john mclachlan respiratory & sleep physician @fsh clinical ... · good lord, deliver us! trad....
TRANSCRIPT
John McLachlan
Respiratory & Sleep Physician @FSH
Clinical Lead Pulmonary Physiology & Sleep Medicine
Sleep Physician x 27 years
Interest in Insomnia management
President Elect, WA Branch Thoracic Society of Australia & NZ
From ghoulies and ghosties
And long-leggedy beasties
And things that go bump in the night,
Good Lord, deliver us!
trad. Scottish
Overview
Normal Sleep
Sleep Disorders
Falls
Sleep Treatments
Falls
Alternative Management
Normal Sleep
Gradual process
Sleep pressure / Circadian / Alerting
> 24 hour clock
Entraining
Cyclical
Stages
Normal Sleep
Normal Sleep
Normal Sleep
Falls due to normal sleep?
Environment
Inertia
REM
Sleep Disorders
Excessive Sleep
Initiating & Maintaining Sleep
Parasomnias
Sleep Disorders
Excessive Sleep
Sleep Apnoea Sleepy
PU
Narcolepsy / Cataplexy
Sleep restriction
Sleep Disorders
Initiating & Maintaining Sleep
Insomnia
Circadian
Sleep Disorders Initiating & Maintaining Sleep
Insomnia
Circadian
Insomnia increase elderly
Increased use of hypnotics in elderly
Narrower therapeutic index
Increased comorbidities
Increased polypharmacy
Often longer duration of action
Sleep Disorders
Parasomnias
Restless Legs
REM behaviour
Arousals Confusional
Sleep walking
Terrors
Sleep Treatments
Oxygen
CPAP
Medications
Hypnotics and Falls
Several studies show increased risk
Elderly Institutionalised Benzos & other psychotropics
J Gerontol 1989;44:M112-117
Some inconstant
Community Large scale suggest increased risk
N Engl J Med 1988; 319: 1701-1707
JAMA 1989; 261: 2663-2668
Hypnotics and Falls
Brassington et al Reported sleep problems Not psychotropic meds
J Am Geriat Soc 2000; 48: 1234-1240
Questionnaire study Falls related to insomnia Falls related insomnia not responding meds Not insomnia responding to meds
J Am Geriat Soc 2005; 53: 955-962
If hypnotic works … not a risk?
Hypnotics and Falls
Stone et al. Community living older women
Actigraphy
Medication list
Risk of falls over 8 years
Arch Intern Med. 2008;168(16):1768-1775
Hypnotics and Falls
Arch Intern Med. 2008;168(16):1768-1775
Sleep and Falls
Arch Intern Med. 2008;168(16):1768-1775
Alternate Treatment
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CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
Exercise
Exercise promotes both sleep onset and sleep consolidation in all groups
Specific studies in the elderly have shown benefits with very minimal exercise
Exercise confers additional benefits on bones, joints, balance
Bright Light
Moderately bright light (1000 lux) or more improves subjective alertness, mood, and sleep quality
Morning bright light promotes sleep onset
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Sleep “Hygiene”
Regular sleep-wake cycle
Bed when sleepy
Avoid caffeine / alcohol
Exercise
Careful use of naps
Conducive environment
Bed for sleeping and sex
Worry time
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CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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Two goals of behavioural component
Stimulus Control Therapy
• Strengthen the relationship between sleep and sleep-related stimuli (i.e., bed, bedtime, bedroom surroundings).
Sleep Restriction
• Consolidate sleep over shorter periods of time.
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Stimulus Control
Bed
Bedroom
Bedtime
Sleep-incompatible activities (reading, watching tv)
Frustration
Anxiety
Worry
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Bed
Bedroom
Bedtime
Drowsiness
Relaxation
Sleep
Stimulus Control
Conditioned Sleep Onset Insomnia
Stimulus Control Therapy 1. Don’t go to bed until sleepy.
2. If not asleep in 10-15 minutes, get out of bed.
3. Go back to bed when sleepy again.
4. Keep repeating #2 & #3 until asleep.
5. Arise at the same early time (eg. 7am) every morning regardless of the time went to sleep.
6. Use the bed only for sleep and sex.
7. Don’t nap (long nap) during the day.
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Sleep Restriction
Individuals with insomnia have reduced sleep efficiency
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Align time in bed (TIB)
Develop a regular sleep-wake rhythm.
Sleep Restriction
Sleep is on our side
Combine stimulus control & sleep
restriction – almost always win!
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CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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Cognitive Component
Challenging unrealistic sleep expectations
Modifying beliefs about causes and consequences of insomnia
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•BELIEF:
It is essential to sleep x number of hours
per day to feel refreshed and function well
during the day
Cognitive Component
Morning sleepiness is normal
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Historical Sleep
Segmented Sleep
1st (deep)
“watch period”
2nd lighter
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CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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Educational Component
Health practices
Environmental influences
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Alternative Approaches
Relaxation
Paradoxical intention
Online CBT
“Sleep (is like) a dove which has landed near one’s hand and stays
there as long as one does not pay any attention to it;
if one attempts to grab it, it quickly flies away.”
Victor E Frankl