want of sleep
Post on 07-May-2015
159 Views
Preview:
DESCRIPTION
TRANSCRIPT
{Want of Sleep
Kyle P. Edmonds, MDFellow, Institute for Palliative MedicineSan Diego Hospice
Sleep and his half-brother
Circadian Rhythm
Getting to sleep
Absence of distress Circadian timing (time of the day)
Sleep drive (time since last slept)
Physical comfort Environment Intact CNS function
Hanks et al. (2010).
Hypnogram
Age Sleep Needs (Hours)
0-2 Mos 12-18 hours3-11 Mos 14-15 hours1-3 Yrs 12-14 hours3-5 Yrs 11-13 hours5-10 Yrs 10-11 hours10-17 Yrs 8-9 hours
Adults (inc seniors) 7-9 hours
Average Sleep NeedsAdapted from Carol (2011).
Why? Who knows?
Biological recovery Enhanced immune function Regulation of circadian hormones
Memory consolidation
Hanks et al. (2010).
Diagnostic Category Representative DiagnosesInsomnia Primary, Secondary
Sleep-related breathing d/o
OSA, CSA
Hypersomnolence Narcolepsy
Circadian rhythm disorder
Shift work
Movement disorder RLS
Parasomnia Night terror; REM sleep behavior
Isolated symptoms Primary snoring; Sleep talking
Disordered SleepAdapted from Table 10.12.1. Hanks et al. (2010).
By the Numbers
General population1 9-12%
Healthy seniors1 12-25%Hospital
population2 23%Chronic lung
disease3 50%
Cancer2 70%
HIV/AIDS3 75%
Hemodialysis3 77%
Depression3 90%
(1) Bastien et al. (2003). (2) Miller & Arnold (2011).(3) Hanks et al. (2010)
Etiology
Psycho-physiologi
c Hyperarou
sal
Increased metabolic
rate
Activated HPA axis
Increased autonomic
nervous system Increased
sleep EEG frequency
Increased cerebral
blood flow
Hanks et al. (2010).
Sleep History: Epworth
SituationSitting and reading
Watching TV
Sitting inactive in a public place (e.g. theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a care, while stopped for a few minutes in traffic
Miller & Arnold (2011).
Hygiene Chronology Environment Physical Symptoms
Medical Conditions
Spiritual ConcernsSleep History
Miller & Arnold (2011).
Sleep History: Chronology
PersistentMedical,
neurologic or psychiatric
Difficulty staying asleep
Nightmares, OSA
Frequent awakening Medications
Early morning
awakeningDepression
Day-night reversal Delirium
Miller & Arnold (2011).
Sleep History: Symptoms
Hugel et al. (2004).
Sleep History: AnxietyHugel et al. (2004).
• Symptom control38%
• Address worry21%
• Combination of measures19%
• Don’t know13%
• Sleep medications4%
Sleep History: Survey
What do you
think would
help you
sleep?
Hugel et al. (2004).
Patient/Family Characteristic
s
Disease Mgmt
Physical issues
Psych & cognitive issues
Social issues
Spiritual issues
Practical issues
End-of-life/
death mgmt
Loss, grief
Adapted from EPEC-O. (2007)
Non-Pharm Therapies
Relaxation therapies Sleep restriction therapy Stimulus control therapy Cognitive behavioral therapy
BiPAP Palatoplasty
Miller & Arnold (2011).
Hanks et al. (2010).
“Patients may be able to avoid [spiritual] concerns during the day
through the distraction of daily activities but have difficulty
ignoring them at night. Thus, it is important to directly address a
patient’s spiritual concerns, worries, and fears about dying
during the day.”
Non-Pharm TherapiesMiller & Arnold (2011).
Pharmaceuticals
Consider stopping: Steroids Stimulant antidepressants
Bronchodilators Diuretics
PharmaceuticalsSanna & Brurera (2002).
Pharmaceuticals: Bzds
Increase stage 2 (N2) Decrease stages 3 and 4 (N3)
Interfere with slow-wave sleep
Bastien et al. (2003).
Pharmaceuticals
Pharmaceuticals
Medication
Dosage
Half-life
Tmax
Metabolites Comments
Other benzodiazepine receptor agonists
Zolpidem 5 1.5-4 1-1.5 NoAmbien®;
imidazopyridine
Zaleplon 5 1 0.5-1 No Sonata®; pyrazolopyrimidine
Eszopiclone 2 5-7 0.5-2 Minimal Lunesta®;
cyclopyrrolone
Melatonin agonists
Ramelteon 8 1-2 0.5-1 NoRozerem®; Not a
controlled substance
Adapted from Table 10.12.7, Hanks et al. (2010).
Studied only in depressed insomniacs
25-100mg may improve sleep*
Biphasic half-life (3-6h, 5-9h)
Pharmaceuticals: Trazodone
Proven phase-shifting capability
Mixed evidence for benefit in elderly
Poorly-regulated formulations
Pharmaceuticals: Melatonin
Pharmaceuticals: Seniors
Sedative-hypnotics Falls Hip fracture Cognitive
impairment
Preferred Zolpidem (Ambien) Eszopiclone
(Lunesta) Ramelteon
(Rozerem)
Hanks et al. (2010).
Great source of oracles to human kind,
when stealing soft, and whispering to the mind,
through sleep’s sweet silence, and the gloom of night,
thy power awakes the intellectual sight;
to silent souls the will of heaven relates, and silently reveals their
future fates.Orphic Hymn 86 to the Oneiroi
Sleep and it’s disturbance are physiologically complex
Begin with a thorough history and sleep hygiene counseling
Pharmaceuticals are only one treatment, even in palliative care
In summary
Bastien CH et al. (2003). Sleep EEG power spectra, insomnia and chronic use of benzodiazepines. Sleep. 26(3): 313-317.
Carol E (2011). "How Much Sleep Do We Really Need?". National Sleep Foundation. Undated. http://www.sleepfoundation.org/article/how-sleep-works/how-much-sleep-do-we-really-need. Retrieved 2012-09-18.
Davidson JR, MacLean AW, Brundage MD & K Schulze (2002). Sleep disturbance in cancer patients. Soc Sci Med. 54: 1309-1321.
EPEC-O (2007). Module 1: Comprehensive Assessment. Hanks G et al., Ed. (2010). Oxford Textbook of Palliative Medicine:
Sleep in palliative care. New York, NY. 1059-1083. Hugel H, et al. (2004). The prevalance, key causes and management of
insomnia in palliative care patients. J Pall Symp Mgmt. 27(4): 316-321. Maslow A (1954). Motivation and Personality. New York: Harper. Pp
236. Miller M & R Arnold (2011). Fast Facts and Conceps #101, 104, 105.
Insomnia: Patient assessment, Non-parmacologic treatments & Phamacological Therapies. EPERC.
Sanna P & E Brurera (2002). Insomnia and sleep disturbances. Eur J Pall Care. 9(1): 8-12.
References
top related