VIP Primary Care Associates, P.A.
 ROBERT A. BRISKIN, M.D., F.A.C.P
Diplomat American Board Internal Medicine
Member of American Academy of Private Physicians (AAPP)
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Insomnia is the perception by the patient of inadequate or abnormal sleep: Difficulty initiating sleep, Frequent awakenings, Reduced sleep time, Non-restorative sleep.

Medical Tips from Dr. Briskin
This newsletter is just one of many methods that we will use to better serve and communicate with our patients online. We hope it will educate you on common medical topics and misconceptions.
Dr. Robert Briskin

Tackling Insomnia

  1. Insomnia is the perception by the patient of inadequate or abnormal sleep:
    • Difficulty initiating sleep
    • Frequent awakenings
    • Reduced sleep time
    • Non-restorative sleep: (fibromyalgia is associated with this)
  2. Most common sleep problem, with 20-40% of adults having sleep difficulty last year; 17% (1/6) considering the problem serious; affects up to 50-70 million U.S.
  3. Prevalence higher in women, increases with age and socioeconomic class.
  4. Acute: days - weeks, acute stress or environmental change, jet lag, drug withdrawal.
  5. Chronic: 25-30% have concomitant psychiatric diagnosis
    • Medical causes: arthritis, COPD, sleep apnea, hyperthyroidism, RLS
    • Alcohol: interferes with REM sleep & ^GERD, sleep apnea
    • Psychiatric: Depression, anxiety, panic disorder, PTSD, S.A.D.
  6. Consequences:
    • Sleepiness
    • Negative mood
    • Impairment of performance
    • Fatigue
    • Mood changes
    • Difficulty concentrating
    • Impaired daytime functioning
  7. Sleep Cycles: 4-5 90-100 min. cycles: Stages 1-4 NREM, then REM:
    • Stage 1- sleep onset: 1-7 minutes; low arousal thresholds (1st cycle)
    • Stage 2- 10-25 minutes (1st cycle)
    • Stages 3-4- slow wave, or delta sleep: 25-45 min.; arousal thresholds highest (1st cycle)
    • REM- end of 1st sleep cycle: 1-5 minutes
    • Normal latency from sleep onset to 1st REM: 90 minutes
  8. Treatment:
    • Behavioral: Relaxation therapy w/ progressive muscle relaxation, imagery training and meditation (reduce intrusive thoughts, racing mind), abdominal breathing, sleep restriction therapy, stimulation control therapy, cognitive therapy.
      • Sleep restriction therapy- curtail time spent in bed to ^ sleep efficiency
      • Stimulus control therapy- bed= rapid sleep onset; no reading/T.V., regular AM rising time, avoid daytime naps
      • Cognitive therapy- replace dysfunctional attitudes re. sleep
    • Drug Therapy:
      • Sedative/ hypnotics:
        • Ambien (Zolpidem): non-benzo. hypnotic; short acting; T1/2= 1.5-2.5 hrs.; 5-10 mg
        • Halcion (Triazolam): benzo., intermed. acting; T1/2= 2-5 hrs.; .25 mg
        • Sonata ( Zaleplon): non-benzo.; 5-10 mg hs
        • Restoril (Temazepam): benzo.; intermed.-acting; T1/2= 10-20 hrs.; 7.5-30 mg hs
        • Dalmane (Fluazepam): benzo.; long-acting; T1/2= 2-4 hrs; 15 mg hs
        • Prosom (Estazolam): benzo.; intermed.-acting; T1/2= 17 hrs; 1-2 mg hs
        • Tranxene (Chorazepate): benzo.; long-acting; T1/2= 2-4 days; 7.5 mg; insomnia+anxiety
        • Klonopin (Clonazepam): benzo.: intermed.-acting; T1/2= 2-3 days; 1 mg hs
        • Lunesta (Eszopicione)- non-benzo. Hypnotic: 1mg hs- difficulty falling asleep, 2mg hs; difficulty staying asleep; avoid high fat meal
        • Rozerem- melatonin mech.; 8 mg 30 min. before hs
      • Antidepressants: SSRIs: (not actual indication): Zoloft, celexa, prozac, paxil, lexapro; remeron; trazodone
      • Atypical antipsychotics: (not an actual indication): zyprexa, seroquel, risperdal
      • Antihistamines: benadryl, atarax
      • Melatonin: helps regulate circadian rhythm; jet lag; aids ability to stay asleep
      • Valerian: sleep-inducing, tranquilizing; depresses CNS & relaxes muscles
  9. Sleep and Aging:
    • After age 20, delta sleep declines as a percentage of total sleep (25%-5%)
    • REM remains preserved
    • Nocturnal awakenings and arousals increase with age
    • Decrease sleep efficiency to about 80%
  10. Restless Leg Syndrome/ PLMS: nocturnal myoclonus
    • Benzos: klonapin
    • Dopamine agonists: sinemet, mirapex .25 mg-.5mg
    • Narcotic analgesics: i.e. Vicodin, etc.

  11. General Sleep Hygiene
    • Wake up same time each day
    • Discontinue caffeine 4-6 hrs. before bedtime
    • Avoid nicotine in late evening (stimulant)
    • Avoid alcohol too close to bedtime; may cause wakening later in the night
    • Avoid heavy meals too close to bedtime; light snack preferable
    • Regular exercise late PM may deepen sleep; avoid vigorous exercise w/in 3-4 hrs. hs
    • Minimize noise, light, excessive temperatures during sleep period
    • Move alarm clock from bed if source distraction
    • Adopt relaxing bedtime routine, i.e.: warm bath, light reading

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