Doctor, I Have Insomnia. What Can I Do? | Alon Avidan, MD | UCLAMDChat

hello my name is Alana Vidan and I direct the UCLA Sleep Disorders Center I'm in the Department of Neurology where I serve as professor of neurology I'd like to give you an introduction to insomnia and really review some of the causes the evaluation of insomnia and some ideas about management that we usually provide our patients as a physician the vast majority of patients that I see have some sort of insomnia they often present with difficulties with falling asleep maintaining sleep and often don't recognize that there are pretty simple and quick fixes to help improve the insomnia that don't really require a lot of medications and a sophisticated evaluation so what I'd like to do is give you some introduction into what is insomnia what causes insomnia and also how we treat insomnia so if you have any questions that this is how you can they log on to Twitter and submit your questions and we'll take a few minutes at the end of the presentation to review and go through some of these what is insomnia insomnia is defined as follows either difficulties with say falling asleep call this difficulties with sleep initiation difficulties maintaining sleep that is awakening that are undesirable in the middle of the night with difficulties falling back asleep or early morning awakening early morning awakening is often a very comparable or pretend potentially suggestive of depression the next day consequences are really what defines insomnia as a disorder and I'll give you some examples when someone defines difficulties with memory and cognitive issues when they describe difficulties which fatigue the next day headaches memory and cognitive disturbances feeling depressed those are the type of symptoms that we are really interested in because just having difficulties with sleep initiation or maintenance without daytime consequences may not be a disorder that we need to treat but if the patient has problems with daytime symptoms that's really a red flag where we need to intervene with management we like to think of a definition of him some to also include a frequency criteria that is at least three times per week for chronic insomnia Turker we need three months of insomnia to occur in at any given time and again when we look at sleep initiation difficulties sleep maintenance difficulties or earlier morning awakening those are the type of symptoms that patients present with now they can have a combination of sleep initiation and sleep maintenance or sleep maintenance only any of those would be sufficient for the diagnosis of insomnia now take a look at this as we grow older the rates of sleep disturbances tend to go higher and so does insomnia and it's not a typical for women right around the time of menopause to begin to express and present with insomnia and have to do with hot flashes has to do with depression anxiety more medications for other medical issues and psychiatric complaints that tend to increase with aging around late life say disturbances of dimension neurodegenerative disease often make sleep disturbances much more difficult to treat and they're often a presenting worth fairly significant insomnia and the problem is they don't come to see the state positions until at having something for multiple years and and one thing I want to mention is that older adults need as much sleep as younger adults and it's their disturbances of a really getting a good night's sleep that is at the core of the issue they need as much sleep seven to eight hours of sleep as let's say 20 year old but their ability to sleep is really disrupted and that's that's really the core issue that when we address insomnia shred it we want to make sure that in order 85 or 9 year old get as much sleep as as restorative sleep as a 20 year old we also think of insomnia is being transient or acute that has to do with an exam or pain or hospitalization versus chronic insomnia which tends to occur with depression and other medical and psychiatric conditions to understand how we getting some and how in some evolves we have to December 3 PS there are predisposing factors there are precipitating factors and there are perpetuating factors and let me tell you what I mean by that so if we look at insomnia as occurring right here at the threshold any patient who has insomnia right here expresses insomnia is a clinical problem but you have to have predisposing factors and criticizing factors include by individuals who have an anxiety disorder or depression or they're just having the symptoms of anxiety just before they're about to fall asleep those are predisposing factors of the patient has there has to be some precipitating factors and what do I mean by that well precipitating factors can include issues related to pain hospitalization loss of a loved one issues with jetlag as if you travel to Europe tomorrow that's the precipitating factor for insomnia it's going to precipitate a sleep issue and then you have insomnia you have clinical insomnia now why does insomnia persist well you have to think of perpetrating clatters that's a final P the third and final P perpetuation and by that I mean st. issues that are related to poor sleep hygiene and what do I mean by for sleep hygiene well caffeine too close to bedtime alcohol alcohol is notorious for worsening the sleep architecture causing multiple awakenings people don't recognize that but having a glass or two of wine before going to bed can they can really disrupt your sleep architecture other issues have to do with watching television or working on the computer just before bedtime because the light from the computer screen is very disruptive and we want to make sure that patients do not drink alcohol do not have caffeine do not smoke before bedtime and do not watch television or work on the computers or answer emails or have any kind of abnormal light exposure that tends to be very activating all of those factors when removed can lessen the intensity of insomnia can actually even reverse the insomnia and improve the symptoms without using any medications alright so here is what I'm talking about that picture is really worth a thousand words here's an insomnia sufferer and take a look she has bright light the hour is 3:20 a.m. and she has bright light she's awake she has a bottle of Jack Daniels behind the alarm clock that's never a good sign in a patient with insomnia having alcohol isn't its enticing because alcohol relaxes you but it really fragments your sweet architecture once you fall asleep it's really to a point where people begin to after an hour - after falling asleep they begin to wake up again because they metabolize the alcohol and it's no longer active so what would we tell her how would we treat her insomnia well when the patient describes that they're in bed and that can shut off the lights and and the arousal in their brain sometimes they're talking about the on/off switch and they can find the off switch to all this rumination and and the thoughts that are coming at 2:00 or 3:00 in the morning we told to get out of bed we turn to do something relaxing boring broke and use a dim light and when they feel sleepy again that can go back to bed the bed is really supposed to be used for 3 s's the first s is sleep second as is sex and the third s is sickness and you should be doing work in the in bed no emails no answering text messages no computers were say doing puzzles or reading the news or watching television and doing puzzles on your iPad's that's never a good idea here's a breakdown of some causes of insomnia and take a look about two-thirds of patients I that we generally see probably have some underlying behavioral or psychotic issues like depression and exactly the generally presents as as a untreated insomnia but take a look sleep apnea can also cause insomnia swip especially sleep maintenance insomnia so if you snore you stop breathing at night that tends to fragment asleep architecture and that's always a good reason to come to see your doctor to get further evaluation using a sleep study and at UCLA it to sleep disorder Center at UCLA we conduct the Civic studies a sleep study evaluation to ensure that the patient doesn't have sleep apnea or other motor disorders other movement disorders that keep them awake at night like periodic leg moments of sleep that's very important to be able to roll out those conditions using a sleep study okay now it's important because knowing the timing of the anomaly can help us say appreciate the type of causes of the insomnia so four people have problems falling asleep we have to think of anxiety disorders Russell's like symptoms problems with sleep sleep maintenance well here we have pitches with fake untreated sleep apnea pain material means frequent urination at night and that has to say that is sometimes correlated with untreated sleep apnea and prostate enlargement in men perfect environment living by the airport having a too much or excessive light Explorer just around at that time is is what's what we're talking about when we mentioned sleep maintenance difficulties and early morning awakening very synonymous with say depression so let's talk about sleep hygiene because that's really the the main e issue the main work that we usually recommend patients when they present with insomnia and here is here are a list of some do's and don'ts most of you are probably familiar with this but all we do here is the first do enhance your sleep environment dark bedroom quiet cold temperature by cold temperature and main something around 68 65 degrees Fahrenheit color is actually better because it allows for and promotes the secretion of melatonin increased light exposure during the day not during the night so we want to maximize light in the morning and afternoon relaxation routine deep breathing some people do yoga before bedtime reduce the timing bed in which you are awake so if you find that it takes you 15 minutes to fall asleep and you haven't fallen a thick you need to get up you need to move to a different room and you need to pick up a boring book and when you feel that you our sweetie you should go back to bed regular exercise but in the morning or early afternoon never too close to bedtime actually regular exercise barely in the day with maintaining a regular sleep schedule is very very effective here are some don't do not watch the clock why is that well you're going to look at the clock and you're going to feel more and more frustrated why it is now 2:00 or 3:00 in the morning and you haven't been able to fall asleep so get rid of the clock no iPhones no iPads no computers get rid of electronics I see a lot of patients who if they can fall think they take the computer and they start doing puzzles while they're in bed never a good idea the use of stimulants particularly caffeine and tobacco is never a good idea especially too close to bedtime if someone may decides to have caffeine during the day enjoy a cup of coffee or two as long as we do that before 1 o'clock it should be fine anytime after that the campaign is going to stay along and the black screen and can they actually affect the sleep architecture nicotine especially e-cigarettes and the caffeine and gums should not be used too close to bedtime a heavy meal waste particularly with alcohol within three hours of bedtime never a good idea having a light snack granola bars yogurt banana probably very helpful because it actually gives you a little bit more melatonin and melatonin is very conducive to improved sleep use of bright light during the night and the computers as I've mentioned never a good idea get rid of all our chronic gadgets you know we see a lot of students who come in and they have to do computer work and they do that up until the very last minute before they go to bed and day they cannot fall asleep because the light exposure the computers actually stimulates the circum clock and keep you awake so have electronic silence no computers no electronic gadgets say that to meet light in bed before sleep here are some may of the 10 commandments for improving sleep maintaining a regular sleep schedule I think that's really important you don't want to be sleep deprived one day and then make it up the next day sleep is not like a bank account you want to get about 7 to 8 hours of sleep every single night and more importantly at the same time during the night on a consistent basis reduce your daily caffeine intake we have already mentioned that and turn off computers and television don't go to bed on a full stomach don't have a steak or a McDonald's before going to bed that's at the same time don't go to bed on an empty stomach when you're feeling hungry and you when you do feel hungry you can may have a piece of banana granola some crackers with cheese which can improve your tryptophan levels regular exercise particularly early in the day limit your brevich consumption too close to bedtime so you can prevent those episodes of say awakening because your bladder is full get your bedroom dark and quiet below on the cooler side go to bed using your internal stroke in clock in our in our branders i suprachiasmatic nucleus which is really setting the sleep and wake timing and we want to make sure that we're going to bed and waking up at the same time as to not to confuse the circadian clock about what is our regular sleep wake timing and usually if you have a mattress that's not very comfortable you might want to invest in a mattress or a pillow that is a more conducive for sleeping say no to alcohol no to alcohol not to caffeine and no to tobacco despite out up to 28 percent of patients will use alcohol before bedtime because alcohol relaxes them the problem is when you fall so if you stop drinking and then you wake up and when you wake up you perpetuate the insomnia so I just want to show you this is at its sleep diary from a patient who woke up at 11 p.m. had scotch selfies at 11:30 woke up at 4 a.m. had another scotch he crossed this out but they think we he actually had it and then they fell asleep again it's 4:15 woke up at 524 had another Scotch really it shows you how poor sleep is when you take a alcohol because every time he wakes up he wakes up because the level of alcohol is decreased only to have another drink to maintain it's a effectiveness but alcohol can fragment your sweet architecture make you have sleep apnea if you just have snoring it can they disrupt your good quality sleep and it has some issues with dependence tolerance never a good idea to use alcohol as a hypnotic you see here is an example of a patient who wakes up and the light exposure is really keeping him awake he should get out of bed pick up a boring book never surf the web never watch TV despite the fact that all this patience this is a study from a patient say with their activities before bedtime and take a look how many of them surf the web or watch TV or read a paper read on their electronic gadgets that's that's never a good idea so the electronic gadget should be eliminated pick up a boring book but when you read don't treat in bed go to a different room in a house and used in light and ever thick of you know it's pineapple or a something that's interesting like watch reading the news pick up something that doesn't really interest you something on the boring side so you won't get interested in it and they keep reading it until 3:00 in the morning regular exercise no caffeine milk alcohol can equal good sleep and what I'd like to go over in the next few minutes are some ideas about medications that actually can help you fall asleep those are called hypnotics hypnotics are medications that we use to help improve your ability to fall asleep dietary supplements that includes melatonin or valerian melatonin actually doesn't have very good data about sleep issues with insomnia it does for jet lag syndrome for example but here's some of the medications that we use specifically to improve sleep wake issues specific to insomnia and what this medications do is they target specific areas in the brain by blocking wakefulness and enhancing sleep so for example a benzodiazepine like a zolpidem or so a plan or a Saba clone what they do is they enhance the inhibitory neurotransmitter in the brain that allows for improved insomnia drugs that the block wakefulness include drugs like a histamine antagonists like k drugs like benadryl type compounds but benadryl by the way is never a good idea for state because it's people wake up very groggy from it because it's not very specific to the histamine receptors and there is a new drug that actually blocks the racks an erection is a neurotransmitter that facilitates and improves wakefulness and we're making here people a little bit narcoleptic before going to bed and that's when you prove their sleep duration the other thing that will always remind our colleagues especially when they prescribe a hypnotics is be very intensive to the half-life of the medication how long it they last in the bloodstream avoid drugs that last too long because then you can I wake up very groggy or avoid drugs that don't really have sufficient activity and duration so if someone uses a drug that only lasts for an hour where a patient has an insomnia issue at 3:00 in the morning that's I'm going to be sufficiently long enough to improve their insomnia we want an ideal time to have the patient take their medication the medication to exert its activity but have it sufficiently long enough to cover the patient when they're experiencing insomnia and I think at this point I'd like to end the formal presentation and I know that that some of you have questions that you have tweeted through our UCLA website and please say take a few minutes to log in and submit your questions and we'll entertain them for the next day ten minutes or so thank you very much this concludes the formal presentation it will now turn into the question-and-answer session so one question that we usually get is what what about the use of melatonin for sleep well the data on melatonin is very interesting melatonin is actually a star in your transmitter that say your body produces and it's say something that people can actually buy over the counter the only problem with melatonin for insomnia specifically is the timing and the dose are not really well established especially for insomnia there is a new medication relatively new medication on the market axonal tonin receptor agonist it actually binds to the body's a melatonin receptors that's approved for sleep initiation insomnia name of the note that the medication is Rimmel John where Malcolm is indicated for folks who have difficulties falling asleep and they take it before bedtime it's actually very effective to help improve a sleep duration how frequent here's a question how frequent is insomnia in the general population well the incidence is about one in ten one in ten people have chronic insomnia more like thirty percent of the population having some it to any given time so it's pretty pretty common and frequent to sleep disorder but interestingly not a lot of people present their physicians talking to them about insomnia because they have so many other sleep not sleep but medical issues to review here's another question which is a when should you when should you see a sleep physician or when should you have a sleep study to evaluate insomnia well as I mentioned earlier insomnia is really not very diagnosis we make based on a sleep study it's a diagnosis that we make clinically meaning that we see the patient they complain of insomnia and have daytime consequences that's a clinical diagnosis you don't really need to do an expensive sleep study to diagnose it however if the patient snores if they stop breathing at night if they kick their legs at night and the leg movements are disruptive that's a really important issue those are important symptoms to evaluate further by doing a sleep study specifically we're looking for sleep apnea when we treat the sleep apnea with say a continuous positive pressure therapy that's the CPAP sleep quality improves the insomnia improves and likewise when we treat the leg movements with specific medications they're less disruptive and the patient can actually have improved the sleep duration here's another question here is a what about using over-the-counter medications for insomnia well depends which over-the-counter medications we are talking about and let me give you an example if you're using 1000 PM or Advil PM and you're using those substances every single night well you're going to have probably you may have improved sleep but you're using this drugs that also contain a lot of tiny low acetaminophen and Advil which is a non-steroidal anti-inflammatory drug that's over a long period of time every single night can damage your liver in the case of faith' Tylenol PM or can damage your stomach and kidneys in the case of a Advil PM the TM formulation is a using vaginal Heidemann which is an antihistamine the problem is those compounds will use the benadryl compound can make you very groggy and can actually in older adults have a paradoxical reaction which actually in family becomes more more severe interestingly it's a paradoxical reaction that those are substances you should never take on a regular basis if you have insomnia once a week or once a month and it's usually associated with pain and using those substances that only maybe once a month basis is is okay but never on there are regular basis on a nightly regular basis here's another question what about using antidepressants for insomnia like a drug like trazadone those drugs actually never have been studied specifically for insomnia and I wouldn't really recommend them for older adults because they do tend to cause your blood pressure to drop your EKG to actually undergo some changes there is also issue of fatigue and sleepiness the next day and the sites that sometimes are too frequent to really make them provide them as our recommended dose a medication every single night I'll conclude with the last day question which is how to treat insomnia young young in young children well in kids I think insomnia is is frequent it's usually a socially we say some other behavior that they child associates with a sleep onset like having their parents rhythm a book we call that sleep onset associated insomnia but we really don't have good treatments for insomnia or really good trials or specific medications that are proved in children and that remains a challenge for everyone because we just don't have any good safety data but if you do if your child or you do have in something you're less than 18 years of age I think that's a time in which you should definitely see your pediatrician because we know there are some behavioral treatments that can be very effective and on that note I think our time is up and I'd like to thank all of you for attending and they have a good night's sleep thank you very much [Music] you

Channel: UCLA Health

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Keywords: sleep, insomnia, good sleep, alon avidan md, ucla health sleep center, how can I get a good night's sleep, poor sleep, get some sleep, rest, exhausted, sleeping, get more sleep, UCLA Sleep Center, Dr. Alon Avidan

Id: WV7slZvTKxo

Length: 30min 9sec (1809 seconds)

Published: Fri Mar 03 2017