Updated: 11/28/2020

Insomnia Disorders / Hypersomnia

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Overview
  • Basic science
    • review sleep mechanics
      • longest stage of sleep: stage 2
      • slow wave/delta wave sleep: stage 3 and 4
      • decreased in elderly, alcoholics: REM sleep
  • Sleep disorders are very common in the general population
    • seen in up to 30% of people
    • seen more commonly in women, substance abusers, and the elderly
Snapshot
  • A 68-year-old woman presents to your office complaining of poor sleep. She describes her sleep as hard to start and hard to stay asleep. Physical exam is unremarkable. Lab studies are within normal limits.
Insomnia Disorder
  • Introduction
    • clinical definition
      • difficulty initiating or maintaining sleep at least 3 times per week for 3 months
        • also defined by non-restorative sleep
      • may be primary or secondary
        • secondary is a result of a physical or mental condition
      • insomnia exacerbated by any cause of anxiety or stress
  • Presentation
    • symptoms
      • daytime fatigue
      • general sleep complaints
  • Evaluation
    • rule out any underlying medical cause
      • especially urinary complaints in the elderly
    • best initial test: polysomnography
      • usually starting with sleep hygiene is a better initial step
    • may also get thyroid function labs and/or urine toxicology screen/UA
  • Treatment
    • lifestyle modification
      • improved sleep hygiene
        • best initial therapy: 
          • establishing regular sleeping schedule
          • avoiding caffeine intake or exercise late in the day
          • avoiding daytime naps
          • employing relaxation techniques and behavioral modifications to only sleep in bed
    • pharmacologic
      • zolpidem (ambien)
        • 2nd line therapy
        • should be prescribed with care and only for short periods
          • best if used less than 2 weeks
          • dependence common
      • melatonin
      • trazodone
        • high yield side-effect: priapism (trazoBONE) 
Snapshot
  • A 47-year-old female comes to your office complaining of excessive sleepiness. She says she has no difficulty falling or staying asleep but finds herself requiring naps during the day to say focused. These symptoms started several years ago. She denies any hallucinations when falling asleep or waking up or any sudden loss of muscle tone. Physical exam and lab studies are within normal limits.
Hypersomnia
  • Introduction
    • clinical definition: excessive nighttime or daytime sleep for > 1 month
  • Presentation
    • symptoms: excessive nighttime or daytime sleep
  • Evaluation
    • rule out any medical (including narcolepsy), psychiatric (atypical depression),  pharmacologic, or poor sleep hygiene causes
    • best initial test: polysomnography
      • important to rule out narcolepsy and obstructive sleep apnea
  • Treatment
    • pharmacologic
      • amphetamines
        • e.g., modafinil or methyphenidate
      • SSRIs
        • helpful in select patients
Snapshot
  • A 69-year-old gentleman presents to his primary care physician due to issues with sleep.  The patient states that he is unable to stay awake later than 5 PM, and is unable to go out in the evening with his wife which has put a strain on his relationship.  The patient is healthy with a lean body habitus.  His wife claims that he does not snore, but she does not that he typically starts his day at 4 AM.
Advanced Sleep Phase Disorder
  • Presentation 
    • trouble staying awake in the early evening which impairs social functioning 

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