Insomnia ndiyo inowanzosangana nehope, inotsanangurwa sehosha yekurara inoitika usiku hutatu kana kupfuura pavhiki, inotora mwedzi inopfuura mitatu, uye haisi kukonzerwa nekushayikwa kwemikana yekurara. Vanenge 10% yevakuru vanosangana nemaitiro ekushaya hope, uye imwe 15% kusvika 20% inoshuma dzimwe nguva zviratidzo zvekushaya hope. Varwere venguva refu vanoshaya hope vari panjodzi yakawedzerwa yekuva nekuora mwoyo kukuru, BP, chirwere cheAlzheimer, uye kurasikirwa nekugona basa.
Nyaya dzekiriniki
Hunhu hwekushaya hope imhando yekurara isingafadzi kana nguva, inoperekedzwa nekunetseka kurara kana kuchengetedza kurara, pamwe nekunetseka kwakanyanya kwepfungwa kana kusashanda kwemasikati. Insomnia chirwere chokurara chinoitika usiku hutatu kana kupfuura pavhiki, chinopfuurira kwemwedzi inopfuura mitatu, uye hachikonzerwi nemikana yokurara shoma. Kusarara kunowanzoitika panguva imwe chete nezvimwe zvirwere zvemuviri (zvakadai sekurwadziwa), zvirwere zvepfungwa (zvakadai sokuora mwoyo), nezvimwe zvirwere zvekurara (zvakadai sechirwere chegumbo chisina kuzorora uye kufema kwehope).
Insomnia idambudziko rinonyanya kunetsa pakurara pakati peruzhinji, uye nderimwe rematambudziko anowanzo kutaurwa apo varwere vanotsvaga kurapwa kuzvipatara zvekutanga, asi kazhinji vasingarapike. Vanenge 10% yevakuru vanosangana nemaitiro ekushaya hope, uye imwe 15% kusvika 20% yevanhu vakuru vanotaura dzimwe nguva zviratidzo zvekushaya hope. Kusarara kunowanzoonekwa muvakadzi uye vanhu vane matambudziko epfungwa kana emuviri, uye chiitiko chayo chinozowedzera muzera repakati uye mushure mezera repakati, pamwe neperimenopause uye menopause. Isu tichiri kuziva zvishoma nezve pathological uye physiological nzira dzekusarara, asi parizvino zvinotendwa kuti psychological and physiological overstimulation ndiwo maitiro ayo makuru.
Kusarara kunogona kunge kuri kwemamiriro ezvinhu kana kuti pano neapo, asi vanopfuura 50% yevarwere vanoramba vachishaya hope. Kushaya hope kwekutanga kunowanzo kukonzerwa nemamiriro ekugara anonetsekana, nyaya dzehutano, zvirongwa zvebasa zvisina kujairika, kana kufamba nepakati penguva dzakawanda (musiyano wenguva). Kunyange zvazvo vanhu vakawanda vachizodzokera kuhope dzenguva dzose mushure mekujairana nezviitiko zvinotanga, avo vane dambudziko rekushaya hope vanogona kutadza kurara. Mafungiro, maitiro, kana zvinhu zvemuviri zvinowanzokonzera matambudziko ekurara kwenguva refu. Kusarara kwenguva refu kunoperekedzwa nenjodzi yakawedzera yekuora mwoyo kukuru, BP, chirwere cheAlzheimer, uye kurasikirwa nekugona basa.
Kuongororwa uye kuongororwa kwekushaya hope kunoenderana nekuferefetwa kwakadzama kwenhoroondo yekurapa, kurekodha zviratidzo, nzira yehurwere, comorbidities, uye zvimwe zvinokonzeresa. 24-awa yekurara yekumuka maitiro kurekodha inogona kuona mamwe maitiro uye nharaunda kupindira zvinangwa. Murwere anonzi maturusi ekuongorora uye diaries yekurara anogona kupa ruzivo rwakakosha nezve hunhu uye kuoma kwezviratidzo zvekushaya hope, skrini yekubatsira kune mamwe matambudziko ekurara, uye kutarisa kufambira mberi kwekurapa.
Nzira uye Uchapupu
Nzira dzemazuva ano dzekurapa kushaya hope dzinosanganisira kunyorerwa nemishonga, psychological and behavioral therapy (inozivikanwawo secognitive-behavioral therapy [CBT-I] yekushaya hope), uye adjuvant uye mamwe marapirwo. Nzira yekurapa yakajairika kuvarwere ndeyekutanga kushandisa zvinodhaka zvinotengeswa nechiremba mushure mekutsvaga kurapwa. Vashoma varwere vanogamuchira kurapwa kweCBT-I, zvimwe nekuda kwekushaikwa kwevarapi vakanyatsodzidziswa.
CBTI-I
CBT-I inosanganisira nhevedzano yezvirongwa zvine chinangwa chekuchinja maitiro uye pfungwa dzepfungwa dzinokonzera kushaya hope, sekunyanya kuzvidya mwoyo uye nekutenda kwakashata pamusoro pekurara. Nheyo yemukati yeCBT-I inosanganisira maitiro ekuita uye kurara kuronga mazano (kurambidza kurara uye kudzora kukurudzira), nzira dzekuzorora, kupindira kwepfungwa nekuziva (kana zvese) zvine chinangwa chekuchinja zvitendero zvisina kunaka uye kunetseka kwakanyanya pamusoro pekusarara, pamwe nedzidzo yehutsanana hwekurara. Dzimwe nzira dzekupindira kwepfungwa dzakadai seAcceptance and Commitment Therapy uye Mindfulness Based Therapy dzakashandiswawo kurapa kushaya hope, asi pane data shoma rinotsigira kushanda kwavo, uye dzinoda kupfuuridzirwa kwenguva yakati rebei kuti dzibatsirwe. CBT-I chirongwa chekurapa chinotarisa pakurara uye chakanangana nedambudziko. Inowanzo kutungamirirwa nemurapi wehutano hwepfungwa (akadai semuongorori wepfungwa) kwe4-8 mazano. Kune nzira dzakasiyana dzekuita dzeCBT-I, kusanganisira fomu pfupi uye fomu yeboka, nekutora chikamu kwevamwe vashandi vezvehutano (sevanamukoti vanodzidzira), pamwe nekushandisa telemedicine kana mapuratifomu edhijitari.
Parizvino, CBT-I inokurudzirwa seyekutanga-mutsetse wekurapa mumirayiridzo yekiriniki nemasangano akawanda ehunyanzvi. Miedzo yemakiriniki uye meta-kuongorora kwakaratidza kuti CBT-Ini ndinogona kuvandudza zvakanyanya murwere akashumwa mhedzisiro. Mune meta-kuongororwa kwemiedzo iyi, CBT-Ini yakawanikwa ichivandudza kuomarara kwezviratidzo zvekushaya hope, nguva yekurara, uye nguva yekumuka yekurara. Kuvandudzwa kwezviratidzo zvemasikati (zvakadai sekuneta uye manzwiro) uye hupenyu hwehupenyu hudiki, pamwe nekuda kwekushandiswa kwemaitiro egeneric asina kunyatsogadzirirwa kushaya hope. Pakazara, vanenge 60% kusvika 70% yevarwere vane mhinduro yekliniki, nekuderera kwe7 points muInsomnia Severity Index (ISI), iyo inotangira kubva ku0 kusvika ku28 points, ine zvibodzwa zvepamusoro zvinoratidza kunyanya kusuruvara kwakanyanya. Mushure memavhiki matanhatu-8 ekurapwa, vanenge 50% yevarwere vanoshaya hope vanowana kuregererwa (ISI yakazara mamakisi, <8), uye 40% -45% yevarwere vanowana kuregererwa kunoramba kuripo kwemwedzi gumi nemiviri.
Mumakore gumi adarika, dhijitari CBT-I (eCBT-I) yakawedzera kufarirwa uye inogona kupedzisira yadzikisa musiyano wakakosha pakati peCBT-I kudiwa uye kuwanikwa. ECBT-I ine mhedzisiro yakanaka pane zvakati wandei zvakabuda pakurara, zvinosanganisira kuoma kwekushaya hope, kugona kurara, subjective kurara mhando, kumuka mushure mekurara, nguva yekurara, yakazara nguva yekurara, uye nhamba yekumuka kwehusiku. Iyi mhedzisiro yakafanana neiyo inocherechedzwa kumeso nechiso CBT-I miedzo uye inochengeterwa 4-48 mavhiki mushure mekutevera.
Kurapa zvirwere zvakadai sekuora mwoyo uye kurwadziwa kusingaperi kunogona kuderedza zviratidzo zvekushaya hope, asi kazhinji hazvigoni kugadzirisa zvachose matambudziko ekushaya hope. Kusiyana neizvi, kurapa kushaya hope kunogona kuvandudza kurara kwevarwere vane comorbidities, asi mhedzisiro paiyo comorbidities pachayo haina kuenderana. Semuenzaniso, kurapwa kwekushaya hope kunogona kuderedza zviratidzo zvekuora mwoyo, kuderedza chiyero chechiitiko uye kudzokazve kwekuora mwoyo, asi kune zvishoma zvinokanganisa kurwadziwa kusingaperi.
Iyo tiered yekurapa nzira inogona kubatsira kugadzirisa nyaya yekusakwana zviwanikwa zvinodikanwa kune echinyakare psychopath uye maitiro ekurapa. Imwe nzira inoratidza kushandisa dzidzo, kutarisa, uye nzira dzekuzvibatsira padanho rekutanga, dhijitari kana boka repfungwa uye maitiro ekurapa padanho rechipiri, kurapa kwepfungwa uye hunhu padanho rechitatu, uye kurapwa kwemishonga semushonga wenguva pfupi padanho rega rega.
Kurapa kwemishonga
Kwemakore makumi maviri adarika, maitiro ekunyorerwa kwemishonga muUnited States akachinja zvakanyanya. Nhamba yemishonga ye benzodiazepine receptor agonists inoramba ichidzikira, nepo chiyero chetrazodone chiri kuramba chichiwedzera, kunyange zvazvo US Food and Drug Administration (FDA) isina kunyora kushaya hope sechiratidzo chetrazodone. Mukuwedzera, kudya kudzvinyirira receptor antagonists kwakatangwa muna 2014 uye yakashandiswa zvakanyanya.
Kukura kwehukuru hwemishonga mitsva (nguva yemishonga, <4 mavhiki) pamigumisiro yekutanga inotsanangurwa kuburikidza nemurwere wekuongorora zviyero, kusanganisira Insomnia Severity Index, Pittsburgh Sleep Quality Index, Leeds Sleep Questionnaire, uye Sleep Diary. Saizi ye0.2 inonzi idiki, saizi ye0.5 inonzi ine mwero, uye saizi ye0.8 inonzi yakakura.
Iyo Beers maitiro (rondedzero yemishonga inoonekwa seisina kukodzera kuvarwere vane makore makumi matanhatu nemashanu kana kupfuura) inokurudzira kudzivirira kushandisa mushonga uyu.
Mushonga hauna kubvumidzwa neFDA pakurapa kwekurara. Mishonga yose yakanyorwa patafura inorondedzerwa seChikamu cheKubata C neUS FDA, kunze kwemishonga inotevera: Triazolam uye Temazepam (Kirasi X); Clonazepam (Kirasi D); Diphenhydramine uye docetamine (kirasi B).
1. Benzodiazepine receptor agonist class hypnotic drugs
Benzodiazepine receptor agonists inosanganisira benzodiazepine zvinodhaka uye isiri benzodiazepine zvinodhaka (inozivikanwawo seZ-class zvinodhaka). Miedzo yemakiriniki uye meta-analyses yakaratidza kuti benzodiazepine receptor agonists inogona kunyatsopfupisa nguva yekurara, kuderedza kumuka kwekurara, uye kuwedzera zvishoma nguva yekurara (Tafura 4). Maererano nemishumo yevarwere, migumisiro ye benzodiazepine receptor agonists inosanganisira anterograde amnesia (<5%), sedation zuva rinotevera (5% ~ 10%), uye maitiro akaoma panguva yekurara zvakadai sekurota masikati, kudya, kana kutyaira (3% ~ 5%). Iyo yekupedzisira side mhedzisiro inokonzerwa nebhokisi dema yambiro yezolpidem, zaleplon, uye escitalopram. 20% kusvika 50% yevarwere vanoona kushivirira kwezvinodhaka uye kutsamira kwepanyama mushure mekutora mishonga husiku hwega hwega, zvichiratidzwa serebound insomnia uye withdrawal syndrome.
2. Sedative heterocyclic zvinodhaka
Sedative antidepressants, kusanganisira tricyclic zvinodhaka zvakadai seamitriptyline, demethylamine, uye doxepin, uye heterocyclic mishonga yakadai se olanzapine uye trazodone, inowanzopiwa mishonga yekurapa kushaya hope. Chete doxepin (3-6 mg zuva nezuva, inotorwa husiku) yakatenderwa neUS FDA yekurapa kushaya hope. Humbowo huripo hunoratidza kuti sedative antidepressants inogona kunatsiridza kunaka kwekurara, kugona kurara, uye kurebesa nguva yekurara yakakwana, asi ine zvishoma zvinokanganisa nguva yekurara. Kunyangwe iyo US FDA isingatarise kushaya hope sechiratidzo chemishonga iyi, varapi nevarwere vanowanzofarira mishonga iyi nekuti ine zvinyoro mhedzisiro pamitengo yakaderera uye ruzivo rwekiriniki rwakaratidza kushanda kwayo. Migumisiro yakaipa inosanganisira sedation, muromo wakaoma, kunonoka kwemoyo conduction, hypotension, uye hypertension.
3. Vanopikisa Appetite receptor
Iyo neurons ine orexin mu lateral hypothalamus inokurudzira nuclei mu brain brain uye hypothalamus inokurudzira kumuka, uye inhibit nuclei mu ventral lateral uye medial preoptic nzvimbo dzinokurudzira kurara. Mukupesana, zvinodzvinyirira kuda kudya zvinogona kutadzisa kufambisa tsinga, kudzvinyirira kumuka, uye kukurudzira kurara. Vatatu vaviri vanopikisa orexin receptor antagonists (sucorexant, lemborxant, uye daridorexint) vakabvumidzwa neUS FDA kurapwa kwekushaya hope. Miedzo yemakiriniki inotsigira kushanda kwavo mukurara kwekutanga uye kugadzirisa. Migumisiro yakaipa inosanganisira sedation, kuneta, uye kurota kusina kujairika. Nekuda kwekushomeka kwe endogenous appetite mahormone, ayo anogona kutungamirira ku narcolepsy ne cataplexy, appetite hormone antagonists inopesana muvarwere vakadaro.
4. Melatonin uye melatonin receptor agonists
Melatonin ihomoni inovanzwa nepineal gland pasi pemamiriro erima usiku. Exogenous melatonin inogona kusvika kumazinga eropa kupfuura mazinga emuviri, aine nguva dzakasiyana zvichienderana nedosi chaiyo uye magadzirirwo. Muyero wakakodzera wemelatonin wekurapa kushaya hope hausati watemwa. Miedzo inodzorwa inobatanidza vanhu vakuru yakaratidza kuti melatonin ine diki mhedzisiro pakurara, uye inenge isina mhedzisiro yekumuka panguva yekurara uye yakazara nguva yekurara. Mishonga inosunga ku melatonin MT1 uye MT2 receptors yakatenderwa kurapa refractory insomnia (ramelteon) uye circadian sleep wake disorder (tasimelteon). Kufanana nemelatonin, mishonga iyi inenge isina mhedzisiro pakumuka kana nguva yekurara yakakwana mushure mekurara. Kurara uye kuneta ndizvo zvinowanzoitika.
5. Mimwe mishonga
Antihistamines mu-over-the-counter zvinodhaka (diphenhydramine uye docetamine) nemishonga yemishonga (hydroxyzine) ndiyo inonyanya kushandiswa kurapa kushaya hope. Iyo data inotsigira kushanda kwayo haina kusimba, asi kuwanikwa kwavo uye kunoonekwa kuchengetedzwa kune varwere kungave zvikonzero zvekuzivikanwa kwavo zvichienzaniswa nebenzodiazepine receptor agonists. Sedative antihistamines inogona kukonzera kuwandisa sedation, anticholinergic side effects, uye kuwedzera njodzi yedementia. Gabapentin uye pregabalin zvinowanzoshandiswa kurapa kurwadziwa kusingaperi uye zvakare mutsara wekutanga kurapa zvinodhaka zvekusazorora gumbo syndrome. Iyi mishonga ine sedative effect, inowedzera kunonoka kwehope, uye inoshandiswa kurapa kushaya hope (kupfuura zviratidzo), kunyanya kana ichiperekedzwa nemarwadzo. Kuneta, kukotsira, dzungu, uye ataxia ndizvo zvinowanzoitika.
Kusarudzwa kwemishonga yehypnotic
Kana mishonga yakasarudzwa kuti irapwe, short acting benzodiazepine receptor agonists, orexin antagonists, kana pasi-dose heterocyclic mishonga ndiyo inonzwisisika yekutanga sarudzo mune dzakawanda kliniki mamiriro ezvinhu. Benzodiazepine receptor agonists inogona kunge iri iyo inosarudzika kurapwa kwevarwere vane kushaya hope vane zviratidzo zvekurara, vechidiki vakura varwere, uye varwere vangangoda kurapwa kwenguva pfupi (sekutadza kurara nekuda kweacute kana periodic stressors). Paunenge uchirapa varwere vane zviratidzo zvine chekuita nekuchengetedza kurara kana kumuka kwekutanga, vanhu vakura, uye avo vane zvinodhaka zvekushandisa zvinodhaka kana kufema kwekurara, yakaderera-dose heterocyclic zvinodhaka kana appetite suppressants ingave sarudzo yekutanga.
Zvinoenderana nemaitiro eBeers, rondedzero yemishonga isingakodzeri varwere vane makore makumi matanhatu nemashanu kana kupfuura inosanganisira benzodiazepine receptor agonists uye heterocyclic zvinodhaka, asi haisanganisi doxepin, trazodone, kana orexin vanopikisa. Mushonga wekutanga unowanzo sanganisira kutora mishonga manheru ega ega kwemavhiki e2-4, uyezve kuongorora mhedzisiro nemhedzisiro. Kana mishonga yenguva refu ichidiwa, kurudzira mishonga inopindirana (2-4 nguva pavhiki). Varwere vanofanira kutungamirirwa kutora mishonga 15-30 maminitsi vasati varara. Mushure mekurapa kwenguva refu, vamwe varwere vanogona kutanga kuvimba nezvinodhaka, kunyanya kana vachishandisa benzodiazepine receptor agonists. Mushure mekushandisa kwenguva refu, kuderedzwa kwakarongwa (kwakadai sokuderedza 25% pavhiki) kunogona kubatsira kuderedza kana kurega zvinodhaka zve hypnotic.
Sarudzo pakati pekusanganisa kurapa uye monotherapy
Mashomanana aripo musoro kusvika kumusoro zvidzidzo zvekuenzanisa zvakaratidza kuti munguva pfupi (4-8 mavhiki), CBT-I uye hypnotic zvinodhaka (kunyanya Z-class zvinodhaka) zvine migumisiro yakafanana pakuvandudza kurara kuenderera mberi, asi kurapwa kwezvinodhaka kunogona kuwedzera zvakanyanya nguva yose yekurara kana ichienzaniswa neCBT-I. Kuenzaniswa nekushandisa CBT-I ndoga, kurapa kwakasanganiswa kunogona kuvandudza kurara nekukurumidza, asi mukana uyu unoderera zvishoma nezvishoma muvhiki yechina kana yechishanu yekurapa. Pamusoro pezvo, zvichienzaniswa nemishonga kana kurapa kusanganisa, kushandisa CBT-I ndoga kunogona kuvandudza kurara zvakanyanya. Kana paine imwe nzira iri nyore yekunwa mapiritsi ekukotsisa, vamwe varwere vanotevedzera zano rekuita zvinogona kudzikira.
Nguva yekutumira: Jul-20-2024