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SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE

SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE Overview Significant numbers of patients with HIV/AIDS complain of sleep difficulties Sleep problems in HIV/AIDS are associated with significant co-morbidity

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SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE

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  1. SLEEP DISORDERS AND INSOMNIA IN HIV DISEASE American Psychiatric Association Office on HIV Psychiatry- Sleep

  2. Overview • Significant numbers of patients with HIV/AIDS complain of sleep difficulties • Sleep problems in HIV/AIDS are associated with significant co-morbidity • Patients with sleep difficulties should be carefully evaluated so that treatment can be initiated promptly to avoid further complications American Psychiatric Association Office on HIV Psychiatry- Sleep

  3. Objectives • To recognize sleep disorders in HIV disease • To understand treatment of HIV-related sleep disorders American Psychiatric Association Office on HIV Psychiatry- Sleep

  4. Outline • Properties of Insomnia • Physiology of Normal Sleep • Insomnia in HIV • Sleep Disturbances in HIV • Disorder of Initiating and Maintaining Sleep (DIMS) • Major Depressive Disorder (MDD) • Anxiety Disorders • Evaluation of Insomnia Variations • Treatment of HIV-associated Sleep Disorders American Psychiatric Association Office on HIV Psychiatry- Sleep

  5. Insomnia: Definition • The subjective complaint of insufficient, inadequate, or poor quality sleep characterized by • Difficulty initiating sleep • Difficulty maintaining sleep • Early morning awakening (EMA) • Experiencing nonrestorative sleep • Associated disturbance of daytime function such as fatigue, mood disturbance, cognitive inefficiency, irritability, or impaired performance American Psychiatric Association Office on HIV Psychiatry- Sleep

  6. Insomnia: Definition(continued) • Acute insomnia • Transient • Short term • Chronic insomnia • Primary American Psychiatric Association Office on HIV Psychiatry- Sleep

  7. Insomnia: Introduction • Typically mistaken for “short” or “poor” sleep • Difficult to objectify (similar to pain) • Function of sleep not well understood • Mechanisms for insomnia not known American Psychiatric Association Office on HIV Psychiatry- Sleep

  8. Diminished sense of well-being Increased absenteeism and disability Lower functional performance Increased inefficiency  increased frequency of accidents Fatigue Loss of enjoyment Diminished coping capacity Memory loss Self-medication Intensified pain Poor mood Insomnia – Consequences American Psychiatric Association Office on HIV Psychiatry- Sleep

  9. Insomnia: Classification • DSM-IV • International Classification of Sleep Disorders American Psychiatric Association Office on HIV Psychiatry- Sleep

  10. Normal Sleep: Physiology • Dynamic process usually organized into REM and non-REM (NREM) sleep • NREM is further organized into stages: 1, 2, 3, and 4 • NREM stages 3 and 4 are often considered as delta or slow wave sleep • Physiologically, they are most important components of sleep activity American Psychiatric Association Office on HIV Psychiatry- Sleep

  11. Normal Sleep: Physiology(continued) • Sleep proceeds normally through NREM 1-4 and returns to stage 2 before entering the first REM period ~ 70-90 minutes after sleep onset • Stage 2 sleep is associated with changes in immunologic functions with decreased production of TNF-alpha and IL-1B and increased production of IL-2 American Psychiatric Association Office on HIV Psychiatry- Sleep

  12. Normal Sleep: Physiology(continued) • NREM and REM alternate about 90 minutes apart • REM increases in length as the night progresses • Delta sleep tapers off during the night American Psychiatric Association Office on HIV Psychiatry- Sleep

  13. Insomnia in HIV Infection • 30 - 40% of patients complain of some difficulty sleeping in the previous year • As many as 50% have experienced insomnia at some time in their life • Between 10-20% of patients characterize their sleep problems as constant and severe • MNA (67%) > DFA (56%) > EMA (48%) American Psychiatric Association Office on HIV Psychiatry- Sleep

  14. Insomnia in HIV Infection(continued) • Insomnia results from various causes in HIV infection • Stage of HIV disease • Associated medical factors • Fever, pain, dehydration, nutrition • Degree of CNS disease • Concurrent HIV related medication American Psychiatric Association Office on HIV Psychiatry- Sleep

  15. Insomnia in HIV Infection(continued) • Other factors involved in HIV related insomnia • Individual’s sleep wake cycle • Life events • Coping mechanisms • Substance abuse • Poor sleep hygiene • Psychiatric problems American Psychiatric Association Office on HIV Psychiatry- Sleep

  16. Sleep Disturbance in HIV • Polysomnography studies • Shorter total sleep time • Longer sleep onset latency • Reduced sleep efficiency • More frequent awakenings • More time spent awake American Psychiatric Association Office on HIV Psychiatry- Sleep

  17. Sleep Disturbance in HIV(continued) • Increased stage-1 sleep • Decreased stage-2 sleep • Reduced REM latency while percentage of slow wave sleep and REM sleep unchanged • In aymptomatic patients without any sleep complaints, similar sleep abnormalities present but in milder forms • Sleep decrements are associated with decreased proliferative response of lymphocytes to mitogen stimulation American Psychiatric Association Office on HIV Psychiatry- Sleep

  18. Insomnia in HIV Disease • One third of patients with pts with symptomatic HIV sought medical help specifically for this problem • Only 5% received a formal psychiatric consult • 25% of patients w/sleep problems used OTC meds • 27% used alcohol as a sleeping aid • 15% used hypnotic • 61% use them for > 1 year • Most commonly used agent was temazepam American Psychiatric Association Office on HIV Psychiatry- Sleep

  19. Insomnia: Social Impact • Naval student performance: poor sleepers received fewer promotions, had lower pay grades, had higher attrition and frequent hospitalizations • Raises questions about cognitive performance in HIV disease • Habitual short sleep duration (< 7 hours) is associated with increased mortality American Psychiatric Association Office on HIV Psychiatry- Sleep

  20. Insomnia: Social Problems • Impaired relationships • Difficulty coping with problems • Trouble concentrating and memory problems • Increased risk of accidents • Poor work performance • Poor mental health American Psychiatric Association Office on HIV Psychiatry- Sleep

  21. Disorder of Initiating & Maintaining Sleep (DIMS) -Psychophysiological • Patients often describe themselves as light sleepers affected by environmental factors • Patients will note improved ability to sleep away for their usual sleep environment • Typically overly concerned about their insomnia and their perceived consequences which is in excess of objectively verifiable deficit American Psychiatric Association Office on HIV Psychiatry- Sleep

  22. Physiological DIMS • Psychological factors • Physiological factors • Altered perception of physiological events • Conditioned phenomena American Psychiatric Association Office on HIV Psychiatry- Sleep

  23. Physiological DIMS: Psychological Factors • High levels of stress • Negative life events, interpersonal loss or change • Highly anxious personality style • Increased levels of psychological symptoms • High trait anxiety American Psychiatric Association Office on HIV Psychiatry- Sleep

  24. Physiological DIMS:Physiological Factors(continued) • Increased levels of physiological arousal • Higher body temperature, skin resistance, peripheral vasoconstriction, heart and respiratory rates • Increased polysomnographic abnormalities • Longer sleep latency, decreased total sleep time, decreased sleep efficiency, MNA • Normal sleep architecture American Psychiatric Association Office on HIV Psychiatry- Sleep

  25. Physiological DIMS:Abnormal Perceptions • Inaccurate perception of their sleep and waking state • Overestimate the degree of their insomnia • When awakened from stage 2 sleep, 80% will claim they were awake • Auditory arousal thresholds are no different from controls or so-called “good” sleepers American Psychiatric Association Office on HIV Psychiatry- Sleep

  26. Phyisiological DIMS:Conditioned Factors • Attempts to sleep are inadvertently coupled to thoughts, attitudes, behaviors or conditions which are incompatible with sleep • Two types of conditioned reinforcers: • Internal (fear of sleeplessness, frustration, internalization of problems) • External (watching TV, eating, reading, lying awake) American Psychiatric Association Office on HIV Psychiatry- Sleep

  27. Insomnia: Secondary Psychiatric Disorders • Major Depressive Disorder • Manic Depressive Illness • Anxiety Disorders • Substance Dependence • Organic Mental Disorders • Schizophrenia American Psychiatric Association Office on HIV Psychiatry- Sleep

  28. Major Depressive Disorder (MDD) • Two weeks of a pervasive change in mood or loss of interest or pleasure in association with: • Insomnia or hypersomnia • Weight change • Psychomotor agitation / retardation • Loss of energy / fatigue • Cognitive inefficiency • Feelings of worthlessness or guilt • Thoughts of death or suicide American Psychiatric Association Office on HIV Psychiatry- Sleep

  29. Major Depressive Disorder sig: E caps American Psychiatric Association Office on HIV Psychiatry- Sleep

  30. Major Depressive Disorder • Sleepdisturbance • Interest • Guilt, worthless, hopeless, hapless • Energy • Concentration / Attention • Appetite or weight change • Psychomotor agitation or retardation • Suicide (passive or active) American Psychiatric Association Office on HIV Psychiatry- Sleep

  31. MDD Electroencephalographic Studies • Prolonged sleep latency • Frequent MNA • EMA • Poor sleep efficiency < 75% • Decreased delta sleep • Shortened REM latency • Redistribution of REM sleep American Psychiatric Association Office on HIV Psychiatry- Sleep

  32. MDD ElectroencephalographicStudies(continued) • Results consistent over a wide range of age groups • Found in both inpatients and outpatients • Vary according to subtype of depression • Psychotic depression - shorter REM latency • Bipolar: mania - severe sleep continuity disturbances • Bipolar: depressed - long REM latency American Psychiatric Association Office on HIV Psychiatry- Sleep

  33. Anxiety Disorders • Generalized anxiety disorder • Panic Disorder • Obsessive Compulsive Disorder • Post-traumatic Stress Disorder American Psychiatric Association Office on HIV Psychiatry- Sleep

  34. Generalized Anxiety (GAD) • Symptoms occurring for the majority of days in a 6-month period: • Excessive anxiety or worry • Insomnia • Irritability • Muscle tension • Impaired social and occupational functioning • Decreased delta sleep and increased sleep continuity disturbance American Psychiatric Association Office on HIV Psychiatry- Sleep

  35. Obsessive Compulsive (OCD) • Recurrent and intrusive, undesired thoughts • Rituals or ruminations interfere with sleep • Decreased sleep time • Decreased delta sleep • Decreased REM latency • Less intense early REM • Increased stage 1 sleep American Psychiatric Association Office on HIV Psychiatry- Sleep

  36. Insomnia: Circadian Rhythm Disturbances • Transient Disorders • “Jet lag” desynchrony between the individual’s biological clock and the environmental clock of destination • “Shift work” associated with premature awakenings, DFA, fatigue • Persistent Disorders • Delayed sleep phase syndrome • Advanced sleep phase syndrome • Hypemycthemeral American Psychiatric Association Office on HIV Psychiatry- Sleep

  37. Alcohol Sedative-hypnotics Stimulants Anticonvulsants Theophylline Beta-blockers Decongestants Heroin/opioids AZT, ddI, ddC DHPG, acyclovir Interleukin-2 Trimethoprim sulfa Dapsone Amphotericin-B Fluconazole Protease inhibitors Insomnia: Substance Induced American Psychiatric Association Office on HIV Psychiatry- Sleep

  38. Insomnia: Due to General Medical Condition • Cardiovascular: CHF, PND, CAD, HPTN, arrhythmia's • Pulmonary: Apnea, asthma, COPD, alveolar hypoventilation • GI: GER, PUD, hepatic failure • Renal: RF, UTI, polyuria (any type) • Endocrine: DM, hypo- or hyperthyroidism • Allergies American Psychiatric Association Office on HIV Psychiatry- Sleep

  39. Insomnia: Due to General Medical Condition(continued) • Uncontrolled or poorly controlled pain • Conditioned or procedural anxiety • Sleep interruption secondary to medication compliance American Psychiatric Association Office on HIV Psychiatry- Sleep

  40. Insomnia Due to General Medical Condition(continued) • Rheumatology: Arthritis, collagen-vascular disorders • Pregnancy • Neurologic: Delirium, TBI, coma, CVA, myoclonus, MD, dementia, migraines, epilepsy • Non-specific: ICU, post-op, pain, pruritus, fever, cough American Psychiatric Association Office on HIV Psychiatry- Sleep

  41. Insomnia: Evaluation • Clinical Interview • Patient • Bed partner • Symptom-Syndromal Approach • DFA, MNA, EMA • Onset • Psychosocial stress • Medications • Illnesses American Psychiatric Association Office on HIV Psychiatry- Sleep

  42. Insomnia: Evaluation(continued) • Duration • Transient (several days) • Short-term (< 3 weeks) • Chronic (> 3 weeks) • Progression • Stable, worse or better • Any new symptoms • Daytime symptoms • Fatigue, drowsiness, cognitive changes American Psychiatric Association Office on HIV Psychiatry- Sleep

  43. Insomnia: Evaluation(continued) • Patient’s response to the problem • Past treatments • Past psychiatric and medical history • Family history • Sleep diary or log • Psychological tests • Physical examination and laboratory tests • Polysomnography American Psychiatric Association Office on HIV Psychiatry- Sleep

  44. Insomnia: Treatment • When is treatment necessary? • Use sleep log to assess efficiency • Keep log for one week • Calculate sleep efficiency = • (time in bed - time in bed awake) X 100 • time in bed • < 85% -- formal treatment should be considered American Psychiatric Association Office on HIV Psychiatry- Sleep

  45. Treatment: Nonpharmacologic • Sleep hygiene rules • Curtail time in bed • Overall sleep needs do not change much from age 20-70 • Inquire about sleep habits prior to insomnia • Recommend bedtime be strictly held to that amount • If amount is unknown, prescribe 7 hours • Never try to make yourself sleep • The more you try the less it works • Trying increases arousal so it is counterproductive • Eliminate the bedroom clock - don’t pressure yourself to sleep American Psychiatric Association Office on HIV Psychiatry- Sleep

  46. Treatment: Nonpharmacologic(continued) • Sleep hygiene rules - cont’d • Exercise - Sleep tends to be related to core body temperature • We sleep best during the trough of core temperature • Exercise increases core body temperature • DON’T exercise just before bedtime BUT DO exercise 4-6 hours before sleeptime • For non- exerciser, taking a hot bath for 20 minutes two hours before going to bed will lead to a compensatory drop in temperature which will aid sleep American Psychiatric Association Office on HIV Psychiatry- Sleep

  47. Treatment: Nonpharmacologic(continued) • Sleep hygiene cont’d • Avoid coffee, alcohol, tea, nicotine & chocolate • Regularize bedtime • Eat a light bedtime snack • Hunger disrupts sleep • Eating releases enzymes which may promote sleep • Warm milk after a high carbohydrate snack with 50 mg pyridoxine may induce sleep • Schedule “thinking” time during the day or early evening American Psychiatric Association Office on HIV Psychiatry- Sleep

  48. Treatment: Nonpharmacologic(continued) • Sleep hygiene cont’d • Relaxation training and tapes • Must become proficient • One shot deal does not do it • Practice during the day then use at night • Ability to focus one’s attention is what is important NOT muscle relaxation per se • Cognitive refocusing to counter maladaptive thinking • Review psychological issues American Psychiatric Association Office on HIV Psychiatry- Sleep

  49. Pharmacologic Treatments: Sedative Hypnotics • Barbiturates • Primary action is CNS depression • Side-effects: hangover, GI distress, myalgias, respiratory depression, paradoxical excitement American Psychiatric Association Office on HIV Psychiatry- Sleep

  50. Pharmacologic Treatments: Sedative Hypnotics(continued) • Barbiturates cont’d • Tolerance develops early and physical dependence is common • Serious withdrawal reactions can occur • Drug interactions secondary to hepatic microsomal system by enzyme induction • Avoid use with alcohol • Low therapeutic index • More toxic than benzodiazepines • Risks outweigh their benefits • Should avoid use of barbiturates in HIV patients American Psychiatric Association Office on HIV Psychiatry- Sleep

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