Dr Alex Bartle. Director Sleep Well Clinic
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1 Dr Alex Bartle Director Sleep Well Clinic 1
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3 Sleep Architecture REM NREM Rapid Eye Movement Non-Rapid Eye Movement Stages 1 and 2 light sleep Stages 3 and 4 deep sleep 25% REM, 50% Stage 2 and 25% stages 3 and 4
4 Symptoms of Sleep Loss Impaired decision making Low motivation Less attention to detail Faulty judgment / Increased risk taking Increased irritability and lower stress tolerance Decreased libido
5 Symptoms of Sleep Loss Slowed reaction time Increased sensitivity to pain
6 Two most common sleep disorders are 1) Insomnia 10 15% of adults suffer from chronic and severe insomnia that affects daytime performance. 2) Snoring and Obstructive Sleep Apnoea (OSA) Snoring up to 60% adults snore regularly OSAS 4% of males, 2% females over 40
7 Medical problems associated with Insomnia Heart Disease x 2.27 Cancer x 2.17 Hypertension x 3.18 Breathing problems x 3.78 Urinary problems x 3.28 Diabetes x 1.8 Chronic pain x 3.19 Gastrointestinal x 3.33
8 Insomnia ( treatments) CHEMICAL Herbal Allopathic BEHAVIOURAL Cognitive/behavioral therapy for Insomnia (CBTI) Sleep hygiene Stimulus control Sleep (bed) restriction
9 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.
10 Sleep Hygiene - Avoid stimulants - - Caffeine (5-8 hour half life) - Cigarettes - Alcohol (initially sedative, later stimulant) - - Psychoactive Drugs - Exercise regularly - Allow at least 1 hr relaxation time to unwind before bedtime - Bedroom environment should be quiet, dark and comfortable and ~ 18 C - Maintain a regular sleep/wake schedule - Avoid clock watching
11 Stimulus Control 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
12 Stimulus Control In Bed - If awake after 20 minutes or your mind is alert, get up for minutes. - use time out of bed to wind down and prepare again for sleep (warm, dim light, write down what is on your mind, light reading material, comfortable chair), return to bed and repeat as necessary - Avoid working or playing in bedroom - The bedroom is for sleep and sex only
13 Go to bed when sleepy Stimulus Control 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 No visible clocks at night Get out of bed if unable to fall asleep in minutes Return to bed when sleepy. Repeat as often as necessary
14 Bed Restriction Therapy for those with insomnia Bed 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
15 INSOMNIA BED RESTRICTION THERAPY Average the time asleep over 2 weeks Add 0 - ½ Hour (Never allow less than 5hrs sleep opportunity) Restrict time in bed to that amount of time Increase time in bed slowly when sleeping is consolidated > 90% increase by 15 minutes 80% -90% remain the same < 80% reduce by 15 minutes
16 A Therapeutic Model Stress management- Write down emotional thoughts and diary - Muscle tension and relaxation - Abdominal breathing - Visualisation Stimulants - Caffeine (5-8 hour half life) - Cigarettes - Alcohol (initially sedative, later stimulant)
17 A Therapeutic Model Temperature - Avoid extremes of temperature - Cooling will keep sleep Light - Light stimulates serotonin and inhibits melatonin and sleep. - Be outside in the day as much as possible Dark - Stimulates Melatonin that helps sleep therefore keep bedroom dark at night
18 A Therapeutic Model Routine - Both daytime and pre-bedtime are important Exercise - Keep fit - No vigorous exercise within 3 hours of bed Food - Avoid a large meal within 3 hours of bedtime - A small carbohydrate intake before bed may be helpful i.e. milky drink, banana
19 A Therapeutic model Noise - Sudden noise awakens. A constant low intensity noise may be helpful The bed - Firmer and larger rather than sagging and small - Avoid synthetic sheets - Use feather or down unless allergic to house dust mite
20 The Agony or the Ecstasy Familiar?
21 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
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23 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 It is important that you put a number (0 to 3) in each of the eight boxes.
24 Situation (0 3) Sitting and reading... Watching TV... Sitting, inactive in a public place (eg a theatre or a meeting)... As a passenger in a car for an hour without a break... Lying down to rest in the afternoon when circumstances permit... Sitting and talking to someone... Sitting quietly after lunch without alcohol... In a car, while stopped for a few minutes in traffic... TOTAL
25 History Taking (If Possible With Partner) Sleepy vs non-sleepy Smoking / alcohol Recent weight gain Consistency of snoring Every night Every position Periods of apnoea
26 Examination BMI Neck circumference Nasal airway: septum/ valves Tonsil size / soft palate Soft palate oedema Base of tongue
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28 Other investigations: Overnight oximetry (level 4) Acoustic recording devices Respiratory monitoring (level 3) Portable polysomnography (level 2) Sleep Unit Polysomnography (level 1 or 2)
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31 Managements Nasal Continuous Positive Air Pressure (ncpap) Mandibular advancement prostheses/splints ( MAP/S )
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33 Devices: Mandibular advancement splints -Fixed ( Snorex device) -Mobile SomnoDent, MDSA Tongue stabilizing devices
34 Managements Lifestyle Sleep position, i.e. Side Upright Control of Obesity Avoidance of alcohol and drugs Surgery Adenotonsilectomy Uvulopalatopharyngoplasty (UPPP) Nasal surgery Palatal surgery
35 Devices: External nasal splints Internal nasal splints
36 Palatal Surgery UPPP Somnoplasty Palate tightening Uvulectomy LAUP
37 Other surgeries Tracheostomy Weight loss surgery
38 Conservative: Weight loss Alcohol avoidance Stopping smoking Sleeping tablets Keep off back
39 KEY QUESTIONS: 1. Do you snore? 2. Are you sleepy?
40 Laugh and the world laughs with you snore and you sleep alone.
41 Parasomnias: (Common) In Non-REM Sleep Walking Night terrors Sleep Related Eating Disorder Sexsomnia REM related sleep disorders Nightmare REM-Sleep Behaviour Disorder Others Bruxism Sleep talking (somniloquy) Enuresis Rhythmic Movement disorders
42 Parasomnias: In Non-REM Treatments:. Reassurance and education. Safety measures. Sleep Hygiene. Address bedtime refusal / night-waking behaviour. Avoid waking. Guide back to bed. Avoid interfering. Avoid next-day discussion
43 Parasomnias: In REM - REM Sleep Behaviour Disorder. (REM without muscle atonia) REM behavior disorder.mp4
44 Parasomnias: In REM - Nightmares: - Treatments. Parental reassurance/positive reinforcement of independent coping skills. Avoid exposure to frightening or over-stimulating images. Reduce stressors. Ensure adequate sleep. Security objects. Dim, low-level nightlight. Relaxation strategies for the older child. Progressive muscle relaxation Visualisation Relaxation tapes/music
45 Parasomnias: In Either REM or Non-REM - Bruxism: 8% of adults, 14% - 20% of children <11yrs Stress related, Sleep-related disorders, Chemical related RLS/PLMS, RBD, OSA, Night Terrors Alcohol, Caffeine, MDMA (ecstasy) SSRI s, Methylphenidate, Antiarrythmics, - Sleep talking: In light non-rem or REM, but no memory in the morning More frequent in times of stress, fever, sleep disturbance
46 Parasomnias: In Either REM or Non-REM - Enuresis: A disorder of arousal. Unknown aetiology. May accompany nocturnal seizures, OSA, or other sleep disorders - Rhythmic Movement Disorders (Jactatio capitis nocturna) head banging / body rocking. Usually a soothing behaviour
47 Sleep Related Movement Disorders: Restless Leg Syndrome (Growing pains in children) Essential features - Unpleasant sensation in the legs requiring the urge to move - Urge to move is worse at times of inactivity - Unpleasant sensation is partially or completely relieved by movement - Unpleasant sensation is worse in the evening or at night.
48 Sleep Related Movement Disorders: Restless Leg Syndrome (Growing pains in children) Other, non-essential but common features - Family history - Association with Periodic Limb Movement in Sleep (80%) - Response to dopaminergic therapy - May cause sleep disturbance, especially sleep onset - May begin at any age, but usually progressively worse with age - Usually gone in the morning
49 Sleep Related Movement Disorders: Restless Leg Syndrome (Growing pains in children) Secondary Restless Leg Syndrome - Anaemia. Ferritin < 50 RLS is associated with low CNS iron (not specifically serum iron) - Uremia. 15% - 40% undergoing dialysis suffer from RLS - Pregnancy. Especially in the third trimester
50 Sleep Related Movement Disorders: Periodic Limb Movements in Sleep (Von Ekbom 1945) - Daytime sleepiness - Restlessness during sleep - Nighttime arousals - Observed limb jerking at night. Typically extension of the big toe, dorsiflexion of the ankle, occasional flexions of the knee, and hip
51 Sleep Related Movement Disorders: Periodic Limb Movements in Sleep (Von Ekbom 1945) - PLM Index (PLM/hr), on PSG or Actigraphy > 20 requires treatment 5 20 treat depends on symptoms (EDS, effect on patient / bed partner) < 5 treatment probably not indicated - 20% Suffer with RLS - May have periodic leg movements at rest
52 Sleep Related Movement Disorders: Treatments. RLS / PLMS Non-pharmacologic - Good sleep practices to avoid psychophysiologic insomnia - Avoidance of caffeine and alcohol in the evening - Massage. Hot/Cold compresses. - Mental distraction - Moderate exercise - Remain physically active until bedtime
53 Sleep Related Movement Disorders: Treatments. RLS / PLMS Pharmacologic - Dopaminergic Medication. L-dopa. (Sinemet. Madopar) Tolerance, augmentation, rebound, side effects ½ life of 3-4hrs Dopaminergic Agonists. (Ropinerole. Bromocriptine) Less tolerance, augmentation and rebound ½ life of ~6hrs - Opioids. Codeine; Oxycodone. Start low and go slow. Check Hx or substance abuse Use low dose in conjunction with domaminergic Rx
54 Sleep Related Movement Disorders: Treatments. RLS / PLMS Pharmacologic - Anticonvulsants. Gabapentin Not as powerful as Dopaminergic Rx useful for those with painful RLS, especially when symptoms begin after the age of ~45yrs Daytime fatigue, and dizziness - Benzodiazepines. Non-Benzodiazepines Used to induce sleep, and improve sleep continuity. No direct beneficial effect on PLS/PLMS - Iron (+- Folate) supplementation. Useful if Ferritin is <50%
55 Sleep Related Movement Disorders: Treatments. RLS / PLMS Drugs that aggravate RLS/PLMS - Antihistamines. Block Dopamine receptors Older antihistamines are worse. Check OTC use - Antiemetics Block Dopamine receptors Metoclopramide, Prochlorperazine - Antidepressants? Because it increases Serotonin TCA s, SSRI s,?maoi s
56 Other Nighttime disorders: - Narcolepsy. Four cardinal symptoms: Excessive Daytime Sleepiness Sleep Paralysis Hypnagogic / Hypnopompic Hallucinations Cataplexy (only Cataplexy is unique to Narcolepsy) Not all are necessary for the diagnosis of Narcolepsy. Other common symptoms: Fragmented nocturnal sleep Sleep attacks Naps are temporarily refreshing. Onset: Most commonly in late teenage, and less often in late 30 s May occur in children, especially with strong genetic links ` May investigate with overnight Polysomnography (PSG), and Multiple Sleep Latency Test (MSLT)
57 Other Nighttime disorders: - Narcolepsy. Prevalence: 1/600 in Japan 1/4000 in North America and Europe 1/500,000 in Israel. Gender: Equal Male/Female. Family History: 8% - 12% have a 1 st degree relative with narcolepsy. Thought to be related to a deficiency of Orexin/Hypocretin. Most carry the Human Leukocyte Antigen (HLA) DQB1*0602 However, so do up to 40% of the population, and some narcolepsy patients do not have this marker
58 Other Nighttime disorders: - Narcolepsy RealPlayer SP.lnk
59 Thank You Dr Alex Bartle The SLEEP WELL Clinic Auckland Christchurch Wellington Nelson, Tauranga, Whangarei
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