HELPING YOUR PATIENTS GET THE SLEEP OF THEIR DREAMS OCFP 51 ST ANNUAL SCIENTIFIC ASSEMBLY NOVEMBER 2013 Dr. CAROLE LAMARCHE, C. Psych.

DECLARATION REGARDING CONFLICT OF INTEREST n I DO NOT HAVE AN AFFILIATION (FINANCIAL OR OTHERWISE) WITH A PHARMACEUTICAL, MEDICAL DEVICE OR COMMUNICATIONS ORGANIZATION copyright Dr. Carole Lamarche, C. Psych.

OBJECTIVES OF TODAY’S SEMINAR n PROVIDE A BRIEF OVERVIEW OF COMMON SLEEP DISORDERS INCLUDING INSOMNIA, OBSTRUCTIVE SLEEP APNEA, AND RESTLESS LEGS SYNDROME. n UNDERSTAND THE COMPONENTS OF COGNITIVE- BEHAVIOURAL TREATMENT FOR INSOMNIA n PROVIDE EXAMPLES OF BRIEF ASSESSMENT AND INTERVENTION STRATEGIES FOR SLEEP DISORDERS n UNDERSTAND WHEN TO REFER TO A SLEEP CLINIC OR PSYCHOLOGIST copyright Dr. Carole Lamarche, C. Psych.

INSOMNIA: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN n REVIEW HEALTH HISTORY FOR COMMON COMORBID DISORDERS: –DEPRESSION –ANXIETY –SUBSTANCE USE –PHYSICAL PAIN –HEART AND LUNG PROBLEMS copyright Dr. Carole Lamarche, C. Psych.

INSOMNIA: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN n HAVE PATIENT KEEP A SLEEP DIARY n OBTAIN COLLATERAL INFORMATION FROM BEDPARTNER n ASK ABOUT RECENT LIFE EVENTS n ASK ABOUT PHYSICAL PAIN n ASK ABOUT MOOD AND INTEREST copyright Dr. Carole Lamarche, C. Psych.

INSOMNIA: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN n ASK PATIENTS HOW MUCH ALCOHOL THEY USE PER DAY n ASK PATIENTS ABOUT CAFFEINE USE n ASK PATIENTS ABOUT NAPPING copyright Dr. Carole Lamarche, C. Psych.

PSYCHOLOGICAL TREATMENT OF INSOMNIA n STIMULUS CONTROL THERAPY n SLEEP RESTRICTION THERAPY n COGNITIVE THERAPY

STIMULUS CONTROL n GO TO BED ONLY WHEN SLEEPY n IF UNABLE TO FALL ASLEEP OR STAY ASLEEP WITHIN 20 MINUTES, LEAVE BEDROOM n RETURN TO BED WHEN SLEEPY n REPEAT AS OFTEN AS NECESSARY n MAINTAIN REGULAR WAKETIME n DO NOT NAP n USE BEDROOM ONLY FOR SLEEP AND SEX copyright Dr. Carole Lamarche, C. Psych.

SLEEP RESTRICTION n ESTIMATE TOTAL SLEEP TIME FROM SLEEP DIARY n PRESCRIBE ESTIMATED TOTAL SLEEP TIME AS NEW TIME TO STAY IN BED n AS SLEEP IMPROVES, ADD 15 ADDITIONAL MINUTES TO TIME IN BED

COGNITIVE THERAPY n IDENTIFY MALADAPTIVE THOUGHTS, PREDICTIONS AND BELIEFS ABOUT SLEEP n CHALLENGE THESE WITH FACTS ABOUT SLEEP AND EVIDENCE FROM PATIENT’S LIFE copyright Dr. Carole Lamarche, C. Psych.

INSOMNIA: ADDITIONAL PSYCHOLOGICAL INTERVENTIONS n RELAXATION TRAINING –PROGRESSIVE MUSCLE RELAXATION –DIAPHRAGMATIC BREATHING –IMAGERY AND VISUALIZATION –AUTOGENICS copyright Dr. Carole Lamarche, C. Psych.

MEDICAL INTERVENTIONS FOR INSOMNIA n MEDICATIONS –BENZODIAZEPINES –BENZODIAZEPINE RECEPTOR AGONITSTS –ANTI-DEPRESSANTS –ANTI-PSYCHOTICS copyright Dr. Carole Lamarche, C. Psych.

WHAT ABOUT MEDICATIONS? n MEDICATIONS ARE APPROPRIATE FOR SHORT-TERM OR INTERMITTENT USE BUT NOT FOR CHRONIC USE n MANY IMPACT SLEEP ARCHITECTURE, HAVE ADDICTION POTENTIAL, CAN CAUSE DAYTIME SLEEPINESS AND CREATE REBOUND INSOMNIA UPON WITHDRAWAL copyright Dr. Carole Lamarche, C. Psych.

INSOMNIA: BRIEF INTERVENTIONS FOR THE PHYSICIAN n ASK PATIENT TO MAKE TO-DO LIST n ASK PATIENT TO JOURNAL n HAVE PATIENT LEARN RELAXATION n ASK PATIENT TO GET OUT OF BED WHEN AWAKE n ASK PATIENT TO GO TO BED LATER/ WAKE UP EARLIER copyright Dr. Carole Lamarche, C. Psych.

INSOMNIA: BRIEF INTERVENTIONS FOR THE PHYSICIAN n ENCOURAGE PATIENTS TO ONLY SLEEP AND HAVE SEX IN BED, NOTHING ELSE n ENCOURAGE A REGULAR WAKE-UP TIME, REGARDLESS OF SLEEP QUANTITY OR QUALITY n HAVE PATIENTS INCREASE AFTERNOON PHYSICAL ACTIVITY copyright Dr. Carole Lamarche, C. Psych.

DSM-5 BREATHING- RELATED DISORDERS n OBSTRUCTIVE SLEEP APNEA HYPOPNEA (OSAH) n CENTRAL SLEEP APNEA n SLEEP-RELATED HYPOVENTILATION copyright Dr. Carole Lamarche, C. Psych.

OSAH: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN: HISTORY n SPECIFIC FACTORS : –OBESITY –CROWDED PHARYNGEAL AIRWAY –AGE –GENDER –MENOPAUSE n COMMON COMORBIDITIES: –HYPERTENSION –CORONARY ARTERY DISEASE –HEART FAILURE –STROKE –DIABETES –DEPRESSION copyright Dr. Carole Lamarche, C. Psych.

OSAH: BRIEF ASSESSMENT STATEGIES FOR THE PHYSICIAN: HISTORY n NON-SPECIFIC FACTORS : –MORNING HEADACHES –HEARTBURN –NOCTURIA –REDUCED LIBIDO –DRY MOUTH –ERECTILE DYSFUNCTION copyright Dr. Carole Lamarche, C. Psych.

OSAH: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN n DO THEY SNORE? n DOES A BEDPARTNER COMPLAIN OF SNORING OR OTHER LOUD NOISES? n DO THEY FALL ASLEEP DURING THE DAY WITHOUT TRYING? n ANY ACCIDENTS OR NEAR MISSES? copyright Dr. Carole Lamarche, C. Psych.

INTERVENTIONS FOR OBSTRUCTIVE SLEEP APNEA HYPOPNEA n CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) n BILEVEL POSITIVE AIRWAY PRESSURE (BiPAP) n ORAL APPLIANCES n POSITIONAL STRATEGIES (I.E. TENNIS BALL) copyright Dr. Carole Lamarche, C. Psych.

INTERVENTIONS FOR OBSTRUCTIVE SLEEP APNEA HYPOPNEA n SURGERY OPTIONS: –TISSUE REMOVAL (UPPP, TONSILS, ADENOIDS –JAW REPOSITIONING –NASAL SURGERY –IMPLANTS INTO THE SOFT PALATE copyright Dr. Carole Lamarche, C. Psych.

OSAH: ADDITIONAL BRIEF INTERVENTIONS FOR THE PHYSICIAN n ENCOURAGE HEALTHY EATING AND PHYSICIAL ACTIVITY IN ORDER TO PROMOTE WEIGHT LOSS n ENCOURAGE SMOKING CESSATION n ENCOURAGE MODERATION WITH ALCOHOL USE n TREAT COMORBID MENTAL AND PHYSICAL HEALTH CONDITIONS copyright Dr. Carole Lamarche, C. Psych.

RESTLESS LEGS SYNDROME (RLS): BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN n RULE OUT OTHER CAUSES OF MOVEMENTS: –ARTHRITIS –LEG EDEMA –LEG CRAMPS –PERIPHERAL ISCHEMIA –HABITUAL FOOT TAPPING –POSITIONAL DISCOMFORT –MEDICATION EFFECTS copyright Dr. Carole Lamarche, C. Psych.

RLS: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN: HISTORY n SPECIFIC FACTORS: –FEMALE GENDER –PREGNANCY –AGE –FAMILY HISTORY –IRON DEFICIENCY –GENETIC RISK FACTORS copyright Dr. Carole Lamarche, C. Psych.

RLS: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN: HISTORY n COMMON COMORBIDITIES: –DEPRESSION –ANXIETY DISORDERS –ATTENTIONAL DIFFICULTIES –CARDIOVASCULAR DISEASE –CHRONIC RENAL FAILURE –PERIODIC LIMB MOVEMENT DISORDER copyright Dr. Carole Lamarche, C. Psych.

INTERVENTIONS FOR RESTLESS LEGS SYNDROME n MEDICATIONS: –DOPAMINERGICS (E.G. REQUIP (ROPINIROLE), MIRAPEX (PRAMIPEXOLE) AND NEUPRO PATCH (ROTIGOTINE) –ANTICONVULSANTS –OPIOIDS –MUSCLE RELAXANTS copyright Dr. Carole Lamarche, C. Psych.

ADDITIONAL INTERVENTIONS FOR RESTLESS LEGS SYNDROME n LIGHT THERAPY n STRETCHING n YOGA n RELAXATION TEACHNIQUES copyright Dr. Carole Lamarche, C. Psych.

RLS: ADDITIONAL BRIEF INTERVENTIONS FOR THE PHYSICIAN n ENCOURAGE DECREASE IN CAFFEINE, ALCOHOL AND NICOTINE USE n ENCOURAGE USE OF MASSAGE OR WARM BATH n ENCOURAGE USE OF HEAT OR ICE n IDENTIFY VITAMIN AND MINERAL DEFICIENCIES (IRON, MAGNESIUM, ETC.) copyright Dr. Carole Lamarche, C. Psych.

WHEN TO REFER TO A SLEEP CLINIC n WHEN YOU SUSPECT THERE IS A SLEEP DISORDER THAT NEEDS POLYSOMNOGRAPHY TO BE CORRECTLY DIAGNOSED –SLEEP APNEA –NARCOLEPSY –REM SLEEP BEHAVIOUR DISORDER copyright Dr. Carole Lamarche, C. Psych.

WHEN TO REFER TO A PSYCHOLOGIST n WHEN YOU SUSPECT A PSYCHOLOGICAL DISORDER THAT IS MODERATE TO SEVERE (MOOD DISORDER, ANXIETY DISORDER, SUBSTANCE USE DISORDER) n WHEN THE PATIENT HAS CHRONIC PHYSICAL PAIN n WHEN THE PATIENT IS HAVING DIFFICULTY IMPLEMENTING YOUR SUGGESTIONS copyright Dr. Carole Lamarche, C. Psych.

SOME USEFUL WEBSITES n Canadian Sleep Society: n Mayo Clinic: n American Sleep Apnea Association: n Restless Legs Syndrome Foundation:

USEFUL REFERENCES n SINK INTO SLEEP J. DAVIDSON n THE INSOMNIA WORKBOOK S. SILBERMAN & C. MORIN n SAY GOODNIGHT TO INSOMNIA G. JACOBS n QUIET YOUR MIND AND GET TO SLEEP C. CARNEY & R. MANBER n INSOMNIA C. MORIN copyright Dr. Carole Lamarche, C. Psych.