Sleep disorders Flashcards
Key NTs
Sleep: GABA, melatonin
Wakefulness: norepinephrine, histamine, acetylcholine
Across the cycle: serotonin, orexin, hypocretin
hat antihistamines typically cause drowsiness and anticholinesterase inhibitors can cause insomnia or wakefulness.
serotonin, which, which actually modulates the movement through the different sleep stages. There are some hypothalamic neuropeptides, orexin hypocretin, and these help with the regulation of sleep.
What is “normal”?
Sleep architecture in the
context of age
Sleep latency - generally < 30 minutes
Sleep quantity - 7-9 hours
Consolidation - uninterrupted sleep
Quality - no daytime impairment
Younger adults - greater difficulty falling
asleep
Older adults - More likely to report middle
of the night or early morning wakening
young adults. And as you can see, they spend more time in stages 3.4. So we’re getting more deeper restorative sleep.
older adults actually lose stages like sleep in stages 3.4. And so stages 3.4 and sleep are associated with deeper or more restorative sleep.
Sleep-Wake Disorders
Dysomnias: Problems getting to sleep or staying asleep
Insomnia, RLS, sleep apnea, narcolepsy
Parasomnias: disorders of arousal (sleep-wake transitions)
Night terrors, sleep walking/talking, bruxism
Circadian Rhythm Disorders: a loss of synchronization between internal biological
clock and external environment
Delayed/advanced sleep phase syndrome, jet-lag
So instead of starting to feel tired around 10:00 P.M. you maybe start to feel tired around 02:00 A.M. then of course, this disrupts your entire sleep cycle because now you’re either sleeping in late or having to wake up early to go to school or go to work, and then having disrupted sleep. And then advanced sleep phase is the opposite. You’re falling asleep very early in the evening and then waking up very early in the morning.
Complications
of insomnia
Cardiovascular:
High blood pressure
Risk of heart disease
Poor immune system function
Other:
Risk of diabetes
Weight gain, obesity
Low quality of life
Psychological:
Lower daytime performance
Slowed reaction time
Risk of depression/relapse
Risk of anxiety disorde
Insomnia
A predominant complaint of dissatisfaction with sleep quantity or quality,
associated with ≥ 1 of:
Difficulty initiating sleep
Difficulty maintaining sleep, characterized by frequent awakenings or
problems returning to sleep after awakenings
Early-morning awakening with inability to return to sleep
Causes clinically significant distress or impairment in important areas of
functioning.
Occurs a least 3x/week for at least 3 months
Stratifying insomnia
Acute (<3 months)
Chronic (>3 months)
Primary (10%)
Seconday (90% - 10-15% attributed to substance use)
Sleep-onset
Sleep-maintenance
acute insomnia is mostly the result of a stressful event or environmental disturbances such as noise, extreme temperature, some of those other external factors we’ve talked about like caring for a newborn, jet lag
chronic insomnia is actually likely to be sustained from factors that are different from what initially triggered the sleep difficulty. What we see with chronic insomnia, that it actually becomes a learned behavior and cognitive factors that actually sustain this cycle of inability to sleep.people then fall into this pattern of being so worried about not being able to fall asleep that it actually prevents them from falling asleep
Sleep onset describes people who are having difficulty falling asleep, but then are able to sleep through the night once they do fall asleep
Maintenance involves waking up frequently throughout the night.
Most comon see a mix of these traits
Objectivity - creating a sleep diary
Have patient record the following DAILY
Time to bed
Time first tried falling asleep
Time to fall asleep
Nighttime awakenings (quantity, duration)
Time of final awakening (wake up time)
Total duration of sleep
Quality of sleep (feel refreshed upon wakening?)
Daytime fatigue
Daytime napping (frequency, duration)
Alcohol, caffeine, drug use (illicit, prescribed, OTC, CAM)
Rule out
other
causes
read slide 16
Clinical Aspects of Insomnia - The 3P Model
Precipitating factors
Emotional distress, onset of medical or psychiatric
disorder
Predisposing factors
Factors increasing risk of developing insomnia (e.g., anxious predisposition,
circular thinking, generalized hyperarousal)
Perpetuating factors
Learned negative sleep behaviours and cognitive
distortions
the longer that acute insomnia goes unnoticed, undiagnosed, untreated, or the longer than its mismanaged, the greater the risk is of someone developing really negative cognitive distortions around sleep. And this increases their chances dramatically of converting into chronic insomnia
Insomnia screening questionnaire
Insomnia severity index
screening q has not been validated
diagnostic domains:
1. insomnia
2. psych disorders
3. circadian rhythm disorder
4. movement disorders
5. parasomnias
Insomnia Severity Index. So this is something that has been validated in a primary care setting and it can be used to monitor the patient’s progress with their treatment for insomnia, as well as to help make decisions around ongoing care and whether we should consider a referral to a sleep specialist.
When is a sleep study needed?
Evaluation of sleep-related systems
Sleep maintenance insomnia
Snoring
Unexplained daytime fatigue or sleepiness
diagnosis of a sleep disorder
Narcolepsy
Parasomnias: formal term for sleep study is polysomnography. And during this process they measure different things so that we can try to identify what the root causes.
So e.g. some of the things that they might measure drain asleep study include how long the person is sleeping for, the number of times they’re waking up during the night, how are their eyes moving while they’re asleep? What is the muscle activity during their sleep? What is their respiratory rate? What is their oxygen saturation, as well as heart rate and rhythm while they’re sleeping
PLMD
REM sleep behavior disorder
Sleep-related breathing disorders (ie. Apnea)
Sleep-related seizure disorders
Treatment of a sleep-related breathing disorders (ie.
using a positive airway pressure titration)
level 1: actually takes place in a lab and they use a lot of fancy equipment to measure, again, brainwave activity, muscle movements, heart rhythms, and the volume of your snoring
level 2: collects the same amount of information, but you can actually do it at home so you don’t need asleep technician to be part of the process.
Level 3: also happens at home and it’s more to collect information around sleep apnea, so it’s less comprehensive than levels 1.2.
Level 4: can be completed at home as well. And this one only measures your oxygen levels while you sleep.
level 1: actually takes place in a lab and they use a lot of fancy equipment to measure, again, brainwave activity, muscle movements, heart rhythms, and the volume of your snoring
level 2: collects the same amount of information, but you can actually do it at home so you don’t need asleep technician to be part of the process.
Level 3: also happens at home and it’s more to collect information around sleep apnea, so it’s less comprehensive than levels 1.2.
Level 4: can be completed at home as well. And this one only measures your oxygen levels while you sleep to identify sleep apnea. Least comprehensive
Goals of
therapy
Establish baseline
Establish patient’s perception of sleep and their goals
Reverse sleep disruption to improve daytime functioning
Prevent progression to chronic insomnia
Resolve or mitigate underlying conditions
Prevent dependence on drug therapy
Reinstate normal sleep pattern without need for medication
If required, minimize side effects of pharmacotherapy
Treatment
of acute
insomnia
What do the guidelines say?
Treat acute insomnia only if there is a substantial
negative impact on daytime performance.
Intervene early and suggest behavioral therapy such as
cognitive behavioural therapy - insomnia (CBT-I).
Consider using short term (e.g., two weeks)
pharmacotherapy with close follow-up based on the
severity and urgency of the presentation.
Start medication at same time as CBT-I.
Follow-up to monitor progress in two to four weeks. And the typical recommended guideline is anywhere from every two to four weeks. So like pretty frequent follow-up
comprised of weekly sessions that go on for a total of six to eight weeks. Cbt is a very important factor in managing the negative associations that patients can develop around sleep, especially those who are suffering from insomnia. And so again, we want to stop people from falling into these cyclical patterns that then further impair their sleep and further impair their functioning.
5 Components of CBT-I
- Stimulus Control
Keep the bedroom for sleep and sex only
Go to bed only when sleepy
Get out of bed after 15 min if sleep does not come
Get out of bed at the same time every morning
No napping - Sleep Hygiene
Maintain good sleep habits (environmental factors, routine)
Limit coffee, nicotine, alcohol, large meals, vigorous exercise before bed - Sleep Restriction
(paradoxical approach)
Limit time in bed to actual time asleep
Increase TIB if SE >90%, or decrease time in bed if SE<80% (~20-30 min/wk) - Relaxation Techniques
Targets hyperarousal
Meditation, progressive muscle relaxation, autogenic training - Cognitive Therapy Target and change patient’s dysfunctional beliefs/attitudes about insomnia
NON-PHARMACOLOGIC TREATMEnt
Manage chronic insomnia with CBT-I.
If no CBT-I program is available, use CBT-I strategies or
online programs.
Emphasize the synergistic effect of combining CBT-I and
medication for those patients who are using
sedative/hypnotic medication.
, if we’re combining both and offering this dual treatment approach after that initial phase of treatment, it’s really important that if we’re considering tapering or discontinuing pharmacotherapy, that we continue the CBT because we don’t want to push someone to kind of fall back into their sleep-wake disorders who want to remove one agent at a time.
