ABSTRACT: Sleep disorders decrease productivity, impair cognitive performance, and increase morbidity and mortality. Early diagnosis and treatment improves quality of life.
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One-Third Of Adults Seen By Primary Care Physicians Report Occasional Insomnia; Up to 15% Report Chronic Problems.
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According to the National Commission on Sleep Disorders Research (NCSDR), 40 million Americans suffer from more than 80 debilitating sleep disorders, including the dyssomnias (sleep apnea syndromes, narcolepsy, insomnia, hypersomnia, periodic movement disorders, and circadian-rhythm disturbances); parasomnias (sleep walking or terrors, nocturnal myoclonus, bruxism, and more); or sleep problems associated with medical or psychiatric conditions. The National Sleep Foundation puts the number even higher, reporting that as many as 63 million Americans have a diagnosable and treatable sleep disorder – yet most sleep-related problems are never identified.
Co-director of UAB’s Sleep/Wake Disorders Center Vernon Pegram, PhD, ABSM, attributes the underdiagnosis of sleep disorders to patient reluctance in seeking medical attention, as well as to physicians being unaccustomed to asking their patients about sleep problems.
Recognition and Assessment
Insomnia is the most prevalent sleep-related complaint, reveals Pegram, noting that about one-third of American adults seen in the primary care setting report occasional insomnia, and 10% to 15% report chronic problems. Insomnia is classified by the duration of symptoms: Sleep difficulty lasting one night to a few weeks is defined as acute insomnia; chronic insomnia refers to sleep difficulty at least 3 nights per week for a month or more.
Assessment includes questions that address both sleep and daytime functioning, mainly because sleep needs vary markedly from person to person, explains Pegram. “Although the ability to maintain sleep decreases with age, the need for sleep does not significantly change. A complaint of not sleeping ‘a full 8 hours’ but otherwise having restorative sleep is normal. In these cases, reassurance may be all that is needed, whereas a complaint of severe insomnia or excessive daytime sleepiness should prompt a thorough evaluation, regardless of the patient’s age. These cases may require overnight polysomnography at an accredited sleep center for an accurate diagnosis,” he counsels.
Oftentimes chronic insomnia can be traced to other medical problems that can cause arousals during sleep, such as sleep apnea, gastrointestional reflux disease, or restless legs syndrome and periodic limb movements.
Pegram reveals that acute insomnia often is caused by a specific event, therefore the need for treatment depends on the severity of the daytime sequelae, the duration of the episode, and the degree to which episodes become predictable. “Untreated acute insomnia can develop into a chronic, learned insomnia. When the insomnia persists beyond a few nights, or becomes predictable, treatment should be considered,” he says. Pharmacologic treatment usually predominates, especially the use of short-acting hypnotics, in addition to adjunctive sleep hygiene measures.
Pharmacological Treatment
Hypnotic Medications — The primary indication for hypnotic medication is the short-term management of insomnia, until the underlying problem is controlled. Benzodiazepine-receptor agonists are the most commonly used. Although most benzodiazepines have sedative and hypnotic properties, only 5 are marketed as hypnotics; all reduce sleep-onset latency, decrease the number and duration of nocturnal wakings, and increase total sleep time and sleep efficiency in varying degrees:
Estazolam (ProSom®, Paxipam®): Rapid onset, modest reduction of sleep-onset latency. Can remain effective for up to 6 weeks of nightly administration.
Flurazepam (Dalmane®, Durapam®): Effective in inducing and maintaining sleep, accumulates over time, and remains effective for up to a month of consecutive nightly administration.
Quazepam (Doral®): Effective for sleep-onset and sleep-maintenance insomnia, long half-life minimizes rebound insomnia. Produces less impairment of daytime functioning than flurazepam.
Temazepam (Restoril®, Razepam®, Temaz®): Better for sleep-maintenance than sleep-onset problems, may produce the least residual impairment, and minimal tolerance has been reported for up to 3 months of use. Probably the best hypnotic for late-life insomnia.
Triazolam (Halcion®): Reduces sleep-onset latency, increases total sleep time, less daytime sleepiness. However, early-morning awakening and daytime anxiety have been associated with the drug; withdrawn from market in several European countries.
Newer, short-acting nonbenzodiazepines have been clinically tested and proven to be effective for months:
Zolpidem (Ambien®): Rapid onset and short duration. Effective in decreasing sleep-onset latency and for sleep maintenance. Slow-wave sleep relatively well preserved.
Zaleplon (Sonata®): Rapid onset and very short half-life. Effective in decreasing sleep-onset latency.
Antidepressants — When prescribed for patients with major
depression, sedating antidepressants improve subjective and objective measures of insomnia; sleep symptoms often improve more quickly than other symptoms of depression. When administered concurrently with “alerting” antidepressants, low doses of sedating antidepressants, such as trazodone, can improve insomnia. In nondepressed individuals, there are minimal data upon which to recommend use of these drugs. Additionally, antidepressants have a range of adverse effects, including anticholinergic effects, cardiac toxicity, orthostatic hypotension, and sexual dysfunction (ie, selective serotonin-reuptake inhibitors [SSRIs]). Tricyclic antidepressants and SSRIs can exacerbate restless legs syndrome and periodic limb movements.
Tricyclic antidepressants with sedative effects are recommended when insomnia is associated with an affective disorder. In this instance, they are better than benzodiazepines, especially when there is a suicide risk.
Amitriptyline (Elavil®, Endep®, Enovil®, Emitrip®) and Trimipramine (Surmontil®): Reduce sleep-onset latency and improve sleep continuity.
Trazodone (Desyrel®): Nontricyclic, increases slow-wave sleep, less anticholinergic action, fewer cardiovascular effects than tricyclics.
More energizing antidepressants, such as protriptyline (Vivactil®) and fluoxetine (Prozac®), can worsen sleep difficulties. On the other hand, antidepressants suppress rapid eye movement (REM) sleep in people with major depression, which benefits those patients with excessive REM sleep.
Antihistamines — Drugs that antagonize central histamine-1 receptors have sedative effects. The most common antihistamines used for insomnia are diphenhydramine and hydroxyzine; most over-the-counter sleep aids include an antihistamine. Few recent studies assess the efficacy of antihistamines for treating insomnia, but older studies demonstrate subjective and objective improvements during short-term treatment. However, because of these drugs anticholinergic effects and daytime drowsiness, they are not a good choice for older individuals.
Other Drugs — Barbiturates and older nonbenzadiazepine, nonbarbiturate drugs, such as chloral hydrate (Noctec®), methyprylon, and meprobamate (Miltown®, Equanil®, Meprospan®) are still available. These drugs are not recommended for insomnia because of their narrow therapeutic ratio, rapid development of tolerance, systemic toxicity, potential for abuse, and possibility of severe complications on withdrawal.
A variety of herbal preparations (eg, valerian root, herbal teas), nutritional supplements (eg, L-tryptophan), and over-the-counter drugs are also promoted for insomnia. In general, there is little scientific evidence for the efficacy or safety of these products. Melatonin’s role remains to be fully defined, says Pegram, but it can be helpful for people with sleep-phased delay problems. By taking melatonin in the early evening, the person may be more likely to fall asleep sooner.
Improving Quality of Life
“The primary care physician is in an ideal position to identify sleep disorders and initiate appropriate therapy, including education about the significant dangers of functioning while impaired by sleepiness,” he concludes. “UAB’s Sleep/Wake Disorders Center is nationally recognized for both teaching and service. We can improve many patients’ quality of life in a short time; it is extremely rewarding work.”
For more information:
Dr. Vernon Pegram
1.800.UAB.MIST
mist@uabmc.edu
UAB Insight, Winter 2001