Transcript Document
1 Important facts ___________________________ • Sleep disorders are common • Sleep disorders are serious • Sleep disorders are treatable • Sleep disorders are under diagnosed 2 Important facts ___________________________ • Sleep complaints are usually not due to psychiatric conditions or character flaws • Most sleep disorders are readily diagnosable and treatable • The studies include – Polysomnography (PSG) – Multiple sleep latency test (MSLT) – Actigraphy 3 Wake System ___________________________ 4 Sleep System ___________________________ 5 Sleep Wake Cycle ___________________________ 6 Changes in sleep with age ___________________________ Stages of sleep ___________________________ 1. NREM Sleep A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 2. REM Sleep 8 Sleep Stages ___________________________ Wake 2/3 of life NREM Sleep REM Sleep ~80% of night ~20% of night 9 Sleep disorders (ICSD 2) ___________________________ 1. Insomnia. 2. Sleep Related Breathing Disorders. 3. Hypersomnia. 4. Cicadian Rhythm Sleep Disorder. 5. Parasomnia. 6. Sleep related Movement Disorder. 10 Insomnia - definition ___________________________ • Insomnia and excessive daytime sleepiness are primary complaints regardless of the stage of the disease • Insomnia includes difficulty falling asleep, difficulty staying asleep, and early morning awakening Insomnia - definition ___________________________ • Insomnia is not defined by the number of hours of sleep, but rather, by an individual‘s ability to sleep long enough to feel healthy and alert during the day. • The normal requirement for sleep ranges between 4 and 10 hours • Insomnia is a symptom, not a disorder by itself Insomnia - assessment ___________________________ • Determine the pattern of sleep problem (frequency, associated events, how long it takes to go to sleep, and how long the patient can stay asleep) • Include a full history of alcohol and caffeine intake and other factors that might affect sleep • Review current medications that patient is taking to eliminate these as possible causes • Take a history to rule out physical cause and/or psychosocial cause Cognitive Model of Insomnia 14 Evolution of Insomnia 15 Possible causes of insomnia ___________________________ Headache Abdominal pains Bad or vivid dreams Fever/night sweats Problems of breathing Leg cramps Chest pain/heartburn Fear/anxiety Need to pass urine or move bowels Depression Insomnia ___________________________ 1. A complaint of difficulty in initiating, maintaining or waking up too early or sleep that is non-restorative or poor in quality. 2. The above sleep difficulty occurs despite adequate opportunity and circumstance for sleep. 3. Insomnia is a symptom – not a disease per se 17 Insomnia – associated features ___________________________ At least one (or more) of the following • Fatigue or malaise • Attention, concentration impairment • Social/ vocational dysfunction/ poor work • Mood disturbance or irritability • Daytime sleepiness 18 Insomnia – resultant problems ___________________________ • Reduction in motivation, energy or initiative • Proneness for errors or accidents at work or while driving • Tension, headaches or gastrointestinal symptoms in response to sleep loss • Concerns or worries about sleep • Secondary psychiatric problems 19 Insomnia - subdivisions ___________________________ • Sleep onset insomnia • Sleep maintenance insomnia • Sleep offset insomnia • Non restorative sleep 21 Types of insomnia ________________________ • Transient insomnia – < 4 weeks triggered by excitement or stress, occurs when away from home • Short-term – 4 wks to 6 mons , ongoing stress at home or work, medical problems, psychiatric illness • Chronic – Poor sleep every night or most nights for > 6 months, psychological factors (prevalence 9%) Medical problems __________________________ • Depression • Hyperthyroidism • Arthritis, chronic pain • Benign prostatic hypertrophy • Headaches; Sleep apnoea • Periodic leg movement, • Restless leg syndrome (RLS) 23 Other problems __________________________ • Caffeine • Nicotine • Alcohol • Exercise • Noise • Light • Hunger 24 Management of insomnia ____________________________ • Good Sleep History • Rule out primary psychiatric disorders • Rule out adverse effects of medications • Sleep Diary • Good Sleep Hygiene Measures • Interventions – CB therapy, medications 25 Management of insomnia ___________________________ • Treat underlying causes whenever possible • Advise patient to avoid exercise, heavy meals, alcohol, or conflict situations just before bed • Plain aspirin or paracetamol in low doses may be helpful; or give short-acting hypnotics or a sedative • Treat underlying depression Management of insomnia ___________________________ • Treat underlying Medical Condition • Treat underlying Psychiatric Condition • Improve sleep hygiene • Change environment • CBT: ‘primary insomnias’, transient insomnia • Pharmacological • Light, melatonin, or ‘chronotherapy’ for circadian disorders Medications and insomnia ___________________________ Type of medication Example CNS stimulants D-amphetamine, Methyphenindrate Blood pressure drugs - blockers, - blockers Respiratory medicines Albuterol, Theophylline Decongestants Phenylephine, Pseudoephedrine Hormones Thyroxin, Corticosteroids Other substances Alcohol, Nocotine, Caffeine 28 Cognitive Behaviour Therapy (CBT) ____________________________ 29 Non pharmacological treatments 30 Bed room __________________________ • Temperature • Fresh air • S&S • Comfortable bed 31 Stimulus control __________________________ • Go to bed when sleepy • Only S & S in bedroom • Get up the same time every morning • Get up when sleep onset does not occur in 20 min, and go to another room • No daytime napping 32 Sleep hygiene __________________________ • Behaviours that interfere with sleep • Caffeine • Alcohol • Nicotine • Daytime napping • Exercise < 4hrs before bed 33 Relaxation training __________________________ • Progressive muscle relaxation • Diaphragmatic breathing • Autogenic training • Biofeedback • Meditation, Yoga • Hypnosis to ↓ anxiety & tension at bedtime 34 Thought stopping __________________________ • Interrupt unwanted pre-sleep cognitive activity by instructing patient to repeat sub-vocally ‘the’ every 3 sec (articulatory suppression) • To yell sub-vocally “stop” (thought stopping) 35 Behavioural therapies __________________________ • Explicit instruction to stay awake when they go to bed; Aim is to reduce anxiety associated with trying to fall asleep – Paradoxical intention • Alter irrational beliefs about sleep, provide accurate information that counteracts false beliefs – Cognitive restructuring • Patient imagines 6 common objects (candle, kite, fruit, hourglass, blackboard, light bulb) emphasis on imagining shape, colour, texture – Imagery training 36 Benzodiazepine receptor agonists __________________________ • Benzodiazepines • Non Benzodiazepines – Lorazepam – Clonezepam – Zolpidem – Zolpidem CR – – – – – Zeleplon – Eszopiclone Temazepam Flurazepam Quazepam Alprazolam – Triazolam – Estazolam • Both these classes act on the GABAA receptors (BzRA) in PCN 37 Other classes of medications __________________________ • Antidepressants – Trazadone – Mirtazapine – Doxepin – Amitryptyline • Antipsychotics – Olanzapine – Quitiepine • Melatonin Receptor Agonists – Melatonin – Ramelteon • Miscellaneous – Valerian – Diphenhydramine – Cyclobenzaprine – Hydroxyzine – Alcohol 38 BzRAs – side effects and safety __________________________ • • • • Anterograde amnesia Residual sedation – longer acting BzRAs Rebound Insomnia? Abuse and dependence? – Mostly used short term (2 weeks) – When used as a sleeping aid dose escalation rare – No physical dependence with night time use – Low psychological dependence with night time use • Increased fall risk, cognitive effects in the elderly Benzodiazepines ____________________________ • Benzodiazepines (GABA receptor agonist) • Transient insomnia, (max 2 wks, ideally 2-3/wk) – Long ½ life - nitrazepam – Medium ½ life - temazepam – Short ½ life - diazepam – Poor functional day time status, cognitive impairment, daytime sleepiness, falls and accidents, depression – Acute withdrawal, confusion, psychosis, fits - may occur up to 3/52 from stopping 40 Benzodiazepine use ____________________________ • Benzodiazepines are the drugs of choice for the treatment of insomnia. • Flurazepam can be used for up to one month with little tolerance. • Temazepam can be used for up to three months with little tolerance. • Intermittent use recommended (every three days). Use for no longer than 3 – 6 months. Benzodiazepine use ____________________________ • Half-life is an important factor • Benzodiazepines with long half lives (e.g., flurazepam) produce sustained sleep, but increased risk of daytime somnolence • Benzodiazepines with short half lives may be best for patients with difficulty falling asleep, but can produce rebound insomnia • Development of tolerance can produce rebound insomnia in compounds with short half lives Benzodiazepine abuse ____________________________ • Benzodiazepines have relatively low abuse potential. • Prolonged use can lead to withdrawal symptoms: headache, irritability, dizziness, abnormal sleep • Rebound insomnia - triazolam Benzodiazepine toxicity ____________________________ • Low toxicity when taken alone • In combination can be fatal • Flumanzenil is a benzodiazepine antagonist that can be used to block adverse effects of benzodiazepines • Stomach pump, charcoal, hemodialysis Non benzodiazepines ____________________________ • Act at the benzodiazepine receptor • Less risk of dependence • Zaleplon short ½ life • Zolipidem, Zopiclone slightly longer ½ life • No difference in effectiveness & safety • More expensive • Only to be used if adverse effects to BZP 45 Zolpidem ____________________________ • Short half life • Does not produce rebound insomnia • Low abuse potential • Less likely to produce withdrawal symptoms • Rebound insomnia after first night of withdrawal, but soon resolves Barbiturates ____________________________ Drug Duration of action Half-life Phenobarbital Long 24 – 140 hrs. Butabarbital Intermediate 34 – 42 hrs. Amobarbital Short-intermediate 8 – 42 hrs. Pentobarbital Short-intermediate 15 – 48 hrs. Secobarbital Short-intermediate 19 – 34 hrs. Other drugs ____________________________ • TCA - Amitriptyline, if depression also an issue • Antihistamines – Promethazine • Melatonin – Hormone secreted by pineal gland, effects circadian rhythm, synthesised at night – Use to counteract jet lag (2-5mg @ bedtime for Four nights after arrival); – Synthetic analogue of malatonin - Remelteon – Used in paediatric sleep disorders 50 Hypersomnia ___________________________ 1. Narcolepsy with Cataplexy 2. Narcolepsy without Cataplexy 3. Narcolepsy due to Medical Condition 4. Idiopathic Hypersomnia with Long Sleep Time 5. Idiopathic Hypersomnia without Long Sl. Time 6. Behaviorally Induced Insufficient Sleep Syn 7. Hypersomnia due to Medical Condition 8. Hypersomnia due to Drug/ Substance 52 Sleep related movement disorders ____________________________ 1. Restless Leg Syndrome 2. Periodic Limb Movement Disorder 3. Sleep Related Leg Cramps 4. Sleep Related Bruxism 53 THANK YOU ALL HAVE GOOD SLEEP 54