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1. 2 Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed Important facts ___________________________.

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Presentation on theme: "1. 2 Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed Important facts ___________________________."— Presentation transcript:

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2 2 Sleep disorders are common Sleep disorders are serious Sleep disorders are treatable Sleep disorders are under diagnosed Important facts ___________________________

3 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 Important facts ___________________________

4 4 Wake System ___________________________

5 5 Sleep System ___________________________

6 6 Sleep Wake Cycle ___________________________

7 Changes in sleep with age ___________________________

8 8 Stages of sleep ___________________________ 1.NREM Sleep A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4 2. REM Sleep

9 9 REM Sleep ~20% of night NREM Sleep ~80% of night Wake 2/3 of life Sleep Stages ___________________________

10 10 Sleep disorders (ICSD 2) ___________________________ 1.Insomnia. 2.Sleep Related Breathing Disorders. 3.Hypersomnia. 4.Cicadian Rhythm Sleep Disorder. 5.Parasomnia. 6.Sleep related Movement Disorder.

11 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 - definition ___________________________

12 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 - definition ___________________________

13 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 - assessment ___________________________

14 Cognitive Model of Insomnia 14

15 Evolution of Insomnia 15

16 Headache Bad or vivid dreams Problems of breathing Chest pain/heartburn Need to pass urine or move bowels Abdominal pains Fever/night sweats Leg cramps Fear/anxiety Depression Possible causes of insomnia ___________________________

17 17 Insomnia ___________________________ 1.A complaint of difficulty in initiating, maintaining or waking up too early or sleep that is non-restorative or poor in quality. 2.The above sleep difficulty occurs despite adequate opportunity and circumstance for sleep. 3.Insomnia is a symptom – not a disease per se

18 18 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

19 19 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

20 20 Insomnia types __________________________ Psycho-physiologic Insomnia Paradoxical Insomnia Inadequate Sleep Hygiene Adjustment Insomnia Insomnia due to Medical Condition/ Mental Disorder/ Drug or Substance

21 Sleep onset insomnia Sleep maintenance insomnia Sleep offset insomnia Non restorative sleep 21 Insomnia - subdivisions ___________________________

22 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%)

23 23 Medical problems __________________________ Depression Hyperthyroidism Arthritis, chronic pain Benign prostatic hypertrophy Headaches; Sleep apnoea Periodic leg movement, Restless leg syndrome (RLS)

24 24 Other problems __________________________ Caffeine Nicotine Alcohol Exercise Noise Light Hunger

25 25 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

26 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 insomnia ___________________________

27 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 Management of insomnia ___________________________

28 Type of medicationExample CNS stimulantsD-amphetamine, Methyphenindrate Blood pressure drugs  - blockers,  - blockers Respiratory medicinesAlbuterol, Theophylline DecongestantsPhenylephine, Pseudoephedrine HormonesThyroxin, Corticosteroids Other substancesAlcohol, Nocotine, Caffeine 28 Medications and insomnia ___________________________

29 29 Cognitive Behaviour Therapy (CBT) ____________________________

30 Non pharmacological treatments 30

31 31 Bed room __________________________ Temperature Fresh air S&S Comfortable bed

32 32 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

33 33 Sleep hygiene __________________________ Behaviours that interfere with sleep Caffeine Alcohol Nicotine Daytime napping Exercise < 4hrs before bed

34 34 Relaxation training __________________________ Progressive muscle relaxation Diaphragmatic breathing Autogenic training Biofeedback Meditation, Yoga Hypnosis to ↓ anxiety & tension at bedtime

35 35 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)

36 36 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

37 Benzodiazepines –Lorazepam –Clonezepam –Temazepam –Flurazepam –Quazepam –Alprazolam –Triazolam –Estazolam Non Benzodiazepines –Zolpidem –Zolpidem CR –Zeleplon –Eszopiclone Both these classes act on the GABA A receptors (BzRA) in PCN 37 Benzodiazepine receptor agonists __________________________

38 Antidepressants –Trazadone –Mirtazapine –Doxepin –Amitryptyline Antipsychotics –Olanzapine –Quitiepine Melatonin Receptor Agonists –Melatonin –Ramelteon Miscellaneous –Valerian –Diphenhydramine –Cyclobenzaprine –Hydroxyzine –Alcohol 38 Other classes of medications __________________________

39 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 BzRAs – side effects and safety __________________________

40 40 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 Benzodiazepines ____________________________

41 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 use ____________________________

42 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 use ____________________________

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

44 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 Benzodiazepine toxicity ____________________________

45 45 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 Non benzodiazepines ____________________________

46 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 Zolpidem ____________________________

47 DrugDuration of actionHalf-life PhenobarbitalLong24 – 140 hrs. ButabarbitalIntermediate34 – 42 hrs. AmobarbitalShort-intermediate8 – 42 hrs. PentobarbitalShort-intermediate15 – 48 hrs. SecobarbitalShort-intermediate19 – 34 hrs. Barbiturates ____________________________

48 Enhance GABA A receptor activity Increase Cl - conductance through site separate from that of benzodiazepines Thiopental also inhibits GABA transaminase Also block glutamate receptor-mediated excitation Barbiturates - neurochemistry ____________________________

49 Progression of effects  Anxiolytic,Sedation, General anesthesia  Medullary paralysis, Death Decrease stage III, IV, REM sleep, sleep latency Tolerance develops to shortening REM sleep Produce REM rebound Anxiolytic, but with substantial drowsiness and ataxia. Anticonvulsant activity. Barbiturates - effects ____________________________

50 50 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 Other drugs ____________________________

51 51 Sleep Related Breathing Disorders ____________________________ Obstructive Sleep Apnea. Primary Central Sleep Apnea. High Altitude Periodic breathing. Cheyne Stokes Breathing Pattern. Central Sleep Apnea due to Drug or Substance.

52 52 Hypersomnia ___________________________ 1.Narcolepsy with Cataplexy 2.Narcolepsy without Cataplexy 3.Narcolepsy due to Medical Condition 4.Idiopathic Hypersomnia with Long Sleep Time 5.Idiopathic Hypersomnia without Long Sl. Time 6.Behaviorally Induced Insufficient Sleep Syn 7.Hypersomnia due to Medical Condition 8.Hypersomnia due to Drug/ Substance

53 53 Sleep related movement disorders ____________________________ 1.Restless Leg Syndrome 2.Periodic Limb Movement Disorder 3.Sleep Related Leg Cramps 4.Sleep Related Bruxism

54 THANK YOU ALL HAVE GOOD SLEEP 54


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