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• Sleep disorders are common

• Sleep disorders are serious

• Sleep disorders are treatable

• Sleep disorders are under diagnosed

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

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Important facts___________________________

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Wake System___________________________

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Sleep System___________________________

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Sleep Wake Cycle___________________________

Changes in sleep with age___________________________

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Stages of sleep___________________________

1. NREM Sleep

A. Stage 1

B. Stage 2

C. Stage 3

D. Stage 4

2. REM Sleep

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REM Sleep~20% of night

NREM Sleep~80% of night

Wake2/3 of life

Sleep Stages ___________________________

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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.

• 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___________________________

• 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___________________________

• 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___________________________

Cognitive Model of Insomnia

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Evolution of Insomnia

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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___________________________

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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

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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

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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

• Sleep onset insomnia

• Sleep maintenance insomnia

• Sleep offset insomnia

• Non restorative sleep

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Insomnia - subdivisions___________________________

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%)

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Medical problems__________________________• Depression

• Hyperthyroidism

• Arthritis, chronic pain

• Benign prostatic hypertrophy

• Headaches; Sleep apnoea

• Periodic leg movement,

• Restless leg syndrome (RLS)

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Other problems__________________________

• Caffeine

• Nicotine

• Alcohol

• Exercise

• Noise

• Light

• Hunger

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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

• 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___________________________

• 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___________________________

Type of medication Example

CNS stimulants D-amphetamine, Methyphenindrate

Blood pressure drugs - blockers, - blockers

Respiratory medicines Albuterol, Theophylline

Decongestants Phenylephine, Pseudoephedrine

Hormones Thyroxin, Corticosteroids

Other substances Alcohol, Nocotine, Caffeine28

Medications and insomnia___________________________

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Cognitive Behaviour Therapy (CBT)____________________________

Non pharmacological treatments

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Bed room__________________________• Temperature

• Fresh air

• S&S

• Comfortable bed

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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

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Sleep hygiene__________________________• Behaviours that interfere with sleep

• Caffeine

• Alcohol

• Nicotine

• Daytime napping

• Exercise < 4hrs before bed

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Relaxation training__________________________• Progressive muscle relaxation

• Diaphragmatic breathing

• Autogenic training

• Biofeedback

• Meditation, Yoga

• Hypnosis to ↓ anxiety & tension at bedtime

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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)

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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

• Benzodiazepines– Lorazepam

– Clonezepam

– Temazepam

– Flurazepam

– Quazepam

– Alprazolam

– Triazolam

– Estazolam

• Non Benzodiazepines– Zolpidem

– Zolpidem CR

– Zeleplon

– Eszopiclone

• Both these classes act on the GABAA receptors (BzRA) in PCN

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Benzodiazepine receptor agonists__________________________

• Antidepressants– Trazadone

– Mirtazapine

– Doxepin

– Amitryptyline

• Antipsychotics– Olanzapine

– Quitiepine

• Melatonin Receptor Agonists– Melatonin

– Ramelteon

• Miscellaneous– Valerian

– Diphenhydramine

– Cyclobenzaprine

– Hydroxyzine

– Alcohol38

Other classes of medications__________________________

• 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__________________________

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• 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____________________________

• 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____________________________

• 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____________________________

• Benzodiazepines have relatively low

abuse potential.

• Prolonged use can lead to withdrawal

symptoms: headache, irritability,

dizziness, abnormal sleep

• Rebound insomnia - triazolam

Benzodiazepine abuse____________________________

• 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____________________________

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• 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____________________________

• 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____________________________

Drug Duration of action Half-life

Phenobarbital Long 24 – 140 hrs.

Butabarbital Intermediate 34 – 42 hrs.

Amobarbital Short-intermediate 8 – 42 hrs.

Pentobarbital Short-intermediate 15 – 48 hrs.

Secobarbital Short-intermediate 19 – 34 hrs.

Barbiturates____________________________

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• 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____________________________

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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

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Sleep related movement disorders____________________________

1. Restless Leg Syndrome

2. Periodic Limb Movement Disorder

3. Sleep Related Leg Cramps

4. Sleep Related Bruxism

THANK YOU ALL

HAVE GOOD SLEEP

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