john mclachlan respiratory & sleep physician @fsh clinical ... · good lord, deliver us! trad....
TRANSCRIPT
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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
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From ghoulies and ghosties
And long-leggedy beasties
And things that go bump in the night,
Good Lord, deliver us!
trad. Scottish
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Overview
Normal Sleep
Sleep Disorders
Falls
Sleep Treatments
Falls
Alternative Management
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Normal Sleep
Gradual process
Sleep pressure / Circadian / Alerting
> 24 hour clock
Entraining
Cyclical
Stages
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Normal Sleep
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Normal Sleep
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Normal Sleep
Falls due to normal sleep?
Environment
Inertia
REM
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Sleep Disorders
Excessive Sleep
Initiating & Maintaining Sleep
Parasomnias
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Sleep Disorders
Excessive Sleep
Sleep Apnoea Sleepy
PU
Narcolepsy / Cataplexy
Sleep restriction
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Sleep Disorders
Initiating & Maintaining Sleep
Insomnia
Circadian
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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
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Sleep Disorders
Parasomnias
Restless Legs
REM behaviour
Arousals Confusional
Sleep walking
Terrors
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Sleep Treatments
Oxygen
CPAP
Medications
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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
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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?
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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
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Hypnotics and Falls
Arch Intern Med. 2008;168(16):1768-1775
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Sleep and Falls
Arch Intern Med. 2008;168(16):1768-1775
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Alternate Treatment
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201503_McLachlan_Insomnia
CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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201503_McLachlan_Insomnia
CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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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
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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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201503_McLachlan_Insomnia
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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201503_McLachlan_Insomnia
CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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201503_McLachlan_Insomnia
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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201503_McLachlan_Insomnia
Stimulus Control
Bed
Bedroom
Bedtime
Sleep-incompatible activities (reading, watching tv)
Frustration
Anxiety
Worry
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201503_McLachlan_Insomnia
Bed
Bedroom
Bedtime
Drowsiness
Relaxation
Sleep
Stimulus Control
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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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201503_McLachlan_Insomnia
Sleep Restriction
Individuals with insomnia have reduced sleep efficiency
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201503_McLachlan_Insomnia
Align time in bed (TIB)
Develop a regular sleep-wake rhythm.
Sleep Restriction
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Sleep is on our side
Combine stimulus control & sleep
restriction – almost always win!
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201503_McLachlan_Insomnia
CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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201503_McLachlan_Insomnia
Cognitive Component
Challenging unrealistic sleep expectations
Modifying beliefs about causes and consequences of insomnia
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201503_McLachlan_Insomnia
•BELIEF:
It is essential to sleep x number of hours
per day to feel refreshed and function well
during the day
Cognitive Component
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Morning sleepiness is normal
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201503_McLachlan_Insomnia
Historical Sleep
Segmented Sleep
1st (deep)
“watch period”
2nd lighter
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201503_McLachlan_Insomnia
CBTi Components
Behavioural component • General
• Specific
Cognitive component
Educational component
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201503_McLachlan_Insomnia
Educational Component
Health practices
Environmental influences
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201503_McLachlan_Insomnia
Alternative Approaches
Relaxation
Paradoxical intention
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Online CBT
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“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