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Insomnia (불면증)

The Root of Ambulatory Care (외래 진료 지침서) 전체 목록 보기
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The Root of Ambulatory Care

The Root of Ambulatory Care

  • 저 자 : 이진우
  • 출 판 : 군자출판사
  • 페이지수: 543면

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KEYWORDS: ..Inability to fall asleep (long sleep latency) or stay asleep (excessive or prolonged awakenings), and sleep disorders may be associated with disruption of the quality, quantity, or timing of one or more stages of sleep. Normal sleep ..대부분의 성인은 하루 6~8시간의 수면이 필요하며, 약 2%에서는 하루 5시간 이하, 또 다른 2%에서는 하루 9시간 이상의 수면을 필요로 한다. ..If insomnia does not cause daytime problems (e.g., fatigue, irritability, somnolence, distractibility), it is not clinically significant. Insomnia Non-rapid eye Light sleep-stage 1, 2 movement(non-REM) Deep sleep-stage 3, 4 REM : decreased muscle tone, Stage 5 BP, repiratory rate Primary Insomnia (10~20%) No identifiable medical or psychiatric cause can be established. Drug/Substances - Caffeine - Alcohol - Nicotine(inhaled and transdermal) - Selected herbal preparations - Selected OTC diet, cold and allergy preparations - SSRI and selected antidepressants - Selected antihypertensives - Corticosteroids - NSAIDs - Theophylline - Diuretics - Stimulants Psychiatric causes - Major depression - Generalized anxiety disorder Secondary - Manic depressive disorder Insomnia (80~90%) - Obsessive compulsive disorder - Psychosis - Pain disorder - Somatoform pain disorders Medical/Surgical causes - Hyperthyroidism/hypothyroidism - Arthritis - Fibromyalgia - GERD - Asthma/COPD - Congestive heart failure - Angina - Urinary tract infection - Benign prostatic hypertrophy - Hyperglycemia - Gallbladder disease - Delirium - Dementia - Pain of any origin Transient insomnia : up to several days Short-term insomnia : up to 3 weeks Chronic insomnia : more than 3 weeks ; 근본 원인 평가가 요구됨 315 The Root of ambulatory care Key tests Key treatments Insomnia 1. Sleep diary : for 2 weeks - this information can provide valuable clues to underlying causes of insomnia 2. Polysomnography : to evaluate complicated chronic insomnias or sleep apnea syndrome Fig 1. Sample sleep diary for use in patients with insomnia - Sleep hygiene recommendation ..Attempt to maintain regularity in the sleep-wake cycle timing ..Avoid caffeine after lunchtime ..Exercise regularly, but not within a few hours of bedtime ..Avoid alcohol, especially within a few hours of bedtime ..Avoid late heavy meals, but consider a small bedtime snack 317 The Root of ambulatory care ..Reserve the bedroom and bed for sleep and sexual activities ..Develop a relaxing evening routine ..Avoid excessive wakeful time in bed ..Avoid bedroom temperature extremes ..Avoid disruptive noises and consider a white-noise machine - Pharmacologic 1. Non-Benzodiazepine ..Stilnox.. 10mg 1T, 1T pohs (1/2T pohs for elderly patients) ; agent of choice for sleep onset problems, less potential for withdrawal and is more specific for sedative properties alone 2. Benzodiazepine ..Halcion.. 0.125mg 1T, 1T-2T pohs ..Dalmadorm.. 15mg 1T, 1T-2T pohs Melatonin (5mg of the immediate-release formulation at the desired bedtime) is effective in patients with jet lag. ..Stilnox.. - zolpidem ..Halcion.. - triazolam ..Dalmadorm.. - flurazepam ..Zolpidem has little risk of residual sedation the following morning after bedtime use because the elimination half-life and duration of action are short. ..3-4주 이상 장기간의 수면제 사용은 의존성(특히 Benzodiazepine계 약물)을 통해 불면증을 영속화할 수 있고 불면증을 일으키는 다른 원인 질환을 은폐 시킬 수 있기 때문에 권고되지 않고, 가능한 소량을 단기간 사용하는 것이 바 람직하다. 노인에서는 용량을 낮추어 사용해야 한다. ..장기간 사용해야 한다면, 일주일에 세번에서 네번 정도만 사용하도록 유도해 야 한다. Key treatments Insomnia 참고 문헌 National Heart, Lung, and Blood Institute Working Group On Imsomnia : Insomnia : Assessment and Management in Primary Care. A journal of the American Family Physicains 1999 ; 59(11) : 3029-3039 Syed M. Ahmed : Insomnia, in Saunders Manual of Medical Practice, 2nd ed, Robert E. Rakel(ed). Philadelphia, Saunders, 2000, P 1411-1414 Jeffrey L. Susman, M.D., Daniel A. Vogel,M.D. : Insomnia, in A Lange clinical manual Family Medicine Ambulatory Care & Prevention, 4th ed, Mark B. Mengel, M.D., L. Peter Schwiebert M.D. (ed). United States of America, The McGrwa-Hill Companies, Inc., 2005, P 224-229 송윤미 : 불면증, in 가정의학 임상편. 서울, 계측문화사, 2002, P 345-352 David N. Neubauer, M.D. : Insomnia, in Conn’s Current Therapy 2004, Robert E. Rakel(ed), Edward T. Bope(ed_). Philadelphia, Saunders, 2004, P 34-36