.
Many insomniacs rely on sleeping tablets and other sedatives to get rest. The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. This
includes drugs such as temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long
periods of time.
Recent research has shown that cognitive behavior therapy can be more effective than medication in controlling insomnia. In this therapy, patients are taught improved sleep
habits and relieved of counter-productive assumptions about sleep.
Non-benzodiazepine prescription drugs, including Ambien and Lunesta, have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over
whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence, and can also
cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.
Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia.
Melatonin agonists, including Ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower
likelihood of causing morning sedation.
The antihistamine diphenhydramine is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New
Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease
over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.
Some antidepressants such as mirtazapine, trazodone and doxepin have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that
they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture.
Low doses of atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these
drugs a poor choice to treat insomnia.
Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone the most studies and appears to be modestly effective.
Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects
from alcohol consumption are common, and hangovers can also lead to morning grogginess.
Marijuana has been known to act as a sleep-aid.
Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon,
eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get
up early in the morning and to retire to bed at a reasonable hour.
Pomegranates are also believed to help insomniacs sleep.
Warm milk contains high levels of tryptophan, a natural sedative. Using aromatherapy, including jasmine oil, lavender oil, Mahabhringaraj and other relaxing essential oils, may
also help induce a state of restfulness. Adding honey to warm milk helps the body to absorb the tryptophan more quickly. Tryptophan absorption is normally
inhibited or deterred by other amino acids but in the presence of sugar tryptophan is absorbed more quickly. Horlicks has been shown to help.
Many believe that listening to slow paced music will help insomniacs fall asleep. This theory is being studied by professor Jedediah Fajman at the University of Illinois.
The more relaxed a person is, the greater the likelihood of getting a good night's sleep. Relaxation techniques such as meditation have been shown to help people sleep. Such
techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.
The Dangers of Sleeping Pills
The following information points out some important reasons why sleeping pills should not be considered.
- Those who use sleeping pills have significantly higher mortality rates than those who do not.
- Sleeping pills (even the newer generations) do little or nothing to improve chronic insomnia and cause long-term chemical dependency.
- Sleeping pills reduce brain cell activity during the day, affecting short-term memory as well as causing a hangover effect.
- Sleeping pills accentuate the GABA neurotransmitter, which keeps the nerve cells in the lung tissue from firing. This is why an overdose of sleeping pills will cause
asphyxiation and over 1000 overdose related deaths each year.
- GABA actuation is also responsible for impaired physical ability. Each year, thousands of traffic deaths, accidents and falls (especially in the elderly) are attributed to
sleeping pills.
- Sleep Apnea Patients should never take sleeping pills. Sleeping pills increase the pauses and length of pause in breathing. Someone with sleep apnea could suffer
brain or ocular damage from the lack of oxygen or even death.
- Anyone over the age of 40 should be cautioned against sleeping pills, and anyone over the age of 65 should never take sleeping pills. Studies show that almost all
people over 40 have some symptoms of sleep apnea, and anyone over 65 would be clinically diagnosed with sleep apnea.
- Sleeping pills create a hypnotic dependency similar to alcohol and lower inhibitions and fear of pain or consequences. This is one reason why sleeping pills
contribute to accidents and why chronic sleeping pill users are less likely to worry or take care of themselves.
- Sleeping pills are highly addictive. Sleeping pills are similar to barbiturates and are extremely difficult to stop using.
- Although sleeping pills do not improve daytime functioning, people still prefer taking them because of the barbiturate feel-good effect they produce. As with many
addictive drugs, they may not be helpful, but the patient feels good when taking them.
Alternative Approaches
Traditional Chinese medicine has included treatment for insomnia. A typical approach may utilize acupuncture, dietary and lifestyle analysis, herbology and other techniques, with
the goal of resolving the problem at a subtle level. Although these methods have not been scientifically proven, some insomniacs report that these remedies are sufficient to break
the insomnia cycle without the need for sedatives and sleeping tablets.
In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or metta. This practice of generating a feeling of love and
goodwill is claimed to have a soothing and calming effect on the mind and body. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly
from the pacification of negative ones. In the Mettā Sutta, Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.
There are a number of alternative cures for this disorder that are marketed. Often, a combination of dietary and lifestyle changes is claimed to be the most helpful approach. However,
it should be noted the reason they are considered "alternative" medical treatments is the lack of empirical evidence to back up such claims. There are always studies going on to
either confirm or deny the effectiveness of such medicine, but in many cases even if no effect is shown to exist in a treatment, proponents will still believe in their effectiveness.
Statistics for Insomnia
According to the U.S. Department of Health and Human Services, approximately 60 million Americans suffer from insomnia each year. Insomnia tends to increase with age and
affects about 40 percent of women and 30 percent of men. The average American gets 7 hours of sleep, instead of the 8 to 10 hours recommended by doctors. Children
however are recommended more than 8 hours.
(adapted from Wikipedia, the free encyclopedia http://en.wikipedia.org/wiki/Insomnia)
How is Persistent Insomnia Maintained? A Prospective Study on 50-60 Years Old Adults in the General Population
Authors: Lundquist D, Lundquis N, Linton SJ.
Objectives: The purpose of this study was to examine whether arousal, distress and sleep-related beliefs are related to the maintenance of insomnia in old adults. Design: From a
randomly selected sample from the general population (N=3,600; 50-60 years old), 2,239 participants filled out a baseline and 1-year follow-up survey. Methods: Logistic
regressions were used to investigate whether psychological mechanisms were related to sleep status (insomnia: N=230; poor sleep: N=210; normal sleep: N=658; good sleep:
N=253) over one year. Cluster analysis was employed to assess whether it was possible to classify the participants based on their profiles of psychological functioning. Results:
The results showed that arousal, sleep-related beliefs about future consequences and
anxiety were significantly related to the maintenance of insomnia (14-66% of the variance).
Out of the individuals with persistent insomnia, 67% belonged to a cluster characterized by high scores on arousal, sleep-related beliefs and
anxiety, 24% to a cluster defined by
medium scores on the three mechanisms and 9% to a cluster characterized by low scores on the three mechanisms. Conclusions: This investigation shows not only that arousal,
sleep-related beliefs and
anxiety are associated with the maintenance of persistent insomnia, but also that these mechanisms often co-occur in individuals with persistent
insomnia.
Journal: Br J Health Psychol. 2007 Jan 5
Adapted from PubMed; click here to access full journal article.
Practice Parameters for the Use of Actigraphy in the Assessment of Sleep and Sleep Disorders: An Update For 2007
Authors: Morgenthaler T, Alessi C, Friedman L, Owens J, Kapur V, Boehlecke B, Brown T, Chesson A, Coleman J, Lee-Chiong T, Pancer J, Swick TJ;
Standards of Practice Committee; American Academy of Sleep Medicine.
Mayo Clinic, Rochester MN, USA.
BACKGROUND: Actigraphy is increasingly used in sleep research and the clinical care of patients with sleep and
circadian rhythm abnormalities. The following practice parameters
update the previous practice parameters published in 2003 for the use of actigraphy in the study of sleep and circadian rhythms. METHODS: Based upon a systematic grading of
evidence, members of the Standards of Practice Committee, including those with expertise in the use of actigraphy, developed these practice parameters as a guide to the
appropriate use of actigraphy, both as a diagnostic tool in the evaluation of
sleep disorders and as an outcome measure of treatment efficacy in clinical settings with appropriate
patient populations. RECOMMENDATIONS: Actigraphy provides an acceptably accurate estimate of sleep patterns in normal, healthy adult populations and inpatients suspected of
certain
sleep disorders. More specifically, actigraphy is indicated to assist in the evaluation of patients with advanced sleep phase syndrome (ASPS),
delayed sleep phase syndrome (DSPS), and shift work disorder. Additionally, there is some evidence to support the use of actigraphy in the evaluation of patients suspected of jet lag disorder and
non-24hr sleep/wake syndrome (including that associated with blindness). When polysomnography is not available, actigraphy is indicated to estimate total sleep time in patients
with obstructive sleep apnea. In patients with insomnia and hypersomnia, there is evidence to support the use of actigraphy in the characterization of circadian rhythms and sleep
patterns/disturbances. In assessing response to therapy, actigraphy has proven useful as an outcome measure in patients with
circadian rhythm disorders and insomnia. In older
adults (including older nursing home residents), in whom traditional sleep monitoring can be difficult, actigraphy is indicated for characterizing sleep and circadian patterns and to
document treatment responses. Similarly, in normal infants and children, as well as special pediatric populations, actigraphy has proven useful for delineating sleep patterns and
documenting treatment responses. CONCLUSIONS: Recent research utilizing actigraphy in the assessment and management of
sleep disorders has allowed the development of
evidence-based recommendations for the use of actigraphy in the clinical setting. Additional research is warranted to further refine and broaden its clinical value.
Journal: Sleep. 2007 Apr 1;30(4):519-29
Adapted from PubMed; click here to access full journal article.
Zolpidem Extended-Release: A Single Insomnia Treatment Option for Sleep Induction and Sleep Maintenance Symptoms
Authors: Barkin RL.
The Department of Anesthesiology, Family Medicine and Pharmacology, The Rush University Medical College, Rush University Medical Center, Chicago, IL.
It is imperative that primary care clinicians have a thorough understanding of insomnia, because they are often the first point of contact for patients who seek assistance when they
have difficulty sleeping. Insomnia may appear with different presentations: sleep onset, sleep maintenances, sleep offset, nonrestorative sleep, or a combination of these symptoms.
Untreated symptoms result in clinically significant distress or impairment in social, occupational, or other important areas of following-day functionality. Physicians, pharmacists,
and other clinicians should be aware of the conditions that contribute to, are antecedent to, and associated with insomnia. These pathophysiological conditions include advanced
age; female gender; respiratory, gastrointestinal, vascular, and rheumatologic
pain syndromes; and other conditions such as
depression and/or
anxiety. Additional health factors
contributing to insomnia include chronic pain, stressors, grief reaction, pharmacotherapeutic side effects, lifestyle contributors such as social/recreational drugs,
phytopharmaceuticals, and ethanol use. The pharmacotherapy focus in this article is a modified-release formulation of the BZ1 (omega1) receptor agonist zolpidem, zolpidem
extended-release. Pharmacokinetic, pharmacodynamic, and safety studies that compare 12.5 mg zolpidem extended-release (Ambien CRtrade markCIV) and 10 mg original
zolpidem were initially conducted in
healthy volunteers to assess the potential for an improved clinical profile. Zolpidem extended-release (12.5 mg and 6.25 mg extended-release
dosage forms) is indicated for the treatment of insomnia characterized by difficulties with sleep onset and/or sleep maintenance. Zolpidem extended-release is devoid of any
short-term use limitation and can be prescribed for the duration of medical necessity. The modified-release zolpidem is a two-layer tablet with a biphasic release profile, releasing
the first layer immediately, whereas the second layer is released at a slower rate. Plasma concentrations are maintained for a longer period of time versus the immediate-release
zolpidem formulation. Pharmacokinetic analysis has also demonstrated that the time to maximum concentration (tmax) and terminal elimination half-life (t1/2) of 12.5 mg zolpidem
extended-release are similar to those of 10 mg zolpidem indicating a similar rapid onset of action and an elimination profile that reduced the risk of next-day decrements in
performance. Zolpidem's CYP 450 hepatic metabolism uses as a substrate CYP3A4 (major) and 1A2, 2C9, 2C19, and 2D6 as minor pathways. Zolpidem extended-release dosage
forms diminish sleep latency, number of awakenings, and wakefulness after sleep onset and augments total time asleep.
Journal: Am J Ther. 2007 May-Jun;14(3):299-305
Adapted from PubMed; click here to access full journal article.
Clinical Neurology of Insomnia in Neurodegenerative and Other Disorders of Neurological Function
Authors: Avidan AY
Department of Neurology, University of California, Los Angeles, Los Angeles, CA.
Complaints of insomnia are prevalent in neurodegenerative and neurological disorders. Neurologists therefore must be aware of the underlying causes, pathophysiologic
mechanisms, and potential interventions when encountering a patient with underlying neurological disorders who is also complaining of poor sleep and insomnia. This article
describes the underlying pathophysiology, diagnostic approaches, and potential interventions for insomnia in the neurological patient. Clinicians need to recognize that insomnia
in older patients with underlying neurological disorders is not only unique, but also complex, demanding comprehensive and careful evaluation and management. Treatment of
insomnia should start by addressing nonpharmacologic options, including improvements in sleep hygiene, improving sunlight exposure during the day, and searching for underlying
reversible causes, such as sleep apnea, restless legs syndrome, periodic leg movements, and circadian rhythm disturbances, all of which can precipitate insomnia when left
untreated. Some patients may benefit from targeted and carefully tailored pharmacologic treatment. Successful amelioration of insomnia can ultimately be a very rewarding
experience for the patient, family members, and the practitioner.
Journal: Rev Neurol Dis. 2007 Winter;4(1):21-34
Adapted from PubMed; click here to access full journal article.
REM Sleep Behavior Disorder and Other Sleep Disturbances in Disney Animated Films
Authors: Iranzo A, Schenck CH, Fonte J
Neurology Service, Hospital Clı´nic and Institut D’Investigació Biomèdiques August Pi i Sunyer (IDIBAPS), C/Villarroel 170, Barcelona 08036, Spain
During a viewing of Disney's animated film Cinderella (1950), one author (AI) noticed a dog having nightmares with dream-enactment that strongly resembled RBD. This prompted a
study in which all Disney classic full-length animated films and shorts were analyzed for other examples of RBD. Three additional dogs were found with presumed RBD in the
classics films Lady and the Tramp (1955) and The Fox and the Hound (1981), and in the short Pluto's Judgment Day (1935). These dogs were elderly males who would pant,
whine, snuffle, howl, laugh, paddle, kick, and propel themselves while dreaming that they were chasing someone or running away. In Lady and the Tramp the dog was also losing
both his sense of smell and his memory, two associated features of human RBD. These four films were released before RBD was first formally described in humans and dogs. In
addition, systematic viewing of the Disney films identified a broad range of
sleep disorders, including nightmares, sleepwalking, sleep related seizures, disruptive
snoring, excessive
daytime sleepiness, insomnia and
circadian rhythm sleep disorder. These
sleep disorders were inserted as comic elements. The inclusion of a broad range of accurately depicted
sleep disorders in these films indicates that the Disney screenwriters were astute observers of sleep and its disorders.
Journal: Sleep Med. 2007 May 17
Adapted from PubMed; click here to access full journal article.
The Effects of an Intensive Lifestyle Modification Program on Sleep and Stress Disorders
Authors: Merrill RM, Aldana SG, Greenlaw RL, Diehl HA, Salberg A
R.M. Merrill, 229A Richards Building, Brigham Young University, Provo, UT, 84602-2214, Phone: +1 801 422 9788, Fax : +1 801 422 0273, E-mail address: Ray_Merrill@byu.edu.
Background: To determine if a lifestyle change program can modify behavior to reduce sleep and stress disorders. Methods: Analyses are based on 2,624 individuals aged 30 to 80
years from the Rockford, Illinois metropolitan area who completed a lifestyle evaluation at baseline and again after four weeks, following participation in a 40-hour educational course
given over a four-week period. Participants receive instruction on the importance of making better lifestyle choices related to making long-term improvements in nutrition and physical
activity and they learn ways to improve sleep and reduce stress in their lives. Results. Significant percent decreases were observed in the number experiencing selected sleep or
stress disorders from baseline to four weeks later for "sleeps restlessly" (-59%), "suffers from insomnia" (-64%), "feels under pressure" (-37%), "easily emotionally upset" (-52%),
and "feels fearful or depressed" (-61%). Experiencing a selected sleep or stress disorder after four weeks among those who had the disorder at baseline was significantly more
likely in those not physically active and/or not having lowered their BMI after four weeks. Changes in alcohol consumption and smoking did not significantly contribute to changes
in the disorders. Those who failed to lower their coffee/tea use after four weeks were significantly more likely to have a
sleep disorder and be easily emotionally upset. Conclusions:
Changes in lifestyle behaviors after attending an educational program significantly reduced sleep and stress disorders in as little as four weeks, primarily explained by decreasing
BMI and/or increasing exercise.
Journal: J Nutr Health Aging. 2007 May-Jun;11(3):242-8
Adapted from PubMed; click here to access full journal article.
Sleep and Aging: 2. Management of Sleep Disorders in Older People
Authors: Wolkove N, Elkholy O, Baltzan M, Palayew M
Sleep Clinic, Mount Sinai Hospital Center, Montreal, Que. norluco@yahoo.com
The treatment of sleep-related illness in older patients must be undertaken with an appreciation of the physiologic changes associated with aging. Insomnia is common among
older people. When it occurs secondary to another medical condition, treatment of the underlying disorder is imperative. Benzodiazepines, although potentially effective, must be
used with care and in conservative doses. Daytime sedation, a common side effect, may limit use of benzodiazepines. Newer non-benzodiazepine drugs appear to be promising.
Rapid eye movement (REM) sleep behavior disorder can be treated with clonazepam, levodopa-carbidopa or newer dopaminergic agents such as pramipexole. Sleep hygiene is
important to patients with
narcolepsy. Excessive daytime sleepiness can be treated with central stimulants; cataplexy may be improved with an antidepressant. Restless legs
syndrome and periodic leg-movement disorder are treated with benzodiazepines or dopaminergic agents such as levodopa-carbidopa and, more recently, newer dopamine
agonists. Treatment of obstructive sleep apnea includes weight reduction and proper sleep positioning (on one's side), but may frequently necessitate the use of a continuous
positive air-pressure (CPAP) device. When used regularly, CPAP machines are very effective in reducing daytime fatigue and the sequelae of untreated obstructive sleep
apnea.
Journal: CMAJ. 2007 May 8;176(10):1449-54
Adapted from PubMed; click here to access full journal article.
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