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Management of sleep Disorders

Management of sleep Disorders. GP Sleep Seminar Manaia Health 2013. REM - Rapid Eye Movement NREM - Non-Rapid Eye Movement Stages 1 and 2 light sleep Stages 3 and 4 deep sleep 90 -100 Minute sleep cycles. 4 – 5 cycles per night to feel refreshed

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Management of sleep Disorders

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  1. Managementof sleep Disorders GP Sleep Seminar Manaia Health 2013

  2. REM - Rapid Eye Movement NREM - Non-Rapid Eye Movement Stages 1 and 2 light sleep Stages 3 and 4 deep sleep 90 -100 Minute sleep cycles. 4 – 5 cycles per night to feel refreshed 25% REM, 50% Stage 2 and 25% stages 3 and 4

  3. Parasomnias: • In REM • REM Sleep Behaviour Disorder. (REM without muscle atonia) REMdisorder.mp4 behavior

  4. The most common sleep disorders are associated with:- 1) Shiftwork Up to 20% of the workforce are shiftworkers 2) Insomnia 10 – 15% of adults suffer from chronic and severe insomnia that affects daytime performance. 3) Snoring and Obstructive Sleep Apnoea (OSA)Snoring – up to 60% adults snore regularly OSAS – 9% of males, 4% females over 40

  5. Circadian Rhythms Circa Dies = About a day Controlled by Internal body clock - The Suprachiasmatic Nucleus (SCN) - Core body temperature circadian cycle - The role of our own Melatonin External environment cues – Zeitgebers (Time keepers) - The effect of light - Exercise - Meals

  6. Insomnia

  7. Insomnia • May be a symptom of a disorder • Initial insomnia • Anxiety and Stress • Chemical Stimulation • Physical Activity • Age (Adolescence) • Interrupted Insomnia • Pain • Respiratory Illness • Habit • Jet Lag • Shiftwork • Early Morning Wakening • Age (Elderly) • Depression

  8. Medical problems associated with Insomnia Heart Disease x 2.27 Cancer x 2.17 Hypertension x 3.18 Neurologic disease x 4.64 Breathing problems x 3.78 Urinary problems x 3.28 Diabetes x 1.8 Chronic pain x 3.19 Gastrointestinal x 3.33

  9. Insomnia 10-15% of adults suffer from chronic and severe insomnia (Complaints of insomnia with daytime consequences) 30–40% of adults complain of insomnia symptoms only 95% experience insomnia at some time in their lives

  10. Insomnia Risk Factors: Female 2:1 (?More likely to report insomnia) Increasing age (? Increased likelihood of medical complaints) Stress/Anxiety (Hyper-arousal Disorder) Psychiatric Illness Medical disorder Social factors (Unemployed, single, physical inactivity) Environmental factors (noisy environment, latitude-SAD)

  11. Insomnia ( treatments) CHEMICAL Herbal Allopathic BEHAVIOURAL Cognitive/behavioral therapy for Insomnia (CBTI) Sleep hygiene Stimulus control Sleep (bed) restriction

  12. Insomnia HERBAL MEDICINES VALARIAN KAVA ST JOHN WORT MELATONIN CHAMOMILLE OTHERS

  13. Insomnia Melatonin Two therapeutic uses: 1.As a chronobiotic Use a small dose (0.5mg), 5hrs before desired sleep onset 2. As a soporific Use a larger dose (2mg or 3mg) ½ -1 hr before desired sleep onset

  14. Insomnia Melatonin Two therapeutic uses: 1.As a chronobiotic Melatonin in the evening will advance the sleep phase (Earlier to sleep and earlier to wake) Melatonin in the morning will (theoretically) delay the sleep phase (Later to sleep and later to wake)

  15. Insomnia Melatonin Two therapeutic uses: 2. As a soporific For children with ADHD or ASD Some small evidence that their melatonin levels are low For those over 55 yrs Melatonin levels tend to fall with age Not helpful for those under 55yrs

  16. Insomnia • Melatonin • Melatonin 2mg Slow release. • Slightly helpful for insomnia over 55yrs • Large supraphysiological dose. • Despite a relatively short ½ life, some may last through to the morning and therefore delay sleep onset. • May result in morning fatigue. Significant individual variability

  17. Insomnia • Melatonin • Melatonin 2mg Slow release. • 5. It is a reliable product. Accurate 2mg • 6. Long term effects of Melatonin are unknown, • especially in the preteen/teenage years • 7. If used for travel (jet lag) trial it first. • Placebo effect is strong for sleep.

  18. Insomnia Chemical Advantages Freely available Probably less side effects Disadvantages Few studies Inconsistent product Unknown interactions of side effects Less effective

  19. Insomnia Allopathic HISTORY Antiquity - Alcohol and Laudanum 1860’s & 70’s - Bromides and Chloral Hydrate 1880’s - Paraldehyde, urethane 1900’s - Barbiturates 1960’s - Benzodiazepines - 1stChlordiazepoxide (Librium) 1980’s – 90’s - Zopiclone, Zolpidem 2000 - Zaleplon

  20. Insomnia Allopathic HYPNOTICS – Which one? Benzodiazepines - Triazolam - Temazepam - Nitrazepam Non Benzodiazepines - Zopiclone - Zolpidem - Zaleplon

  21. Insomnia Allopathic Benzodiazepines Benefits - effective - wide margin of safety - slow tolerance Adverse effects - residual sedation - anterograde amnesia - rebound insomnia - Dependance Contraindications and Precautions

  22. Insomnia Allopathic Hi Antihistamine - daytime drowsiness - impaired learning Sedating Antidepressants - cardiotoxic - anticholinergic - increase RLS/P.L.M.s - impaired daytime performance - rapid tolerance

  23. Insomnia Allopathic Use short acting hypnotics for short term treatment in low dose Use sedating antidepressants in full doses for insomnia associated with depression

  24. Insomnia Evaluation: The three P’s - Predisposing Factors Genetics, Personality type, Social Pressures - Precipitating Factors Stressful life event(s). “Trigger” for insomnia. - Perpetuating Factors. Compensatory strategies. Eg longer in bed. Staying in bed. Alcohol use

  25. Sleep Hygiene • To Provide information about lifestyle, and environment that might interfere with sleep, or promote better sleep. • These strategies are important as a baseline, and should be combined with the other treatments. • As a sole therapy, it is not effective for the more severe insomnia, but should be addressed in therapy.

  26. Sleep Hygiene • - Avoid stimulants • - Caffeine (5-8 hour half life) - Cigarettes - Alcohol (initially sedative, later stimulant) • - Psychoactive Drugs • - Exercise regularly • - Allow at least 1 hr relaxation time to unwind before bedtime • - Bedroom environment should be quiet, dark and comfortable and ~ 18 ˚C • - Maintain a regular sleep/wake schedule • - Avoid clock watching

  27. Stimulus Control Stimulus Control is based on classical conditioned response to certain stimuli. This involves strengthening the relationship between bed and sleep, and breaking the negative relationship between bed and anxiety and wakefulness Important and Effective

  28. Stimulus Control • Go to bed when sleepy • Do not watch TV, read, eat or worry while in bed • Do not nap during the day • Set regular wake up/get up time – including weekends • No visible clocks at night • Get out of bed if unable to fall asleep in 15 – 20 minutesReturn to bed when sleepy. Repeat as often as necessary

  29. Bed Restriction Therapy for those with insomnia Bed restriction therapy is designed to improve sleep consolidation and sleep efficiency. This is achieved by initially increasing the homeostatic drive to sleep. Sleep efficiency improves. Time in bed can then be increased. Difficult, but the most effective

  30. INSOMNIA • BED RESTRICTION THERAPY • Average the time asleep over 2 weeks • Add 0 - ½ Hour (Never allow less than 5hrs sleep opportunity) • Restrict time in bed to that amount of time • Increase time in bed slowly when sleeping is consolidated • > 90% increase by 15 minutes • 80% -90% remain the same • < 80% reduce by 15 minutes

  31. A Therapeutic model Having discussed Sleep Hygiene, and Relaxation therapies, discuss Stimulus Control, and Bed Restriction.

  32. A Therapeutic Model • Stress management- Write down emotional thoughts and diary - Muscle tension and relaxation • - Abdominal breathing - Visualisation • Stimulants - Caffeine (5-8 hour half life) - Cigarettes - Alcohol (initially sedative, later • stimulant)

  33. A Therapeutic Model • Routine - Both daytime and pre-bedtime are important • Exercise - Keep fit- No vigorous exercise within 3 hours of bed • Food - Avoid a large meal within 3 hours of bedtime • - A small carbohydrate intake before bed may • be helpful i.e. milky drink, banana

  34. A Therapeutic Model • Temperature - Avoid extremes of temperature - Cooling will keep sleep • Light - Light stimulates serotonin and inhibits melatonin and sleep. - Be outside in the day as much as possible • Dark - Stimulates Melatonin that helps sleep • therefore keep bedroom dark at night

  35. A Therapeutic model • Noise - Sudden noise awakens. A constant low • intensity noise may be helpful • The bed - Firmer and larger rather than sagging and • small • - Avoid synthetic sheets • - Use feather or down unless allergic to house • dust mite

  36. Stimulus Control • In Bed - If awake after 20 minutes or your mind is • alert, get up for 20-30 minutes. • - use time out of bed to “wind down” and prepare • again for sleep (warm, dim light, write • down what is on your mind, light reading • material, comfortable chair), • return to bed and repeat as necessary • - Avoid working or playing in bedroom • - The bedroom is for sleep and sex only

  37. The Agony or the Ecstasy Familiar?

  38. Snoring Related Complaints - Drives wife from bedroom - Girlfriend won’t marry me - Shakes entire house - Ask me to leave movies and church - Has had to leave boat so friends could sleep - Fall asleep at traffic lights waiting for red light to change

  39. Snoring and Obstructive Sleep Apnoea

  40. Consequences of Sleep Apnoea 1. Daytime fatigue, especially sleepiness 2. Bed partner sleep disturbance 3. Cardiovascular complications

  41. Consequences of Sleep Apnoea Medical consequences :- Hypertension Insulin Resistance Cardiac Arrhythmia Heart Attack Stroke Nocturnal GORD Nocturia Depression

  42. Risk Factors for Sleep Apnoea Male: Female 2 : 1 Increasing age Body Mass Index > 30 Neck Circumference > 42cm ( 17ins) Alcohol ( > 2 units) Smoking Post Menopausal Women Sleeping Pills

  43. The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations, in contrastto just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how theywould have affected you. Use the following scale to choose the most appropriate number for eachsituation: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing It is important that you put a number (0 to 3) in each of the eight boxes.

  44. History Taking (If Possible With Partner) Sleepy vs non-sleepy Smoking / alcohol Recent weight gain Consistency of snoring Every night Every position Periods of apnoea

  45. Examination BMI Neck circumference Nasal airway: septum/ valves Tonsil size / soft palate Soft palate oedema Base of tongue

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