John McLachlan Respiratory & Sleep Physician @FSH Clinical Lead Pulmonary Physiology & Sleep Medicine Sleep Physician x 27 years Interest in Insomnia management President Elect, WA Branch Thoracic Society of Australia & NZ
From ghoulies and ghosties And long-leggedy beasties And things that go bump in the night, Good Lord, deliver us! trad. Scottish
Overview Normal Sleep Sleep Disorders Falls Sleep Treatments Falls Alternative Management
Normal Sleep Gradual process Sleep pressure / Circadian / Alerting > 24 hour clock Entraining Cyclical Stages
Normal Sleep
Normal Sleep
Normal Sleep Falls due to normal sleep? Environment Inertia REM
Sleep Disorders Excessive Sleep Initiating & Maintaining Sleep Parasomnias
Sleep Disorders Excessive Sleep Sleep Apnoea Sleepy PU Narcolepsy / Cataplexy Sleep restriction
Sleep Disorders Initiating & Maintaining Sleep Insomnia Circadian
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
Sleep Disorders Parasomnias Restless Legs REM behaviour Arousals Confusional Sleep walking Terrors
Sleep Treatments Oxygen CPAP Medications
Hypnotics and Falls Several studies show increased risk Elderly Institutionalised Benzos & other psychotropics J Gerontol 1989;44:M112-117 Some inconstant Community Large scale suggest increased risk N Engl J Med 1988; 319: 1701-1707 JAMA 1989; 261: 2663-2668
Hypnotics and Falls Brassington et al Reported sleep problems Not psychotropic meds J Am Geriat Soc 2000; 48: 1234-1240 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: 955-962
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):1768-1775
Hypnotics and Falls Arch Intern Med. 2008;168(16):1768-1775
Sleep and Falls Arch Intern Med. 2008;168(16):1768-1775
Alternate Treatment
CBTi Components Behavioural component General Specific Cognitive component Educational component 201503_McLachlan_Insomnia
CBTi Components Behavioural component General Specific Cognitive component Educational component 201503_McLachlan_Insomnia
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
Bright Light Moderately bright light (1000 lux) or more improves subjective alertness, mood, and sleep quality Morning bright light promotes sleep onset
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 201503_McLachlan_Insomnia
CBTi Components Behavioural component General Specific Cognitive component Educational component 201503_McLachlan_Insomnia
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. 201503_McLachlan_Insomnia
Stimulus Control Bed Bedroom Sleep-incompatible activities (reading, watching tv) Frustration Bedtime Anxiety Worry 201503_McLachlan_Insomnia
Stimulus Control Bed Bedroom Bedtime Drowsiness Relaxation Sleep 201503_McLachlan_Insomnia
Conditioned Sleep Onset Insomnia Stimulus Control Therapy 1. Don t go to bed until sleepy. 2. If not asleep in 10-15 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.
Sleep Restriction Individuals with insomnia have reduced sleep efficiency 201503_McLachlan_Insomnia
Sleep Restriction Align time in bed (TIB) Develop a regular sleep-wake rhythm. 201503_McLachlan_Insomnia
Sleep is on our side Combine stimulus control & sleep restriction almost always win!
CBTi Components Behavioural component General Specific Cognitive component Educational component 201503_McLachlan_Insomnia
Cognitive Component Challenging unrealistic sleep expectations Modifying beliefs about causes and consequences of insomnia 201503_McLachlan_Insomnia
Cognitive Component BELIEF: It is essential to sleep x number of hours per day to feel refreshed and function well during the day 201503_McLachlan_Insomnia
Morning sleepiness is normal
Historical Sleep Segmented Sleep 1st (deep) watch period 2nd lighter 201503_McLachlan_Insomnia
CBTi Components Behavioural component General Specific Cognitive component Educational component 201503_McLachlan_Insomnia
Educational Component Health practices Environmental influences 201503_McLachlan_Insomnia
Alternative Approaches Relaxation Paradoxical intention 201503_McLachlan_Insomnia
Online CBT
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