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Natural treatment for insomnia in elderly, tinnitus retraining therapy - For You

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While it’s admirable to try to put a positive spin on a negative situation, taking a heroic attitude toward sleeplessness can be bad for your health. These meds can also cause rebound insomnia, meaning it becomes even harder to fall asleep without the medication. Insomnia is a disorder characterized by chronic sleep disturbance associated with daytime disability or distress, such as memory impairment and fatigue, that occurs despite adequate opportunity for sleep.
In this Clinical Information Supplement, Thomas Roth, PhD, describes the nature of insomnia and its pathophysiology. Insomnia is a symptom-based diagnosis.3 Patients with insomnia experience one or more sleep-related complaints, including difficulty falling asleep, difficulty staying asleep, early-morning awakenings, and sleep that is nonrestorative or not adequately restorative (Slide 1). The disparity between the prevalence in the general population and that in the clinical population may be explained by the risk factors associated with insomnia.
Although 30% of patients with a medical disorder have insomnia, one must consider the fact that 70% do not.
While most people experience a decline in body temperature at night, this is not as consistently seen among insomniacs.
The sleep systems in patients with insomnia are relatively normal, but the individuals are hyperaroused, as reflected in catecholamines, brain metabolism, and body metabolism. Several epidemiologic studies1-7 have used cross-sectional analysis or longitudinal data to compare people with insomnia to normal sleepers in an effort to determine the specific impairments and alterations in quality of life associated with insomnia. Findings from cross-sectional studies show a strong correlation between insomnia and impairment.
An enlightening study by Katz and McHorney2 compared the SF-36 findings in a group of patients with severe insomnia to those in a group of patients with major depression and a group of patients with congestive heart failure.
Longitudinal data demonstrate that people with insomnia experience increased absenteeism and decreased productivity in their work roles.
There are limitations to our knowledge of how treatments for insomnia affect the impairments and risks associated with the disorder.8 Examinations of some measures of daytime function have produced negative findings.
At the National Institutes of Health (NIH) State-of-the-Science Consensus Conference on insomnia, held in June 2005 in Washington, DC, the Federal government addressed insomnia and its associated problems for the first time in >20 years.
Other forms of behavioral treatment may be administered in the clinician’s office, however. Sleep restriction and stimulus control are other behavioral treatments for sleep disorders.
Patients with insomnia should engage in relaxing activities as part of their sleep preparation ritual. Laudanum, a combination of opium and alcohol, has been around for over 100 years, and was used extensively during the American Civil War, when it was available at every corner grocery store. The selective melatonin receptor agonist ramelteon is a recent addition to the sleep-agent armamentarium and is also approved by the FDA for the treatment of insomnia.
Currently, the nonbenzodiazepines and ramelteon are the newest pharmacologic treatments for insomnia patients. Q: Most clinicians, particularly psychiatrists, are trained to think about insomnia as a symptom of another disorder. Roth is director of the Sleep Disorders and Research Center at Henry Ford Health System in Detroit, and clinical professor of psychiatry at the University of Michigan School of Medicine in Ann Arbor.
Krystal is director of the Sleep Research and Insomnia Program at Duke University School of Medicine in North Carolina. Some of the greatest risk factors for insomnia are age and psychiatric disorders (Slide 3). On the other hand, it is very clear that shift work contributes to insomnia by causing changes in circadian rhythm.
It is important for clinicians to understand that while insomnia interacts with other medical disorders, it is not necessarily caused by them.
Several studies in the medical literature demonstrate that insomnia increases the risk of depression by a factor of 5. Hyperarousal overrides these normal sleep systems and causes insomnia, which then interacts with the comorbid medical and psychiatric disorders.
While impairment and decreased quality of life are included among the criteria for the diagnosis of insomnia, the nature and degree of these impairments are difficult to ascertain. In another type of study, patients with insomnia receive insomnia-specific therapies and are followed to determine how their function and quality of life improve. Compared to normal sleepers, people who meet insomnia criteria have impaired quality of life.
The striking results indicated that people with insomnia had more impairment in areas of vitality, general health, and physical ability to function than those with congestive heart failure and those with major depression. Breslau and colleagues5 looked at a group of patients who met insomnia criteria at baseline and a group of people without insomnia. In a study by Suka and colleagues,6 4,794 male workers from one company in Japan were diagnosed with insomnia at initial evaluation and followed for 4 years. In four of these studies, people completed morning self-ratings that indicated their alertness or ability to function had significantly improved after insomnia treatment.
Two of the major chronic insomnia treatment endorsements came out of that conference: First, cognitive-behavioral therapy (CBT) for insomnia is effective and should be utilized.
The role of CBT in insomnia is to challenge the dysfunctional beliefs and misconceptions about sleep held by a person with insomnia (Slide 2).2 One of the cornerstones of CBT for insomnia is to stop the patient from focusing too much on the time. Patients with insomnia should exercise in the morning or, at the very latest, by early afternoon. They should begin these activities early in the evening so that they are set for sleep at bedtime.
However, it is strongly recommended that physicians not engage only in pharmacologic treatment. Clinicians may look very hard for an underlying psychiatric disorder or for an associated medical problem—even an acute stressor.

Roth: The National Institutes of Health (NIH) realized that insomnia is not a symptom, but rather a chronic disorder.
Krystal: When treatment is started, one does not know how long a patient will have insomnia.
Krystal: For some people, you can institute these behavioral changes right away, but their sleep does not improve for several weeks.
Any one of these latter symptoms must be present with the sleep-related complaint, and must occur despite adequate opportunity for sleep. Familial aggregation is a risk factor, suggesting that there is a genetic basis for this disorder. The majority of patients with medical disorders such as rheumatoid arthritis or neuropathic pain do not have insomnia. Patients with a history of depression are also at a greater risk of relapse if they have insomnia. Derivation of Research Diagnostic Criteria for Insomnia: Report of an American Academy of Sleep Medicine Workgroup.
National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005.
Eszopiclone co-administered with fluoxetine in patients with insomnia coexisting with major depressive disorder. Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects.
One important question is whether insomnia causes alterations in physiology or behavior that might lead to longer-term adverse consequence.
A 1997 retrospective analysis by Simon and VonKorff3 compared a database of ~2,000 primary care patients with insomnia to controls.
The incidence of hypertension increased in those who had difficulty initiating sleep or staying asleep compared with those who did not meet have insomnia. The relationship between insomnia and health-related quality of life in patients with chronic illness. Nightly treatment of primary insomnia with eszopiclone for six months: Effect on sleep, quality of life and work limitations. Ever since the 2005 NIH State-of-the-Science Consensus Conference on insomnia, all drugs approved by the Food and Drug Administration have been indicated for the long-term therapy of insomnia. And after a patient starts pharmacologic treatment, one will not know if the patient still does have insomnia.
Pain conditions and depression are commonly associated with insomnia, either as secondary or comorbid conditions.
Finally, the sleep difficulty must occur at least three times per week for at least 1 month.
The night after a tornado, for example, a town population may have a sleep disturbance prevalence as high as 70% to 80%.
The clinical subpopulation that does have insomnia is composed of patients with a predisposition for it. The more medical conditions they have, the greater the number of precipitants, and the greater their likelihood of developing insomnia.
Other medical disorders commonly associated with insomnia include arthritis and other chronic pain syndromes, congestive heart failure, cerebral vascular disease, chronic pulmonary disease, Parkinson’s disease, dementia, gastroesophageal reflux, and renal failure (Slide 6).
As is the case with treating other comorbid conditions, treatment of insomnia diminishes illness severity and improves response to antidepressant treatment. Nofzinger and colleagues8 demonstrated increased brain metabolism in the arousal centers in the brain, indicating that insomnia does not result from broken sleep systems but from over-engaged arousal systems (Slide 7). Lushington and colleagues12 demonstrated that those with insomnia experience an increase in body temperature, and Stepanski and colleagues13 indicated that insomniacs also experience increased heart rate—both at night and during the day. In a study involving 261 insomnia patients and 101 controls, Zammit and colleagues1 employed the 36-item Short Form (SF-36) Health Survey, a well-validated epidemiologic measure of quality of life. After that interval, there was a much greater incidence of major depression, anxiety, and alcohol and drug dependence problems in those who had insomnia. These studies show that reported sleepiness, number of naps, and time spent napping all decreased following treatment, while ability to carry out professional activity increased. Although effective, the application of CBT as a wide-spread treatment is hampered by its availability (since specialized training is required) and its lack of consistent coverage by medical insurance carriers. People without any insomnia at all were asked whether they have difficulty sleeping when they experience stress. Equally important, the pharmaceutical companies that are trying to get drugs on the market have to provide chronic data so that those medications can be used in long-term treatment.
There is a natural resistance on the part of physicians to using long-term, scheduled products. We use the cognitive interventions first, and then we use pharmacotherapeutic agents for awakening or increased alertness, and to help with sleep. However, before one decides that a patient has insomnia, one should make sure that the patient has adequate opportunity to sleep. In addition, a greater incidence of anxiety, alcohol and drug dependence, and cardiovascular disease is found in people with insomnia. Lieberman III, MD, MPH, provides an overview of therapeutics utilized in patients with insomnia, including behavioral therapies and pharmacologic options. However, the 30% sleep disturbance prevalence does not account for the population suffering from insomnia.
Age is the greatest risk factor for insomnia; however, the reason elderly people experience increased risk of insomnia is not due to a breakdown of their sleep systems. However, the fact that the incidence of insomnia is not 100% among patients who have three or four medical disorders indicates that medical disorders themselves are not responsible for causing insomnia. Virtually every medical disorder can be associated with insomnia because most medical disorders require an arousal response.

Fava and colleagues7 demonstrated that patients with comorbid insomnia and depression experience a quicker, more effective antidepressant response when treated with a sleep agent and antidepressant combination than when treated with either a sleep agent or antidepressant alone. The results demonstrated that people with insomnia differ from normal sleepers in their vitality, their emotional role, their health, and their physical role. The results showed that insomnia was correlated with global impairments in patients’ ability to live their lives (Slide 3). A 4-watt nightlight, for example, might provide light sufficient to prevent injury without interfering with a patient’s ability to go back to sleep. It turns out that those people who have more disturbed sleep in stressful circumstances, in age- and sex-matched controls, have an ~11-fold increased risk of developing insomnia in the future.
However, comorbid insomnia is very different from secondary insomnia, in which a condition or disorder is the primary cause of insomnia. The decision of the NIH indicates that there is a role for chronic therapy, but for whom and under what circumstances depend very much on the patient, just as in determining treatment for patients with depressive disorders. Clinicians must consider whether chronic treatment of insomnia can prevent the relapse of depression or other like conditions.
In all of the different subscales of the survey, quality of life was diminished in the patients with insomnia (Slide 1). Finally, there are no studies that have had a primary focus on morbidity; a study of the effects of insomnia therapy on morbidities must examine a group of people who have an identified set of morbidities, and then follow them in a method powered to detect those effects.
Treatment seems to improve the deficits people with insomnia experience, including those in quality of life, social role, and work performance.
The bed should not be used for television watching, dog grooming, stamp collecting, or any other activity executed in hopes of eventually falling asleep.
They know that in cases like patients with recurrent episodes of depression, lifelong pharmacologic therapy is required, so I think they are more easily convinced to use chronic treatments for insomnia.
Several trials have shown that wake-enhancing compounds, such as modafinil, can be helpful for people trying to stay awake during nightshifts.
Some interesting data suggest that if you continue insomnia medication long term, the behavioral therapy benefits do not seem to manifest, perhaps because there is no motivation to change behavior. Insomnia patients experience increased metabolic rate, body temperature, and heart rate, and elevated levels of norepinephrine and catecholamines. Finally, the prevalence of insomnia varies among medical practices in the clinical population. Effects of treatment on risks for medical and psychiatric disorders have not yet been sufficiently studied. I think the more interesting question is how much of that hyperarousal is due to the insomnia, rather than the cause of insomnia. We do not have as much longitudinal data for chronic treatment of insomnia as we do for depressive disorders. Second, the temptations not to maintain a regular sleep schedule are greater for shift workers, because, for example, they can attend their children’s t-ball games in the middle of the afternoon. Pharmacologic options for the treatment of insomnia include benzodiazepine hypnotics, a selective melatonin receptor agonist, and sedating antidepressants.
For example, insomnia prevalence in geriatric medicine differs from that in athletic medicine. Clinicians may be trained to infer that a patient’s depression causes their insomnia. Some patients respond to a limited course of therapy; after a while the insomnia is ostensibly cured and the therapy can be withdrawn. However, insomnia may be best treated with cognitive-behavioral therapy and instruction in good sleep hygiene, either alone or in concert with pharmacologic agents. However, across all medical specialties and all medical clinics, ~50% of patients meet diagnostic criteria for insomnia (Slide 2).
However, if insomnia is caused by depression, treating depression should, and does, alleviate sleep disruptions.
Studies on the effects of insomnia treatment use variable methodologies or do not publish negative results, and there are currently no studies of treatment focusing on morbidity.
There is equally a large body of data indicating that those who suffer from insomnia also experience cognitive hyperarousal, indicating the pathophysiology is not simply biological.
Further research is necessary to better understand the effects of insomnia therapies on medical and psychiatric disorders.
Krystal presented data from Breslau and colleagues,2 which shows that in the majority of cases, insomnia precedes the depression. However, some patients who have hypertension are treated temporarily and some require lifelong treatment. The use of light can be helpful in moving their internal clocks, though this may not be the best choice for shift workers with family or social obligations on weekends. There are also data that would suggest that if you treat depression, then the more refractory symptom is insomnia. But the notion that we need to use some medications chronically, in patients who have severe recurring conditions, is not foreign.
Hence, although it is clear that insomnia often is comorbid, this does not preclude the treatment of insomnia as its own distinct condition.
This is appropriate so long as we can make the association between that insomnia and some of the other conditions that these clinicians treat.

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