佐匹克隆（Zopiclone)非苯二氮卓催眠药，服药2小时血浓度达到高峰。对REM睡眠有影响，因此影响了睡眠周期。维持睡眠时间8-9小
时，对于频醒和早醒患者效果好，但是次日有短暂宿醉及口苦感。（未被FDA批准)对记忆功能有影响扎来普隆（Zaleplon)
非苯二氮卓类催眠药，服药1小时血药浓度达高峰。血浆半衰期短，不能给患者足够的睡眠时间，次日残余效应轻微。临床研究结果显示扎来普
隆能缩短入睡时间，但还未表明能增加睡眠时间和减少清醒次数。对记忆功能有损害，随剂量增加损害增加。剂量增加会出现失眠反弹。思
诺思（唑吡坦）咪唑吡啶类酒石酸唑吡坦全球最多选用的非安定类安眠药收录于美国食品药品管理局目录(FDA)思诺思?
的药代学特点迅速从肠胃道吸收：Tmax=1.6小时半衰期短：T1/2=2.5小时代谢产物无活性下列人群使用时注意老年人：
剂量减少(Cmax和Tmax增加，但无蓄积作用)肾功能障碍：无需剂量调整肝功能障碍：减量使用思诺思?作用机制选择性作用于?
-氨基丁酸/苯二氮卓复合物上的?1受体?1受体：催眠作用?2受体：肌肉松弛、抗焦虑、抗惊厥作用?3受体：作用至今不明，估计与
肌肉松弛作用相关使?-氨基丁酸受体对?-氨基丁酸位点A的亲和力得到增强来自脑的兴奋性冲动得以抑制导入睡眠新型非苯二氮卓类催
眠药物------右佐匹克隆右佐匹克隆，是从母体药物佐匹克隆中分离出的单一右旋异构体，属非BZs镇静催眠药，作用主要
通过与GABAA受体位点上的与α1、α2、α3和α5亚型结合①；与GABAA受体的结合亲和力是佐匹克隆的2倍；是效力最强的非苯
二氮卓类GABAA调节剂①。★成年患者：推荐起始剂量入睡前2mg；可根据临床需要起始剂量为3mg或增加到3mg。★老年患
者：入睡困难推荐起始剂量睡前1mg，必要时可增加到2mg；有睡眠维持障碍推荐剂量入睡前2mg；★特殊人群：严重肝脏损伤患者
慎重，初始剂量为1mg;★合用CYP抑制剂：与CYP3A4强抑制剂合用，初始剂量不应大于1mg，必要时可增加至2mg适应
症：用于治疗失眠。右佐匹克隆是第一个由美国FDA批准的没有短期使用限制的镇静催眠药物，已被批准用于入睡困难患者及睡眠维持困难患
者的治疗。①长达12个月的长期使用后没有发生耐药性的证据，中断治疗后无反跳性失眠或严重的撤药反应。②1、TheRole
ofEszopicloneintheTreatmentofInsomnia.AdvTher(2009)26(
5):500-518.DOI10.1007/s12325-009-0026-52、Lunesta＠(eszopiclone)
prescribinginformation.Sepracor,Inc.website.Availableat:ww
w.lunesta.com.AccessedDecember16,2008.适应症：用于治疗失眠。1、TheR
oleofEszopicloneintheTreatmentofInsomnia.AdvTher(2009)
26(5):500-518.DOI10.1007/s12325-009-0026-52、Lunesta＠(eszopiclon
e)prescribinginformation.Sepracor,Inc.website.Availableat:
www.lunesta.com.结论(2)无次日残余效应无记忆功能影响无失眠反跳现象无耐受现象与中枢抑制药物合用
时有可能的相加作用副反应少见失眠是一个世界性问题，在全球范围内，失眠的发生率高。在英国、美国的发生率分别为37%和40%，
而在中国达到43.4%。而长期失眠也使精神疾病的发生危险性更高，研究发现，失眠的患者中抑郁症的发生率远远高于无失眠人，达4倍
之多。Variousmedicationsthatthepatientmaybetakingforothe
rdisordersaswellassubstanceslikenicotine,alcoholandcaff
einecancauseinsomnia.1-3Certainover-the-counterproductsmay
alsocauseinsomnia.1-3Elderlypatientsmaybeparticularlypro
netodrug-inducedinsomnia.Notonlydomanyofthemtakenumero
usprescriptionandnonprescriptionmedications,butbecauseoft
heirlightersleep,olderpatientsmaybemoresusceptibletothe
effectsofmedicationsthatactontheCNS.KEYPOINTS Various
medicationscandisruptsleep. Elderlypatientsareatgreater
riskfordrug-inducedinsomniaduetomore frequentuseofmedic
ationsandgreatersusceptibilitytoCNS-active medications,com
paredwithyoungerpatients.1. AshtonH.Theeffectsofdrugson
sleep.In:CooperR,ed.Sleep.London:Chapman&Hall Medical;
1994:175-211.2. BeckerPM,JamiesonAO,BrownWD.Insomnia.Use
ofa‘decisiontree’toassessand treat.PostgradMed.1993;93
:66-85.3. BruntonSA.Whenyourpatientcan’tsleep.FamilyPrac
ticeRecertification. 1992;14:149-168.Certainlifestyleactiv
itiesconstitutepoorsleephygiene.Keepingirregulartimesfor
sleepingandwaking,exercisingtoolateatnightornotatall,
androutinelyusingcaffeine,nicotine,and/oralcoholbeforebed
timecaneachresultininsomnia.Educatingpatientsabouttheim
portanceofgoodsleephygiene,includingthesleephygienemeasu
reslistedinthisslide,isabasiccomponentoftreatinginsom
nia.1,2KEYPOINTS Insomniacanbecausedbycertainlifestyle
activities. Educatingpatientsabouttheimportanceofgoodsle
ephygieneisabasic componentoftreatinginsomnia.1.Brunton
SA.Whenyourpatientcan’tsleep.FamilyPracticeRecertificati
on. 1992;14:149-170.2.HauriPJ.Insomnia.ClinChestMed.199
8;19:157-168.Severalothernonpharmacologicinterventionshav
ebeenfoundtobeeffectiveintreatinginsomnia.Allofthesei
nterventionsaimtopromoteimprovedsleepbyalteringmaladapti
vebehavioralandcognitiveroutinesassociatedwithsleep.1Fo
rexample,relaxationtherapy,suchasprogressivemusclerelaxat
ion,meditation,andbiofeedback,mayhelptoreducephysiologic
arousallevelsatornearbedtime,andthisinturnmayhelpthe
patienttofallasleepmoreeasilyandquickly.1Anotherinterv
entioncalledsleeprestrictionaimstomaximizetheamountoft
imespentsleepinginbed.1Initially,patientsexperiencepartia
lsleepdeprivation,whichhelpstoconsolidatetheirsleep.Byg
raduallyincreasingtheamountoftimetheyspendinbedwhilem
aintainingtheimprovedsleepefficiency,patientsworktowardac
hievinganormalnight’ssleep.1Cognitivebehaviortherapyattem
ptstoalterthepatient’sviewofsleepproblems.Insomniapatie
ntsmayholdfalseormaladaptivebeliefsconcerningsleep,such
asthattheyneedaspecificnumberofhoursofsleepinorderto
functionproperlyduringtheday,ortheymayselectivelyrememb
eronlythosenightsduringwhichtheyhadlongboutsofwakefuln
ess.Withcognitivetherapy,patientsaregiveninformationabout
sleeptohelpthemcorrecttheirdysfunctionalbeliefsandmispe
rceptions.1Littlescientificresearchhasbeenconductedconce
rningthehypnoticefficacyofvariousmineral,vitamin,andherb
alsupplements,including,butnotlimitedto,calcium,magnesium
,kavakava,andvalerianroot.However,somereportsinthelay
mediasuggesttheymaybeusefulforthereliefofinsomniasympt
oms.1Ifpatientsexpressadesiretotrysuchcompounds,physici
ansmaysuggestusingasleepdiarytoevaluateefficacy,beings
uretoevaluatesleepduringconsecutiveweekswithandwithoutu
seofthecompound.1KEYPOINTS Whilethereislittlescientific
evidencetosupporttheuseofvitamin,mineral andherbalsupp
lementsforthereliefofinsomnia,reportsinthelaypress con
cerningtheirefficacymayleadsomepatientstousethem. Physi
cianscanhelppatientsevaluateefficacybyinstructingthemto
usea sleepdiary,andthencomparingratingsofsleeponnights
withand withoutthesupplement.1. HauriPJ.Insomnia.ClinCh
estMed.1998;19:157-168.Melatoninisahormonesecretedatn
ightbythepinealgland,locatedinthebrain.1Melatoninmayin
teractwithreceptorsinthesuprachiasmaticnucleiofthehypoth
alamus.Melatoninmayalsopromotesleepinessandaltercircadian
rhythms.2Arecentopen-labelpilotstudysuggeststhatitmayi
mprovesleepamongmiddle-agedandelderlypatientswithinsomnia
.3However,mostpatientsinthisstudywereconcomitantlytaking
abenzodiazepine,andsothedirecteffectsofmelatoninonslee
premainunclear.Ingeneral,resultsofclinicalstudiesinpati
entswithinsomniahavebeeninconsistent.2Therecentpilotstud
yconcludedthatmelatoninissafeandwelltoleratedevenwhent
akendailyforaslongas6months.3Itshouldbenoted,however,
thatwell-controlled,large-scaletrialsofthisagentareabsen
t.KEYPOINTS Melatoninissecretedatnightbythepinealgland
andmayactonreceptors locatedinthesuprachiasmaticnuclei.
Insomestudiesitappearedtopromotesleepinessandtoalter
circadian rhythms. Someresearchsuggestsitmaybeusefulint
reatinginsomniaamongmiddle- agedandelderlypatientsandasa
nadjuncttobenzodiazepinetherapy; however,ingeneral,study
resultshavebeeninconsistent. Thesafetyandtolerabilityofm
elatoninareunclearduetolackofstudies. Nolarge-scaleclin
icaltrialshaveyetbeenconducted.1. HauriPJ.Insomnia.Clin
ChestMed.1998;19:157-168.2. NationalHeart,Lung,andBloodI
nstitute(NHLBI)WorkingGrouponInsomnia.Insomnia: assessment
andmanagementinprimarycare.AmFamPhysician.1999;59:3029-3
038.3. SiegristC,BenedettiC,OrlandoA,etal.Lackofchang
esinserumprolactin,FSH,TSH, andestradiolaftermelatonint
reatmentindosesthatimprovesleepandreduce benzodiazepinec
onsumptioninsleep-disturbed,middle-aged,andelderlypatients.
JPineal Res.2001;30:34-42.Sedatingantihistamines,asacl
ass,aredrugsthatantagonizecentralH1receptors.Thisisthe
classofantihistaminesthatwillbediscussedinthispresentati
on.Mostover-the-countersleepaidscontainanantihistamine,an
dtheonemostcommonlyusedisdiphenhydramine.1Olderstudiesh
avedemonstratedefficacyfortheshort-termimprovementofsleep
.However,long-termefficacyhasnotbeenshown.Adverseeffects
ofantihistaminescommonlyincludeanticholinergiceffectsaswe
llasdaytimesedationandcognitiveimpairment.1KEYPOINTS Ant
ihistaminesarecommonlycontainedinover-the-countersleepaids
. Olderstudiesindicatetheyareeffectivefortheshort-termr
eliefofinsomnia. Long-termefficacyhasnotbeendemonstrated.
Adverseeffectsassociatedwiththeuseofantihistaminesinclu
dedaytime sedation,cognitiveimpairmentandanticholinergicef
fects.1. NationalHeart,Lung,andBloodInstitute(NHLBI)Work
ingGrouponInsomnia. Insomnia:assessmentandmanagementinp
rimarycare.AmFamPhysician. 1999;59:3029-3038. Althoughs
edatingantihistaminesmaybethoughtofasatreatmentforsleep
disturbances,adverseeffectsmaylimittheiruse.1Effectson
thecentralnervoussystemarethemostfrequenteffectsobserved
withtheseantihistamines.Theseeffectscanincludedizziness,
nervousness,blurredvisionandtremors.Insomnia,tinnitus,las
situdeandpoorcoordinationcanalsoresult.Gastrointestinalsi
deeffectsarethesecondmostfrequentsideeffectsobservedwit
hantihistamineuse.Thesecanincludelossofappetite,vomiting
,nausea,diarrhea,constipationandepigastricdistress.KEYPOI
NT Adverseeffectsfromantihistaminescanaffectthecentralne
rvoussystem andthegastrointestinalsystemandmaylimittheir
useincertainpatients.1. BrownNJ,RobertsLJ.Histamine,bra
dykinin,andtheirantagonists.In:HardmanJG, LimbirdLE,Gilm
anAG,eds.Goodman&Gilman’sThePharmacologicBasisof Therap
eutics.10thed.NewYork,NY:McGraw-Hill;2001:645-667.Anti
cholinergicactionscanresultfromfirst-generation(sedating)H
1–receptorantagonistsandmayincludedrymouth,drynessofthe
respiratorypassages,constipation,urinaryretentionorfrequenc
y,anddysuria.1KEYPOINT Anticholinergicactionscanresultf
romfirst-generation(sedating) H1–receptorantagonists.1. B
rownNJ,RobertsLJ.Histamine,bradykinin,andtheirantagonists
.In:HardmanJG, LimbirdLE,GilmanAG,eds.Goodman&Gilman’s
ThePharmacologicBasisof Therapeutics.10thed.NewYork,NY:
McGraw-Hill;2001:645-667.Antidepressantswithsedativeside
effectsareincreasinglybeingusedashypnoticagents.1Amongt
hetricyclicantidepressants,Elavil?(amitriptyline10or25mg)
andSinequan?(doxepin≤25mg)havepotentsedatingeffectsand
areusedashypnotics.Whenusedforthispurpose,theyarepresc
ribedinverylowdoses.However,evenattheselowdoses,during
theinitialphaseofsuchtreatment,daytimesedationmaybemar
ked.Further,lowdosesofthesetricyclicantidepressantshaveb
eennotedtoaggravateperiodiclimbmovementdisorderandrestle
sslegssyndrome.1,2Trazodone(Desyrel?)isanantidepressantt
hatisalsousedasahypnoticatlowdoses.Lessoften,nefazodo
ne(Serzone?),astructurallyrelatedcompound,isused.Trazodon
edoesnotaggravateperiodiclimbmovementsorrestlesslegs,an
disthussometimeschosenoverElavilandSinequan.1失眠的特征入睡
困难夜间易醒并且再次入睡困难次日早醒不能恢复体力的睡眠睡眠质量不好失眠的表现（1）睡眠时间不足入睡困难：超过30分钟
熟睡维持困难：易醒（>2次/夜，>5min/次）、早醒睡眠效率下降：浅睡眠为主，缺乏III期与IV期睡眠，无生长激素分泌峰值
失眠的表现（2）白天有缺睡症状晨起后无清晰感，不能恢复精力充沛白天头昏、疲乏、无力或嗜睡认知功能受损 工作与学习能力
下降 记忆力下降 注意力不能集中等 短暂失眠或短期失眠常见的原因是睡眠环境（如不熟悉或不适于睡觉的环境）或起居习惯
的突然改变（如跨时区）或应激性生活事件。饮酒、吸烟或服用某些药物也可致短暂失眠。 短期失眠常见原因长期失眠常见原因
长期失眠的常见原因有精神方面的失调、抑郁症、长期用药或饮酒。 短期失眠可转变成长期失眠。失眠增加了发生精神疾病的危险02
46810121416抑郁焦虑酗酒滥用药物失眠(n=240)无失眠(n=739)Bresla
uetal.,BiolPsychiatry,19963.5年的发生率(%)4-倍2倍8倍0.5倍能够
引起失眠的物质抗胆碱能药抗抑郁药抗高血压药抗肿瘤药支气管扩张药CNS兴奋药处方药1,2:药物和精神活性物质的不
恰当使用1-3:酒咖啡因尼古丁平时营养药物皮质类固醇减充血药利尿药组织胺2受体阻断药AshtonH.
Sleep.1994;175-211.BeckerPM,etal.PostgradMed.1993;93:66-
85.BruntonSA.FamilyPracticeRecertification.1992;14:149-168.
失眠的治疗非药物治疗药物治疗非药物治疗的方法保持规律的作息时间1营造安静的就寝环境1避免床上看电视1限制傍晚以后
使用尼古丁\咖啡因和酒1,2适当的锻炼,但不要在就寝前锻炼1,2避免打瞌睡1,2如果饥饿的话,就寝前可以少吃一些东西1
“睡眠卫生”放松治疗 降低警觉性生物反馈渐进性肌肉松弛睡眠限制治疗 提高睡眠效率限制床上时间增加床上睡觉时间
%认知行为治疗 纠正不恰当的睡眠观念提高应对技巧减轻对睡眠的焦虑非药物治疗的方法行为干预NHLBIWorking
GrouponInsomnia.AmFamPhysician.1999;59:3029-3038.药物治疗的方法草
药:例如:绝大多数没有特点几乎没有科学证据支持其能改善失眠颉草根(ValerianRoot)钙片卡哇卡哇(Kava
Kava)非处方安眠药颉草会致多梦(16%),卡哇会致头晕(12%).副反应:褪黑素（脑白金）:松果体分泌
的激素1可作用于视交叉神经核受体2可增加睡眠2可调整生物节律1,2安全性和耐受性尚不清楚3对失眠病人的疗效不肯定2大样
本临床验证缺乏药物治疗的方法非处方安眠药(cont)HauriPJ.ClinChestMed.1998;19:1
57-168.NHLBIWorkingGrouponInsomnia.AmFamPhysician.1999;5
9:3029-3038.SiegristC,etal.JPinealRes.2001;30:34-42.药物治疗
的方法）阻断H1受体推荐剂量下是安全的短期治疗失眠可能有效长期疗效尚无证据可能有不良反应非处方安眠药有镇静
作用的抗组胺药:苯海拉明异丙嗪（非那根）氯苯吡胺（扑尔敏NHLBIWorkingGrouponInsomnia.
AmFamPhysician.1999;59:3029-3038.有镇静作用的抗组胺药中枢神经系统:镇静视物模糊
头晕神经质耳鸣失眠无精打采震颤共济失调胃肠道:食欲丧失恶心呕吐 上腹不适便秘腹泻可能的不良反应Bro
wnNJ,RobertsLJ.In:Goodman&Gilman’sThePharmacologicBasis
ofTherapeutics.10thed.NewYork,NY:McGraw-Hill;2001:645-66
7.有镇静作用的抗组胺药口干呼吸道干燥便秘尿储留或尿频排尿困难抗胆碱能作用BrownNJ,RobertsLJ
.In:Goodman&Gilman’sThePharmacologicBasisofTherapeutics.
10thed.NewYork,NY:McGraw-Hill;2001:645-667.有镇静作用的抗抑郁药作为催
眠常用非常小的剂量在抑郁症的临床研究中显示有催眠作用但在非抑郁症病人中几乎没有催眠这方面的疗效研究阿米替林多塞平米氮平
曲唑酮HauriPJ.ClinChestMed.1998;19:157-168.Elavilisareg
isteredtrademarkofAstraZenecaPharmaceuticalsLP.
SinequanisaregisteredtrademarkofPfizerInc.
DesyrelandSerzonearearegis
teredtrademarksofBristol-MyersSquibbCompany.巴比妥类在20世纪初使用。主
要特征包括：有效，但打乱睡眠节律，不诱导生理性睡眠；明确产生耐受性和依赖性；过量时有严重不良反应甚至致死，使用酒精后尤甚；
目前禁用此药做为催眠剂。苯巴比妥异戊巴比妥
司可巴比妥苯二氮卓类在20世纪60年代开始使用。主要特征有：非选择性拮抗GABA
-A复合受体，具有镇静、肌松和抗痉挛作用；通过改变睡眠结构延长总体睡眠时间，缩短睡眠潜伏期不良反应及并发症包括：日间困倦、认知
和精神运动损害、失眠反弹及戒断综合征；长期大量使用产生耐受性和依赖性。安定，舒乐安定，硝基安定等安定类药物
BZDs的药代学特点口服吸收快、分布广，具脂溶性，可通过血脑屏障和胎盘屏障（对胎儿会带来不利影响）主要通过肝微粒体P
450酶系代谢，多数BZDs有活性代谢物。长期应用可产生药物蓄积。BZDs品种繁多，基本化学结构、药理作用、代谢特点相似。然
而，每种药物的毫克效能、受体亲和性、脂溶性、代谢途径、半衰期等具有差异，临床应用须予考虑。BZDs与其他药物间的相互作用
由于药物对肝药酶的影响，BZDs与其他药物和用须注意相互影响：（1）慎与合用红霉素、伊曲康唑、酮康唑、地尔
硫卓及蛋白酶抑制剂等（抑制CYP3A4），增加血药浓度。（2）慎合用西米替丁、氟西汀、帕罗西汀、神经阻滞剂（抑制CYP2D6）
，增加各自血药浓度。（3）卡马西平降低BDZs血药浓度（兴奋CYP）。（4）BZDs与酒合用，导致精神运动损害和过度镇静。B
ZDs与其他药物间的相互作用（5）BZDs与戒酒硫合用，增加镇静作用，降低BZDs清除率。（6）BZDs与抗胆碱能药物合用，加
重对认知功能的损害。（7）高剂量氯氮平与长时效的BZDs合用可产生严重不良反应。
按时效（取决于半衰期的长
短）BZDs的分类（1）超短半衰期的BZDs：T1/2短于5hr，不引起蓄积。适应症：
麻醉前给药和催眠。代表药：三唑仑（海洛神，Triazolam），
咪达唑仑（多美康，midazolam或
Dormicam）。不同半衰期的BZDs（2）短和中半衰期的BZDsT1/2为5~24hr，母药有蓄积
作用，其代谢物无蓄积作用。适应症：治疗焦虑、失眠、戒酒、术前用药、癫痫持续状态。代
表药：奥沙西泮（舒宁，Oxazepam）、劳拉西泮（Lorazepam,氯
羟安定）、佳静安定（阿普唑仑）。（3）长半衰期的BZDs
T1/2长于24hr，母药及多代谢产物有蓄积作用。适应症：治疗焦虑、抗癫痫、治疗肌肉痉挛；心梗、室性心
律不齐、心衰的辅助治疗。代表药：利眠宁（氯氮卓,chlodiazepoxide）
普拉西泮（prazepam）氯硝安定（clon
azepam）BEDs的禁忌症：禁用：严重心血管疾病，肾病，药物过敏，青光眼，重症肌无力，药瘾，妊娠期的前
3个月，与酒精及CNS抑制剂的合用。慎用：老年人，儿童，分娩前及分娩中。特殊人群用药：（1）肝
肾功能损害者，药物代谢减慢，排泄减缓，应小剂量应用。（2）妊娠：BEDs可通过胎盘屏障，进入胎盘，作用于胎儿组织，可致唇裂，
心房或室间隔缺损等。（3）哺乳：BEDs少量由乳汁排出，可致婴儿昏睡，黄疸。（4）癫痫：突然停药可发生癫痫。BZDs
的不良反应：（1）呼吸抑制，血压下降，心率上升，心输出量可能减少。（2）CNS抑制：困倦，乏力，嗜睡，头晕，操作和认
知功能受损。（3）周围神经功能受损：口干，视物模糊。（4）矛盾反应：BZDs引起?抑制现象：失眠，恶梦，心动过速，焦虑
，恐惧，精神病性症状，癫痫发作。BEDs的成瘾性：（1）BEDs具有成瘾性，属IV类管制药，使用时需权衡利弊，突
然停药，失眠会很快反跳。（2）成瘾性的影响因素：1高剂量，长期应用，2本人或家族中有
酒精依赖或酒精中毒者。3其它镇静剂成瘾者。BEDs戒断综合征（症状可能发生在治疗剂量撤药时）（1）
症状表现：焦虑，激越，失眠，噩梦，意识混浊，精神性症状，厌食等，心动过速，心
悸等，视物模糊，对声光敏感，感觉异常，肌肉抽搐等。（2）预防：1逐渐减少
剂量或服药次数，渐停药2交替用药，3换用非BEDs的催眠药，4
强调非药物治疗。BZDs的超量中毒：（1）单一BZDs超量相对安全。（2）注意混合药物超量，如BZDs与
三环类药等。（3）GABA受体阻断剂氟吗西尼（Flumazenil安易醒）可逆转BZDs的抑制作用（包括超量中毒昏迷及
基础麻醉的镇静作用。）非苯二氮卓类安眠葯非苯二氮卓受体激动剂，包括唑吡坦（思诺思）、佐匹克隆、扎来普
隆，由于此类药物较BZDs副作用少，已成为使用催眠药较好的选择。新一代非苯二氮卓类催眠药，不同于BZD
s的药理作用是选择性的作用于BZ1型（BZ1或称?1受体）受体，镇静催眠作用强，而副作用少。失眠的治疗川北医学院附属医院
吴碧华前言人一生中有三分之一的时间是在睡眠中度过，五天不睡眠人就会死去，可见睡眠是人的生理需要。睡眠作为生命所必须
的过程，是机体复原、整合和巩固记忆的重要环节，是健康不可缺少的组成部分。据世界卫生组织调查，27%的人有睡眠问题。国际精神卫生组
织主办的全球睡眠和健康计划于2001年发起了一项全球性的活动――将每年的3月21日，即春季的第一天定为“世界睡眠日”。什么是睡眠
？生存有两种状态：睡眠，觉醒。睡眠是感官意识降低、自主活动丧失的一种生理状态。睡眠是一种主动的大脑活动过程，并非被动状态或现
象。睡眠是一种周期性状态。正常睡眠睡眠结构正常睡眠周期分5个时期两个时相非快速眼动睡
眠(NREM)(或称慢波睡眠)快速眼动睡眠(REM)(或称快波睡眠)以NREM睡眠开始，通常整个晚上3-5个循环每个周期大约9
0-110分钟睡眠结构1期睡眠，占总睡眠时间约5%处于半睡半醒之间眼球活动缓慢肌肉活动放缓易被唤醒2期睡眠，占总睡眠
时间约50%大脑活动减慢呼吸均匀眼动停止睡眠结构3、4期睡眠，占总睡眠时间约25%对恢复体力起重要作用肌肉活动消失
很难唤醒5快速眼动睡眠，占总睡眠时间约20%大脑对白天的经验进行整合呼吸加快、变浅、不规则眼球向各方向快速跳动，肢体肌肉
暂时瘫痪睡眠结构的重要性睡眠的生理作用与稳定、完整的睡眠结构有关，因此任何形式的睡眠障碍，只要影响睡眠结构，均可能影响机体的
生理功能临床最常见的睡眠障碍是各种形式的失眠、入睡障碍、醒转次数增加、早醒、浅睡眠等，均为睡眠结构稳定性与完整性产生影响
睡眠障碍失眠定义：严格意义上说是指入睡或维持睡眠困难。临床通常指患者对睡眠时间和/或质
量不满意并且影响白天社会功能的一种主观体验。失眠是全球高发的睡眠障碍Henry,DHenry,D.,etal
.Issleepreallyforsissies?Understandingtheroleofworkin
insomniaintheUS.SocialScience&Medicine(2007),doi:10.1016
/j.socscimed.2007.10.007；OhayonMM,PartinenM.Insomniaandglo
balsleepdissatisfactioninFinland.JSleepRes.2002Dec;11(4)
:339-46.,etal.Issleepreallyforsissies?Understandingthe
roleofworkininsomniaintheUS.SocialScience&Medicine(20
07),doi:10.1016/j.socscimed.2007.10.007；OhayonMM,PartinenM.
InsomniaandglobalsleepdissatisfactioninFinland.JSleepRes
.2002Dec;11(4):339-46失眠是世界性的问题，全球范围内失眠发生率高是世界性的问题，全球范围内失眠发生率
高
失眠的发病率(%)中国43.4曼彻斯特32安卡拉32.9
长崎8.3雅典21.7巴黎29.3班加罗尔20.2
圣地亚哥39.5柏林29.0西雅图23.3格罗宁根34.0
所有城市26.8伊巴丹14.5美因兹32失眠的分类根据病程分为：急性失眠：病程小于4周；
亚急性失眠：病程大于4周,小于6个月；慢性失眠：病程大于6个月。中华神经科杂志。2006，39（2）：141-143失眠
的分类依据严重程度分类：轻度失眠：偶尔发生，对生活质量影响小；中度失眠：每晚发生，中度影响生活质量，伴有一定的症状（
易激惹、焦虑、疲乏等）；重度失眠：每晚发生，中度或严重影响生活质量，临床症状表现突出（易激惹、焦虑、疲乏等）。失眠的分类依
据临床表现形式分类入睡期失眠睡眠维持期失眠睡眠结束期失眠失眠是一个世界性问题，在全球范围内，失眠的发生率高。在英国、美
国的发生率分别为37%和40%，而在中国达到43.4%。而长期失眠也使精神疾病的发生危险性更高，研究发现，失眠的患者中抑郁症
的发生率远远高于无失眠人，达4倍之多。Variousmedicationsthatthepatientmaybe
takingforotherdisordersaswellassubstanceslikenicotine,
alcoholandcaffeinecancauseinsomnia.1-3Certainover-the-coun
terproductsmayalsocauseinsomnia.1-3Elderlypatientsmaybe
particularlypronetodrug-inducedinsomnia.Notonlydomanyof
themtakenumerousprescriptionandnonprescriptionmedications,
butbecauseoftheirlightersleep,olderpatientsmaybemoresu
sceptibletotheeffectsofmedicationsthatactontheCNS.KEY
POINTS Variousmedicationscandisruptsleep. Elderlypatients
areatgreaterriskfordrug-inducedinsomniaduetomore frequ
entuseofmedicationsandgreatersusceptibilitytoCNS-active
medications,comparedwithyoungerpatients.1. AshtonH.Theeff
ectsofdrugsonsleep.In:CooperR,ed.Sleep.London:Chapman
&Hall Medical;1994:175-211.2. BeckerPM,JamiesonAO,BrownW
D.Insomnia.Useofa‘decisiontree’toassessand treat.Postg
radMed.1993;93:66-85.3. BruntonSA.Whenyourpatientcan’tsl
eep.FamilyPracticeRecertification. 1992;14:149-168.Certain
lifestyleactivitiesconstitutepoorsleephygiene.Keepingirre
gulartimesforsleepingandwaking,exercisingtoolateatnight
ornotatall,androutinelyusingcaffeine,nicotine,and/oral
coholbeforebedtimecaneachresultininsomnia.Educatingpatie
ntsabouttheimportanceofgoodsleephygiene,includingthesle
ephygienemeasureslistedinthisslide,isabasiccomponento
ftreatinginsomnia.1,2KEYPOINTS Insomniacanbecausedbyc
ertainlifestyleactivities. Educatingpatientsabouttheimport
anceofgoodsleephygieneisabasic componentoftreatinginso
mnia.1.BruntonSA.Whenyourpatientcan’tsleep.FamilyPracti
ceRecertification. 1992;14:149-170.2.HauriPJ.Insomnia.Cli
nChestMed.1998;19:157-168.Severalothernonpharmacologici
nterventionshavebeenfoundtobeeffectiveintreatinginsomnia
.Alloftheseinterventionsaimtopromoteimprovedsleepbyal
teringmaladaptivebehavioralandcognitiveroutinesassociated
withsleep.1Forexample,relaxationtherapy,suchasprogressiv
emusclerelaxation,meditation,andbiofeedback,mayhelptored
ucephysiologicarousallevelsatornearbedtime,andthisint
urnmayhelpthepatienttofallasleepmoreeasilyandquickly.
1Anotherinterventioncalledsleeprestrictionaimstomaximize
theamountoftimespentsleepinginbed.1Initially,patientse
xperiencepartialsleepdeprivation,whichhelpstoconsolidatet
heirsleep.Bygraduallyincreasingtheamountoftimetheyspen
dinbedwhilemaintainingtheimprovedsleepefficiency,patient
sworktowardachievinganormalnight’ssleep.1Cognitivebehavi
ortherapyattemptstoalterthepatient’sviewofsleepproblems
.Insomniapatientsmayholdfalseormaladaptivebeliefsconcern
ingsleep,suchasthattheyneedaspecificnumberofhoursofs
leepinordertofunctionproperlyduringtheday,ortheymayse
lectivelyrememberonlythosenightsduringwhichtheyhadlongb
outsofwakefulness.Withcognitivetherapy,patientsaregiveni
nformationaboutsleeptohelpthemcorrecttheirdysfunctionalb
eliefsandmisperceptions.1Littlescientificresearchhasbeen
conductedconcerningthehypnoticefficacyofvariousmineral,v
itamin,andherbalsupplements,including,butnotlimitedto,ca
lcium,magnesium,kavakava,andvalerianroot.However,somerep
ortsinthelaymediasuggesttheymaybeusefulforthereliefo
finsomniasymptoms.1Ifpatientsexpressadesiretotrysuchco
mpounds,physiciansmaysuggestusingasleepdiarytoevaluatee
fficacy,beingsuretoevaluatesleepduringconsecutiveweekswi
thandwithoutuseofthecompound.1KEYPOINTS Whilethereisl
ittlescientificevidencetosupporttheuseofvitamin,mineral
andherbalsupplementsforthereliefofinsomnia,reportsinth
elaypress concerningtheirefficacymayleadsomepatientsto
usethem. Physicianscanhelppatientsevaluateefficacybyinst
ructingthemtousea sleepdiary,andthencomparingratingsof
sleeponnightswithand withoutthesupplement.1. HauriPJ.I
nsomnia.ClinChestMed.1998;19:157-168.Melatoninisahormo
nesecretedatnightbythepinealgland,locatedinthebrain.1
Melatoninmayinteractwithreceptorsinthesuprachiasmaticnucl
eiofthehypothalamus.Melatoninmayalsopromotesleepinessand
altercircadianrhythms.2Arecentopen-labelpilotstudysugges
tsthatitmayimprovesleepamongmiddle-agedandelderlypatien
tswithinsomnia.3However,mostpatientsinthisstudywereconc
omitantlytakingabenzodiazepine,andsothedirecteffectsofm
elatoninonsleepremainunclear.Ingeneral,resultsofclinical
studiesinpatientswithinsomniahavebeeninconsistent.2Ther
ecentpilotstudyconcludedthatmelatoninissafeandwelltoler
atedevenwhentakendailyforaslongas6months.3Itshouldbe
noted,however,thatwell-controlled,large-scaletrialsofthis
agentareabsent.KEYPOINTS Melatoninissecretedatnightby
thepinealglandandmayactonreceptors locatedinthesuprach
iasmaticnuclei. Insomestudiesitappearedtopromotesleepine
ssandtoaltercircadian rhythms. Someresearchsuggestsitma
ybeusefulintreatinginsomniaamongmiddle- agedandelderlyp
atientsandasanadjuncttobenzodiazepinetherapy; however,in
general,studyresultshavebeeninconsistent. Thesafetyandt
olerabilityofmelatoninareunclearduetolackofstudies. No
large-scaleclinicaltrialshaveyetbeenconducted.1. HauriPJ.
Insomnia.ClinChestMed.1998;19:157-168.2. NationalHeart,L
ung,andBloodInstitute(NHLBI)WorkingGrouponInsomnia.Insom
nia: assessmentandmanagementinprimarycare.AmFamPhysician
.1999;59:3029-3038.3. SiegristC,BenedettiC,OrlandoA,eta
l.Lackofchangesinserumprolactin,FSH,TSH, andestradiola
ftermelatonintreatmentindosesthatimprovesleepandreduce
benzodiazepineconsumptioninsleep-disturbed,middle-aged,ande
lderlypatients.JPineal Res.2001;30:34-42.Sedatingantihis
tamines,asaclass,aredrugsthatantagonizecentralH1recepto
rs.Thisistheclassofantihistaminesthatwillbediscussedin
thispresentation.Mostover-the-countersleepaidscontainana
ntihistamine,andtheonemostcommonlyusedisdiphenhydramine.1
Olderstudieshavedemonstratedefficacyfortheshort-termimpr
ovementofsleep.However,long-termefficacyhasnotbeenshown.
Adverseeffectsofantihistaminescommonlyincludeanticholinerg
iceffectsaswellasdaytimesedationandcognitiveimpairment.1
KEYPOINTS Antihistaminesarecommonlycontainedinover-the-co
untersleepaids. Olderstudiesindicatetheyareeffectivefor
theshort-termreliefofinsomnia. Long-termefficacyhasnotbe
endemonstrated. Adverseeffectsassociatedwiththeuseofanti
histaminesincludedaytime sedation,cognitiveimpairmentandan
ticholinergiceffects.1. NationalHeart,Lung,andBloodInstit
ute(NHLBI)WorkingGrouponInsomnia. Insomnia:assessmentand
managementinprimarycare.AmFamPhysician. 1999;59:3029-3038
. Althoughsedatingantihistaminesmaybethoughtofasatre
atmentforsleepdisturbances,adverseeffectsmaylimittheirus
e.1Effectsonthecentralnervoussystemarethemostfrequent
effectsobservedwiththeseantihistamines.Theseeffectscanin
cludedizziness,nervousness,blurredvisionandtremors.Insomni
a,tinnitus,lassitudeandpoorcoordinationcanalsoresult.Gas
trointestinalsideeffectsarethesecondmostfrequentsideeffe
ctsobservedwithantihistamineuse.Thesecanincludelossofappetite,vomiting,nausea,diarrhea,constipationandepigastricdistress.KEYPOINT Adverseeffectsfromantihistaminescanaffectthecentralnervoussystem andthegastrointestinalsystemandmaylimittheiruseincertainpatients.1. BrownNJ,RobertsLJ.Histamine,bradykinin,andtheirantagonists.In:HardmanJG, LimbirdLE,GilmanAG,eds.Goodman&Gilman’sThePharmacologicBasisof Therapeutics.10thed.NewYork,NY:McGraw-Hill;2001:645-667.Anticholinergicactionscanresultfromfirst-generation(sedating)H1–receptorantagonistsandmayincludedrymouth,drynessoftherespiratorypassages,constipation,urinaryretentionorfrequency,anddysuria.1KEYPOINT Anticholinergicactionscanresultfromfirst-generation(sedating) H1–receptorantagonists.1. BrownNJ,RobertsLJ.Histamine,bradykinin,andtheirantagonists.In:HardmanJG, LimbirdLE,GilmanAG,eds.Goodman&Gilman’sThePharmacologicBasisof Therapeutics.10thed.NewYork,NY:McGraw-Hill;2001:645-667.Antidepressantswithsedativesideeffectsareincreasinglybeingusedashypnoticagents.1Amongthetricyclicantidepressants,Elavil?(amitriptyline10or25mg)andSinequan?(doxepin≤25mg)havepotentsedatingeffectsandareusedashypnotics.Whenusedforthispurpose,theyareprescribedinverylowdoses.However,evenattheselowdoses,duringtheinitialphaseofsuchtreatment,daytimesedationmaybemarked.Further,lowdosesofthesetricyclicantidepressantshavebeennotedtoaggravateperiodiclimbmovementdisorderandrestlesslegssyndrome.1,2Trazodone(Desyrel?)isanantidepressantthatisalsousedasahypnoticatlowdoses.Lessoften,nefazodone(Serzone?),astructurallyrelatedcompound,isused.Trazodonedoesnotaggravateperiodiclimbmovementsorrestlesslegs,andisthussometimeschosenoverElavilandSinequan.1 |
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