john mclachlan respiratory & sleep physician @fsh clinical ... · good lord, deliver us! trad....

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

201503_McLachlan_Insomnia

CBTi Components

Behavioural component • General

• Specific

Cognitive component

Educational component

201503_McLachlan_Insomnia

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

201503_McLachlan_Insomnia

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

201503_McLachlan_Insomnia

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

201503_McLachlan_Insomnia

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