Sleep Disorders

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  • Key points50% of population - some sleep-related problem /year. 25% of population - trouble getting enough sleep.It is important to take a drug history from patients complaining of insomnia or hypersomnolence.alcohol, nicotine, antihistamines, (SSRIs), venlafaxine, selected -blockers, 2-agonists, theophylline, corticosteroids sympathomimetic agents. Sleep disorders in children, including snoring are serious, results in - learning difficulties, hyperactivity, behavioural disorders, failure to thrive and short stature.

  • Key pointsThe majority of cases of excessive somnolence are caused by OSA and narcolepsy. Non-pharmacological therapies, which include basic education and practice of sleep hygiene and behavioural therapy, are 1st line. It is illegal for a driver with a commercial driver's licence to continue to drive while suffering from untreated OSA.

  • Q. Martin, aged 50 years, complains of insomnia for two weeks. He says this relates to anxiety about problems at work which surround the end of the financial year. While he is describing his problem, he is excited and agitated. On examination, his pulse rate is 75/min and BP 135/95 mm Hg. Which of the following behavioural therapies would be MOST helpful to Martin?

    a) Cognitive therapy b) Sleep restriction therapy c) Stimulus control therapy d) Relaxation therapy e) Interpersonal therapy

  • ( D )The successful treatment of insomnia depends on both behavioural and pharmacological approaches. Relaxation therapy would be the most useful behavioural therapy for Martin, because he displays exaggerated arousal - emotional, cognitive and physiological, shown by his mental approach when describing the problem and his physiological response in terms of pulse rate and BP. Progressive muscle relaxation aims to reduce somatic arousal and attention focussing techniques (e.g. on tranquil situations) to reduce cognitive and emotional arousal.)

  • Sleep disorders Primary sleep disorder.DyssomniaParasomnia Secondary sleep disorder.Sleep disorders secondary to mental or physical diseases.


  • Primary Sleep disordersDyssomnia ( changes in the quality, quantity and/or timing of sleep)

    Primary insomnia Other disorders initiating or maintaining sleep - Nocturnal myoclonus- Restless legs syndrome Excessive somnolence Primary hypersomnia Narcolepsy Breathing-related sleep disorder OSACircadian rhythm sleep disorder Jet lag

    Parasomnia (undesirable phenomena occurring during sleep)Nightmare disorder.Night terror disorder.Sleepwalking disorder.

    Secondary sleep disorders Medical condition disorder Mental disorder Substance abuse


  • DYSSOMNIAChanges in the quality, quantity and/or timing of sleep


  • Primary insomniaDisorders of initiating and maintaining sleep (DIMS). Inadequate amount and quality.

    May complain of:difficulty getting to sleep or staying asleep,frequent intermittent nocturnal arousals, early morning awakening or combinations of these.


  • ManagementHistory: lifestyle, painful conditions, drug use and abuse, appetite, energy, sexual issues and physical factors. Check thyroid status, especially hyperthyroidism.Aim and discuss to treat without medication.Evaluate daytime functioning with sleep diary.Exclude and treat any underlying problem:drugs (e.g. caffeine, alcohol, -blockers, nicotine)anxiety, stress, depressionrestless legs syndromesleep apnoeaparasomnias - nightmares, sleepwalkingphysical disorders (e.g. CCF, arthritis, asthma), reflux disease, thyrotoxicosis, menopausal symptomslower urinary tract symptoms with nocturiasnoring partner

  • Management5. Explanation and reassurance, including patient education handout.Sleep hygiene advice.

    6. Non-pharmacological treatment.Depending on patients personality and preference, relaxation therapy, meditation and stress management, which are all highly recommended. Other measures include cognitive-behaviour therapy, structured problem solving.Hypnosis is worth considering.

  • Medication7. Pharmacological treatment. Advisable to avoid hypnotic agents as first-line treatment. If not then limit it to 2 weeks. temazepam 10 - 20 mg tablets (o) noctezopiclone 3.75 - 7.5 mg (o) nocte, orzolpidem 10 mg (o) nocteNote: zopiclone and zolpidem, are non-benzodiazepine hypnotics with a similar action as Temazepam. However, they have adverse neurological and psychiatric reactions. Tricyclic antidepressants with sedative effects (e.g. amitriptyline) are often used as hypnotics but should generally be avoided in the absence of depressive disorders.

  • Q.Insomnia is defined as inability to: a) Fall asleep b) Maintain sleep c) Sleep at normal times d) Obtain good quality sleep e) Obtain enough sleep

  • ( D )Insomnia is the commonest sleep disorder and is defined as poor quality sleep which often results in daytime symptoms, including fatigue, irritability, problems with concentration and memory, and feeling unwell. The other options describe features of various insomnia syndromes but do not define the overall problem.

  • Which of the following is a cause of primary insomnia? a) Obstructive sleep apnoea b) Restless legs syndrome c) Behavioural conditioning d) Sleep phase disorder e) Bereavement

  • ( C )In primary insomnia there is no pre-existing cause of sleep disorder as there is, for example, in obstructive sleep apnoea, restless legs syndrome, sleep phase disorder and bereavement. With behavioural conditioning or behaviours impairing sleep the patient has developed a habit of doing things immediately before bedtime which are not conducive to sleep, such as sitting in bed watching television. With the other options there is another established condition or situation which disrupts sleep. Hence insomnia is regarded as secondary in these cases.

  • The prevalence of insomnia in the Australian community is about: A)10% b) 20% C) 30% D) 40% e) 50%

  • ( c )The prevalence of insomnia in Australia is about 30%. The situation is similar in other industrialised nations. Male sufferers outnumber females by 1.3 to 1 in the 40+ years age group. Other factors which increase the prevalence of insomnia are old age, unemployment and lower socio-economic status. The majority of patients have a co-existing disorder, such as depression or generalised anxiety, and often present with fatigue or daytime sleepiness

    rather than insomnia.

  • Undesirable phenomena occurring during sleep. Common in children.


  • Nightmares (dream anxiety) Occur later in the sleep period and are accompanied by dreams with unconscious body movements, which usually wakes the person. Can recall the dream.Associations:traumatic stress disorders, GADdrug withdrawal (e.g. alcohol, barbiturates, drugs such as SSRIs, -blockers, benzodiazepines). Violent behavior can occur during dreams and this requires a sleep study.

    Treatment:Psychological evaluation with (CBT).Medication that may help includes phenytoin, clonazepam or diazepam.

  • Somnambulism (sleepwalking) The person performs some repetitive activity in bed or walks around freely. Walking during sleep + copmlex behaviors. Without full alertness or memory to episode. Usually go back into sleep (rarely awake). Stress, sleep deprivation, tardiness, No treatment is usually required but, if it is repetitive and potentially dangerous, then the sleeping environment should be rendered safe. Psychological assistance is required for recurring episodes. Benzodiazepines such as diazepam may be useful but withdrawal usually leads to rebound problems

  • Night terrors Characteristics : sharp screams, violent thrashing movements autonomic overactivity, including sweating tachycardia. The sufferers may or may not awaken and usually cannot recall the event. within 2 hours of sleep and last 1 - 2 minutes, the child is usually inconsolable and has no memory of the eventMore in children (1%-6%). Boys > Girls. Indicating intense stress.Require psychological evaluation and therapy. Similar medication as used for nightmares may help (e.g. a 6-week trial of phenytoin, diazepam or clonazepam).

  • Martin is 5 years old. His mother reports he has been waking her at night screaming in apparent fear. She is extremely worried. Although Martin is obviously frightened during these episodes, he does not seem fully awake, and she is unable to comfort him or wake him fully. He is sweaty, tachypnoeic and tachycardic. Martin does not recall these episodes in the morning. He is MOST LIKELY suffering from:

    a) Nightmares b) Thyrotoxicosis c) Night terrors d) Panic disorder e) Seizure disorder

  • ( C )Night terrors are a disorder of arousal from NREM sleep, usually occurring in 3 to 8 year olds. The child wakes only partially, cannot be fully roused or comforted, and will have no recall of the episode. Autonomic symptoms as described are common. With nightmares, the child wakes fully, and frequently has full recall of dreams. Night terrors may be precipitated by anxiety or an experience which has frightened the child prior to sleep.

  • ( C )Night terrors are a disorder of arousal from NREM sleep, usually occurring in 3 to 8 year olds. The child wakes only partially, cannot be fully roused or comforted, and will have no recall of the episode. Autonomic symptoms as described are common. With nightmares, the child wakes fully, and frequently has full recall of dreams. Night terrors may be precipitated by anxiety or an experience which has frightened the child prior to sleep.

  • Sleep disorder In ElderlyConstitute the bulk of long-term users of hypnotics and benzodiazepines. Two key issues to consider are sleep and confusion in the elderly. Problems associated with long-term benzodiazepine use are dependence, confusion, memory impairment and falls. 25% has insomnia either coexisting with or related to other sleep disorders, (as sleep apnoea or periodic limb movement disorder)10% has insomnia related to medical or psychiatric conditions13% has insomnia associated with an inability to stop taking sedative - hypnotic agents

  • Management in elderly

    Exclude underlying causes of sleep disturbance.Educate patients and carers about the changing needs with ageing and the rational use of medicines.Avoid hypnotics combined with alcohol..Consider non-drug measures where possible (e.g. CBT).

    Medication: (only if necessary)Short-acting benzodiazepine (Temazepam) for as limited a time as possible. An alternative non-benzodiazepine hypnotic (e.g. zopiclone or zolpidem) taken just before retiring may be useful in the elderly (beware of adverse effects)

  • Doris is a 74 year old woman whose husband has died suddenly a week ago. She seeks your help in dealing with insomnia which has been troubling her since her husband's death. She has tried an over-the-counter preparation which she obtained at the local pharmacy but has not found it helpful. Which of the following drugs would you offer to prescribe for Doris? a) Temazepam b) Zopiclone c) Zolpidem d) Amitriptyline e) Any of the above

  • ( E )There is a well defined role for short-term use of a hypnotic medication in a situation like sudden bereavement. None of the drugs listed stands out as the best hypnotic with few side effects. Temazepam is the most often prescribed hypnotic in Australia. However, benzodiazepines have generally fallen from favour because of their addictive properties if taken for more than several weeks. Zopiclone and zolpidem share some of the properties of benzodiazepines but have fewer adverse effects. Amitriptyline is a tricyclic antidepressant which is a useful hypnotic in lower doses than are used for depression.

  • Sleep only when sleepy This reduces the time you are awake in bed. If you can't fall asleep within 20 minutes, get up and do something boring until you feel sleepy Sit quietly in the dark or read the warranty on your refrigerator. Don't expose yourself to bright light while you are up. The light gives cues to your brain that it is time to wake up Don't take naps This will ensure you are tired at bedtime. If you just can't make it through the day without a nap, sleep less than one hour, before 3 pm. Get up and go to bed the same time every day Even on weekends! When your sleep cycle has a regular rhythm, you will feel better. Refrain from exercise at least 4 hours before bedtime Regular exercise is recommended to help you sleep well, but the timing of the workout is important. Exercising in the morning or early afternoon will not interfere with sleep. Develop sleep rituals .It is important to give your body cues that it is time to slow down and sleep. Listen to relaxing music, read something soothing for 15 minutes, have a cup of caffeine free tea, do relaxation exercises.


  • Only use your bed for sleeping Refrain from using your bed to watch TV, pay bills, do work or reading. So when you go to bed your body knows it is time to sleep. Stay away from caffeine, nicotine and alcohol at least 4-6 hours before bed Caffeine and nicotine are stimulants that interfere with your ability to fall asleep. Coffee, tea, cola, cocoa, chocolate and some prescription and non-prescription drugs contain caffeine. Cigarettes and some drugs contain nicotine. Alcohol may seem to help you sleep in the beginning as it slows brain activity, but you will end end up having fragmented sleep. Have a light snack before bed If your stomach is too empty, that can interfere with sleep. However, if you eat a heavy meal before bedtime, that can interfere as well. Dairy products and turkey contain tryptophan, which acts as a natural sleep inducer. Tryptophan is probably why a warm glass of milk is sometimes recommended.Take a hot bath 90 minutes before bedtime A hot bath will raise your body temperature, but it is the drop in body temperature that may leave you feeling sleepy. Read about the study done on body temperature below. Make sure your bed and bedroom are quiet and comfortable A hot room can be uncomfortable. A cooler room along with enough blankets to stay warm is recommended. If light in the early morning bothers you, get a blackout shade or wear a slumber mask. If noise bothers you, wear earplugs or get a "white noise" machine.Use sunlight to set your biological clock As soon as you get up in the morning, go outside and turn your face to the sun for 15 minutes.


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