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Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnos

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 diagnos

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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

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