AASM Membership Sections Newsletter Issue #2
8
American Academy
of Sleep Medicine
Future Directions in Insomnia:
Familiar Tools, New Approaches
Recognizing Medical Comorbidities Of Insomnia
by Fahd A. Zarrouf, MD
A growing literature supports the association be-
tween insomnia and obesity, hypertension, diabetes,
cardiovascular disease, mortality and multiple other
medical diseases.
Cardiovascular disease (CVD) may aggravate or
be aggravated by insomnia. In a recent Meta-analysis,
(13
studies, 122,501 insomniac subjects) insomnia
determined an increased risk (+45%) of developing
or dying from cardiovascular disease during the 3-20
years follow-up (
relative risk 1.45, 95% confidence in-
terval 1.29-1.62; p < 0.00001
) (
Sofi et al., 2012). Other
studies show that short sleep duration and difficulty
falling asleep were positively associated with CVD
after adjusting for demographic, lifestyle, and clinical
risk factors. One study suggested that sleep duration
≤ 5 h was associated with a CVD odds ratio of 2.89
(1.17-7.16)
compared with a sleep duration of 7 h
(
Sabanayagam, Shankar, Buchwald, & Goins, 2011).
On the vascular level, carotid intima-media thick-
ness (IMT) was significantly correlated with TST
(
r = -0.28, P = 0.010) (Nakazaki et al., 2012). Chronic
insomnia with short sleep duration is also associated
with an increased risk for incident hypertension in
a degree comparable to sleep-disordered breathing
(
Fernandez-Mendoza, et al., 2012).
The reasons behind this association are not yet
clear. Insomnia was thought to increase the risk
of CVD through inflammatory mechanisms, but a
recent study did not support the hypothesis that in-
flammation, as reflected by elevated levels of hsCRP,
is an important factor linking insomnia to CVD
(
Laugsand, Vatten, Bjørngaard, Hveem, & Janszky,
2012).
Other studies explored the sympathetic hyper-
activation throughout the night (a main feature of
primary insomnia) as a reason for increased cardio-
vascular risk (de Zambotti et al., 2012).
Insomnia is common in patients with COPD
(
Budhiraja et al., 2012) and acute lung injury sur-
vivors (Parsons et al., 2012) and has been shown to
impair quality of life in both diseases.
The relationship between insomnia and malignan-
cies has been studies before, in fact, insomnia was
found to be; among fatigue, neuropathy, and pain; the
most common troublesome symptom experienced by
cancer survivors (Pachman, Barton, Swetz, & Lo-
prinzi, 2012).
Various pharmacological treatments affect or
induce insomnia. For example, use of β-blockers may
cause insomnia and central nervous system and/or
psychological side effects, (Chang et al., 2012) other
medications used by primary care providers may sig-
nificantly affect insomnia and sleep architecture.
One the other side, pharmacology or therapy
based treatments for insomnia may improve medi-
cal illnesses. Cognitive behavioral therapy is useful
for insomnia symptom and also to improve outcome
of CVD and metabolic syndrome in general prac-
tice. Melatonin is used for specific types of insomnia
and at the same time may have potential clinical
applicability for individuals with cardiovascular
disease(Dominguez-Rodriguez, 2012).
In summary, addressing insomnia in the primary
care setting has not been fully explored. Many times a
referral is made to a psychiatrist. Accumulating data
that insomnia affects almost all other medical prob-
lems may change this direction in the future and lead
to further exploration and research in this area.
Revisting the Role of Polysomnogramphy and
Insomnia
by Rebecca Q. Scott, PhD
Insomnia, whether onset or maintenance, is a serious
health condition that effects over 30% of the general
population. There is no debate about the deleteri-
ous effects of insomnia. It is well documented that
chronic insomnia is often associated with subjective
reports of significant distress, impaired quality of life,
and impaired cognition. It is also understood and that
insomnia can result in an increased risk of developing
or exacerbating other medical (pain disorders, neuro-