A person spends a third of his life in a dream. The fullness of sleep determines the overall level of health and quality of life, measured in terms of social, mental, emotional and physical well-being. Sleep disorders naturally lead to a significant decrease in the quality of life. Even more significantly, they affect the health of a sick person, become the cause of fatal disorders.
Are we often interested in the patient’s sleep state? Does the patient often contact us with this problem? According to WHO, about half of the world’s population is at risk for sleep disorders.
Recall some of the “significant” consequences of sleep disorders: a
drop in overall health, a
decrease in immunological homeostasis,
mental and emotional disorders, migraine, a
decrease in labor productivity, an
increase in injuries (20% of drivers fell asleep at least once while driving), an
increase in the frequency and aggravation of somatic diseases,
o “cardiac”, “respiratory” and other catastrophes during sleep.
Sleep disorders are conditionally classified into hyper- and insomnia. Hypersomnia – a violation of wakefulness and insomnia (incomplete and inaccurate Russian equivalent – insomnia) – a violation of sleep itself. They are closely related, since it is wakefulness disorders that are often the cause of sleep disorders, just as inferior sleep also determines inferior wakefulness.
In Western countries there is a developed somnological service. There are more than 500 somnological centers in the USA; hundreds of them are in Germany, France, and other countries. The first centers appeared in the Russian Federation. The topic of sleep disorders is not only medical, but also economic. The annual costs associated with this problem in the United States alone exceed $ 100 billion.
The topic of the article is insomnia, dissatisfaction with night sleep, from some age it is well known to a significant part of the adult population. The general practitioner most often has to meet, if only he knows how to correctly interpret the patient’s complaints, namely with insomnia.
What is a dream?
Sleep is a physiological state that occurs primarily in the dark, characterized by inhibition of active interaction with the environment. Conscious mental activity does not stop completely. Outwardly, sleep is manifested by a certain stereotypical position of the body, minimal motor activity, a decrease in reactions to stimuli, reversibility and characteristic cyclic changes in brain functions.
Sleep is a cyclic process. Each cycle consists of two phases – the slow phase and the fast (paradoxical) sleep phase. The slow sleep phase is NREM sleep (without rapid eyeball movements) and the REM sleep phase is REM sleep (with fast eyeball movements). In the phase of NREM-sleep, slow activity is determined on the EEG, vegetative activity subsides, pulse slows down, blood pressure decreases. It is believed that this is a phase of energy recovery. In the REM-sleep phase, fast rhythmic activity is recorded in the brain, fast movements of the eyeballs occur, vegetative and endocrine “storms” occur, blood pressure, respiratory rate, heart rate fluctuate, and dreams are seen at this time. The NREM sleep phase occupies 75-80% and REM sleep – 25-20% of the duration of one cycle, which generally lasts about 60-90 minutes. For one dream, from 3 to 6 cycles are observed. The last cycles in a dream can be interrupted by very short episodes of wakefulness. During sleep, regular changes in the brain occur , accompanied by corresponding reactions of autonomic and humoral regulation. They are associated with the psychological processing of experience, stabilization of the psycho-emotional sphere, synchronization of systems and processes, restoration of energy potential. All this is aimed at ensuring effective wakefulness.
The need for sleep in different individuals varies from 4-6 to 8-10 hours or more. It is interesting that it is established in early adolescence and then changes little throughout life. Physiological determinants of sleep – age, daily period of day and night and its disturbances, geomagnetic effects, physical and emotional stress, etc. The properties of NREM sleep determine the depth of sleep.
Causes and criteria for insomnia
Insomnia is acute, intermittent, and chronic. Acute (transient) is associated with acute causal factors, such as mental trauma, physical distress. With it, sleep disorders last from two nights to several weeks. With periodic insomnia, sleep is disturbed in certain life or seasonal cycles. Chronic is said to be when sleep disorders last more than a month.
The most common causes of insomnia:
violations of hygiene of sleep and wakefulness (late going to bed, early awakening, lack of sleep, irregular sleep patterns, poor nutrition, lack of exercise),
changes in environmental factors (change of time zone, shift work with disturbance of the cyclic rhythm of sleep and wakefulness),
mental illnesses of neurotic and psychotic levels, the
use of neurotropic pharmacological drugs or substances that affect the central nervous system (certain groups of drugs – beta-blockers, antidepressants, etc., alcohol, nicotine, excessive use of caffeine and other psychostimulants in the daytime),
organic damage to brain structures, involved in the regulation of the sleep-wake cycle (tumors, inflammatory diseases, etc.),
somatic and neuroendocrine diseases (arterial hypertension, chronic heart failure, cardiac asthma, obstructive pulmonary disease,
hyperthyroidism, metabolic syndrome X, liver failure, renal insufficiency, enlargement of the prostate gland, diabetes mellitus, joint diseases, tumors, gastroesophageal reflux disease, etc.),
primary genuin disorders of the intimate brain mechanisms of sleep regulation and its cyclical nature (insomnia of childhood and old age, narcolepsy).
Diagnosis of insomnia is based on interviews and a clinical picture with syndromic and etiological identification. In special somnological laboratories can conduct polysomnography. The clinical signs and variants of insomnia on which the diagnosis is based are as follows:
difficulty falling asleep,
sleep apnea (often in patients with arterial hypertension),
combination of symptoms.
Criteria for insomnia of an inorganic nature:
complaints of sleep disturbance, sleep maintenance or poor quality,
sleep disturbances occur for at least a month, at least three times a week,
sleep disorders cause distinct subjective suffering or impede social and professional functioning,
condition cannot be explained by any neurological or somatic disease or by taking psychoactive substances and drugs.
If the diagnosis is correct, the patient with insomnia responds well to therapeutic measures. The primary task is to eliminate or weaken the cause of insomnia, first, if possible, without the use of potent sleeping pills.
General principles of treatment:
attention to hygiene of sleep and wakefulness,
solution of concomitant mental problems,
treatment of the disorder causing insomnia,
use of sleeping pills for short-term treatment and for chronic insomnia.
Bedtime should be at least 5 hours. If it is difficult to fall asleep, it is recommended that you go to bed later. Improving sleep is facilitated by psychotherapeutic measures, which, however, are associated with significant time costs and require the participation of a well-trained specialist. These activities are carried out against the background of basic therapy aimed at treating underlying suffering.
There are different options for basic therapy in psychiatric, pulmonological, cardiological, rheumatological, etc. the clinic. In psychiatric disorders, antidepressants are often used,
which, however, can increase insomnia. In a pulmonary clinic for chronic obstructive pulmonary diseases, emphasis is placed on bronchodilators with anti-inflammatory effects. In cardiological practice in heart failure, first-line drugs are diuretics, beta-blockers, and angiotensin-converting enzyme inhibitors. In rheumatology, emphasis is placed on non-steroidal anti-inflammatory drugs, among which selective cyclooxygenase 2 blockers have recently been given priority. When insomnia is based on sleep apnea, weight loss and alcohol refusal may be beneficial. Violations of circadian rhythms suggest chronotherapeutic measures. It may be useful to find the patient in bright light in the morning. With motor disorders, hypnotic drugs of a receptor effect can give an effect.
Drugs with sleeping pills
As the main treatment for periodic insomnia,
as the main treatment for chronic insomnia,
as an auxiliary treatment for insomnia due to another disease. Criterias of choice
patients who must be in good functional condition during the daytime are prescribed drugs with a half-life of less than 5 hours, and
patients with increased anxiety during the daytime may be prescribed long-acting drugs.
Rules of appointment
Starting with a minimum dose,
selection of an effective dose, dose
reduction in elderly people,
dose reduction in case of dysfunction of the organs that excrete the drug (half dose, dose reduction, increase in the interval between doses), the
duration of treatment in most cases is from 2 to 4 weeks ,
course, alternating with 1-2 week breaks with a longer appointment,
replacing the drug with a new one with a decrease in effectiveness,
reinforcing the effect with hygienic recommendations for healthy sleep,
refraining from drinking alcohol and other inhibitors of the central nervous system,
recommendations to avoid potentially dangerous activities, requiring increased attention and a quick reaction, for example, driving a car,
if it is difficult to fall asleep, a drug with a short period of action (up to 5 hours) is selected for sleep induction,
with frequent waking up or early waking up, drugs with an average duration of action (up to 8-10 hours) o)
if sleep cannot be normalized in the next 1-2 weeks, you should think about a possible undiagnosed somatic or mental illness with the need for further examination of the patient,
Despite the fact
that sleeping pills have a negative effect on memory, insomnia itself has the same effect. Memory when prescribing benzodiazepine sleeping pills can improve, they do not cause rebound insomnia, even when prescribed for a long time. Drug dependence was noted for barbiturates and drugs similar in structure. Sleeping pills inhibit breathing during sleep apnea and can disrupt sleep patterns.
should not be prescribed to children under 15 years old,
obstructive sleep apnea,
pregnancy and lactation,
hypersensitivity to the drug,
work requiring concentration.
Groups of drugs prescribed for insomnia
tranquilizers – short-term use, a sedative effect may be sufficient to normalize sleep,
short-acting hypnotic midazolam with difficulty falling asleep,
cyclopyrrolone and imidazopyridine drugs – no longer than 2 months,
antidepressants with sedative effects,
barbiturates – short-term use of other sleeping pills,
Insignificant drugs in the treatment of insomnia
In the treatment of insomnia, insignificant drugs are often used. The most famous are antagonists of H1-histamine receptors. Their effect on sleep has not been specifically studied. Another group is low-dose antidepressants for sleep disorders without depression. At the same time, concern is expressed about their residual daily effect and the possibility of an overdose.
Homeopathic preparations and herbal preparations are also presented on the pharmaceutical market, the current level of knowledge regarding the safety and effectiveness of which does not yet give grounds for widespread use for the treatment of insomnia. Despite the fact that the natural substances L-tryptophan and melatonin are also popular with insomnia, they have not yet received sufficient clinical research.