Download - Insomnia by Dr Sarma
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Sleep disorders arecommon
Sleep disorders are serious
Sleep disorders are treatable
Sleep disorders areunder diagnosed
Important facts
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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
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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
Wake
2/3 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.
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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
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Insomnia is not defined by the number of
hours of sleep, but rather, by an individuals
ability to sleep long enough to feel healthy
and alert during the day.
The normal requirement for sleep rangesbetween 4 and 10 hours
Insomnia is a symptom, not a disorder byitself
Insomnia - definition
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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
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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 ormove 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 orsleep that is non-restorative or poor inquality.
2. The above sleep difficulty occurs despiteadequate opportunity and circumstance
for sleep.
3. Insomnia is a symptom not a diseaseper 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 gastrointestinalsymptoms in response to sleep loss
Concerns or worries about sleep
Secondary psychiatric problems
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Sleep onset insomnia
Sleep maintenance insomnia
Sleep offset insomnia
Non restorative sleep
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Insomnia - subdivisions___________________________
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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
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Treat underlying causes whenever possible
Advise patient to avoid exercise, heavy
meals, alcohol, or conflict situations justbefore bed
Plain aspirin or paracetamol in low doses
may be helpful; or give short-actinghypnotics or a sedative
Treat underlying depression
Management of insomnia___________________________
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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___________________________
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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, Caffeine
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Medications and insomnia___________________________
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Cognitive Behaviour Therapy (CBT)____________________________
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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 occurin 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
asleepParadoxical intention
Alter irrational beliefs about sleep, provide accurate
information that counteracts false beliefsCognitive
restructuring
Patient imagines 6 common objects (candle, kite, fruit,
hourglass, blackboard, light bulb) emphasis on
imagining shape, colour, textureImagery training
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Benzodiazepines
Lorazepam
Clonezepam Temazepam
Flurazepam
Quazepam
Alprazolam
Triazolam
Estazolam
Non Benzodiazepines
Zolpidem
Zolpidem CR Zeleplon
Eszopiclone
Both these classes acton the GABAA receptors(BzRA) in PCN
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Benzodiazepine receptor agonists__________________________
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Antidepressants
Trazadone
Mirtazapine Doxepin
Amitryptyline
Antipsychotics Olanzapine
Quitiepine
Melatonin Receptor Agonists
Melatonin
Ramelteon
Miscellaneous
Valerian
Diphenhydramine
Cyclobenzaprine
Hydroxyzine
Alcohol
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Other classes of medications__________________________
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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 life - nitrazepam
Medium life - temazepam
Short 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____________________________
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Benzodiazepines are the drugs of choice for the
treatment of insomnia.
Flurazepam can be used for up to one monthwith 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____________________________
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Half-life is an important factor
Benzodiazepines with long half lives (e.g.,
flurazepam) produce sustained sleep, butincreased 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____________________________
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Benzodiazepines have relatively low
abuse potential.
Prolonged use can lead to withdrawal
symptoms: headache, irritability,
dizziness, abnormal sleep
Rebound insomnia - triazolam
Benzodiazepine abuse____________________________
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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 life Zolipidem, Zopiclone slightly longer life
No difference in effectiveness & safety
More expensive
Only to be used if adverse effects to BZP
Non benzodiazepines____________________________
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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____________________________
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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, effectscircadian rhythm, synthesised at night
Use to counteract jet lag (2-5mg @ bedtime forFour 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 Condition4. 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
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THANK YOU ALL
HAVE GOOD SLEEP