Case: 45-year-old with Difficulty Sleeping

by Roy Strowd, MD

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    00:00 Now, let's talk about insomnia disorders. Let's start with a case. This is a 45-year-old man who presents with difficulty falling asleep and staying asleep. The problem started after the death of his mother 2 months ago. He says that he is unable to fall asleep until about an hour after going to bed. So his time in bed is an hour until getting to sleep. He has no previous sleep problems. He initially tried taking over-the-counter sleep aids, but this caused daytime drowsiness. Other than the sleep complaints, he denies changes in his appetite, his job, or pleasurable activities. There is no anhedonia. He consumes 6 cups of coffee during an average day. He drinks a beer each night before bed to try and get him to sleep. He has a television in his room that he watches sometimes at night when he can't get to sleep or stay asleep. The patient's wife has noted that his legs do jerk occasionally during sleep though he was not aware of these movements. So, what's the most likely diagnosis for this patient? Is this depression? Excessive coffee or caffeine intake? Adjustment sleep disorder? Or inadequate sleep hygiene? Well, we don't have features that support a diagnosis of depression. The patient does have a recent stressor and that raises concern about the possibility of depression, but those other findings that would support this diagnosis. Changes in appetite, pleasurable activities, or impact on work are not present and don't support that diagnosis. This doesn't sound like excessive caffeine or coffee intake as the contributor for his sleep dysfunction. The patient has significant caffeine intake that may be contributing to his symptoms and reducing caffeine intake will likely improve his sleep but there is something more recent that's going on that is contributing to his clinical symptoms.

    02:00 The most likely diagnosis isn't inadequate sleep hygiene. That may be the case for this patient but is not the primary cause of his complaints.

    02:09 This is a typical presentation of someone with adjustment sleep disorder. This is a self-limited disorder often resolving once the patient comes to terms and copes with the stressor that triggered this event. The course is usually transient, lasting a few days to less than a few weeks but sometimes even up to months after a significant life event. And the death of this patient's close family member likely contributed to this adjustment sleep disorder for this patient.

    03:41 So let's talk a little bit more about insomnia.

    03:46 First, let's start with a definition. Insomnia is the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality despite adequate opportunities for sleep resulting in daytime functional impairment. So there are a number of things going on there. One, it's the patient's perception. They don't feel like they're sleeping enough or getting asleep or staying asleep. The second and critically important is the impairment in daily function. We all have better nights of sleep and worse nights of sleep, but we're able to function regardless of how we then slept and the consistent impairment in daily function is an important aspect of a diagnosis of insomnia. When we think about insomnia, we can classify it as acute beginning and occurring over less than 3 months or chronic, persisting over more than 3 months. Acute insomnia is transient and short term.

    04:44 It's often due to a number of triggers, perhaps environmental or a recent illness and usually associated with a change in anxiety or life events or social events or those sorts of things or a physical stressor. And it can evolve from acute insomnia into the chronic form of this condition. Chronic insomnia includes both primary and comorbid insomnia and we can also often see muscular weakness, hallucinations, or double vision which may be present in these patients as a result of this chronic and longstanding reduction in sleep. When we think about insomnia, we can classify insomnia by how sleep is impaired. So we think about sleep onset insomnia. This is a difficulty with falling asleep at the beginning of the night.

    05:32 There is also sleep maintenance insomnia, which as it's described is difficulty with staying asleep. Patients are often able to get to sleep but the problem is maintaining consistent sleep throughout the night. Early morning awakening is insomnia as a result of early awakening, waking up too early and difficulty with getting back to sleep. And then finally, paradoxical insomnia, which is a sleep state misperception.

    05:59 This is disassociation between the patient's self-reported quality of sleep and the findings from objective polysomnography which are normal. In terms of epidemiology, insomnia is not uncommon. At least 30% of patients report symptoms of insomnia at some point in their life. It's more common in women and older adults and there is an increase prevalence in those who are unemployed, divorced, widowed, or experiencing physical or emotional stressors. In terms of risk factors, inadequate sleep hygiene is one of the most important. Irregular bedtime schedules can contribute to insomnia. Using bed for work, eating, watching television can also contribute to insomnia. When the brain thinks it's going to do other things in bed, it's not prepared to sleep when you're there. Naps especially those after 3 pm can contribute to insomnia. And stimulating activities, exercising right before bedtime are all risk factors for the development and continuation of insomnia. There are a number of environmental factors that can contribute to insomnia, noise, lights, and extreme temperatures. Light is one of the critical wakefulness producing stimuli and so bright lights around bedtime or in bed can contribute to insomnia. Underlying sleep disorders like restless leg syndrome can also contribute to insomnia and when treated we can see insomnia improve. And then behavioral insomnia. Jet lag or shift worker's disorder can result in insomnia as a result of abnormalities in that typical circadian rhythm. When the brain isn't expecting to sleep and needs to sleep, this can contribute to insomnia.

    07:45 And then finally, some medical conditions are associated with insomnia; diabetes, GERD, hyperthyroidism, asthma, Alzheimer's disease, menopause, and chronic pain. So when we think about managing insomnia and treating patients, we walk through things like sleep hygiene, environmental factors, underlying sleep disorders, behavioral changes, and medical conditions, and managing these can be important in our treatment and management of patients presenting with insomnia.

    08:16 In addition, mental health disorders can contribute to insomnia; things like depression, anxiety, and posttraumatic stress disorder. Substance use and medication-induced insomnia is also an important consideration. Stimulants can cause insomnia and benzodiazepines or particularly withdrawal can also contribute to changes in sleep. So let's talk briefly about the pathophysiology. What's going on to contribute to insomnia? Well, there are a number of brain structures involved and wakefulness and sleep and abnormalities in the wakefulness centers or the sleep centers can contribute to insomnia. There are a number of neurotransmitters that play a major role in insomnia. Decreased inhibitory signals, reduced gaba in the brainstem reduce the brain's ability to get to sleep. Activation of the suprachiasmatic nucleus and inhibition of melatonin that's produced by the pineal gland can also contribute to alterations in wakefulness and contribute to insomnia. And then finally, increased levels of stress hormones like cortisol can alter the brain's ability to go to sleep or be awake and contribute to insomnia.

    10:58 How do we diagnose insomnia? Well, we look for a number of symptoms, difficulty falling asleep, daytime sleepiness or excessive daytime sleepiness, fatigue and tiredness can be seen, problems with concentration or memory can actually be some of the presenting symptoms of insomnia, and memory dysfunction or cognitive dysfunction can indicate further evaluation of the patient's sleep and be the underlying cause. Irritability and increased errors or accidents at work or other activities may herald symptoms that are indicative of an underlying sleep disorder.

    11:34 When we think about the diagnosis of sleep, the DSM 5 has a series of criteria that are used to diagnose an insomnia disorder. The first is difficulty initiating or maintaining sleep or early morning awakening without being able to return to sleep. We look for social, occupational, and behavioral impairment which is a critical part of the diagnosis of an insomnia disorder. Symptoms should be present for at least 3 nights per week and symptoms should be noticed for at least 3 months.

    12:06 Sleep difficulty present despite having ample opportunity for sleep should be present. Sleep disturbances cannot be explained by any other sleep-wake disorders. We want to exclude other potential causes. And then sleep difficulty should not be due to physiologic effects of substance use or mental health disorders or other medical conditions. We want to rule out other causes particularly those that are treatable or reversible of these symptoms. In terms of diagnosis, we can use a number of diagnostic aids to help support a diagnosis of an insomnia disorder and the first is history. A comprehensive medical and psychiatric history is important in these patients. We want to take a sleep history and really interrogate the time of onset of sleep, the maintenance and adequacy of sleep, and symptoms around awakening. And we can also interview not just the patient but a bed partner about the quality and quantity of sleep. In terms of physical exam, this can help evaluate comorbid conditions and rule out other potential explanations. Self-reported screening tools can also be helpful and evaluate problems with sleep, sleep quality or sleep duration. And then a sleep diary can be helpful. It's typically kept over the course of 2-4 weeks where the patient records the time of onset of sleep, when they get in the bed, when they tend to fall asleep, their sleep maintenance or awakenings during the night, and when they get up for their daytime. The Epworth Sleepiness Scale is one of the most pervasive scales used to evaluate patients with symptoms of excessive daytime sleepiness. A series of questions evaluates the patient''s sleepiness during the day and can be used to stratify potential causes of sleep dysfunction and the presence of sleep dysfunction.

    13:55 And then lastly, polysomnography or evaluation of sleep is, it can be helpful in the diagnosis of an insomnia disorder but is not required. This is utilized really to evaluate alternative explanations for the insomnia as opposed to confirm a diagnosis of insomnia disorder. Here, we see the Epworth Sleepiness Scale, which is a really important self-administered scale to evaluate the degree of excessive daytime sleepiness. One of the most prominent symptoms of an insomnia disorder is excessive daytime sleepiness and this is how we evaluate and stratify those symptoms. Patients are asked a series of questions about how likely they are to sleep in a number of different settings such as sitting and reading or watching television or sitting in a public place or sitting in a car as a passenger lying down to rest, sitting and talking to someone, sitting quietly after lunch without alcohol, or being in a car when stopped for a few minutes in traffic. Patients rate each of these questions on a scale 0 that this would never happen or they would never doze off.

    15:00 One, there is a slight chance of dozing during this activity, 2 a moderate chance, and 3 a high chance of dozing off or sleeping with this activity. A score of 10 or more suggest the presence of excessive daytime sleepiness and should warrant evaluation of an underlying sleep disorder. What other diagnostic tools can be used to evaluate patient's sleep, sleep onset, sleep quality, or sleep quantity? The Pittsburg Sleep Quality Index is an important self-administered, self-reported scale to evaluate sleep quality. And actigraphy watches can evaluate the quantity, onset, and duration of sleep and be helpful in objectively evaluating what's happening in a patient's home.

    17:11 Let's talk about the approach to managing patients with insomnia.

    17:17 And here, I want you to think about the 3 P model. There are 3 Ps that we evaluate when managing patients with insomnia. The first is we want to think about and look for predisposing conditions. Things like anxiety that may predispose the patient to developing insomnia. The second is we want to look for precipitating factors, a recent illness, bereavement, death, a physical or mental stressor that may have precipitated this episode of insomnia. And then the last are perpetuating factors, things that keep the insomnia going. And we think about patient's sleep hygiene, sleep-wake cycle schedules, daytime behaviors. When we manage patients, we want to intervene, treat predisposing conditions, avoid and resolve precipitating factors, treat and improve perpetuating events, and the combination of all 3 of these management strategies is most successful when treating patients with insomnia. Let's talk about some of the non-pharmacologic management for short-term acute insomnia. First, we want to identify the stressor and address it accordingly and this is the most beneficial way to manage acute insomnia. We can use medications particularly if the insomnia is interfering with daytime function, but we want this to be temporary. Treating any underlying comorbidity, pain, depression, and other comorbidities before intensive sleep treatment can be important for these patients. what about non-pharmacologic management of chronic insomnia? Here, we have a number of goals. We want to improve sleep hygiene by avoiding alcohol, caffeinated drinks, or large meals within 4 hours of bedtime. Regular exercise patterns are important but we want to avoid vigorous exercise too close to bedtime within 3 hours of going to sleep. We want to avoid napping during the day or daytime sleeping, we counsel patients to use the bed only for sleep and other related activities. No eating, telephone, or other stimulation within bed. And reduce light exposure around bedtime. Cognitive behavioral therapy is an important intervention for patients with chronic insomnia.

    19:35 It's a first line treatment. We have a number of goals including the increased sleep efficiency, address maladaptive thoughts, and promote a stable routine of sleep and wake times. We can conduct this in a number of ways, we can set a time for sleep each day, and encourage the patient to follow a sleep schedule and that regular schedule helps to change melatonin secretion and the circadian rhythm to promote sleep. Sleep restriction or reducing the amount of time that the patient is in bed, delaying this further and further to limit time in bed without sleeping can be a helpful strategy. Stimulus control. Patient is anxious and cannot sleep, getting out of bed, doing another activity, and then returning to bed to sleep can be helpful.

    20:21 And then we think about interventions to improve sleep hygiene. What about pharmacotherapy? What medications are available to treat sleep? We typically think about these for a temporary course. The first category are the hypnotic benzodiazepines. These act on gaba receptors and you can see some examples.

    20:40 Temazepam, clonazepam, being 2 common examples. There are the non- benzodiazepine agents. These are benzodiazepine agonists and they also act on gaba receptors and some examples include zolpidem. Melatonin agonist can be used.

    20:58 Melatonin is the natural hormone that promotes sleep. We ask patients to take naturally occurring melatonin about an hour before bed to promote that boost of melatonin that encourages the brain to sleep and can reset the circadian rhythm and sleep-wake cycle. Dual orexin receptor antagonist can also be used. Orexin or hypocretin is important in the control of sleep and wake cycles and you can see several agents that act on these receptors. Histamine receptor antagonist can be used. The H1 receptor antagonist produces sedation and can help promote sleep.

    21:39 There is the potential for tolerance and withdrawal from this agent and these are not commonly used except in very short circumstances temporarily. And antidepressants with sedating properties also can improve the ability to get to sleep and can be helpful in treating both comorbid conditions as well as insomnia in off-label use.

    About the Lecture

    The lecture Case: 45-year-old with Difficulty Sleeping by Roy Strowd, MD is from the course Sleep Disorders​.

    Included Quiz Questions

    1. Insomnia
    2. Anhedonia
    3. Parasomnia
    4. REM sleep behavior disorder
    5. Hypersomnolence
    1. Adjustment sleep disorder
    2. Depression
    3. Poor sleep hygiene
    4. Parasomnia
    5. Night terrors

    Author of lecture Case: 45-year-old with Difficulty Sleeping

     Roy Strowd, MD

    Roy Strowd, MD

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