35. Sleep disturbance Flashcards
what is insomnia
In the DSM-V, insomnia is defined as difficulty initiating or maintaining sleep, or early-morning awakening that leads to dissatisfaction with sleep quantity or quality. This is despite adequate time and opportunity for sleep and results in impaired daytime functioning.
History taking sleep disturbance
PC: define exactly what is the problem eg falling asleep, staying asleep, triggers that wake you up… how often. any hallucinations, day time ??
collateral history: snoring, apnoea,
bedtime routine? - describe from when you get home from work to bedtime
MHx: chronic conditions, psychiatric conditions
DHx: steroids, alcohol, stimulants
SHx: diet? caffiene? occupation etc.. DO THEY DRIVE
acute vs chronic insomnia
Acute insomnia is more typically related to a life event and resolves without treatment.
Chronic insomnia may be diagnosed if a person has trouble falling asleep or staying asleep at least three nights per week for 3 months or longer.
features associated with insomnia
Female gender
Increased age
Lower educational attainment
Unemployment
Economic inactivity
Widowed, divorced, or separated status
MHx risk factors insomnia
Chronic pain
Chronic illness: patients with illnesses such as diabetes, CAD, hypertension, heart failure, BPH and COPD have a higher prevalence of insomnia than the general population.
Psychiatric illness: anxiety and depression are highly correlated with insomnia. People with manic episodes or PTSD will also complain of extended periods of sleeplessness.
DHx risk factors insomia
DHx:
corticosteroids
Alcohol and substance abuse
Stimulant usage
diagnosing insomia
mainly clinical
- pt hostory and RF
can also use:
- sleep diaries
- actigraphy (watch)
management of insomnia
conservative
+ Identify any potential causes e.g. mental/ physical health issues or poor sleep hygiene.
+ Advise good sleep hygiene: no screens before bed, limited caffeine intake, fixed bed times etc.
safety
Advise the person not to drive while sleepy.
Pharmacological - ONLY consider use of hypnotics if daytime impairment is severe.
- short acting benzo or Z drug
(zopiclone, zolpidem and zaleplon)
If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given.
It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT).
when is use of hypnotics indocated for insomnia
if daytime impairment is severe
Pharamcological management of insomnia
- short-acting benzodiazepines or non-benzodiazepines (zopiclone, zolpidem and zaleplon)
if no response to hypnotic for insomnia, what to do next?
If there has been no response to the first hypnotic, do not prescribe another. You should make the patient aware that repeat prescriptions are not usually given.
It is important to review after 2 weeks and consider referral for cognitive behavioural therapy (CBT).
risk factors OSA
obesity
macroglossia: acromegaly, hypothyroidism, amyloidosis
large tonsils
Marfan’s syndrome
consequence OSA
daytime somnolence
compensated respiratory acidosis
hypertension
what shold you use to assess sleepiness in OSA pts
Epworth Sleepiness Scale - questionnaire completed by patient +/- partner
Multiple Sleep Latency Test (MSLT) - measures the time to fall asleep in a dark room (using EEG criteria)
diagnostic tests OSA
sleep studies (polysomnography) - ranging from monitoring of pulse oximetry at night to full polysomnography where a wide variety of physiological factors are measured including EEG, respiratory airflow, thoraco-abdominal movement, snoring and pulse oximetry
