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Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed

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Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed - PowerPoint PPT Presentation


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Important facts ___________________________. Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed. Important facts ___________________________.

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Presentation Transcript
slide2

Important facts___________________________

  • Sleep disorders arecommon
  • Sleep disorders are serious
  • Sleep disorders are treatable
  • Sleep disorders areunder diagnosed
slide3

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
stages of sleep
Stages of sleep___________________________
  • NREM Sleep

A. Stage 1

B. Stage 2

C. Stage 3

D. Stage 4

2. REM Sleep

sleep stages

Wake

2/3 of life

REM Sleep

~20% of night

NREM Sleep

~80% of night

Sleep Stages ___________________________
sleep disorders icsd 2
Sleep disorders (ICSD 2) ___________________________
  • Insomnia.
  • Sleep Related Breathing Disorders.
  • Hypersomnia.
  • Cicadian Rhythm Sleep Disorder.
  • Parasomnia.
  • Sleep related Movement Disorder.
insomnia definition
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 definition12
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
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
insomnia
Insomnia___________________________
  • A complaint of difficulty in initiating, maintaining or waking up too early or sleep that is non-restorative or poor in quality.
  • The above sleep difficulty occurs despite adequate opportunity and circumstance for sleep.
  • Insomnia is a symptom – not a disease per se
insomnia associated features
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
insomnia resultant problems
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
insomnia subdivisions
Insomnia - subdivisions___________________________
  • Sleep onset insomnia
  • Sleep maintenance insomnia
  • Sleep offset insomnia
  • Non restorative sleep
types of insomnia
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
Medical problems__________________________
  • Depression
  • Hyperthyroidism
  • Arthritis, chronic pain
  • Benign prostatic hypertrophy
  • Headaches; Sleep apnoea
  • Periodic leg movement,
  • Restless leg syndrome (RLS)
other problems
Other problems__________________________
  • Caffeine
  • Nicotine
  • Alcohol
  • Exercise
  • Noise
  • Light
  • Hunger
management of insomnia
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
management of insomnia25
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 insomnia26
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
slide28

Cognitive Behaviour Therapy (CBT)____________________________

bed room
Bed room__________________________
  • Temperature
  • Fresh air
  • S&S
  • Comfortable bed
stimulus control
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
sleep hygiene
Sleep hygiene__________________________
  • Behaviours that interfere with sleep
  • Caffeine
  • Alcohol
  • Nicotine
  • Daytime napping
  • Exercise < 4hrs before bed
relaxation training
Relaxation training__________________________
  • Progressive muscle relaxation
  • Diaphragmatic breathing
  • Autogenic training
  • Biofeedback
  • Meditation, Yoga
  • Hypnosis to ↓ anxiety & tension at bedtime
thought stopping
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)
behavioural therapies
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
benzodiazepine receptor agonists
Benzodiazepine receptor agonists__________________________
  • Non Benzodiazepines
    • Zolpidem
    • Zolpidem CR
    • Zeleplon
    • Eszopiclone
  • Both these classes act on the GABAA receptors (BzRA) in PCN
  • Benzodiazepines
    • Lorazepam
    • Clonezepam
    • Temazepam
    • Flurazepam
    • Quazepam
    • Alprazolam
    • Triazolam
    • Estazolam
other classes of medications
Other classes of medications__________________________
  • Melatonin Receptor Agonists
    • Melatonin
    • Ramelteon
  • Miscellaneous
    • Valerian
    • Diphenhydramine
    • Cyclobenzaprine
    • Hydroxyzine
    • Alcohol
  • Antidepressants
    • Trazadone
    • Mirtazapine
    • Doxepin
    • Amitryptyline
  • Antipsychotics
    • Olanzapine
    • Quitiepine
bzras side effects and safety
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____________________________
  • 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
benzodiazepine use
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 use41
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
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
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
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
zolpidem
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
other drugs
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
hypersomnia
Hypersomnia___________________________
  • Narcolepsy with Cataplexy
  • Narcolepsy without Cataplexy
  • Narcolepsy due to Medical Condition
  • Idiopathic Hypersomnia with Long Sleep Time
  • Idiopathic Hypersomnia without Long Sl. Time
  • Behaviorally Induced Insufficient Sleep Syn
  • Hypersomnia due to Medical Condition
  • Hypersomnia due to Drug/ Substance
sleep related movement disorders
Sleep related movement disorders____________________________
  • Restless Leg Syndrome
  • Periodic Limb Movement Disorder
  • Sleep Related Leg Cramps
  • Sleep Related Bruxism
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