John McLachlan. Clinical Lead Pulmonary Physiology & Sleep Medicine. President Elect, WA Branch Thoracic Society of Australia & NZ
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1 John McLachlan Respiratory & Sleep Clinical Lead Pulmonary Physiology & Sleep Medicine Sleep Physician x 27 years Interest in Insomnia management President Elect, WA Branch Thoracic Society of Australia & NZ
2 From ghoulies and ghosties And long-leggedy beasties And things that go bump in the night, Good Lord, deliver us! trad. Scottish
3 Overview Normal Sleep Sleep Disorders Falls Sleep Treatments Falls Alternative Management
4 Normal Sleep Gradual process Sleep pressure / Circadian / Alerting > 24 hour clock Entraining Cyclical Stages
5 Normal Sleep
6 Normal Sleep
7 Normal Sleep Falls due to normal sleep? Environment Inertia REM
8 Sleep Disorders Excessive Sleep Initiating & Maintaining Sleep Parasomnias
9 Sleep Disorders Excessive Sleep Sleep Apnoea Sleepy PU Narcolepsy / Cataplexy Sleep restriction
10 Sleep Disorders Initiating & Maintaining Sleep Insomnia Circadian
11 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
12 Sleep Disorders Parasomnias Restless Legs REM behaviour Arousals Confusional Sleep walking Terrors
13 Sleep Treatments Oxygen CPAP Medications
14 Hypnotics and Falls Several studies show increased risk Elderly Institutionalised Benzos & other psychotropics J Gerontol 1989;44:M Some inconstant Community Large scale suggest increased risk N Engl J Med 1988; 319: JAMA 1989; 261:
15 Hypnotics and Falls Brassington et al Reported sleep problems Not psychotropic meds J Am Geriat Soc 2000; 48: Questionnaire study Falls related to insomnia Falls related insomnia not responding meds Not insomnia responding to meds If hypnotic works not a risk? J Am Geriat Soc 2005; 53:
16 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):
17 Hypnotics and Falls Arch Intern Med. 2008;168(16):
18 Sleep and Falls Arch Intern Med. 2008;168(16):
19 Alternate Treatment
20 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia
21 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia
22 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
23 Bright Light Moderately bright light (1000 lux) or more improves subjective alertness, mood, and sleep quality Morning bright light promotes sleep onset
24 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 _McLachlan_Insomnia
25 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia
26 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 _McLachlan_Insomnia
27 Stimulus Control Bed Bedroom Sleep-incompatible activities (reading, watching tv) Frustration Bedtime Anxiety Worry _McLachlan_Insomnia
28 Stimulus Control Bed Bedroom Bedtime Drowsiness Relaxation Sleep _McLachlan_Insomnia
29 Conditioned Sleep Onset Insomnia Stimulus Control Therapy 1. Don t go to bed until sleepy. 2. If not asleep in 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.
30 Sleep Restriction Individuals with insomnia have reduced sleep efficiency _McLachlan_Insomnia
31 Sleep Restriction Align time in bed (TIB) Develop a regular sleep-wake rhythm _McLachlan_Insomnia
32 Sleep is on our side Combine stimulus control & sleep restriction almost always win!
33 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia
34 Cognitive Component Challenging unrealistic sleep expectations Modifying beliefs about causes and consequences of insomnia _McLachlan_Insomnia
35 Cognitive Component BELIEF: It is essential to sleep x number of hours per day to feel refreshed and function well during the day _McLachlan_Insomnia
36 Morning sleepiness is normal
37 Historical Sleep Segmented Sleep 1st (deep) watch period 2nd lighter _McLachlan_Insomnia
38 CBTi Components Behavioural component General Specific Cognitive component Educational component _McLachlan_Insomnia
39 Educational Component Health practices Environmental influences _McLachlan_Insomnia
40 Alternative Approaches Relaxation Paradoxical intention _McLachlan_Insomnia
41 Online CBT
42 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
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