Difficulty Sleeping

Insomnia

• Presentation:
  • three-week history of difficulty falling asleep. sleeps 7 hours per night without nightmares or snoring. recently began college and is having trouble with partner. drinks 3-4 cups of coffee a day.
  • – Stress
  • – Caffeine
  • – State of hyperarousal
  • – CC = Dissatisfaction with sleep quantity or quality, associated with ≥1 following symptoms:
  • – Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)
  • – Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)
  • – Early-morning awakening with inability to return to sleep.
  • – ≥ 3 nights per a week for ≥ 3 months with adequate opportunity to sleep
  • – Caffeine induced insomina = MC pharm cause of insomnia
  • – People w/ OSA, >50% complain of insomnia sx
• Physical Exam:
  • – VS
    – Mental Status Exam
• DDX:
  • – Stress-induced Insomnia
    
  • – Caffeine-induced Insomnia
    
  • – Insomnia with Circadian Rhythm Sleep Disorder
    
  • – Insomnia related to Major Depressive Disorder
    
  • – Major Depressive Disorder (MDD)
    
  • – Obstructive Sleep Apnea
• Work-up:
  • – Polysomnography
    
  • – Mental Status Exam (MSE)
    
  • – Urine Toxicology (Urine Tox)
    
  • – CBC with diff, TSH
• Treatment:
  • Self Care
    • Sleep Hygiene
  • Medication
    • Sedative – Zolpidem, Temazepam, Lorazepam, Eszopiclone, Trazodone
    • Antihistamine – Diphenhydramine, Doxylamine
    • Antidepressant – Mirtazapine, Trazodone
  •  Therapy
    • Cognitive behavioral therapy and Light therapy

Insomnia related to Major Depressive Disorder

• Presentation: 
  • three weeks of fatigue and trouble sleeping. falls asleep easily but wakes up at 3 AM and cannot return to sleep.
  • an unintentional weight loss of 3.5 kg along with an inability to enjoy the things once liked to do.
  • (SIGECAPS)
    • Depressed Mood
    • Sleep decreased (Insomnia with 2-4 am awakening)
    • Interest decreased in activities (anhedonia)
    • Guilt or worthlessness (Not a major criteria)
    • Energy decreased
    • Concentration difficulties
    • Appetite disturbance or weight loss
    • Psychomotor retardation/Agitation
    • Suicidal thoughts
  •  
• DDX:
  • – Insomnia related to Major Depressive Disorder
    
  • – Primary Hypersomnia
    
  • – Insomnia with Circadian Rhythm Sleep Disorder
• Work-up:
  • – Mental status exam
    
  • – CBC with diff, TSH
    
  • – Polysomnography
• Specialist:
  • Clinical psychologist
  • Psychiatrist
  • Primary care provider (PCP)
• Treatments:
  • Therapy
    • CBT, Behavioral Therapy, Psychotherapy
  • Medication
    • Selective Serotonin Reuptake Inhibitor (SSRI)
    • Antidepressant, Anxiolytic
    • Antipsychotic
  • Electroconvulsive therapy

Obstructive Sleep Apnea (OSA)

• Presentation:
  • several months of poor sleep and daytime fatigue. spouse reports that he snores loudly.
  • – fatigue and daytime sleepiness. snores heavily and naps 3-4 times per day but never feels refreshed. Hx of hypertension.
  • – Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.
  • – Breathing pauses can last from a few seconds to minutes. They may occur 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.
  • – Cessation for >10 seconds → ↓ O2 saturation → Episodes of breathing cessation for 10 seconds during sleep, 10 – 15 events per hour with ↓ O2 saturation
  • – Associated signs → Snoring, gasping, GI reflux (GERD), nocturia, excessive moving, night sweats, morning headaches, daytime sleepiness, sleep attacks
  • – Psychological: Slow thought process, memory impairment, inattention
• DDX:
  • – Obstructive Sleep Apnea (OSA)*\
    
  • – Daytime fatigue in Primary Hypersomnia
    
  • – Insomnia with Circadian Rhythm Sleep Disorder
    
  • – Insomnia related to Major Depressive Disorder
• Work-up:
  • – CBC with diff, TSH
    – Polysomnography
    – ECG
• Specialist:
  • Primary care provider (PCP)
  • Sleep medicine
  • Otolaryngologist
• Treatment:
  • Self Care
    • Sleeping on side, Avoid alcohol, and Weight loss
  • Supportive Care
    • Continuous positive airway pressure (CPAP) and BiPap
  • Surgery
    • Tonsillectomy and Adenoid removal