00:01
Right.
00:02
Let's all wake up and talk about insomnia.
00:04
Insomnia is a very common
condition we see in primary care.
00:07
It can promote a lot of anxiety
and worry in my patients.
00:11
And the funny thing is that leads to a
cycle where they experience more insomnia.
00:15
So, therefore, breaking the cycle
is really, really important.
00:18
So, we’ll talk about sleep and
some general properties of sleep
and then focus on defining insomnia
and how to treat it appropriately.
00:28
So, I’m going to start with a case.
00:29
I’ve got a 50-year-old female.
00:32
She experiences early and middle
insomnia and she has daytime fatigue.
00:36
That means she has trouble initiating sleep.
00:39
She has trouble with staying asleep in
the middle of the night and she gets tired.
00:44
You know what fatigue is.
00:45
She gets tired in the day.
00:47
She doesn’t have any significant
medical illnesses thankfully.
00:50
And a review of systems and a
physical examination are negative.
00:54
So, what do you do now?
Is it, A, do you recommend sleep
hygiene and a sleep diary?
B, initiate a laboratory evaluation?
C, just start treating with something
like a melatonin antagonist or agonist?
Or D, initiate a 4 to 6 week
trial with a hypnotic drug?
Here, I would strongly argue for A
because this patient, we don’t know
enough about her insomnia yet.
01:21
A sleep diary can be a great way to actually document
just how severe the insomnia is when it bothers her.
01:27
May give some clues too with –
maybe it's stress
or something related to her life,
with her work,
her family, where she has certain
shifts where she’s staying up late.
01:36
And then working on sleep hygiene is
always a good idea and highly effective.
01:42
And we’ll be talking about that quite a bit.
01:45
So, just to define insomnia,
it's a subjective perception
of difficulty with sleep initiation,
duration,
consolidation or quality that occurs
despite the adequate opportunity for sleep.
01:57
So, in a situation where you're sharing a bedroom with like
14 other people and you're having a hard time sleeping,
that doesn't necessarily qualify
it’s insomnia because that's
not really an adequate opportunity.
02:13
If you’re sleeping on a factory floor,
that's not an adequate opportunity.
02:17
And it also needs to involve
some form of daytime impairment.
02:22
Acute insomnia is considered
less than three months in duration
and chronic is longer than that,
longer than three months.
02:30
So, in terms of epidemiology,
it's very common.
02:34
Insomnia affects 10 to 30% of adults.
02:37
It’s more common in women.
02:38
It’s more common as you get older.
02:41
It’s definitely more
common in chronic pain.
02:43
Chronic pain and insomnia
tend to go hand-in-hand.
02:46
And unfortunately,
they exacerbate each other.
02:48
So, patients who sleep
less also have more pain.
02:53
And it can be hereditary.
02:54
It tends to run in families, insomnia.
03:00
And it is also associated with –
besides feeling tired during the day,
it is associated with some
more severe consequences,
such as cognitive difficulty.
03:08
It’s also associated with a
higher risk of accidents.
03:12
And it’s also associated with a
higher risk of mood disorders as well.
03:15
So, insomnia can be a
feature of anxiety and depression,
but it can also promote
worse anxiety and depression.
03:24
And finally,
chronic insomnia is linked
to intravascular inflammation
and a higher risk for
cardiovascular disease.
03:33
Now, sleep does change with age and
I think it's important to counsel older adults
because many of them are less
satisfied with their sleep overall.
03:41
So, it's good to think about
how sleep naturally changes with age.
03:45
There's more of a latency.
03:46
So, patients may complain
of early insomnia symptoms.
03:49
It takes longer to get to sleep.
03:51
They also have reduced time in REM as you
get older and they are more likely to wake up.
03:57
That said, it's a fallacy that sleep always –
duration always decreases as you get older.
04:04
It can.
04:05
It can also stay about the same.
04:08
But generally, as I said,
patients who are older have
less satisfaction with their sleep.
04:13
And it’s due to all of those causes.
04:14
It takes longer to fall asleep.
04:16
Plus, they are waking up
more in the middle of the night.
04:18
And so, therefore,
it's something to counsel patients about and
tell them this is going to be a normal part of aging.
04:24
Just that reassurance is a good
start as a therapeutic relationship.