Dr Alex Bartle. Medical Director Sleep Well Clinic Christchurch

Transcription

1 Dr Alex Bartle Medical Director Sleep Well Clinic Christchurch 11:00-11:55 WS #113: Circadian Sleep Disorders 12:05-13:00 WS #125: Circadian Sleep Disorders (Repeated)

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3 Overview The Structure of Sleep Circadian Rhythms Circadian Rhythm disorders - Delayed Sleep Phase Disorder - Advanced Sleep Phase Disorder - Irregular Sleep Phase Disorder - Non-24hr Sleep Phase Disorder Sleep investigations & treatments in General Practice

4 REM - Rapid Eye Movement NREM - Non-Rapid Eye Movement Stages 1 and 2 light sleep Stages 3 and 4 deep sleep Minute sleep cycles. 4 5 cycles per night to feel refreshed 25% REM, 50% Stage 2 and 25% stages 3 and 4

5 Circadian Rhythms Controlled by Circa Dies = About a day Internal body clock - The Suprachiasmatic Nucleus (SCN) External environment cues Zeitgebers (Time keepers)

6 Circadian Rhythms Sleep / Wake cycle hours if left free running Controls sleep architecture Varies with age 1 : 2 ratio

7 Controlled by: Circadian Rhythms Internal Body Clock o The Suprachiasmatic Nucleus (SCN) o Melatonin o Core body temperature o Many hormonal fluctuations External Environment Cues Zeitgebers (time keepers) o Light o Exercise o Meal times o Work schedule

8 Circadian Rhythms Internal Body Clock Temperature Reflects the sleep wake cycle Association with melatonin secretion

9 Circadian Rhythms Internal Body Clock Growth Hormone Maximum at night in non REM Crucial for healing, growth and immunity

10 Circadian Rhythms Internal Body Clock Cortisol Rises in the morning Increases blood pressure and alertness Testosterone Higher over night and in the morning

11 Internal Body Clock Melatonin Circadian Rhythms Endogenous (our own) is more effective than exogenous (tablets) Related to temperature and sleep Tablets (0.5mg) are most effective at altering the sleep phase when taken 4 6hrs before sleep

12 Circadian Rhythms External Environmental Cues Light - Direct effect on the SCN The most alerting Antidepressant Can alter sleep / wake cycle Exercise - Alerting May compliment or inhibit the effect of light

13 Circadian Rhythms External Environmental Cues Temperature - Environmental temperature can be used to enhance or inhibit sleep Feeding - Affects Gastric acid Affects bowel motility Stimulants / sedatives Inhibition of gastric healing

14 Circadian Rhythms External Environmental Cues Social Stimulus Daytime and night-time behaviour Shiftwork Jet lag Work / play Rituals

15 Circadian Rhythms Internal Circadian Controls (Endogenous) These have their own cycle, but can be modified by: External Circadian Controls (Exogenous) These can be manipulated

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17 Circadian Sleep/Wake Disorders - Delayed Sleep Phase Disorder - Advanced Sleep Phase Disorder - Irregular Sleep Phase Disorder - Non-24hr sleep Phase Disorder

18 Circadian Sleep/Wake Disorders Delayed Sleep Phase Disorder (Night Owl) - The most commons Sleep Phase Disorder - Physiological delay (in Adolescents) - Social Jet Lag (esp.in Adolescents) - Typically persistent 2hrs+ phase shift. - Both sleep onset and morning waking are delayed

19 Delayed Sleep Phase Syndrome Prevalence: In Adolescence: 7.0% In Middle Age: 0.7% In a Sleep Disorders Clinic: > 17.0%

20 Circadian Sleep/Wake Disorders Delayed Sleep Phase Disorder (Night Owl) Treatment:- 1. Chronotherapy 2. Slow advancement of the sleep/wake cycle (See Adolescent sleep) 3. Use of timed morning light exposure and evening darkness

21 Circadian Sleep/Wake Disorders Advanced Sleep Phase Disorder (Larks) - More common in the elderly - Slowly advancing sleep phase with age (and work) - Excessive evening sleepiness - Sleep Maintenance insomnia

22 Circadian Sleep/Wake Disorders Advanced Sleep Phase Disorder (Larks) Treatment :- - Reassurance. - Timed evening light exposure and morning dark - Evening exercise

23 Circadian Sleep/Wake Disorders Irregular Sleep Phase Disorder - More common in Children and Adolescents - More common with Neurodevelopmental disorders (ASD) and Brain injury (TBI & brain tumours) - No defined Sleep/Wake cycle - Falling asleep and waking at any time, Total sleep time is not affected - Poor consolidation of sleep

24 Circadian Sleep/Wake Disorders Irregular Sleep Phase Disorder Treatment :- - Use of Melatonin at night and morning outside light - Morning stimulants if necessary - Sleep hygiene and routine day and night schedule

25 Circadian Sleep/Wake Disorders Non-24hr Sleep Phase Disorder - Lack of entrainment of the circadian pacemaker - Associated with - Blindness (esp. nerve damage or enucleation) - Developmental / intellectual disability - Short periods of alignment may occur

26 Circadian Sleep/Wake Disorders Non-24hr Sleep Phase Disorder - Treatment :- - Evening Melatonin and Morning outside light - Day and Night Routine, especially exercise and meal times

27 Adolescent Sleep How much sleep do they need? 8½ 9¼ hrs How much sleep do they get? Only 15% reported getting 8½hrs sleep on week nights

28 Factors Affecting Adolescent Sleep Biological Influences Emotional development Psychological development Physical development o hormonal changes o somatic growth o circadian rhythm changes

29 Circadian Rhythms Important considerations: Teenager buy-in. Appeal to: o Sporting ability o Academic performance o Vanity! Parent buy-in : o Explanation of the process o Construct a schedule

30 Circadian Rhythms Two behavioral treatment regimes: 1. Phase delay (chronotherapy) 2. Phase advancement

31 Circadian Rhythms 1. Phase delay: Best for those with very severe DSP (>4am) o Delay bed time and wake time by 3 hours every night until target sleep time is reached o Allow no more than 8 hours sleep opportunity ie 4am midday 7am pm 10am pm etc o Difficult to manage in a family environment

32 Circadian Rhythms 2. Phase advancement: Best for those with less severe DSP o Go to bed when sleepy o Advance bed time and wake time by 15 minutes every night until target sleep time is reached o Allow no more than 8 hours sleep opportunity ie 2:00am :00am 1:45am :45am 1:30am :30am etc o Easier to manage in a family environment

33 Circadian Rhythms Summary: Morning light o Timing after lowest core body temperature o Intensity the brighter the light the more rapid the effect (outside is ideal) o Duration ideally at least ½ hour outside (longer in dim light)

34 Circadian Rhythms Summary: Evening darkness o Dim the lights in the evening o Avoid electronic media for at least two hours before bed o Use blue blocking glasses in the evening o Avoid caffeine in the afternoon and evening o Avoid vigorous exercise within 4 hours of bedtime

35 Melatonin: Circadian Rhythms o Produced in the Pineal gland o Has a number of physiological functions o Responsible for peripheral vasodilation (consequent fall in core body temperature) From: The journal of clinical endocrinology & metabolism; Salti,R; 85(6): (2000)

36 Circadian Rhythms Summary Melatonin: o Less effective than light manipulation o Large doses (3mg 5mg) tend to be sedative o Small doses (0.3mg 0.5mg) given 5-6 hours before target sleep onset is effective o Most effective when endogenous melatonin is not present e.g. shiftwork / jet lag o Results in peripheral vasodilation and fall in core body temperature

37 Important considerations: Circadian Rhythms Relaxation of the process will result in a rapid return to the DSP Late nights to bed on Friday and Saturday nights will result in difficulty sleeping on Sunday night and difficulty getting up on Monday morning. Moving West will have immediate benefit but it won t last!

38 Circadian Rhythms Important considerations: Remove all electronic media from the bedroom. The earlier this regime is begun the better, especially in pre-teen years. Blue-blocking sunglasses in the evening No sunglasses in the morning Ensure morning light exposure is after the calculated lowest core body temperature

39 Brief questionnaires: - Epworth Sleepiness scale (General feeling of Sleepiness in 8 situations) - Stop-bang (Considering the possibility of OSA) - Auckland Sleep Questionnaire (Is longer, but covers many aspects of sleep) - Morningness-Eveningness Questionnaire

40 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.

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42 Brief questions: Example Questions from the MEQ (19 Questions) 1. What time would you get up if you were entirely free to plan your day? 2 What time would you go to bed if you were entirely free to plan your day? 7. During the first half-hour after you wake up in the morning, how tired do you feel? 12. If you got into bed at 11:00 PM, how tired would you be?

43 Thank You Dr Alex Bartle The SLEEP WELL Clinics Throughout Mew Zealand