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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


New Approaches to the Patient with Insomnia


GOAL
To provide nurse practitioners and physician assistants with up-to-date information on the treatment and management of patients with insomnia.

TARGET AUDIENCE
This activity is designed for nurse practitioners and physician assistants. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, the participant should be able to:

  • Translate the sleep-wake cycle.
  • Identify cognitive-behavior medications and understand their clinical application.
  • Express appropriate pharmacologic interventions.

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
This program has been approved for 1.8 contact hours of continuing education by the American Academy of Nurse Practitioners.  Program ID 0609349.

The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The estimated time to complete this educational activity: 1.5 hours.

Release date: November 15, 2006. Expiration date: November 15, 2008.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of The Johns Hopkins University School of Medicine name implies review of educational format, design, and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an educational grant from Takeda Pharmaceuticals North America, Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

David N. Neubauer, MD, MA
Assistant Professor
Psychiatry and Behavioral Sciences
The Johns Hopkins University School of Medicine
Associate Director
The Johns Hopkins Sleep Disorders Center
Baltimore, Maryland
Dr Neubauer reports serving as a consultant for Neurocrine Biosciences, Pfizer Inc, Sanofi Aventis, and Takeda Pharmaceuticals North America, Inc; and serving on the speakers' bureau for Sanofi-Aventis and Takeda Pharmaceuticals North America, Inc.

PARTICIPATING FACULTY

Leslie Lundt, MD
Director
Foothills Foundation
Boise, Idaho
Dr Lundt reports receiving grants/research support/honoraria and serving on the speakers' bureau for Sanofi-Aventis, Sepracor Inc, and Takeda Pharmaceuticals North America, Inc; and serving as a consultant for Sepracor Inc and Takeda Pharmaceuticals North America, Inc.

Nancy Nadolski, FNP, MSN, MEd, RN
Nurse Practitioner
Foothills Foundation
Boise, Idaho
Ms Nadolski reports receiving grants/research support from Cephalon Inc, Eli Lilly and Company, Forest Laboratories, and GlaxoSmithKline; and serving on the speakers' bureau for Cephalon Inc, Forest Laboratories, Pfizer Inc, Sanofi-Aventis, Sepracor Inc, and Takeda Pharmaceuticals North America, Inc.

Notice: The audience is advised that an article in this CE activity contains reference(s) to unlabeled or unapproved uses of drugs or devices.

Dr Neubauer—unlabeled use of antidepressants and antipsychotics for the treatment of insomnia will be discussed, but not recommended.

All other faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

New Approaches to the Patient with Insomnia
David N. Neubauer, MD, MA*

For some individuals, sleep arrives naturally; others are unable to sleep under the best of conditions. Most people require approximately 8 hours of sleep per 24-hour period. Given our current average life span, this results in a total of 26 years spent sleeping. Given that 33% of our time is consumed by this activity, it is surprising how little we know about it. Think about how little time you spent studying sleep disorders during your medical education.

As pointed out by our faculty in this monograph, our society struggles with conflicting views on sleep. The rational side, which strives to be educated in matters of personal health and well-being, understands the importance of a good night's sleep, whereas the other side views it as a "treat" for hard work, or perhaps a waste of time, or simply a task of low priority in our overscheduled lives. Vice or virtue? Although we preach to our children the virtues of a good night's sleep, we live and operate in a 24/7 society. We can even connect with another human being anywhere in the world, any time of day or night, through the Internet. As a result of such breakthroughs in global communication and advances in standards of living, we, as a society, do not embrace—and perhaps even reject—the necessity of this restorative ritual, sleep.

For many years, clinical researchers were completely unaware of sleep processes. However, over the past several decades, sleep disorders research has grown into a formal clinical discipline that now uses clinical research and modern molecular biology tools.1 Unfortunately, it is taking some time for these discoveries to filter out to our patients. Studies have shown that people who are chronically sleep deprived can be completely unaware of the cause of their fatigue, in part because sleep is a state of altered consciousness.1 The National Sleep Foundation conducts an annual survey about Americans' habits of and attitudes toward sleep. In recent years, the survey has revealed that 75% of adults experience daytime sleepiness, and 34% say that sleepiness interfered with daytime activities.1 In addition, 23% of people polled admitted to falling asleep while driving in the past year, and 14% drive drowsy at least once a week.1 Not surprisingly, these statistics are mirrored in our children. The 2006 survey revealed that more than 50% of adolescent drivers had driven drowsy in the past year, and 15% drive drowsy at least once a week.2 Sadly, most people think that daytime fatigue or sleepiness is normal. How much productivity and vitality are we losing if this is our state of normalcy? And what message are we sending to the next generation?

This issue of Johns Hopkins Advanced Studies in Medicine chronicles presentations from 2 thought leaders in the field of sleep disorders at the 2006 National Conference of the American Academy of Nurse Practitioners (AANP). Leslie Lundt, MD, offers an important review of sleep architecture and the sleep-wake cycle, in addition to methods for diagnosing and assessing sleep disorders. As she notes, a wide variety of user-friendly tools are now available, thus, the nurse can and should take the initiative to inquire about sleep hygiene during each office visit. This is especially important because only a fraction of patients with sleep disorders ever consult a healthcare professional about it.

Nancy Nadolski, FNP, MSN, MEd, RN, continues this discussion with a review of the current treatments that have been found in clinical studies to treat insomnia safely and effectively. Contrary to another popular myth about insomnia, therapy should not necessarily begin with medication. Many Americans self-medicate their insomnia with alcohol or over-the-counter products (eg, antihistamine or Tylenol PM [acetaminophen and diphenhydramine hydrochloride]). In fact, cognitive-behavioral therapy (CBT) has a critical role to play in short- and long-term alleviation of chronic insomnia. Ms Nadolski also offers an important discussion on the role of the nurse practitioner (NP) in treating insomnia.

The issue concludes with a clinician interview, in which I discuss specific challenges faced by healthcare practitioners when diagnosing and treating patients with insomnia. Topics include the assessment of parasomnias, whether it is necessary to distinguish the primary condition when a patient has depression and insomnia, and the role of herbal therapy in the treatment of insomnia. The information provided in this clinician interview is meant to serve as an addendum to the content presented at the 2006 National Conference of the AANP and provide additional insight into the management of insomnia.

Insomnia is often a recurring symptom with many potential causes. Thus, patients need tools to handle future bouts of insomnia. Studies have shown that combination CBT and pharmacotherapy offer the best outcomes, and we now have several new effective agents that offer full relief—a full night's sleep, the ability to awaken, and functionality the next day—with lower risks of side effects. This monograph is designed to introduce you to the latest developments in insomnia research and further your understanding of the tools and options available to the NP and physician assistant who most likely face patients with insomnia on a daily basis.

References

1. Dement WC, Vaughan C. The Promise of Sleep. New York, NY: Dell Publishing; 1999.
2. National Sleep Foundation Web site. 2006 Sleep in America Poll: Key Findings. Available at: http://www.sleepfoundation.org/_content/hottopics/Highlights_facts_06.pdf. Accessed August 31, 2006.

*Assistant Professor, Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Associate Director, The Johns Hopkins Sleep Disorders Center, Baltimore, Maryland.
Address correspondence to: David N. Neubauer, MD, MA, Assistant Professor, Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Department of Psychiatry 461A, 4940 Eastern Avenue, Baltimore, MD 21224. E-mail: neubauer@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.