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Insomnia: Management

by Charles Vega, MD
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    00:01 In terms of treatment of insomnia, I wouldn't rush right to a sleep study or right to doing a bunch of laboratory testing.

    00:10 Start with a sleep diary to actually document what's going on.

    00:13 Think about those conditions that can make insomnia worse.

    00:16 Treat their depression, treat pain before ordering a workup and certainly before recommending other hypnotic therapy for sleep, medications.

    00:28 And start with some non-nonpharmacologic interventions.

    00:32 These are effective.

    00:33 They’re safe and they can prove to be helpful in other aspects of health beyond sleep.

    00:39 So, moderate intensity exercise definitely helps regulate your cycle and it helps you sleep, but you want to complete that exercise at least four hours before bedtime.

    00:48 Avoiding sleep during the day, if somebody is napping two-and-a-half hours during the afternoon, they're going to experience some awakenings and sleep latency.

    00:58 That's normal.

    00:59 And it has to be cut out if they ever want to sleep fully through the night.

    01:03 Of course, limiting caffeine, tobacco and alcohol use is a good idea and not eating at least four hours before going to bed, avoiding any meal during that time as well.

    01:15 Now, let’s talk about advice to give the patient with insomnia and just general sleep hygiene.

    01:20 First of all, just go to bed when tired.

    01:22 The patients who – again, who get into real trouble with insomnia are the ones who really try to force the sleep upon themselves and sleep just doesn't work like that.

    01:33 And I think that promotes an anxiety.

    01:35 Whether they had anxiety before or not, it promotes an anxiety in trying to sleep and worrying about this problem, such that it self-perpetuates and you're guaranteed to have more insomnia.

    01:45 So, use the bed only when tired.

    01:49 Use the bedroom only for sleep and for intimacy.

    01:51 That's it.

    01:52 Try to settle down before bedtime.

    01:55 So, do really boring things.

    01:56 I don’t know if chess necessarily boring.

    01:58 There’s a pawn there, but maybe it’s reading.

    02:01 It’s nothing crazy and active and you’re not running around, doing a million chores.

    02:06 You do have a little time to settle down.

    02:09 And if you wake up, do more boring things.

    02:12 And if you do get up, and I think this is one of the most critical things, don't just lie and push yourself to try to sleep.

    02:18 That again doesn't work.

    02:19 Get up, get out of bed, do something for 20 minutes, 40 minutes and then return when you feel sleepy.

    02:26 That one really does work.

    02:28 And usually, between these recommendations and the lifestyle recommendations, you’re going to manage about 80 to 90% of insomnia cases effectively, just with these alone.

    02:42 So, pharmacologic treatment, limited to the short term.

    02:45 The drugs can disturb sleep architecture.

    02:49 They have addictive potential.

    02:51 And as well, among older adults, they can promote falls and more cognitive problems.

    02:57 So, benzodiazepines, they have a higher risk of abuse.

    03:00 I really use them for only very limited periods of time, no more than a week generally speaking for those drugs.

    03:09 Over-the-counter treatments like diphenhydramine don't work very well, but they can promote some of that cognitive dysfunction, somnolence and falls.

    03:18 And finally, just a quick word on melatonin.

    03:21 It probably works particularly for switching time zone, but we’re talking about reducing sleep latency by a few minutes on average.

    03:29 So, it's probably not something patients are really going to feel as a benefit.

    03:33 But if it helps them relax and makes them feel a little bit better, that's great.

    03:38 There is a risk of daytime grogginess afterwards as well with melatonin.

    03:42 So, it's not a completely benign agent.

    03:46 So, this gives you a nice overview of sleep.

    03:50 It helps, I think, you to discuss normal sleep and changes with sleep as you age with your patients and then that's a nice entrée for starting to talk about sleep hygiene and how to how to set the right environment and tone for sleep.

    04:06 And as I said, that's going to help you with the majority of your patients.

    04:09 Thanks very much.


    About the Lecture

    The lecture Insomnia: Management by Charles Vega, MD is from the course Acute Care.


    Included Quiz Questions

    1. Sleep hygiene
    2. One-week benzodiazepine taper
    3. Diphenhydramine as needed
    4. Melatonin agonists
    5. Zolpidem trail for 1 month
    1. Go to bed only when tired as opposed to a regular set time regardless of state of alertness
    2. Moderate intensity exercise right before bedtime to expend extra energy and tire out
    3. Eat a heavy meal or snack right before bed time to settle the stomach and initiate "rest and digest" parasympathetic nervous system
    4. Avoid getting out of bed if experiencing night-time awakenings to prevent "fully" waking up
    5. Drink alcohol right before bedtime to relax the body
    1. Increased anxiety
    2. Increased falls
    3. Disruption of sleep architecture
    4. Daytime somnolence
    5. Cognitive impairment
    1. Treat her depression
    2. Treat her insomnia
    3. Perform a urine toxicology test
    4. Obtain a complete blood panel and thyroid function evaluation
    5. Start chronic pain opioid drug therapy

    Author of lecture Insomnia: Management

     Charles Vega, MD

    Charles Vega, MD


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