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Insomnia

by Charles Vega, MD
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    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.


    About the Lecture

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


    Included Quiz Questions

    1. A 36-year-old woman with anxiety who feels like her quality of sleep has been poor for the past 3 months, and has difficulty waking up in the morning and feeling motivated to get to work on time
    2. A 24-year-old female who is having trouble initiating sleep for the past 4 weeks while studying for her first board examination
    3. A 78-year-old man who is waking up more often in the middle of the night to use the bathroom
    4. A 16-year-old male who is finding it difficult to wake up early in the mornings for school, despite going to bed at the usual hour around 10 pm
    5. A 34-year-old woman who has trouble falling asleep and staying asleep at night for the past 4 months since having her first baby, but is not having any difficulty going about her daily business
    1. Inflammatory bowel disease
    2. An increased risk of cardiovascular disease
    3. An increased risk of developing mood disorders
    4. Chronic pain
    5. A family history of insomnia
    1. More frequent night time awakenings
    2. Decreased sleep latency
    3. Increased REM sleep
    4. Significantly reduced total sleep time
    5. Increased delta-wave sleep

    Author of lecture Insomnia

     Charles Vega, MD

    Charles Vega, MD


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