Programme. Why bother? The effects of sleep loss. Common Sleep Disorders, Identification and investigation Treatments
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2 Programme. Why bother? The effects of sleep loss. Common Sleep Disorders, Identification and investigation Treatments Brief (but important ) questions.
3 Why bother? The three Pillars of health: - Nutrition - Exercise - SLEEP
4 Why bother? SLEEP impacts on ALL aspects of our lives. - Physically - Cognitively - Behaviouraly
5 PHYSICAL associations with Sleep Disorder Cardiovascular: Hypertension; MI; AF; CVA; CHF; Pulmonary Hypertension; CRP. Endocrine: Obesity; Insulin Resistance; Cortisol; Lipids; Leptin; Libido Cancer: Increased risk (especially breast, also bowel)
6 PHYSICAL associations with Sleep Disorder Urological: Nocturia (may be frequent) Erectile Dysfunction Gastroenterological: GORD; Gastric Ulcer Gynecological: PCO; Menstrual irregularities; Menopause Obstetric: Toxemia; Premature births; Low birth weighs
7 PHYSICAL associations with Sleep Disorder Musculoskeletal: Kyphoscoliosis Genetic: Down s syndrome; Macroglossia etc. Neurodegenerative: Alzheimer's Disease; MS. Respiratory: Obesity-Hypoventilation syndrome.
8 PSYCHOLOGICAL consequences of Sleep Disorder Increased irritability & lower stress tolerance Poor Motivation ( Can t be bothered! ) Faulty Judgment Lapses in Attention and Vigilance Impaired Decision Making & Logical reasoning Depression / Anxiety Personality Change
9 BEHAVOURAL consequences of Sleep Disorder Poor short term memory Risk taking Erratic driving Slower Reaction Time Increased Sensitivity to pain Hyperactivity in Children Accidentally falling asleep!
10 Brief questions: - Do you have any concern about your sleep? - Have you been told that you snore? - Do you wake refreshed in the morning?
11 The most common sleep disorders are associated with:- 1) Shiftwork Up to 20% of the workforce are shiftworkers 2) Insomnia 10 15% of adults suffer from chronic and severe insomnia that affects daytime performance. 3) Snoring and Obstructive Sleep Apnoea (OSA) Snoring up to 60% adults snore regularly OSAS 9% of males, 4% females over 40
12 Insomnia Risk Factors: Female 2:1 (?More likely to report insomnia) Increasing age (? Increased likelihood of medical complaints) Stress/Anxiety (Hyper-arousal Disorder) Psychiatric Illness Medical disorder Social factors (Unemployed, single, physical inactivity) Environmental factors (noisy environment, latitude-sad)
13 Insomnia Treatments: CHEMICAL Herbal Allopathic BEHAVIOURAL (CBTi) Seep hygiene Relaxation therapies Stimulus control Bed Restriction Therapy
14 Insomnia Allopathic Use short acting hypnotics for short term treatment in low dose Use sedating antidepressants in full doses for insomnia associated with depression
15 Brief Questions: Insomnia Evaluation: The three P s - Predisposing Factors Genetics, Personality type, Social Pressures - Precipitating Factors Stressful life event(s). Trigger for insomnia. - Perpetuating Factors. Compensatory strategies. eg Spending longer in bed. Staying in bed. Monitoring sleep. Alcohol use
16 Insomnia Behavioral Treatments CBTi Sleep Hygiene Relaxation therapies / Mindfulness meditation Stimulus Control Sleep (Bed) Restriction Therapy
17 Sleep 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.
18 Sleep Hygiene - Avoid stimulants - Exercise regularly - Caffeine (5-8 hour half life) - Cigarettes - Alcohol (initially sedative, later stimulant) - Psychoactive Drugs - Allow at least 1 hr relaxation time to unwind before bedtime - Bedroom environment should be quiet, dark and comfortable and ~ C - Avoid clock watching
19 Relaxation Therapies - Abdominal breathing - Progressive muscle relaxation - Visualisation - Mindfulness meditation (
20 Stimulus Control for those with insomnia Stimulus Control is based on classical conditioned response to certain stimuli. This involves strengthening the relationship between bed and sleep, and breaking the negative relationship between bed and anxiety and wakefulness Important and Effective
21 STIMULUS 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 Get out of bed if unable to fall asleep in minutes or anxious Return to bed after mins, Repeat as often as necessary
22 Bed Restriction Therapy for those with insomnia Sleep restriction therapy is designed to improve sleep consolidation and sleep efficiency. This is achieved by initially increasing the homeostatic drive to sleep. Sleep efficiency is improved. Time in bed can then be increased The most difficult, but the most effective
23 BED RESTRICTION THERAPY Average the time asleep over 2 weeks Restrict time in bed to that time. (never less than 5hr sleep opportunity) Increase time in bed slowly when sleeping is consolidated to >85%, Stay the same if 80%-85% Reduce time in bed if <80%.
24 Brief Solutions: Insomnia - Journaling - Improve sleep efficiency Later to bed Stimulus Control Bed restriction - Avoid clock-watching - Remove electronic devices from the bedroom - Sleep Diary
25 Tempting! Familiar?
26 Snoring 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
27
28 Consequences of Sleep Apnoea Poor quality Sleep resulting in :- Excessive Daytime Sleepiness.( EDS) Impaired cognitive function. Poor concentration Learning and Memory difficulties Depression Personality changes Hyperactivity in children Road Accidents
29 Risk Factors for Sleep Apnoea Male: Female 2 : 1 Increasing age Body Mass Index > 30 Neck Circumference > 42cm ( M) 38cm (F) Alcohol ( > 2 units) Smoking Post Menopausal Women Sleeping Pills But: 20% of those with sleep apnoea are not overweight
30 Consequences of Sleep Apnoea 1. Daytime fatigue, especially sleepiness 2. Bed partner sleep disturbance 3. Cardiovascular complications
31 History Taking (If Possible With Partner) Sleepy vs non-sleepy (Epworth Sleepiness Scale) Smoking / alcohol Recent weight gain Family history Consistency of snoring Every night Every position Periods of apnoea
32 The 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 they would 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
33
34 Examination BMI Neck circumference Tonsil size (Friedman score) Tongue size (Mallampati Score) Retrognathia / overjet Crossbite / crowded teeth / sufficient number Signs of Bruxism TMJ mobility / ability to protrude the mandible Soft palate/uvula oedema
35 Brief investigation: Snoring/OSA Overweight or Long face Thick neck Oral examination. Teeth/ Tongue/Tonsils Overnight Sleep Study
36 Brief Investigation: Snoring/OSA
37 Brief Investigation: Snoring/OSA c
38 Brief Investigation: Snoring/OSA
39 Brief Investigation: Snoring/OSA
40 Brief questions: STOP-BANG 1. Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors)? 2. Do you often feel TIRED, fatigued, or sleepy during daytime? 3. Has anyone OBSERVED you stop breathing during your sleep? 4. Do you have or are you being treated for high blood PRESSURE? 5. BMI more than 35? 6. AGE over 50 years old? 7. NECK circumference > 42 cms? 8. Male GENDER? 3 yes answers: High-risk for OSA <3 yes answers: Low-risk for OSA
41 Brief questions: - Auckland Sleep Questionnaire This is longer, but covers many aspects of sleep
42 Summary 1. Sleep impacts on virtually all aspects of medical practice. 2. It may be worthwhile setting aside a separate consultation to explore insomnia. Snoring/Sleep Apnoea can be suspected, but investigation is less easy. 3. Just asking about sleep is helpful. 4. Ignore sleep and you ignore 1/3 of life!
43 Thank You Dr Alex Bartle The SLEEP WELL Clinic Throughout New Zealand
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