Insomnia

INTRODUCTION TO SLEEP •Sleep provides the rest, our body needs. •If you sleep well at night,you function well in at day time. •Thus sleep is vital for healthy brain activity during day time such as moods, emotions, refluxes etc.

The Sleep Cycle • During some portion of their sleep their eyes darted rapidly in a highly co-ordinated way.This is called Rapid Eye Movement(REM). • Using electroencephalogram (EEG) that measures the electrical activity in the brain and differentiated between REM and NonREM sleep.

•Sleep occurs in a series of cycle , each lasting between sixty and ninety minutes. Each cycle has two main parts: In first part,our level of consciousness falls, change in heart rate, breathing, and overall slowing of brain activity. We do not dream during this phase.

• In the second part of the cycle we do dream.Its is characterized by rapid eye movement. • Each of this two main period occupies about 50% of the cycles elapsed time. • However, the balance between the two periods shifts during the course of the night. • Non-REM sleep actually consists of four distinct sub stages . • The stages are defined according to the types and intensity of brain wave activity as measured by EEG tracings . • Initial stage of sleep is known as Threshold.

THE DIFFERENT STAGES OF SLEEP CYCLE • Stage 1 Non-REM Sleep • Breathing becomes slow and even • The heartbeat becomes regular • Blood pressure falls • Brain temperature decreases • Blood flow to the brain is reduced • Little or no body movement

• Lasts for 10min. • Brain waves become smaller and irregular characterized by low voltage fast EEG.

Stage 2 NREM • It initially lasts about twenty minutes. • Stage 2 is an intermediate stage of sleep. It initially lasts about twenty minutes. The sleeper will gradually descend deeper into sleep, becoming more and more detached from the outside world and progressively more difficult to awaken. Stage 2 is characterized by: • Larger brain waves and occasional quick bursts of activity • The sleeper will not see anything even if the eyes are opened • A sleeper can easily be awakened by sounds • Bodily functions slow down, Blood pressure, metabolism, secretions, and cardiac activity decrease

Stage 3 NREM • Stage 3 is the beginning of deep sleep, occurring about thirty to forty five minutes after you first fall asleep. Stage 3 is characterized by: • Brain waves are slow and quite large. These brain waves are known as delta waves • The sleeper is far more difficult to awaken as compared to stage 1 or 2 sleep; it takes a louder noise or an active attempt to wake him or her.

Stage 4 NREM •

The brain waves are quite large, making a slow, jagged pattern on the EEG • The sleeper experiences virtual oblivion. If the sleeper is a sleepwalker or a bed wetter, those activities will begin in this phase •The sleeper awakened from deep sleep will probably be groggy, confused, or disoriented.

Amount of sleep as we age • Newborn infants need sixteen hours of sleep for every twenty-four-hour day. • By age six, children need only nine hours of sleep. • By age twelve, it is down to eight hours of sleep. • • By adulthood, our totals sleep time requirement drops to an average of seven and a half hours.

Deep sleep as we age • Young adults spend some 25 percent of their sleep time in deep sleep. • Adults aged fifty to sixty spend 10 percent or less of their sleep time sleeping deeply. • For many older adults, they worry that they are not getting enough sleep and have developed insomnia.

REM Sleep Stage Characteristics of REM State : • Brain waves are small and irregular, with big bursts of eye activity. • The four NREM phases are characterized by progressive relaxation. But during REM phase, the body's activity perks up considerably • • • • •

Blood pressure may increase drastically . Pulse rates increase in an irregular way . The sleeper with cardiac problems faces the greatest risk of heart attack at this time . Breathing becomes irregular and oxygen 'consumption increases . The first REM period is usually brief. After this, the sleeper may wake up briefly. This is quite normal. A good sleeper may not remember it the next day. A poor sleeper, however, may wake up at this point and have difficulty getting back to sleep

THE INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS • B. iii.

Dyssomnias Intrinsic sleep disorders Psychophysiological insomnia iv. Idiopathic insomnia B. Extrinsic sleep disorders vi. Altitude insomnia vii. Insufficient sleep syndrome C. Circadian rhythm sleep disorders ix. Time zone change (jet lag) syndrome x. Shift work sleep disorder

2. Parasonmias • • •

Arousal disorders Confusional arousals Sleepwalking B. Sleep-wake transition disorders • Rhythmic movement disorder • Sleep talking C. Parasomnias usually associated with REM sleep • Nightmares • Sleep paralysis D. Other Parasomnias • Sleep bruxism • Sleep enuresis

3. Sleep Disorders Associated

with Medical/Psychiatric Disorders B. Associated with mental disorders • Mood disorders • Alcoholism B. Associated with neurological disorders • Dementia • Parkinsonism C. Associated with other medical disorders • Sleeping sickness • Sleep-related asthma

4.Proposed sleep disorders i. Menstruation-associated sleep disorder ii. Pregnancy-associated sleep disorder

Causes of Insomnia Sleep-Onset Insomnia • Anxiety or tension EnvirolID1entai change Emotional arousal • Fear of insomnia • Phobia of sleep • Disruptive environment • Pain or discomfort • Caffeine • Alcohol

Sleep-Maintenance Insomnia • Depression • Environmental change • Nocturnal myoclonus • Hypoglycemia • Parasomnias such as apnea, restless legs syndrome, etc. • Pain or discomfort Drugs • Alcohol

Vulnerability to Insomnia • • • • • • • • •

Persistant Stress Depression Anxiety Post-Traumatic Stress Disorder (PTSD) Learned Insomnia Use of stimulants Use of alcohol Erratic hours Sedentary Behaviour

Food Foods That Can Interfere With Sleep

•Coffee •Soft Drinks •Tea •Chocolate candy or dessert •Chocolate milk or hot chocolate •Onion

Vulnerability to Insomnia (cont.) • • • • • • •

Food Intolerance Nocturnal Hypoglycemia Physiological Factors Misuse or overuse of sleeping pills Environmental Factors Noise Light

Insomnia due to Medication • • • • • • •

Alcohol Antihypertensives Antineoplastics Beta Blockers Caffeine Diuretics Levodopa

• • • • • • •

Oral Contraceptives Phenytoin (Dilantin) Protriptyline (Vivactil) Corticosteroids Stimulants Theophylline Thyroxine

Treatment • • • • • • • • •

Conventional Treatment Transient Insomnia Medication (Drug Therapy) Education Chronic Insomnia Cognitive restructuring Light phase shift Support, counseling, or psychotherapy Cognitive behavioral therapy (CBT)

DRUG CLASSES USED TO TREAT SLEEP DISORDERS

Barbiturates Barbiturates slow down central nervous system function, heart rate, an use them continually may become tolerant to the effects of barbiturate potentially serious side effects. Drugs in the class Amobarbital (Amytal) Butabarbital (Butalan Elixir, Butisol, Sarisol No.2) Pentobarbital Oral (Nembutal) Phenobarbital (Bellatol, Solfoton) Secobarbital (Seconal) Pentobarbital Injection (Nembutal Injection)

MEDICATIONS COMMONLY USED FOR THE TREATMENT OF INSOMNIA -Nonbenzodiazepine, selective benzodiazepine receptor agonists Zaleplon Common Initial Dose (half-dose is generally recommended in elderly): 10 mg FDA Approved Maximum Daily Dose 20 mg When: at bed time or during night Residual Effects - none Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: none Zolpidem Common Initial Dose (half-dose is generally recommended in elderly) 10 mg FDA Approved Maximum Daily Dose 10 mg When: at bed time only Residual Effects - minimal Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: minimal

Sedating antidepressants frequently used as hypnotics (off-label) Trazodone Common Initial Dose (half-dose is generally recommended in elderly) 50 mg FDA Approved Maximum Daily Dose 400 mg divided (for depression) Amitriptyline Common Initial Dose/(half-dose is generally recommended in elderly) 50 mg FDA Approved Maximum Daily Dose 300 mg divided (for depression) Doxepin Common Initial Dose (half-dose is generally recommended in elderly) 50 mg FDA Approved Maximum Daily Dose 300 mg divided (for depression) Diphenhydramine Common Initial Dose (half-dose is generally recommended in elderly) 25 mg FDA Approved Maximum Daily Dose 100 mg Gabapentin Common Initial Dose (half-dose is generally recommended in elderly) 300 mg FDA Approved Maximum Daily Dose 1800 mg divided (for seizures)

Melatonin Melatonin has been called the body's own natural sleeping pill. It is N-acetyl-5methoxy tryptamine, the principal hormone of pineal gland. It plays a key role in the sleep cycle by helping you fall asleep. Low melatonin levels can cause sleep-onset insomnia. This is how our body utilizes melatonin in controlling our sleep: The body changes serotonin into melatonin. • The pineal gland releases melatonin only during times when the level of light is low. Practically Melatonin is speaking, stored inthis the means pineal that gland melatonin inside theis brain. secreted only at night, while you are asleep. In the morning, when you open your eyes, the presence of light is a sign to your brain to shut down the melatonin production.

Do not take melatonin supplement if: You are pregnant or breast-feeding You are under the age of 35 You are suffering from cancer of the blood or immune system You have kidney disease Dosage: Start with 1.5 mg daily, taken 2 hours or less before bedtime. If this is not effective, gradually

5-HTP 5-HTP (5-hydrbxytryptophan) is a compound produced by the body from tryptophan. It is naturally found in many foods and most commonly extracted from the seeds of the Griffonia plant. 5-HTP increases REM sleep significantly (typically by about 25 percent) while simultaneously increasing deep sleep stages 3 and 4 without increasing total sleep time.

Higher doses may lead to a greater number of disturbing· dreams and nightmares due to abnormally prolonged REM sleep. It can also lead to mild nausea.

New Drug with novel mechanism of action (MOA) to be developed in 35 years in the area of insomnia Takeda Global Research & Development Center announced today that it has submitted a new drug application (NDA) to the U.S. Food and Drug Administration (FDA) to market :ramelteon (TAK-375), its investigational drug for insomnia. Ramelteon belongs to a new class of prescription drugs . Ramelteon specifically targets the MT 1 and MT 2 receptors in the brain, which are believed to be critical in the regulation of the body's sleep-wake cycle.

Common Sense Remedies • 1. Go to bed only when you are sleepy. Get up at about the same time every morning, no matter when you go to bed. ∀ 2. If you wake up at night and can't go back to sleep, remain quiet and relaxed. Be patient; sleep usually returns. • 3.Laughter is a powerful way to defuse stress and anxiety. • 4. A void alcohol and caffeine for several hours before bedtime. • 5. Set an alarm clock and get out of bed at the same time every morning. • 6. Exercise regularly in the late afternoon or early evening- but not right before bedtime. • 7.Learn to put worries out of your mind.