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

Sleep disorders are common sleep disorders are serious sleep disorders are treatable sleep disorders are under diagnosed
1 / 50

  • Uploaded on
  • Presentation posted in: General

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

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentationdownload

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

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Slide2 l.jpg

Important facts___________________________

  • Sleep disorders arecommon

  • Sleep disorders are serious

  • Sleep disorders are treatable

  • Sleep disorders areunder diagnosed

Slide3 l.jpg

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

Wake system l.jpg

Wake System___________________________

Sleep system l.jpg

Sleep System___________________________

Sleep wake cycle l.jpg

Sleep Wake Cycle___________________________

Slide7 l.jpg

Changes in sleep with age___________________________

Stages of sleep l.jpg

Stages of sleep___________________________

  • NREM Sleep

    A. Stage 1

    B. Stage 2

    C. Stage 3

    D. Stage 4

    2. REM Sleep

Sleep stages l.jpg


2/3 of life

REM Sleep

~20% of night

NREM Sleep

~80% of night

Sleep Stages ___________________________

Sleep disorders icsd 2 l.jpg

Sleep disorders (ICSD 2) ___________________________

  • Insomnia.

  • Sleep Related Breathing Disorders.

  • Hypersomnia.

  • Cicadian Rhythm Sleep Disorder.

  • Parasomnia.

  • Sleep related Movement Disorder.

Insomnia definition l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Cognitive Model of Insomnia

Evolution of insomnia l.jpg

Evolution of Insomnia

Possible causes of insomnia l.jpg

Possible causes of insomnia___________________________

Insomnia l.jpg


  • 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 l.jpg

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 l.jpg

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 l.jpg

Insomnia - subdivisions___________________________

  • Sleep onset insomnia

  • Sleep maintenance insomnia

  • Sleep offset insomnia

  • Non restorative sleep

Types of insomnia l.jpg

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 l.jpg

Medical problems__________________________

  • Depression

  • Hyperthyroidism

  • Arthritis, chronic pain

  • Benign prostatic hypertrophy

  • Headaches; Sleep apnoea

  • Periodic leg movement,

  • Restless leg syndrome (RLS)

Other problems l.jpg

Other problems__________________________

  • Caffeine

  • Nicotine

  • Alcohol

  • Exercise

  • Noise

  • Light

  • Hunger

Management of insomnia l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

Medications and insomnia___________________________

Slide28 l.jpg

Cognitive Behaviour Therapy (CBT)____________________________

Non pharmacological treatments l.jpg

Non pharmacological treatments

Bed room l.jpg

Bed room__________________________

  • Temperature

  • Fresh air

  • S&S

  • Comfortable bed

Stimulus control l.jpg

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 l.jpg

Sleep hygiene__________________________

  • Behaviours that interfere with sleep

  • Caffeine

  • Alcohol

  • Nicotine

  • Daytime napping

  • Exercise < 4hrs before bed

Relaxation training l.jpg

Relaxation training__________________________

  • Progressive muscle relaxation

  • Diaphragmatic breathing

  • Autogenic training

  • Biofeedback

  • Meditation, Yoga

  • Hypnosis to ↓ anxiety & tension at bedtime

Thought stopping l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg


  • 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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg

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 l.jpg


  • 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 l.jpg


Other drugs l.jpg

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 l.jpg


  • 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 l.jpg

Sleep related movement disorders____________________________

  • Restless Leg Syndrome

  • Periodic Limb Movement Disorder

  • Sleep Related Leg Cramps

  • Sleep Related Bruxism

Thank you all have good sleep l.jpg

Thank you allHave good sleep

  • Login