Insomnia

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.