I am having difficulty sleeping!

Transcription

1 I am having difficulty sleeping! a practical approach Bruce Arroll dept of general practice and primary health care school of population health

2 goodfellowunit.org short course: diagnosis and treatment of insomnia

3

4

5

6

7 what is insomnia what type of insomnia what can I/we do about it

8 what is insomnia do you have trouble with your sleeping (on at least 3 nights per week) such that it interferes with your activities the following day (eg unrefreshed in the morning, fatigued, poor concentration or irritabilitylasting for more than one month 41% in Auckland GP Study Arroll et al Br J Gen Pract 2102; Feb:e99-e103

9 range of definitions major current insomnia (taking at least two hours to fall asleep nearly every night 10% in Seattle Study Simon GE, et Am j Psychiatr 1997;154(10):

10

11 patient # 1 50 year old BMI 35 snores loudly at night not feeling rested the next day falls asleep at work

12

13 patient # 2 75 year old woman Bed at 2100 wakes for 2 hours gets up at 0600 does not feel rested when she wakes

14

15 patient # year old acoustic engineer 2.bed at 2 am 3.weekend wakes at 1000 hrs 4.during up at 6 am to go to work tired all day

16 return to patients later

17 dr tony fernando

18 dr karen falloon

19 an interest in insomnia tony fernando s story primary insomnia all better with bed time restriction BA skeptical need an RCT

20 an interest in insomnia primary insomnia insomnia with no other cause needed to know other causes?other causes in primary care

21 causes of insomnia depression 50% anxiety 48% sleep apnea 9% general health 43% parasomnias (Sleep walk 1%, restless legs bruxism 2% in reality about 5% Br J Gen Pract 2012; 62:e99-e103.

22 causes of insomnia alcohol problem 8% other substance 4% *delayed sleep phase disorder 2% *primary insomnia 12% * mutually exclusive of other conditions

23 weird conditions REM disorder sleep eating

24 interest in insomnia conducted RCT 1 0 insomnia * 75% intervention got a better sleep * 35% control group got better sleep sleep hygiene effective J Prim Health Care 2013;5(1):5-10.

25 time in bed restriction effective -?compression More on time in bed restriction later

26

27 patient # 1 50 year old BMI 35 very tired in in daytime-asleep at work!!!!!! wife notices that stops breathing for up to 15 seconds snores loudly at night wakes with dry mouth morning headache

28 patient # 1 meets criteria for sleep apnoea very tired during day stops breathing and gasping episodes minor criteria snores loudly at night wakes with dry mouth morning headache

29 patient # 1 needs assessment for CPAP pulse oximetry at night polysomnography (sleep lab) Treatment CPAP (continuous positive airways pressure) weight loss?? mandibular advancement splints (MAS) surgery???

30

31 patient # 2 75 year old woman goes to bed a 2100 wakes for 2 hours in middle of night gets up at 0600 does not feel rested when she wakes bored, cold lonely use screening tool

32 patient # 2 looking at the screening tool will tick yes to first 2 questions insomnia will tick no to all after bottom two questions i.e. no other cause for insomnia hence she has primary insomnia

33 patient # 2 what to do sleep hygiene check on naps ( 1200 to 1500) ~ 30 minutes max exercise time in bed restriction medication

34 sleep hygiene bed only for sleep or intimacy don t watch TV or computer screen in bed if not asleep within 20 minutes get up avoid caffeine before bed time avoid energetic activity before bed time avoid naps the during the day or before 3 pm make sure environment is comfortable quiet correct temperature comfortable bed

35 sleep advice slow down breathing make your eyes half closed eyes app- mysleepbutton- nonsense words listen to podcasts sleep routine

36 Exercise Cochrane review 2002 Sleep problems become more common with age, affect quality of life for individuals and their families, and can increase healthcare costs. Older people are often prescribed a range of drugs for their health problems (including with sleep) many of which have side effects. This review considered the effectiveness of a programme of physical exercise involving brisk walking and moderate resistance training tailored for the needs of the older adult. These reviewers report that evidence from one small trial is encouraging, and further research is needed.

37 treatment * bed time restriction * ask how long in bed ~ 9 hours * estimate time asleep approximately -or use sleep diary AASM

38 treatment * usually 5 to 6 hours * advise spend 5 to 6 hours in bed

39 treatment * if wake at 0600 hrs - go to bed 2400 * difficult to keep occupied -reading, light house work

40 treatment * if drowsy next day-increase by 15/30 * all changes need 1 week * may resist consider compression

41 treatment * notice that getting deeper sleep * professional drivers do in vacation

42 treatment other/meds 1. CBTi if you can find it 2. Melatonin 3. tricyclic in low doses?? -amitriptyline 10 mg - nortriptyline 10 mg

43 treatment other 4. mirtazapine 15mg 5. quetiapine 6.25 to 25 mg 6. all else fails low dose hypnotic -tolerance? fall

44 other conditions- meds 1. depression and anxiety 1. TCAs 2. Mirtazapine (weight issues) 3. Add benzodiazepines 2. stop SSRIS, SNRI, buproprion

45 treatment- supplements good evidence -acupressure, tai chi, yoga mixed evidence -L tryptophan, mindfulness Sleep Med Rev Dec;24C:1-12

46 treatment- supplements unsupportive -valerian, valerian, chamomile, kava, wuling -AEs more with valerian than placebo Sleep Med Rev Dec;24C:1-12

47 treatment- supplements good evidence mg magnesium in elderly J res med sci 2012 Dec;17(12): five mg melatonin, 225 mg magnesium, and mg zinc in elderly J am geriatr soc 2011 Jan;59(1):82-90.

48

49 patient # year old acoustic engineer 2. goes to bed at 2 am and in weekend wakes at 1000 hrs 3. during the week gets up at 6 am to go to work tired all day 4. diagnosis??

50 patient # 3 1. Delayed sleep phase disorder (teenage pattern) 2. a dysregulation of a person's circadian rhythm (biological clock), compared to the general population and societal norms generally fall asleep some hours after midnight and have difficulty waking up in the morning. 3. Treat: melatonin at night and light box in am 4. Often get night jobs

51 take home message insomnia is common need to make a specific diagnosis primary insomnia when no other cause sleep hygiene first time in bed restriction for primary insomnia