Defined as difficulty falling asleep, waking frequently during the night, waking early with inability to get back the sleep, and awakening unrefreshed.
Insomnia, is characterized by the dissatisfaction with the quality of sleep or duration associated with difficulty falling or staying asleep and substantial distress or daytime impairments.
It is a disorder in sleep disturbance that occurs three nights or more per week, and persists for more than three months.
Insomnia is not the result of inadequate opportunities to sleep.
It is a frequent accompanied with other medical conditions, such as pain, psychiatric disorders of depression, as well as other sleep disorders, such as restless leg syndrome, and sleep apnea.
Rates of insomnia have risen dramatically over the past two decades.
Associated with impaired quality of life, affective disorders, and increased use of medical services.
Most common sleep complaint.
The most prevalent sleep disorder in the general population.
Approximately 10% of adults meet the criteria for insomnia disorder and 15 to 20% report occasional insomnia symptoms.
Affects as many as 1/3 of the world’s population.
In about 40% of cases, it develops into more chronic and persistent condition.
About 10 to 15% of adults labeled as having chronic insomnia.
CDC: 1/3 of US children and adolescents are getting insufficient sleep.
It is more prevalent among women and people with mental or medical problems.
Its incident increases in middle age and later, as well as during perimenopause and menopause.
Contributing factors include: behavioral, cognitive, emotional, and genetic factors.
Accompanied by daytime functional impairment, irritability, fatigue during wakefulness, disability, increased risk of motor vehicle crashes, workplace absenteeism, errors, and excess medical utilization.
Increased association with depression, impaired daytime function, reduced libido, and increased use of healthcare for women.
Nearly 90% of people with major depressive disorder report disturbed sleep.
Ot can be situational or episodic, but follows a persistent course in more than 50% of patients.
The first episode typically is related to a stressful life situation, health problem, atypical work schedule, or travel across several time zones.
Chronic insomnia may develop in persons who are vulnerable to insomnia.
Psychological, behavioral or medical factors can perpetuate chronic sleep difficulties.
Chronic insomnia is associated with increased risk for major depression, hypertension, Alzheimer’s disease, and work disability.
Associated with difficulty concentrating, fatigue, irritability, lethargy, emotional instability, and memory lapses along with increased risk of road or work accidents.
Associated with increased risk for obesity, diabetes, stroke, and coronary artery disease in women.
Older adults are more likely to have sleep difficulties, so the aging US population may be contributing to the increased incidence of insomnia.
24/7 work hour schedules and constant social media may also expose individuals to blue light at night, which can inhibit endogenous melatonin production and increase the incidence of insomnia.
Aggregates or increases risk of alcoholism, depression, obesity, diabetes and stroke.
Predisposing factors include advanced age, female gender, anxiety prone personality, a family or personal history of insomnia and or psychiatric disorder, and genetic characteristics.
Precipitating factors are stressful life events, and medical, psychologic, and environmental factors.
Perpetuating factors include: maladaptive behavior, and patient beliefs that patients feel that help them cope with sleep problems.
Estimated costs about 14 billion dollars annually.
The economic burden of untreated insomnia is much higher than costs associated with treating insomnia.
Up to 85% of patients remain untreated.
Affect 50% of adults and more than 90% of the population have trouble with sleep at some point in their lives.
10-15% of adults have insomnia, and approximately 50% have a chronic course.
Chronic insomnia occurs if these problems persist for 3 or more nights per week for at least 3 months.
Chronic insomnia is an unrelenting disturbance in sleep with marked daytime impairment and distress. and depression.
In addition to its social and psychological effects such as fatigue, deficient performance, and decreased memory and attention, chronic insomnia causes over activation of the hypothalamus-pituitary-adrenal axis and the sympathoadrenal system and is associated with increased cerebrovascular and cardiovascular diseases, and metabolic abnormalities.
Chronic insomnia is associated with the high risk for the development and progression of chronic kidney disease, but not ESRD.
The term sleep-wake disturbances encompasses perceived or actual alterations in night time sleep with subsequent daytime impairment, without a diagnosis.
Normally, the sleep phase of circadian rhythm occurs about two hours after the onset of melatonin secretion, but may occur later or earlier than society driven scheduled sleep time, resulting in a delayed or advanced sleep-wake phase disorder.
In delayed sleep-wake phase disorder, sleep occurs later than needed, whereas in advanced sleep-wake phase, sleep occurs earlier than needed.
Sleep-wake disorders often present with difficulty falling asleep, staying asleep, not feeling refreshed on awakening, and daytime dysfunction, and also include circadian changes, sleep fragmentation and other sleep alterations.
Circadian rhythm sleep disorders indicate that the timing of sleep and wakefulness is maintained by homeostatic factors and by the endogenous circadian system.
The diagnosis is made when a patient reports dissatisfaction with sleep such as sleep-onset or sleep-maintenance as well as other daytime symptoms such as sleepiness, impaired attention, mood disturbances, for at least three nights per week and lasts more than three months.
Older adults have a prevalence of insomnia estimated to be 15-35%.
Is frequently a comorbid condition that has a negative effect on many medical conditions.
Pain increases an individual’s risk for developing insomnia.
Several types have been delineated-idiopathic, psychophysiological, and paradoxical, however the diagnosis and treatment is similar.
30 to 50% of patients suffering from chronic pain also report insomnia, and 53% of such patients require medical attention for their sleep dysfunction.
Insomnia has been associated with death.
May be a presenting symptom of a sleep related breathing disorder.
Persistent, not intermittent insomnia, is associated with increased risk for all-cause and cardiopulmonary mortality.
With chronic obstructive pulmonary disease concurrent insomnia is an independent risk factor with a fourfold increase in exacerbations, and 11 fold increase in respiratory related emergencies, worse cardiovascular outcomes and a five fold increase in mortality.
A risk factor for the development of impaired function, mental and medical disorders and increased medical costs.
In the elderly insomnia associated with falls and hip fractures.
Stimulants, bronchodilators, xanthines, decongestants, diuretics, histamine antagonists, antihypertensives, and steroids can cause sleep difficulties.
Persistent primary insomnia predicts clinical depression and affects up to 5% of the general population.
Insomnia is both a symptom of depression and also a potential precursor.
Concerns about the consequences of poor sleep may lead to changes and beliefs about inability to control sleep and lead to feelings of helplessness and hopelessness.
Causes significant morbidity with increased use of medical and mental health resources.
Prevalence in cancer patients estimated to be two times that of the general population.
Newer perspectives about insomnia suggest that it may be a comorbid disorder rather than the symptom and warrants independent clinical assessment and management.
Detrimental behaviors include: spending too much time in bed, taking frequent and prolonged naps, following an irregular sleep schedule, and inactivity.
Fear of sleeplessness and worries about daytime consequences of poor sleep may slow sleep onset and prolong wakefulness.
Curtailment of sleep is associated with elevation in bio markers of inflammation, and systemic inflammation measured by circulating levels of CRP is independently associated with increased risk for cardiovascular disease and death.
Persistent insomnia is associated with inflammation and elevations in CRP.
When pharmacotherapy treatment fails, patients require a sleep medicine evaluation to find different therapeutic options.
With pharmacotherapeutic failure of insomnia occurs it is suggested additional physiologic etioloies for sleeplessness a present and is an indication for polysomnography.
Polysomnography findings revealed that there is a high rate of physiologic disorder sleep disordered breathing in , many patients with insomnia and this is ref2241ed to as complex insomnia.
Insomnia associated with very high rates of obstructive sleep apnea or upper airway resistance syndrome.
Insomnia and sleep-disordered breathing (SDB) are confused because each process causes sleep fragmentation and also because both cause overlapping symptoms such as non-restorative sleep, awakenings, and difficulty returning to sleep.
Treatment focuses on two problems: falling asleep and remaining asleep.
Most common agents utilized for treatment are gamma-aminobutyric acid type A modulators acting at the benzodiazepine recognition site and include zolpidem tartrate (Ambien), eszopiclone (Lunesta), temazepam (Restoril) and trizolam (Halcion).
Prescriptions for benzodiazepine receptor agonisists have steadily declined and prescriptions for trazodone have steadily increased.
Hypnotic medications are prescribed at higher rates for women, older adults, and White patients reflecting the epidemiology characteristics of insomnia.
Treatment considerations includes comorbidities that lead to sleep disruption, including other primary sleep disorders such as sleep apnea and periodic limb movement in sleep.
Pharmacologic and behavioral treatments for chronic insomnia have equal efficacy.
Cognitive behavioral therapy includes psychological techniques to modify misconceptions about sleep, insomnia and behavioral methods include stimulus contro, sleep restriction therapy, relaxation training and educational techniques.
In cases of persistent insomnia, cognitive behavioral therapy has been shown to be equal or better than pharmacological treatment, and the effect is longer lasting.
CBT produces improvements patient reported outcomes, improved sleep continuity, increase sleep efficiency, sleep onset latency, long-term efficacy, and ratio of time asleep at time spent in bed.
Medications most frequently used in the treatment of insomnia include: benzodiazepines, hypnotics such as zolpidem, zaleplon, and eszopiclone, melatonin antagonists, orexin antagonist, antihistamines and antidepressants.
The appropriate dose of melatonin for treating insomnia, is not known and clinical trials in adults have shown a small effect on sleep onset, with little effectiveness on wakefulness during sleep or on total sleep time.
Drug that bind to melatonin MT1 and MT2 receptors are approved for treatment of sleep on- setinsomnia, but have little effect on wakefulness after sleep onset or on total sleep time.
Nonbenzodiazepine receptor agonists are useful in treating insomnia and work by selectively binding to the Alpha-1 subtype Gamma-aminobutyric acid type A subunit preferentially causing sedation, and less likely to cause muscle relaxation or anxiolysis.
Nonbenzodiazepine receptor agonists include: eszopiclone, zaleplon and zolpidem.
Nonbenzodiazepine receptor agonists associated with complex sleep related behaviors including falls.
Zolpidem is associated with gait unsteadiness, increased traffic accidents, increased falls in community-based and skilled nursing facilities, increased falls in hospitalized patients, amnestied sleep related eating, sleep driving, amnestic sleep related sexual activities and other complex related behaviors.
Sedating anti-depressant drugs include: tricyclic drugs, amitriptyline, nortriptyline, and doxepin, and heterocycle drugs, mirtazapine and trazodone are commonly prescribed to treat insomnia.
Of these drugs only doxepin is supported by controlled trials.
Hypnotics for sleep increase the risk of serious injury by up to 60%, and the risk of hospital falls by a factor of 4-6, and they double the risk of motor vehicle accidents.
Orexin containing neurons in the lateral hypothalamus stimulate wake promoting nuclei in the brain stem and hypothalamus, and inhibited sleep promoting nuclei in the ventral lateral and median preoptic areas:inhibiting or anergic neurotransmission, inhibits, wakefulness and promote sleep.
Three dual orexin receptor antagonists, survorexant, lemborexant and daridorexant are approved for insomnia.
Treatment should include sleep hygiene coaching about diet, exercise, avoidance of caffeine, nicotine and alcohol, attention to environmental factors that interfere with sleep, and maintenance of sleep schedules.
Antihistamine medications obtained, over-the-counter such as diphenhydramine and prescription agents such as hydroxyzine are the most commonly used medications for the treatment for insomnia, but data supporting the efficacy is weak.
Gabapentinoids such as gabapentin and pregabalin are commonly used for chronic pain, and restless leg syndrome can produce sedation and increase slow wave sleep, and prescribed off label for insomnia, particularly when accompanied by pain.
Good sleep habits include: keeping regular wake times, explaining the duration of wakefulness and circadian rhythms that affect sleep onset, limiting time in bed to sleep time, use of bed for sleep/intimacy only, avoiding afternoon caffeine and limiting alcohol intake, and avoiding daytime napping.
Prescription sedatives help some patients with insomnia but overall controversy exists as to the long-term benefits of such treatment.
Sedatives in this setting, for the most part , are associated with minimal complications, however other studies report increased mortality, suicide and other adverse effects.
Randomized trials involving cognitive behavioral therapy, pharmacological agents, or both, demonstrate clinically meaningful response rates between 50 and 75%: relapse rate is about 25% within the first year and is more common in patients on sedatives and hypnotics than in those receiving psychobehavioral management.
Cognitive behavior therapy involves a combination of strategies to change behavior practices and psychological factors that contribute to insomnia.
Cognitive behavior techniques include behavioral and sleep, scheduling strategies, relaxation techniques, psychological, and cognitive interventions, aimed at changing unhelpful, beliefs, and excessive worrying about insomnia, and sleep hygeine education.