Sleep initiation and maintenance disorders: Difference between revisions
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In [[medicine]], '''sleep initiation and maintenance disorders''', including '''insomnia''', are "disorders characterized by impairment of the ability to initiate or maintain sleep. This may occur as a primary disorder or in association with another medical or psychiatric condition."<ref>{{MeSH}}</ref><ref name="pmid16120860">{{cite journal| author=Silber MH| title=Clinical practice. Chronic insomnia. | journal=N Engl J Med | year= 2005 | volume= 353 | issue= 8 | pages= 803-10 | pmid=16120860 | In [[medicine]], '''sleep initiation and maintenance disorders''', including '''insomnia''', are "disorders characterized by impairment of the ability to initiate or maintain sleep. This may occur as a primary disorder or in association with another medical or psychiatric condition."<ref>{{MeSH}}</ref><ref name="pmid16120860">{{cite journal| author=Silber MH| title=Clinical practice. Chronic insomnia. | journal=N Engl J Med | year= 2005 | volume= 353 | issue= 8 | pages= 803-10 | pmid=16120860 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16120860 | doi=10.1056/NEJMcp043762 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16120860 | doi=10.1056/NEJMcp043762 }}</ref> | ||
==Epidemiology/causes== | |||
There are many underlying associations<ref name="pmid22520782">{{cite journal| author=Arroll B, Fernando A, Falloon K, Goodyear-Smith F, Samaranayake C, Warman G| title=Prevalence of causes of insomnia in primary care: a cross-sectional study. | journal=Br J Gen Pract | year= 2012 | volume= 62 | issue= 595 | pages= e99-103 | pmid=22520782 | doi=10.3399/bjgp12X625157 | pmc=PMC3268500 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22520782 }} </ref><ref name="pmid9475443">{{cite journal| author=Maggi S, Langlois JA, Minicuci N, Grigoletto F, Pavan M, Foley DJ et al.| title=Sleep complaints in community-dwelling older persons: prevalence, associated factors, and reported causes. | journal=J Am Geriatr Soc | year= 1998 | volume= 46 | issue= 2 | pages= 161-8 | pmid=9475443 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9475443 }} </ref> including psychiatric disorders<ref name="pmid2769898">{{cite journal| author=Ford DE, Kamerow DB| title=Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? | journal=JAMA | year= 1989 | volume= 262 | issue= 11 | pages= 1479-84 | pmid=2769898 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2769898 }} </ref><ref name="pmid9475443">{{cite journal| author=Maggi S, Langlois JA, Minicuci N, Grigoletto F, Pavan M, Foley DJ et al.| title=Sleep complaints in community-dwelling older persons: prevalence, associated factors, and reported causes. | journal=J Am Geriatr Soc | year= 1998 | volume= 46 | issue= 2 | pages= 161-8 | pmid=9475443 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9475443 }} </ref>. | |||
==Diagnosis== | |||
While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a [[polysomnogram]] is often needed for the differential diagnosis. | |||
==Treatment== | ==Treatment== | ||
{| class="wikitable" align="right" | |||
|+ Randomized controlled trial of treatment options for insomnia.<ref name="pmid19454639">{{cite journal| author=Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et al.| title=Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. | journal=JAMA | year= 2009 | volume= 301 | issue= 19 | pages= 2005-15 | pmid=19454639 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19454639 | doi=10.1001/jama.2009.682 }} </ref> | |||
! rowspan=2|Treatment!! colspan=2|Outcome at 6 months | |||
|- | |||
! Responders!! Remitters | |||
|- | |||
| 6 weeks of [[Cognitive behavioral therapy|CBT]]|| 55% || 40% | |||
|- | |||
| 6 months of [[Cognitive behavioral therapy|CBT]]|| 63% || 44% | |||
|- | |||
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 weeks of [[zolpidem]]||style="background:lightgreen"| 81% ||style="background:lightgreen"| 68% | |||
|- | |||
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 months of [[zolpidem]]|| 65% || 42% | |||
|- | |||
| colspan=3 | Adapted from Table 4 of Morin et al.<ref name="pmid19454639"/> | |||
|- | |||
|} | |||
Treatment options for [[geriatrics|geriatric]] patients have been reviewed.<ref name="pmid19484833">{{cite journal| author=Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al.| title=Evidence-based recommendations for the assessment and management of sleep disorders in older persons. | journal=J Am Geriatr Soc | year= 2009 | volume= 57 | issue= 5 | pages= 761-89 | pmid=19484833 | Treatment options for [[geriatrics|geriatric]] patients have been reviewed.<ref name="pmid19484833">{{cite journal| author=Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al.| title=Evidence-based recommendations for the assessment and management of sleep disorders in older persons. | journal=J Am Geriatr Soc | year= 2009 | volume= 57 | issue= 5 | pages= 761-89 | pmid=19484833 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19484833 | pmc=PMC2748127 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19484833 | pmc=PMC2748127 }}</ref> | ||
===Non-drug treatment=== | ===Non-drug treatment=== | ||
No-drug treatments such as light therapy, exercise, and sleep-hygiene modification have been reviewed.<ref name="pmid19256583">{{cite journal| author=Shub D, Darvishi R, Kunik ME| title=Non-pharmacologic treatment of insomnia in persons with dementia. | journal=Geriatrics | year= 2009 | volume= 64 | issue= 2 | pages= 22-6 | pmid=19256583 | No-drug treatments such as light therapy, exercise, and sleep-hygiene modification have been reviewed.<ref name="pmid19256583">{{cite journal| author=Shub D, Darvishi R, Kunik ME| title=Non-pharmacologic treatment of insomnia in persons with dementia. | journal=Geriatrics | year= 2009 | volume= 64 | issue= 2 | pages= 22-6 | pmid=19256583 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19256583 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19256583 }}</ref> | ||
A combination of education, sleep hygiene, exercise, and light therapy helped patients with [[Alzheimer's disease]] in the NITE-AD [[randomized controlled trial]].<ref name="pmid15877554">{{cite journal| author=McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L| title=Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial. | journal=J Am Geriatr Soc | year= 2005 | volume= 53 | issue= 5 | pages= 793-802 | pmid=15877554 | A combination of education, sleep hygiene, exercise, and light therapy helped patients with [[Alzheimer's disease]] in the NITE-AD [[randomized controlled trial]].<ref name="pmid15877554">{{cite journal| author=McCurry SM, Gibbons LE, Logsdon RG, Vitiello MV, Teri L| title=Nighttime insomnia treatment and education for Alzheimer's disease: a randomized, controlled trial. | journal=J Am Geriatr Soc | year= 2005 | volume= 53 | issue= 5 | pages= 793-802 | pmid=15877554 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=15877554 | doi=10.1111/j.1532-5415.2005.53252.x }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=15877554 | doi=10.1111/j.1532-5415.2005.53252.x }}</ref> | ||
Indirect evidence suggests a warm bath may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352 | Indirect evidence suggests a warm bath may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }}</ref> | ||
Exercise, perhaps by raising body temperature, may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352 | Exercise, perhaps by raising body temperature, may help.<ref name="pmid2578352">{{cite journal| author=Horne JA, Moore VJ| title=Sleep EEG effects of exercise with and without additional body cooling. | journal=Electroencephalogr Clin Neurophysiol | year= 1985 | volume= 60 | issue= 1 | pages= 33-8 | pmid=2578352 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=2578352 }}</ref> | ||
===Medications=== | ===Medications=== | ||
Pharmacological interventions for sleepiness and sleep disturbances caused by shift work has been reviewed by the [[Cochrane Collaboration]].<ref name="pmid25113164">{{cite journal| author=Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen M, Isotalo LK et al.| title=Pharmacological interventions for sleepiness and sleep disturbances caused by shift work. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 8 | issue= | pages= CD009776 | pmid=25113164 | doi=10.1002/14651858.CD009776.pub2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25113164 }} </ref> | |||
====GABA agonists==== | ====GABA agonists==== | ||
These medications are agonists of the [[ | These medications are agonists of the [[gamma aminobutyric acid]]. | ||
=====Nonselective BZ1 and BZ2 agonists===== | |||
{{main|Benzodiazepine}} | |||
=====BZ<sub>1</sub> selective agonists ===== | =====BZ<sub>1</sub> selective agonists ===== | ||
These medications include [[zopiclone]], [[eszopiclone]], zolpidem, and [[zaleplon]]. In treating persistent [[insomnia]] in adults, 6 weeks of zolpidem 10 mg nightly along with weekly sessions of [[cognitive behavioral therapy]] followed by 6 months of monthly sessions and no medications yielded the most remission of insomnia in a [[randomized controlled trial]].<ref name="pmid19454639" | These medications include [[zopiclone]], [[eszopiclone]], zolpidem, and [[zaleplon]]. Overall, the benefit of these medications is small.<ref>{{Cite journal | ||
| doi = 10.1136/bmj.e8343 | |||
| issn = 1756-1833 | |||
| volume = 345 | |||
| issue = dec17 6 | |||
| pages = e8343-e8343 | |||
| last = Huedo-Medina | |||
| first = T. B. | |||
| coauthors = I. Kirsch, J. Middlemass, M. Klonizakis, A. N. Siriwardena | |||
| title = Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration | |||
| journal = BMJ | |||
| accessdate = 2012-12-19 | |||
| date = 2012-12-17 | |||
| url = http://www.bmj.com/content/345/bmj.e8343 | |||
}}</ref> | |||
In treating persistent [[insomnia]] in adults, 6 weeks of zolpidem 10 mg nightly along with weekly sessions of [[cognitive behavioral therapy]] followed by 6 months of monthly sessions and no medications yielded the most remission of insomnia in a [[randomized controlled trial]].<ref name="pmid19454639"/> | |||
In [[geriatrics]], the benefits of [[zolpidem]] for insomnia to not clearly exceed the [[drug toxicity]].<ref name="pmid16284208">{{cite journal| author=Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE| title=Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. | journal=BMJ | year= 2005 | volume= 331 | issue= 7526 | pages= 1169 | pmid=16284208 | In [[geriatrics]], the benefits of [[zolpidem]] for insomnia to not clearly exceed the [[drug toxicity]].<ref name="pmid16284208">{{cite journal| author=Glass J, Lanctôt KL, Herrmann N, Sproule BA, Busto UE| title=Sedative hypnotics in older people with insomnia: meta-analysis of risks and benefits. | journal=BMJ | year= 2005 | volume= 331 | issue= 7526 | pages= 1169 | pmid=16284208 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16284208 | doi=10.1136/bmj.38623.768588.47 | pmc=PMC1285093 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16813362 Review in: ACP J Club. 2006 Jul-Aug;145(1):14] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=17213123 Review in: Evid Based Med. 2006 Aug;11(4):110] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16865838 Review in: Evid Based Nurs. 2006 Jul;9(3):87] | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16284208 | doi=10.1136/bmj.38623.768588.47 | pmc=PMC1285093 }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16813362 Review in: ACP J Club. 2006 Jul-Aug;145(1):14] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=17213123 Review in: Evid Based Med. 2006 Aug;11(4):110] [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=16865838 Review in: Evid Based Nurs. 2006 Jul;9(3):87]</ref><ref name="pmid9417012">{{cite journal| author=Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ| title=Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy. | journal=JAMA | year= 1997 Dec 24-31 | volume= 278 | issue= 24 | pages= 2170-7 | pmid=9417012 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=9417012 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=9417012 }}</ref> | ||
The benefit of [[eszopiclone]] may not be strong.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841 | The benefit of [[eszopiclone]] may not be strong.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841 | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }} | | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }}</ref> | ||
====Melatonin agonists==== | ====Melatonin agonists==== | ||
[[Ramelteon]] is one available agonist. Its magnitude of benefit may be small | These may increase sleep by less than 30 minutes.<ref name="pmid25113164">{{cite journal| author=Liira J, Verbeek JH, Costa G, Driscoll TR, Sallinen M, Isotalo LK et al.| title=Pharmacological interventions for sleepiness and sleep disturbances caused by shift work. | journal=Cochrane Database Syst Rev | year= 2014 | volume= 8 | issue= | pages= CD009776 | pmid=25113164 | doi=10.1002/14651858.CD009776.pub2 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25113164 }} </ref> | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }} | |||
[[Ramelteon]] is one available agonist. Its magnitude of benefit may be small among outpatients.<ref name="pmid19846841">{{cite journal| author=Schwartz LM, Woloshin S| title=Lost in transmission--FDA drug information that never reaches clinicians. | journal=N Engl J Med | year= 2009 | volume= 361 | issue= 18 | pages= 1717-20 | pmid=19846841 | |||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19846841 | doi=10.1056/NEJMp0907708 }}</ref> | |||
[[Tasimelteon]] can help transient insomnia due to shift changes related to employment | [[Tasimelteon]] can help transient insomnia due to shift changes related to employment.<ref name="pmid19054552">{{cite journal| author=Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al.| title=Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials. | journal=Lancet | year= 2009 | volume= 373 | issue= 9662 | pages= 482-91 | pmid=19054552 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19054552 | doi=10.1016/S0140-6736(08)61812-7 }}</ref> | ||
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19054552 | doi=10.1016/S0140-6736(08)61812-7 }} | |||
==References== | ==References== | ||
<small> | |||
<references/> | <references/> | ||
</small>[[Category:Suggestion Bot Tag]] | |||
Latest revision as of 06:01, 19 October 2024
In medicine, sleep initiation and maintenance disorders, including insomnia, are "disorders characterized by impairment of the ability to initiate or maintain sleep. This may occur as a primary disorder or in association with another medical or psychiatric condition."[1][2]
Epidemiology/causes
There are many underlying associations[3][4] including psychiatric disorders[5][4].
Diagnosis
While an extremely thorough history, including observations from sleeping partners or household members, is the proper starting point, a polysomnogram is often needed for the differential diagnosis.
Treatment
| Treatment | Outcome at 6 months | |
|---|---|---|
| Responders | Remitters | |
| 6 weeks of CBT | 55% | 40% |
| 6 months of CBT | 63% | 44% |
| 6 months of CBT 6 weeks of zolpidem |
81% | 68% |
| 6 months of CBT 6 months of zolpidem |
65% | 42% |
| Adapted from Table 4 of Morin et al.[6] | ||
Treatment options for geriatric patients have been reviewed.[7]
Non-drug treatment
No-drug treatments such as light therapy, exercise, and sleep-hygiene modification have been reviewed.[8]
A combination of education, sleep hygiene, exercise, and light therapy helped patients with Alzheimer's disease in the NITE-AD randomized controlled trial.[9]
Indirect evidence suggests a warm bath may help.[10]
Exercise, perhaps by raising body temperature, may help.[10]
Medications
Pharmacological interventions for sleepiness and sleep disturbances caused by shift work has been reviewed by the Cochrane Collaboration.[11]
GABA agonists
These medications are agonists of the gamma aminobutyric acid.
Nonselective BZ1 and BZ2 agonists
BZ1 selective agonists
These medications include zopiclone, eszopiclone, zolpidem, and zaleplon. Overall, the benefit of these medications is small.[12]
In treating persistent insomnia in adults, 6 weeks of zolpidem 10 mg nightly along with weekly sessions of cognitive behavioral therapy followed by 6 months of monthly sessions and no medications yielded the most remission of insomnia in a randomized controlled trial.[6]
In geriatrics, the benefits of zolpidem for insomnia to not clearly exceed the drug toxicity.[13][14]
The benefit of eszopiclone may not be strong.[15]
Melatonin agonists
These may increase sleep by less than 30 minutes.[11]
Ramelteon is one available agonist. Its magnitude of benefit may be small among outpatients.[15]
Tasimelteon can help transient insomnia due to shift changes related to employment.[16]
References
- ↑ Anonymous (2024), Sleep initiation and maintenance disorders (English). Medical Subject Headings. U.S. National Library of Medicine.
- ↑ Silber MH (2005). "Clinical practice. Chronic insomnia.". N Engl J Med 353 (8): 803-10. DOI:10.1056/NEJMcp043762. PMID 16120860. Research Blogging.
- ↑ Arroll B, Fernando A, Falloon K, Goodyear-Smith F, Samaranayake C, Warman G (2012). "Prevalence of causes of insomnia in primary care: a cross-sectional study.". Br J Gen Pract 62 (595): e99-103. DOI:10.3399/bjgp12X625157. PMID 22520782. PMC PMC3268500. Research Blogging.
- ↑ 4.0 4.1 Maggi S, Langlois JA, Minicuci N, Grigoletto F, Pavan M, Foley DJ et al. (1998). "Sleep complaints in community-dwelling older persons: prevalence, associated factors, and reported causes.". J Am Geriatr Soc 46 (2): 161-8. PMID 9475443. [e]
- ↑ Ford DE, Kamerow DB (1989). "Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?". JAMA 262 (11): 1479-84. PMID 2769898. [e]
- ↑ 6.0 6.1 6.2 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial.". JAMA 301 (19): 2005-15. DOI:10.1001/jama.2009.682. PMID 19454639. Research Blogging.
- ↑ Bloom HG, Ahmed I, Alessi CA, Ancoli-Israel S, Buysse DJ, Kryger MH et al. (2009). "Evidence-based recommendations for the assessment and management of sleep disorders in older persons.". J Am Geriatr Soc 57 (5): 761-89. PMID 19484833. PMC PMC2748127.
- ↑ Shub D, Darvishi R, Kunik ME (2009). "Non-pharmacologic treatment of insomnia in persons with dementia.". Geriatrics 64 (2): 22-6. PMID 19256583.
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- ↑ Huedo-Medina, T. B.; I. Kirsch, J. Middlemass, M. Klonizakis, A. N. Siriwardena (2012-12-17). "Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration". BMJ 345 (dec17 6): e8343-e8343. DOI:10.1136/bmj.e8343. ISSN 1756-1833. Retrieved on 2012-12-19. Research Blogging.
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- ↑ Nowell PD, Mazumdar S, Buysse DJ, Dew MA, Reynolds CF, Kupfer DJ (1997 Dec 24-31). "Benzodiazepines and zolpidem for chronic insomnia: a meta-analysis of treatment efficacy.". JAMA 278 (24): 2170-7. PMID 9417012.
- ↑ 15.0 15.1 Schwartz LM, Woloshin S (2009). "Lost in transmission--FDA drug information that never reaches clinicians.". N Engl J Med 361 (18): 1717-20. DOI:10.1056/NEJMp0907708. PMID 19846841. Research Blogging.
- ↑ Rajaratnam SM, Polymeropoulos MH, Fisher DM, Roth T, Scott C, Birznieks G et al. (2009). "Melatonin agonist tasimelteon (VEC-162) for transient insomnia after sleep-time shift: two randomised controlled multicentre trials.". Lancet 373 (9662): 482-91. DOI:10.1016/S0140-6736(08)61812-7. PMID 19054552. Research Blogging.