Insomnia_management.pmd

Clinical Practice Guideline
2007 Update
Adult Primary Insomnia:
Diagnosis to Management
This guideline was developed by a Clinical Practice Guidelines Behavioural Therapies
Working Group to assist physicians in the management of primary insomnia in adults. A companion guideline for the assessment of patients with insomnia accompanies this document. This guideline does not address the assessment and individualized to address patient needs/situation.
management of excessive daytime sleepiness (EDS) or themanagement of other primary sleep disorders (ie; obstructive PRACTICE POINT
sleep apnea, movement disorders in sleep or parasomnias). Initially, review of sleep behaviours and sleephygiene advice with recommendations to adhere EXCLUSIONS
strictly to the principles of sleep hygiene will provide the clinician with an indication of the patient’s motivation to change the behaviours that are
Geriatric patients: While the general principles of the management of primary insomnia applyto all adult patients it is important to note that “late life insomnia” requires specific • Avoid vigorous exercise within 2 hours of
interventions not addressed in this guideline.1 • Avoid sleeping-in after a poor night of sleep.
• Avoid watching/checking the clock.
RECOMMENDATIONS
• Avoid excessive liquids or heavy evening meals.
The management of primary insomnia is based • Avoid caffeine, nicotine, and alcohol before bed.
on the foundation of behavioural and cognitive • Maintain a quiet, dark, safe, and comfortable
non-pharmacologic strategies. Pharmacologic • Schedule a wind-down period before bed.
pharmacotherapy is used on a short-term (less PRACTICE POINT
than 7 days on a nightly basis) or intermittent INSOMNIA
(2-3 nights per week) for the sole purpose of Educate the patient about the following issues: preventing an exacerbation of the primary
• Alcohol helps with sleep initiation, it impairs
sleep maintenance and can exacerbate other The patient must be an active participant in • Nicotine is a potent stimulant with a short half-life
chronic illness that requires regular follow-up and monitoring to evaluate the patient’s response to treatment and motivation to resolve • Smoking cessation aids (nicotine replacement
products and bupropion) can cause insomnia.
The goal of management is to provide thepatient with the tools necessary to manage the chronic nature of the illness and minimize Some insomnia patients spend excessive time in bed trying to attain more sleep. Sleep consolidation isaccomplished by compressing the total time in bed to Non-pharmacologic
match the total sleep need of the patient. This Non-pharmacologic therapies are effective in the management of primary insomnia especially when • Devise a “sleep prescription” with the patient: a
behavioural and cognitive techniques are used in combination.2 Behavioural techniques include sleep • Determine the average total sleep time.
hygiene, sleep consolidation, stimulus control, and • Prescribe the time in bed to current total sleep
relaxation therapies. Cognitive techniques include • The minimum sleep time should be no less than
The above recommendations are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. They should be used as an adjunct to sound clinical decision making Set a consistent wake time (firmly fixed 7 days/ and psychological arousal to promote sleep.
The bed time is determined by counting backwards from the fixed wake time (For example: a patient estimates the total sleep time to be 5-6 hours/night, the total time in bed is 8 hours/night for a sleep efficiency of 5.5/8 = 68%. The prescribed total sleep time would be 6.5-7 hours/night, if the wake time is 6AM then the prescribed bedtime is 11-1130 For the first 2-4 weeks these times should remain Cognitive Therapies3,4
consistent and the clinician should monitor the patients adherence to the program with sleep logs CBT addresses the inappropriate beliefs and attitudes that perpetuate the insomnia. The goal of this Advise the patient that napping will reduce the technique/process is to identify dysfunctional sleep depth and restorative quality of sleep the following cognitions, challenge the validity of those cognitions, and replace those beliefs and attitudes with more Once the patient is sleeping for about 90 percent of appropriate and adaptive cognitions. Common faulty the time spent in bed for five consecutive days, then beliefs and expectations that can be modified include: the amount of time spent in bed is slowly increased Unrealistic sleep expectations (e.g., “I need to have by 15- 30 minute every 5 days. If sleep efficiency of 90 percent is maintained, then therapy is Misconceptions about the causes of insomnia (e.g., successful. The average total sleep time for most “I have a chemical imbalance causing my people is between 6 and 8 hours a night.
Amplifying the consequences (e.g., “I cannot do PRACTICE POINT
anything after a bad night’s sleep”).
Performance anxiety and loss of control over ability 1. Advise patients that the goal of treatment is to to sleep (e.g., “I am afraid of losing control over improve the continuity and restorative quality of sleep, not to make them “8-hour sleepers”. Moreoften than not the total sleep time will be less than Pharmacologic
Pharmacotherapy should be considered an adjunctive 2. Advise patients that they may suffer from therapy to cognitive and behavioural therapies in the daytime sleepiness in the initiation phase of comprehensive management of primary insomnia.
Pharmacotherapy is generally recommended at the Stimulus control is designed to re-associate the bed/ lowest effective dose as short-term treatment lasting bedroom with sleep and to re-establish a consistent less than 7 days. Although long-term use of hypnotic sleep-wake schedule. This is achieved by limiting agents is discouraged due to the potential for tolerance activities that serve as cues for staying awake. The and dependence, there are specific situations and treatment consists of the following behavioural circumstances under which long term use of hypnotics Avoid arousing activities before bed (late night Initially used to break the cycle of chronicinsomnia and allow the patient to adapt to Go to bed only when sleepy, even if later than cognitive and behavioural interventions.
Used to manage an exacerbation of previously Set alarm for agreed upon wake time.
Long term intermittent6 (self administered therapy Get out of bed if not able to sleep - go to another to decrease arousal and prevent relapse): Used on a limited PRN basis (<3 times/week) Avoid eating, ingesting caffeine or smoking Used on a scheduled basis (i.e., <3 times/week) to ensure consistent adequate sleep in a patient with chronic primary insomnia where Relaxation therapy is designed to reduce physiological the goal of therapy is to prevent relapse.
Therapeutic Options
First-line Pharmacotherapy: Highest level of evidence supporting efficacy and safety
Recommended Dose
Comments
Zopiclone
• Short half-life provides lower risk of morning hang-over effect • Metallic after-taste most common adverse reaction.
Zaleplon
• Ultra-short half-life. Used for sleep initiation and also PRN for night-time awakenings when there is still a minimum of 3 to 4 Temazepam
Intermediate half-life carries a low-moderate risk of morninghang-over effect.
Second-line Pharmacotherapy
Moderate level of formal evidence. Extent of current use and favorable tolerability support use as second-line agents Recommended Dose
Comments
Amitriptyline
• Longer half-life carries risk of morning hang-over effect Trazodone
• Shorter half-life carries lower risk of morning hang-over effect.
Variable Evidence
Recommended Dose
Comments
L’Tryptophan
• Evidence supporting efficacy is variable and insufficient.
Melatonin
May be requested by individual patients looking for a“natural source” agent.
Valerian
Not Recommended
The following agents are not recommended for the management of conditioned insomnia except in cases where the agent is being used specifically to mange a co-morbidity such as depression.
Comments
Antidepressants - mirtazapine, fluvoxamine,
Antihistamines - chlorpheniramine,
• Relative lack of evidence or excessive risk of daytime sedation, psychomotor impairment andanticholinergic toxicity.
Antipsychotics (Conventional or
• Relative lack of evidence and unacceptable risk of anti- cholinergic and neurological toxicity.
Antipsychotics (Atypical or 2nd-Generation)
• Relative lack of evidence and unacceptable cost and risk of Benzodiazepines (Intermediate and Long-
• Excessive risk of daytime sedation and psychomotor Acting) - diazepam, clonazepam, flurazepam, lorazepam, nitrazepam, alprazolam, oxazepam
Benzodiazepines (Short-Acting) - triazolam
• No longer recommended due to unacceptable risk of memory disturbances, abnormal thinking and psychotic behaviors.
Chloral’s - chloral hydrate, ethchlorvinyl
• Excessive risk of tolerance, dependence and abuse as well as adverse gastrointestinal and CNS effects.
Muscle relaxants
• Relative lack of evidence and excessive risk of adverse CNS effects.
Management Plan
“Guidance on the use of Zaleplon, Zolpidem andZopiclone For The Short-Term Management of PRACTICE POINT
Insomnia”, the British National Health Service,National Institute for Clinical Excellence.5 The foundation of the management of primary 4) “Insomnia”, Sleep Medicine Clinics, Volume 1, insomnia is behavioural and cognitive therapy.
Ongoing evaluation of the patient’s motivation toadhere to the behavioral and cognitive strategies is The results and recommendations of these documents an important part of monitoring the patient’s have been reviewed by the guideline committee and progress. Adherence to, and compliance with these form the basis of the evidence for the background strategies is usually effective and minimizes the material and recommendations. The clinical tools have potential for dependence on medication.
been developed by the guideline committee based onCanadian expert and primary care physician consensus. Funding for this project has been provided • Prescribe behavioural and cognitive
by the TOP program and no members of the guideline committee have received pharmaceutical or industry • Use sleep logs and diaries to monitor
funding or support in their role as a committee member.
the patient’s progress (see sleep logattachment).
References
• Consider pharmacotherapy based on
the patient’s sense of urgency, needfor relief and willingness (motivation) 1. Ancoli-Israel. S. (2006). Sleep Medicine Clinics: Sleep in the Older Adults. Volume 1, Number 2.
Philadelphia: W.B. Saunders Company.
2. National Institutes of Health State-of-the-Science • Evaluate sleep efficiency and daytime
Management of Chronic Insomnia in Adults.
August 2005. http://consensus.nih.gov/2005/ • Reinforce behavioural interventions.
• Review or reconsider pharmacotherapy.
3. Morin. C.M. Insomnia, Psychological Assessment and Management. New York, NY: The Guilford 4. Roth. T. (2006). Sleep Medicine Clinics: Insomnia. Volume 1, Number 3. Philadelphia: 5. Buscemi. N., Vandermeer. B., Friesen. C. et al.
Credibility
Evidence Report/Technology Assessment Number125 Manifestations and Management of ChronicInsomnia in Adults. National Institute of Clinical The insomnia guideline working group was comprised Excellence. Zaleplon, zolpidem and zopiclone for of family physicians, sleep medicine specialists, general the short-term management of insomnia. 2005.
internists, a psychiatrist, and a clinical pharmacist. The 6. Walsh. J.K., Roth.T., Randazzo. M.A. et al. Eight Alberta Medical Association Toward Optimized Practice (TOP) program guided the development Primary Insomnia. SLEEP, 2000;23(8):1-10.
process using the Appraisal of Guidelines For Research 7. Manifestations and Management of Chronic and Evaluation (AGREE) Instrument to evaluate the Insomnia in Adults”, The Agency for Healthcare quality of the guideline.8 An extensive review of the Research and Quality, University of Alberta, literature was performed and provided the following key documents as the foundation for the current state 8. Appraisal Of Guidelines for Research & Evaluation (AGREE) Instrument”, September “Current State Of The Science Of Chronic Insomnia”, National Institutes of Health.2 “Manifestations and Management of ChronicInsomnia in Adults”, The Agency for HealthcareResearch and Quality, University of Alberta,Evidence based Practice Center.7 Selected Readings
TOWARD OPTIMIZED PRACTICE (TOP)
1. Morin. C.M. (1993). Insomnia: Psychological Assessment and Management. New York : TheGuilford Press.
2. Reite, M., Ruddy, J., Nagel. K. (2002). Concise The TOP Program is an initiative directed jointly by Guide To Evaluation and Management of Sleep the Alberta Medical Association, Alberta Health and Disorders (3rd Edition). Washington, DC : Wellness, the College of Physicians and Surgeons, and American Psychiatric Publishing, Inc.
Alberta’s Health Regions. The TOP Program 3. Dement. W.C., Vaughan. C. (1999). The Promise promotes appropriate, effective and quality medical of Sleep. New York: Dell Publishing.
4. Hauri. P., Linde. S. (1996). No More Sleepless care in Alberta by supporting the use of evidence-based Nights. New York: John Wiley & Sons, Inc.
5. Moore-Ede. M. (1993). Understanding Human TOP Leadership Committee
Limits in a World That Never Stops : The TwentyFour Hour Society. New York: Addison-Wesley 6. Lamberg. L. (2000). Bodyrhythms: Chronobiology and Peak Performance. New College of Physicians and Surgeons of Alberta 7. Kryger. M. (2004). Can’t Sleep, Can’t Stay TO Provide Feedback
Awake : A Women’s Guide To Sleep Disorders. The Guideline Working Group for Insomnia is a multi- Toronto: HarperCollins Publisher Ltd.
disciplinary team composed of family physicians, sleepmedicine specialists, a pharmacist, psychiatrist and apsychologist.
The team encourages your feedback. If you havedifficulty applying this guideline, if you find the recom-mendations problematic, or if you need more informa-tion on this guideline, please contact: Clinical Practice Guidelines ManagerTOP Program12230 - 106 Avenue NWEdmonton AB T5N 3Z1Phone: 780.482.0319or toll free 1.866.505.3302Fax: 780.482.5445Email: cpg@topalbertadoctors.orgWebsite: www.topalbertadoctors.org Adult Insomnia: Diagnosis to Management, February 2006

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