Rest issue are normal Sleep issue are not kidding Sleep issue are treatable Sleep issue are under analyzed - PowerPoint PPT Presentation

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Rest issue are normal Sleep issue are not kidding Sleep issue are treatable Sleep issue are under analyzed PowerPoint Presentation
Rest issue are normal Sleep issue are not kidding Sleep issue are treatable Sleep issue are under analyzed

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Rest issue are normal Sleep issue are not kidding Sleep issue are treatable Sleep issue are under analyzed

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  1. Important facts___________________________ • Sleep disorders arecommon • Sleep disorders are serious • Sleep disorders are treatable • Sleep disorders areunder 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___________________________

  7. Stages of sleep___________________________ • NREM Sleep A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 2. REM Sleep

  8. Wake 2/3 of life REM Sleep ~20% of night NREM Sleep ~80% of night Sleep Stages ___________________________

  9. Sleep disorders (ICSD 2) ___________________________ • Insomnia. • Sleep Related Breathing Disorders. • Hypersomnia. • Cicadian Rhythm Sleep Disorder. • Parasomnia. • 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

  11. 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

  12. 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

  13. Cognitive Model of Insomnia

  14. Evolution of Insomnia

  15. Possible causes of insomnia___________________________

  16. 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

  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

  20. 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%)

  21. Medical problems__________________________ • Depression • Hyperthyroidism • Arthritis, chronic pain • Benign prostatic hypertrophy • Headaches; Sleep apnoea • Periodic leg movement, • Restless leg syndrome (RLS)

  22. Other problems__________________________ • Caffeine • Nicotine • Alcohol • Exercise • Noise • Light • Hunger

  23. 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

  24. 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

  25. 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

  26. Medications and insomnia___________________________

  27. Cognitive Behaviour Therapy (CBT)____________________________

  28. Non pharmacological treatments

  29. Bed room__________________________ • Temperature • Fresh air • S&S • Comfortable bed

  30. 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

  31. Sleep hygiene__________________________ • Behaviours that interfere with sleep • Caffeine • Alcohol • Nicotine • Daytime napping • Exercise < 4hrs before bed

  32. Relaxation training__________________________ • Progressive muscle relaxation • Diaphragmatic breathing • Autogenic training • Biofeedback • Meditation, Yoga • Hypnosis to ↓ anxiety & tension at bedtime

  33. 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)

  34. 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

  35. 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

  36. Other classes of medications__________________________ • Melatonin Receptor Agonists • Melatonin • Ramelteon • Miscellaneous • Valerian • Diphenhydramine • Cyclobenzaprine • Hydroxyzine • Alcohol • Antidepressants • Trazadone • Mirtazapine • Doxepin • Amitryptyline • Antipsychotics • Olanzapine • Quitiepine

  37. 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

  38. 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

  39. 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.

  40. 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

  41. Benzodiazepine abuse____________________________ • Benzodiazepines have relatively low abuse potential. • Prolonged use can lead to withdrawal symptoms: headache, irritability, dizziness, abnormal sleep • Rebound insomnia - triazolam

  42. 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

  43. 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

  44. 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

  45. Barbiturates____________________________

  46. 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

  47. 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

  48. Sleep related movement disorders____________________________ • Restless Leg Syndrome • Periodic Limb Movement Disorder • Sleep Related Leg Cramps • Sleep Related Bruxism

  49. Thank you allHave good sleep