REM - Rapid Eye Movement NREM - Non-Rapid Eye MovementREM - Rapid Eye Movement NREM - Non-Rapid Eye Movement

Stages 1 and 2 light sleep Stages 3 and 4 deep sleepStages 1 and 2 light sleep Stages 3 and 4 deep sleep

90 -100 Minute sleep cycles. 4 – 5 cycles per night to feel refreshed90 -100 Minute sleep cycles. 4 – 5 cycles per night to feel refreshed

25% REM, 50% Stage 2 and 25% stages 3 and 425% REM, 50% Stage 2 and 25% stages 3 and 4

Parasomnias:Parasomnias: In REMIn REM

REM Sleep Behaviour Disorder. (REM without muscle REM Sleep Behaviour Disorder. (REM without muscle atonia)atonia)

REMdisorder.mp4 behavior

The most common sleep disorders are The most common sleep disorders are associated with:-associated with:-

1) Shiftwork1) Shiftwork Up to 20% of the workforce are shiftworkersUp to 20% of the workforce are shiftworkers

2)2) InsomniaInsomnia10 – 15% of adults suffer from chronic and severe 10 – 15% of adults suffer from chronic and severe insomnia that affects daytime performance.insomnia that affects daytime performance.

3)3)Snoring and Obstructive Sleep Apnoea (OSA)Snoring and Obstructive Sleep Apnoea (OSA)Snoring – up to 60% adults snore regularlySnoring – up to 60% adults snore regularlyOSAS – 9% of males, 4% females over 40OSAS – 9% of males, 4% females over 40

Circadian RhythmsCircadian Rhythms

Circa Dies = About a dayCirca Dies = About a day

Controlled byControlled by

Internal body clock Internal body clock - The Suprachiasmatic Nucleus (SCN)- The Suprachiasmatic Nucleus (SCN)

- Core body temperature circadian cycle- Core body temperature circadian cycle - The role of our own Melatonin- The role of our own Melatonin

External environment cues External environment cues – Zeitgebers (Time keepers)– Zeitgebers (Time keepers) - The effect of light- The effect of light - Exercise- Exercise - Meals - Meals

InsomniaInsomnia

InsomniaInsomnia May be a symptom of a disorder Initial insomnia

•Anxiety and Stress•Chemical Stimulation•Physical Activity•Age (Adolescence)

 Interrupted Insomnia

•Pain•Respiratory Illness•Habit•Jet Lag•Shiftwork

Early Morning Wakening•Age (Elderly)•Depression

Medical problems associated withMedical problems associated with InsomniaInsomnia

Heart Disease x 2.27Heart Disease x 2.27Cancer x 2.17Cancer x 2.17Hypertension x 3.18Hypertension x 3.18Neurologic disease x 4.64Neurologic disease x 4.64Breathing problems x 3.78Breathing problems x 3.78Urinary problems x 3.28Urinary problems x 3.28Diabetes x 1.8Diabetes x 1.8Chronic pain x 3.19Chronic pain x 3.19Gastrointestinal x 3.33Gastrointestinal x 3.33

InsomniaInsomnia

10-15% of adults suffer from chronic and severe insomnia10-15% of adults suffer from chronic and severe insomnia (Complaints of insomnia with daytime consequences)(Complaints of insomnia with daytime consequences)

30–40% of adults complain of insomnia symptoms only30–40% of adults complain of insomnia symptoms only

95% experience insomnia at some time in their lives95% experience insomnia at some time in their lives

InsomniaInsomnia

Risk Factors:Risk Factors: Female 2:1 (?More likely to report insomnia)Female 2:1 (?More likely to report insomnia) Increasing age (? Increased likelihood of medical Increasing age (? Increased likelihood of medical

complaints)complaints) Stress/Anxiety (Hyper-arousal Disorder)Stress/Anxiety (Hyper-arousal Disorder) Psychiatric IllnessPsychiatric Illness Medical disorderMedical disorder Social factors (Unemployed, single, physical inactivity)Social factors (Unemployed, single, physical inactivity) Environmental factors (noisy environment, latitude-SAD) Environmental factors (noisy environment, latitude-SAD)

CHEMICAL   Herbal

  Allopathic 

BEHAVIOURAL

Cognitive/behavioral therapy for Insomnia (CBTI)

Sleep hygiene

Stimulus control

Sleep (bed) restriction

Insomnia Insomnia ( treatments)( treatments)

HERBAL MEDICINESHERBAL MEDICINES 

VALARIANVALARIAN

KAVAKAVA

ST JOHN WORTST JOHN WORT

MELATONINMELATONIN

CHAMOMILLECHAMOMILLE

OTHERSOTHERS

InsomniaInsomnia

MelatoninMelatonin

Two therapeutic uses:Two therapeutic uses:

1.As a chronobiotic1.As a chronobiotic Use a small dose (0.5mg), 5hrs before desired sleep onsetUse a small dose (0.5mg), 5hrs before desired sleep onset

2. As a soporific2. As a soporific Use a larger dose (2mg or 3mg) ½ -1 hr before desiredUse a larger dose (2mg or 3mg) ½ -1 hr before desired sleep onset sleep onset

 

InsomniaInsomnia

MelatoninMelatonin

Two therapeutic uses:Two therapeutic uses:

1.As a chronobiotic1.As a chronobiotic

Melatonin in the Melatonin in the eveningevening will will advanceadvance the sleep the sleep phase phase (Earlier to sleep and earlier to wake)(Earlier to sleep and earlier to wake)

Melatonin in the Melatonin in the morningmorning will (theoretically) will (theoretically) delaydelay the sleep phase the sleep phase (Later to sleep and later to wake)(Later to sleep and later to wake)

 

InsomniaInsomnia

MelatoninMelatonin

Two therapeutic uses:Two therapeutic uses:

2. As a soporific2. As a soporific For children with ADHD or ASD For children with ADHD or ASD Some small evidence that their melatonin levels are lowSome small evidence that their melatonin levels are low

For those over 55 yrsFor those over 55 yrs Melatonin levels tend to fall with age Melatonin levels tend to fall with age Not helpful for those under 55yrsNot helpful for those under 55yrs

 

InsomniaInsomnia

MelatoninMelatonin

Melatonin 2mg Slow release.Melatonin 2mg Slow release.

1.1.Slightly helpful for insomnia over 55yrsSlightly helpful for insomnia over 55yrs

2.2.Large supraphysiological dose. Large supraphysiological dose.

3.3.Despite a relatively short ½ life, some may last Despite a relatively short ½ life, some may last through to the morning and therefore delay sleep through to the morning and therefore delay sleep onset.onset.

4.4.May result in morning fatigue. Significant May result in morning fatigue. Significant individual variability individual variability

 

InsomniaInsomnia

MelatoninMelatonin

Melatonin 2mg Slow release.Melatonin 2mg Slow release.

5. It is a reliable product. Accurate 2mg5. It is a reliable product. Accurate 2mg

6. Long term effects of Melatonin are unknown,6. Long term effects of Melatonin are unknown, especially in the preteen/teenage yearsespecially in the preteen/teenage years

7. If used for travel (jet lag) trial it first.7. If used for travel (jet lag) trial it first.

Placebo effect is strong for sleep. Placebo effect is strong for sleep.

 

InsomniaInsomnia

 AdvantagesAdvantagesFreely availableFreely availableProbably less side effectsProbably less side effects

  DisadvantagesDisadvantagesFew studiesFew studiesInconsistent productInconsistent productUnknown interactions of side effectsUnknown interactions of side effectsLess effectiveLess effective

InsomniaInsomnia

ChemicalChemical

AllopathicAllopathic

HISTORYHISTORY

AntiquityAntiquity - Alcohol and Laudanum- Alcohol and Laudanum

1860’s & 70’s1860’s & 70’s - Bromides and Chloral Hydrate- Bromides and Chloral Hydrate

1880’s1880’s - Paraldehyde, urethane- Paraldehyde, urethane

1900’s1900’s - Barbiturates- Barbiturates

1960’s1960’s - Benzodiazepines - 1- Benzodiazepines - 1stst Chlordiazepoxide (Librium) Chlordiazepoxide (Librium)

1980’s – 90’s1980’s – 90’s - Zopiclone, Zolpidem- Zopiclone, Zolpidem

20002000 - Zaleplon- Zaleplon

InsomniaInsomnia

InsomniaInsomnia

AllopathicAllopathic

HYPNOTICSHYPNOTICS – – Which one?Which one?

BenzodiazepinesBenzodiazepines - Triazolam- Triazolam

- Temazepam- Temazepam- Nitrazepam- Nitrazepam

Non BenzodiazepinesNon Benzodiazepines - Zopiclone- Zopiclone- Zolpidem- Zolpidem- Zaleplon- Zaleplon

InsomniaInsomniaAllopathicAllopathic

BenzodiazepinesBenzodiazepines

BenefitsBenefits-- effectiveeffective-- wide margin of safetywide margin of safety-- slow toleranceslow toleranceAdverse effectsAdverse effects-- residual sedationresidual sedation-- anterograde amnesiaanterograde amnesia-- rebound insomniarebound insomnia-- Dependance Dependance

Contraindications and PrecautionsContraindications and Precautions

InsomniaInsomnia

AllopathicAllopathic

Hi AntihistamineHi Antihistamine-- daytime drowsinessdaytime drowsiness-- impaired learningimpaired learning

Sedating AntidepressantsSedating Antidepressants-- cardiotoxiccardiotoxic-- anticholinergicanticholinergic-- increase RLS/P.L.M.sincrease RLS/P.L.M.s-- impaired daytime performanceimpaired daytime performance- - rapid tolerancerapid tolerance

InsomniaInsomnia

AllopathicAllopathic

Use short acting hypnotics for short term treatment in Use short acting hypnotics for short term treatment in low doselow dose

Use sedating antidepressants in full doses for Use sedating antidepressants in full doses for insomnia associated with depressioninsomnia associated with depression

InsomniaInsomnia

Evaluation: Evaluation: The three P’sThe three P’s

- Predisposing Factors- Predisposing Factors Genetics, Personality type, Social PressuresGenetics, Personality type, Social Pressures

- Precipitating Factors- Precipitating Factors Stressful life event(s). “Trigger” for insomniaStressful life event(s). “Trigger” for insomnia..

- Perpetuating Factors. - Perpetuating Factors. Compensatory strategies. Eg longer in bed.Compensatory strategies. Eg longer in bed. Staying in bed. Alcohol useStaying in bed. Alcohol use

Sleep HygieneSleep Hygiene

To Provide information about lifestyle, and environment that might interfere with sleep, or promote better sleep.

These strategies are important as a baseline, and should be combined with the other treatments.

As a sole therapy, it is not effective for the more severe insomnia, but should be addressed in therapy.

Sleep HygieneSleep Hygiene

- Avoid stimulants- - Caffeine (5-8 hour half life)

- Cigarettes - Alcohol (initially sedative, later stimulant)

- - Psychoactive Drugs

- Exercise regularly

- Allow at least 1 hr relaxation time to unwind before bedtime

- Bedroom environment should be quiet, dark and comfortable and ~ 18 ˚C

- Maintain a regular sleep/wake schedule

- Avoid clock watching

Stimulus ControlStimulus Control

Stimulus Control Stimulus Control is based on classical is based on classical conditionedconditioned response response to certain stimuli.to certain stimuli.

This involves This involves strengtheningstrengthening the relationship the relationship between between bedbed and and sleepsleep, and , and breakingbreaking the the negative relationship between negative relationship between bedbed and and anxietyanxiety and and wakefulnesswakefulness

Important and Effective Important and Effective

Stimulus ControlStimulus Control

• Go to bed when sleepy

• Do not watch TV, read, eat or worry while in bed

• Do not nap during the day

• Set regular wake up/get up time – including weekends

• No visible clocks at night

• Get out of bed if unable to fall asleep in 15 – 20 minutesReturn to bed when sleepy. Repeat as often as necessary

Bed Restriction TherapyBed Restriction Therapyfor those with insomniafor those with insomnia

Bed restriction Bed restriction therapy is designed to improve therapy is designed to improve sleep consolidation sleep consolidation and and sleep efficiencysleep efficiency..

This is achieved by initially This is achieved by initially increasingincreasing the the homeostatic drive homeostatic drive to sleep. Sleep efficiency to sleep. Sleep efficiency improves. Time in bed can then be increased.improves. Time in bed can then be increased.

Difficult, but the most effectiveDifficult, but the most effective

INSOMNIAINSOMNIA

BED RESTRICTION THERAPY

Average the time asleep over 2 weeks

Add 0 - ½ Hour (Never allow less than 5hrs sleep opportunity)

Restrict time in bed to that amount of time

Increase time in bed slowly when sleeping is consolidated

> 90% increase by 15 minutes

80% -90% remain the same

< 80% reduce by 15 minutes

A Therapeutic modelA Therapeutic model

Having discussed

Sleep Hygiene, and

Relaxation therapies, discuss

Stimulus Control, and

Bed Restriction.

A Therapeutic ModelA Therapeutic Model

Stress management- Write down emotional thoughts and diary

- Muscle tension and relaxation

- Abdominal breathing - Visualisation

Stimulants - Caffeine (5-8 hour half life)- Cigarettes- Alcohol (initially sedative, later

stimulant)

A Therapeutic ModelA Therapeutic Model

• Routine - Both daytime and pre-bedtime are important

• Exercise - Keep fit - No vigorous exercise within 3 hours of bed

• Food - Avoid a large meal within 3 hours of bedtime

- A small carbohydrate intake before bed may

be helpful i.e. milky drink, banana

A Therapeutic ModelA Therapeutic Model

• Temperature - Avoid extremes of temperature- Cooling will keep sleep

• Light - Light stimulates serotonin and inhibits melatonin and sleep.

- Be outside in the day as much as possible

• Dark - Stimulates Melatonin that helps sleep

therefore keep bedroom dark at night

A Therapeutic modelA Therapeutic model

• Noise - Sudden noise awakens. A constant low

intensity noise may be helpful

• The bed - Firmer and larger rather than sagging and

small

- Avoid synthetic sheets

- Use feather or down unless allergic to house

dust mite

Stimulus ControlStimulus Control

• In Bed - If awake after 20 minutes or your mind is

alert, get up for 20-30 minutes.

- use time out of bed to “wind down” and prepare

again for sleep (warm, dim light, write

down what is on your mind, light reading

material, comfortable chair),

return to bed and repeat as necessary

- Avoid working or playing in bedroom

- The bedroom is for sleep and sex only

The Agony or the EcstasyThe Agony or the Ecstasy

Familiar?

Snoring Related ComplaintsSnoring Related Complaints

- Drives wife from bedroom

- Girlfriend won’t marry me

- Shakes entire house

- Ask me to leave movies and church

- Has had to leave boat so friends could sleep

- Fall asleep at traffic lights waiting for red light to change

Snoring and Obstructive Sleep ApnoeaSnoring and Obstructive Sleep Apnoea

Consequences of Sleep ApnoeaConsequences of Sleep Apnoea

1. Daytime fatigue, especially sleepiness

2. Bed partner sleep disturbance

3. Cardiovascular complications

Consequences of Sleep ApnoeaConsequences of Sleep Apnoea

Medical consequences :- Hypertension

Insulin Resistance Cardiac Arrhythmia Heart Attack Stroke Nocturnal GORD Nocturia

Depression

Risk Factors for Sleep ApnoeaRisk Factors for Sleep Apnoea

Male: Female 2 : 1 Increasing ageBody Mass Index > 30Neck Circumference > 42cm ( 17ins)Alcohol ( > 2 units)SmokingPost Menopausal Women Sleeping Pills

The Epworth Sleepiness ScaleThe Epworth Sleepiness Scale  

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired?

 

This refers to your usual way of life in recent times.

 

Even if you have not done some of these things recently, try to work out how theywould have affected you.

 

Use the following scale to choose the most appropriate number for each situation:

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

 

It is important that you put a number (0 to 3) in each of the eight boxes.

Situation (0 – 3)

Sitting and reading ...............................................................................

Watching TV .........................................................................................

Sitting, inactive in a public place (eg a theatre or a meeting)................

As a passenger in a car for an hour without a break.............................

Lying down to rest in the afternoon when circumstances permit...........

Sitting and talking to someone..............................................................

Sitting quietly after lunch without alcohol ..............................................

In a car, while stopped for a few minutes in traffic ................................

TOTAL

History Taking History Taking (If Possible With Partner)(If Possible With Partner)

Sleepy vs non-sleepy

Smoking / alcohol

Recent weight gain

Consistency of snoringEvery night

Every position

Periods of apnoea

ExaminationExamination

BMINeck circumferenceNasal airway: septum/ valvesTonsil size / soft palateSoft palate oedemaBase of tongue

ConservativeConservative

Weight loss

Alcohol reduction

Stop smoking

Avoid sleeping tablets

Keep off back

Managements 

Lifestyle

Sleep position, i.e. SideUpright

Control of Obesity

Avoidance of alcohol and drugs  (especially BZD’s)

 

Surgical Managements 

Adenotonsilectomy -- especially in children, rarely in adults

Uvulopalatopharyngoplasty (UPPP) -- rarely helpful

Nasal surgery generally unhelpful Palatal surgery

 

Surgical ManagementsSurgical Managements

Other surgery

Tracheostomy

Weight loss surgery

DevicesDevices

Mandibular Advancement SplintsMandibular Advancement Splints

SomnoMed/MDSASomnoMed/MDSA

DevicesDevices

Aveo TSDAveo TSDTongue Stabilising DeviceTongue Stabilising Device

DevicesDevices

External nasal splints

Not helpful

Internal nasal splints

Continuous Positive Air Pressure

CPAP

 

KEY QUESTIONS:

1.Do you snore?

2.Are you sleepy?

Laugh and the world laughs with you…

…snore and you sleep alone.

Thank YouThank YouDr Alex BartleDr Alex Bartle

MB BS FRNZCGP Dip ObstMB BS FRNZCGP Dip ObstMMed (Sleep Medicine) MMed (Sleep Medicine)

SLEEP WELL CLINICSLEEP WELL CLINICAuckland Christchurch WellingtonAuckland Christchurch Wellington

Tauranga Whangarei NelsonTauranga Whangarei Nelson& Invercargill& Invercargill