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

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Important facts___________________________

  • Sleep disorders arecommon

  • Sleep disorders are serious

  • Sleep disorders are treatable

  • Sleep disorders areunder diagnosed

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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

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Wake System___________________________

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Sleep System___________________________

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Sleep Wake Cycle___________________________

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Changes in sleep with age___________________________

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Stages of sleep___________________________

  • NREM Sleep

    A. Stage 1

    B. Stage 2

    C. Stage 3

    D. Stage 4

    2. REM Sleep

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2/3 of life

REM Sleep

~20% of night

NREM Sleep

~80% of night

Sleep Stages ___________________________

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Sleep disorders (ICSD 2) ___________________________

  • Insomnia.

  • Sleep Related Breathing Disorders.

  • Hypersomnia.

  • Cicadian Rhythm Sleep Disorder.

  • Parasomnia.

  • Sleep related Movement Disorder.

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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

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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

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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

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Cognitive Model of Insomnia

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Evolution of Insomnia

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Possible causes of insomnia___________________________

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  • 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

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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

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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

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Insomnia - subdivisions___________________________

  • Sleep onset insomnia

  • Sleep maintenance insomnia

  • Sleep offset insomnia

  • Non restorative sleep

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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%)

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Medical problems__________________________

  • Depression

  • Hyperthyroidism

  • Arthritis, chronic pain

  • Benign prostatic hypertrophy

  • Headaches; Sleep apnoea

  • Periodic leg movement,

  • Restless leg syndrome (RLS)

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Other problems__________________________

  • Caffeine

  • Nicotine

  • Alcohol

  • Exercise

  • Noise

  • Light

  • Hunger

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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

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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

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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

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Medications and insomnia___________________________

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Cognitive Behaviour Therapy (CBT)____________________________

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Non pharmacological treatments

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Bed room__________________________

  • Temperature

  • Fresh air

  • S&S

  • Comfortable bed

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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

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Sleep hygiene__________________________

  • Behaviours that interfere with sleep

  • Caffeine

  • Alcohol

  • Nicotine

  • Daytime napping

  • Exercise < 4hrs before bed

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Relaxation training__________________________

  • Progressive muscle relaxation

  • Diaphragmatic breathing

  • Autogenic training

  • Biofeedback

  • Meditation, Yoga

  • Hypnosis to ↓ anxiety & tension at bedtime

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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)

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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

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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

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Other classes of medications__________________________

  • Melatonin Receptor Agonists

    • Melatonin

    • Ramelteon

  • Miscellaneous

    • Valerian

    • Diphenhydramine

    • Cyclobenzaprine

    • Hydroxyzine

    • Alcohol

  • Antidepressants

    • Trazadone

    • Mirtazapine

    • Doxepin

    • Amitryptyline

  • Antipsychotics

    • Olanzapine

    • Quitiepine

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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

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  • 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

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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.

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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

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Benzodiazepine abuse____________________________

  • Benzodiazepines have relatively low abuse potential.

  • Prolonged use can lead to withdrawal symptoms: headache, irritability, dizziness, abnormal sleep

  • Rebound insomnia - triazolam

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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

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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

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  • 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

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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

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  • 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

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Sleep related movement disorders____________________________

  • Restless Leg Syndrome

  • Periodic Limb Movement Disorder

  • Sleep Related Leg Cramps

  • Sleep Related Bruxism

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Thank you allHave good sleep

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