Sleep disturbance

Question 1

Risk factors for insomnia

Answer 1

1. Female
2. Advancing age
3. Night/shift work
4. Chronic conditions
5. Chronic pain
6. Psychiatric illness
7. Stimulant use
8. Alcohol and drugs
9. Poor sleep hygeine

Question 2

Investigations

Answer 2

1. Pittsburgh sleep quality index
2. Insomnia severity index
3. Stanford sleepiness scale
4. Epworth sleepiness scale

If thyroid dysfunction suspected (hyperthyroid)
5. TSH, free T4

Question 3

History

Answer 3

1. Time go to bed
2. Onset of sleep
3. Duration of sleep
4. Wake times
5. Perceived quality of sleep
6. Multiple awakenings at night
7. Poor work functioning, daytime naps
8. Stimulants, drugs, alcohol, medication
9. Flight, shift work
10. Bipolar, schizophrenia, anxiety
11. Sleep apnea, thyroid, chronic pain
12. Questionairres

Question 4

Physical examination

Answer 4

1. Chronic medical conditions
2. Sleep apnea
3. Thyroid ++

Question 5

Management overview

Answer 5

1. Manage underlying
Stressors
Dyspnea, GOR, nocturia, pain
Psychiatric
Drug use
Adverse effects of prescribed medication
Refer to specialist if: diagnosis unclear, advice needed, long history, Xresponse to therapy, intrinsic sleep disorder
2. Good sleep practises
3. Psychological and behavioural
Relaxation: hypnosis, meditation, deep breathing, progressive muscle relaxation
Cognitive therapy->usually get more sleep than realise, doesn't cause major health concerns.
Stimulus control->associate bedroom with frustration, worry, poor sleep. Limit time in bed awake. If 15-20 pass, get up, return when sleep again
Sleep restriction
4. Pharmacological
Temazepam 10mg PO before bed
Zolpidem
Zopiclone

Question 6

Intrinsic sleep disorders

Answer 6

1. Restless leg syndrome

2. Sleep apnea

Question 7

Advice for good sleep

Answer 7

1. Sleep wake activity regulation
   Go to bed same time, arise at regular time.
   Avoid laying in bed ++time worrying, avoid oversleeping
   Avoid napping
2. Sleep setting
   Avoid bright light, seek exposure to light after rising
   Avoid heavy meals within 3 hours, regular daily exercise
   Quiet, dark room
   Avoid pets
   Use suitable matress/pillow, reserve bedroom for sleep and intimacy
   Avoid alerting, stressful ruminations before bedtime
   Avoid caffeine after midday
   Reduce excessive alcohol, avoid tobacco, avoid illicit drug
3. Sleep promoting
   Light snack, warm milk before bed
   Warm bath before bed
   Comfortable temperature for sleep

Question 8

Sleep restriction program

Answer 8

For those with low sleep drive

1. A person with insomnia feels they sleep only 4 hours per night, despite generally being in bed from 10.00 pm until 8.00 am.
2. Instruct the person to start restricting their sleep to only 4 hours per night, as this is the length of time they think they are sleeping (eg go to bed at 2.00 am and wake up at 6.00 am).
3. The person must comply with this schedule until they are regularly sleeping solidly throughout the 4 hours and feel increasingly sleepy, wanting to go to bed earlier.
4. Once this target is reached, they can increase the time in bed by 30 minutes until they are sleeping through and craving sleep at an earlier time. Again the reward of an extra 30 minutes sleep will occur when the person is sleeping through their allocated time.

Question 9

Prior to commencing hyptonics, counselling

Answer 9

1. Used at lowest dose for shortest time
2. Risk of impaired daytime alertness, tolerance and dependance, may not find their sleep refreshing
3. Limited quantity prescribed
4. Limited for 2 weeks
5. Broken sleep with vivid dreams may occur on cessation, can take several days/weeks to recover normal sleep rhythm

Question 10

In what circumstances might long term hypnotic use be appropriate

Answer 10

1. Not on increasing doses
2. No reports of adverse effects
3. Knows they may be dependant
4. Efforts to taper down have been unsucessful

Question 11

Definition of OSA

Answer 11

1, Episodes of complete or partial airway obstruction

2. >10 sec, 10/hour

Question 12

Pathophysiology of OSA

Answer 12

1. During sleep, the pharynx is most vulnerable to collapse at end expiration secondary to the loss of the neural tone of the pharyngeal dilators, and especially at end expiration due to the loss of the positive intraluminal pressure.
2. Narrow pharyngeal cross-sectional area,++risk of an episode of apnoea during sleep. When aw
3. When awake, genioglossus activity is increased in OSA patients to compensate for reduced pharyngeal area and to maintain pharyngeal patency. However, this tone is decreased during sleep and the pharynx obstructs.
4. Hypoxaemia and hypercapnia may result from airway obstruction,
5. Episodes of apnoea and hypopnoea terminate with cortical or subcortical arousal.
6. Autonomic sympathetic activation occurs, which may result in cardiac dysrhythmias and vasoconstriction. If sleep is resumed after the arousal, pharyngeal obstruction may recur and the cycle is repeated.

Question 13

Associated risks with OSA

Answer 13

1. HTN
2. Stroke
3. MI, HF, dysrythmias
4. Cognitive dysfunction
5. Depression
6. Metabolic syndrome
7. Oxidative stress
8. Motor vehicle accidents

Question 14

Symptoms of OSA

Answer 14

1. +Daytime sleepiness
2. Apneas, gasping
3. Restless sleep
4. Insomnia
5. Fatigue
6. Snoring

Question 15

Risk factors for OSA

Answer 15

1. Male
2. Obesity
3. Post menopausal
4. Large neck
5. Maxillofacial abnormalities
6. +Soft tissue->tonsils, adenoids
7. Chronic snoring
   8/ Family history
8. PCOS
9. Hypothyroidism
10. Down syndrome
11. Smoking, alcohol

Question 16

Investigations in OSA

Answer 16

1. Polysomnography

2. Assess CV risks

Question 17

Treatment in OSA

Answer 17

1. CPAP
2. Weight loss
3. Positional therapy
4. Modafanil for hypersolomnence
5. Lipids, BP, DM, physical activity, smoking, alcohol modification
6. Avoid driving drowsy