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For the Clinician
Insomnia in HIV and Its Management: One Clinician's Perspective

By Zishan Samiuddin, M.D., Baylor College of Medicine

December 2000

This article is a practical, precise and concise overview of my 7.5 years of experience treating a broad range of sleep problems in a heterogeneous group of HIV-infected individuals at the Thomas Street Clinic (TSC) in Houston. TSC is a community-based clinic that provides primary medical care to the indigent HIV/AIDS community.


Introduction

Like HIV infection itself, insomnia is a significant public health problem. The economic, human, and societal costs of insomnia affect health care utilization, quality of life, relationships, and productivity. Rosekind (1992) estimates that while 95% of the U.S. population experiences occasional insomnia, only one third to one half of these people seek medical help and seldom report insomnia as their primary complaint. Furthermore, an average of 14 years elapse before they come in for treatment. These odds get stacked even higher when HIV and related issues are added to the mix, as demonstrated by Rubinstein and Selwyn (1998). They classified 73% of 115 patients as having a sleep disturbance. Insomnia rose to 86% in drug users and to a whopping 100% in those with cognitive impairment. Similar to the under-reporting of patient sleep problems, clinicians identified insomnia in only 33% of medical records. Prenzlauer et al. (1993) correlated sleep with the stage and markers of HIV illness and with psychosocial factors in 68 patients. Fifty patients (79%) had a sleep disturbance. The trend towards higher beta 2 microglobulin levels in this group may well be an early indicator of disease progression.

Sleep is not just the absence of wakefulness. It is also a state of rest for voluntary functions while vitally important involuntary functions persist. The dormancy may be essential to reduce the energy requirements of the brain and to allow adequate rest for the forebrain. Long- and short-term sleep deprivation results in impaired thinking, speaking, memory, concentration, and judgement. Irritability increases and reaction time slows down. Paranoia and visual, tactile, and auditory hallucinations are often a result of long-term sleep deprivation. It is easy to extrapolate the impact of these symptoms on objective productivity, subjective quality of life and mutual relationships. The Gallup Survey estimates that sleep problems cost the health care system alone $30 billion annually.


Diagnosis

Given the fact that sleep problems are under-reported, under-diagnosed, costly, and proven to have a negative impact on our patients' lives, it is important for us all to have a working knowledge of commonly encountered sleep disorders in HIV/AIDS. The symptoms of insomnia may result from a variety of medical, psychiatric, or neurologic conditions. A thorough sleep history is usually sufficient to diagnose the bulk of etiologies. Occasionally though I have had to send patients to the sleep lab not only for diagnosis but also for intervention like the continuous positive airway pressure (C-PAP) machine.

The sleep history must include the following considerations:


Nonpharmacological Management

An old Indian proverb suggests, "One kind of stick cannot be used to corral all sheep." While it loses something in the translation, this proverb is quite apropos to the current discussion in the sense that a single approach cannot fix all patients' problems. Nonpharmacological options remain the mainstay of dealing with psychological factors that hinder sleep. They include the following approaches:

A) Behavioral

B) Psychological

To summarize in practical terms, the do's and don'ts that should discussed with patients include the following points.

Do

Don't


Pharmacological Management

Frequently used classes of medications at TSC include benzodiazepines, sedating antidepressants, imidazopyridines and over-the-counter drugs. Many of the drugs mentioned below are available as either generics or brand-name drugs. Principles of treatment of insomnia are illustrated by the following case examples that are composites of HIV-infected patients commonly seen at TSC.

I present these case examples as stereotypes of patients I treat. Rarely are the histories so clear-cut. I have deliberately omitted specifics about dosing strategies and follow-up care in the interest of brevity and clarity. General guidelines I would like to stress for the pharmacological treatment of insomnia, in particular with controlled substances, can be summarized as follows:

Do prescribe

Don't prescribe


Conclusion

Insomnia is common in HIV/AIDS. It is under-diagnosed and under-treated. To be treated, insomnia must be diagnosed. A combination of behavioral and psychological approaches are highly effective in managing complaints of insomnia. Treating insomnia can be rewarding for patients and physicians alike.


Glossary

Analgesic: producing an insensibility to pain, without a loss of consciousness.

Autogenic: relating to relaxation techniques (such as biofeedback or meditation) in an attempt to control physiological characteristics (blood pressure, heart rate, etc.).

Neurovegetative: occurring involuntarily (autonomic).

Priapism: an abnormal, persistent, and usually painful erection of the penis (not caused by sexual desire).


References

  1. Ashton H. The effect of drugs on sleep. In Cooper, ed. Sleep. London: Chapman & Hall Medical, 1994: 175-211.

  2. Becker B. Relief from sleep disorders. New York: Dell Medical Library, 1993.

  3. Bootzin RR, Perlis ML. Nonpharmacologic management of insomnia. J Clin Psychiatry 1992; 53 (suppl 6): 37-41.

  4. The Gallup Survey. Sleep in America. A National Survey of US Adults: Final Report. Princeton, NJ: The Gallup Organization, 1995.

  5. Prenzlauer SL, Bogdanov L ,Tiamson ML ,Bialer PA Wilets I. Sleep and HIV illness. Int Conf AIDS 1993 Jun 6-11;9(1);427.

  6. Gokcebay N, Cooper R, Williams RI, Hirshkowitz M, Moore CA. Function of sleep. In Cooper, ed. Sleep. London: Chapman and Hall Medical, 1994: 47-59.

  7. Rosekind MR. The epidemiology and occurrence of insomnia. J Clin Psychiatry. 1992;(suppl 6):4-6.

  8. Rubinstein ML, Selwyn PA. High prevalence of insomnia in an outpatient population with HIV infection. J Acquir Immune Defici Syndr Hum Retrovirol.1998. Nov 1;19(3):260-265.


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