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

Parasomnias: In REM In REM REM Sleep Behaviour Disorder. (REM without muscle atonia) REM Sleep Behaviour Disorder. (REM without muscle atonia) REMdisorder.mp4 behavior REMdisorder.mp4 behavior

The most common sleep disorders are associated with:- 1) Shiftwork 1) Shiftwork Up to 20% of the workforce are shiftworkers Up to 20% of the workforce are shiftworkers 2)Insomnia 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 3)Snoring and Obstructive Sleep Apnoea (OSA) Snoring – up to 60% adults snore regularly OSAS – 9% of males, 4% females over 40

Circadian Rhythms Circa Dies = About a day Controlled by Internal body clock - The Suprachiasmatic Nucleus (SCN) - Core body temperature circadian cycle - Core body temperature circadian cycle - The role of our own Melatonin - The role of our own Melatonin External environment cues – Zeitgebers (Time keepers) - The effect of light - The effect of light - Exercise - Exercise - Meals - Meals

Insomnia Insomnia

Insomnia May be a symptom of a disorder Initial insomnia Anxiety and Stress Chemical Stimulation Physical Activity Age (Adolescence) Interrupted Insomnia Pain Respiratory Illness Habit Jet Lag Shiftwork Early Morning Wakening Age (Elderly) Depression

Medical problems associated with Medical problems associated with Insomnia Insomnia Heart Disease x 2.27 Cancer x 2.17 Hypertension x 3.18 Neurologic disease x 4.64 Breathing problems x 3.78 Urinary problems x 3.28 Diabetes x 1.8 Chronic pain x 3.19 Gastrointestinal x 3.33

Insomnia 10-15% of adults suffer from chronic and severe insomnia 10-15% of adults suffer from chronic and severe insomnia (Complaints of insomnia with daytime consequences) (Complaints of insomnia with daytime consequences) 30–40% of adults complain of insomnia symptoms only 30–40% of adults complain of insomnia symptoms only 95% experience insomnia at some time in their lives 95% experience insomnia at some time in their lives

Insomnia Risk Factors: Risk Factors: Female 2:1 (?More likely to report insomnia) Female 2:1 (?More likely to report insomnia) Increasing age (? Increased likelihood of medical complaints) Increasing age (? Increased likelihood of medical complaints) Stress/Anxiety (Hyper-arousal Disorder) Stress/Anxiety (Hyper-arousal Disorder) Psychiatric Illness Psychiatric Illness Medical disorder Medical disorder Social factors (Unemployed, single, physical inactivity) Social factors (Unemployed, single, physical inactivity) Environmental factors (noisy environment, latitude-SAD) Environmental factors (noisy environment, latitude-SAD)

CHEMICAL Herbal Allopathic BEHAVIOURAL Cognitive/behavioral therapy for Insomnia (CBTI) Sleep hygiene Stimulus control Sleep (bed) restriction Insomnia ( treatments)

HERBAL MEDICINES VALARIANKAVA ST JOHN WORT MELATONINCHAMOMILLEOTHERS Insomnia

Melatonin Two therapeutic uses: 1.As a chronobiotic Use a small dose (0.5mg), 5hrs before desired sleep onset Use a small dose (0.5mg), 5hrs before desired sleep onset 2. As a soporific Use a larger dose (2mg or 3mg) ½ -1 hr before desired Use a larger dose (2mg or 3mg) ½ -1 hr before desired sleep onset sleep onset Insomnia

Melatonin Two therapeutic uses: 1.As a chronobiotic Melatonin in the evening will advance the sleep Melatonin in the evening will advance the sleep phase (Earlier to sleep and earlier to wake) phase (Earlier to sleep and earlier to wake) Melatonin in the morning will (theoretically) delay Melatonin in the morning will (theoretically) delay the sleep phase (Later to sleep and later to wake) the sleep phase (Later to sleep and later to wake) Insomnia

Melatonin Two therapeutic uses: 2. As a soporific For children with ADHD or ASD For children with ADHD or ASD Some small evidence that their melatonin levels are low Some small evidence that their melatonin levels are low For those over 55 yrs For those over 55 yrs Melatonin levels tend to fall with age Melatonin levels tend to fall with age Not helpful for those under 55yrs Not helpful for those under 55yrs Insomnia

Melatonin Melatonin 2mg Slow release. Melatonin 2mg Slow release. 1.Slightly helpful for insomnia over 55yrs 2.Large supraphysiological dose. 3.Despite a relatively short ½ life, some may last through to the morning and therefore delay sleep onset. 4.May result in morning fatigue. Significant individual variability Insomnia

Melatonin Melatonin 2mg Slow release. Melatonin 2mg Slow release. 5. It is a reliable product. Accurate 2mg 6. Long term effects of Melatonin are unknown, especially in the preteen/teenage years especially in the preteen/teenage years 7. If used for travel (jet lag) trial it first. Placebo effect is strong for sleep. Placebo effect is strong for sleep. Insomnia

Advantages Freely available Probably less side effects Disadvantages Few studies Inconsistent product Unknown interactions of side effects Less effective Insomnia Chemical

AllopathicHISTORY Antiquity- Alcohol and Laudanum 1860’s & 70’s- Bromides and Chloral Hydrate 1880’s- Paraldehyde, urethane 1900’s- Barbiturates 1960’s- Benzodiazepines - 1 st Chlordiazepoxide (Librium) 1980’s – 90’s- Zopiclone, Zolpidem Zaleplon Insomnia

Insomnia Allopathic HYPNOTICS – Which one? Benzodiazepines - Triazolam - Triazolam - Temazepam - Nitrazepam Non Benzodiazepines- Zopiclone - Zolpidem - Zaleplon

Insomnia AllopathicBenzodiazepinesBenefits -effective -wide margin of safety -slow tolerance Adverse effects -residual sedation -anterograde amnesia -rebound insomnia -Dependance Contraindications and Precautions

Insomnia Allopathic Hi Antihistamine -daytime drowsiness -impaired learning Sedating Antidepressants -cardiotoxic -anticholinergic -increase RLS/P.L.M.s -impaired daytime performance - rapid tolerance

Insomnia Allopathic Use short acting hypnotics for short term treatment in low dose Use sedating antidepressants in full doses for insomnia associated with depression

Insomnia Insomnia Evaluation: The three P’s Evaluation: The three P’s - Predisposing Factors - Predisposing Factors Genetics, Personality type, Social Pressures Genetics, Personality type, Social Pressures - Precipitating Factors - Precipitating Factors Stressful life event(s). “Trigger” for insomnia. Stressful life event(s). “Trigger” for insomnia. - Perpetuating Factors. - Perpetuating Factors. Compensatory strategies. Eg longer in bed. Compensatory strategies. Eg longer in bed. Staying in bed. Alcohol use Staying in bed. Alcohol use

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.

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

Stimulus Control Stimulus Control is based on classical conditioned Stimulus Control is based on classical conditioned response to certain stimuli. response to certain stimuli. This involves strengthening the relationship This involves strengthening the relationship between bed and sleep, and breaking the between bed and sleep, and breaking the negative relationship between bed and negative relationship between bed and anxiety and wakefulness anxiety and wakefulness Important and Effective Important and Effective

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 No visible clocks at night Get out of bed if unable to fall asleep in 15 – 20 minutes Return to bed when sleepy. Repeat as often as necessary

Bed Restriction Therapy for those with insomnia Bed restriction therapy is designed to improve Bed restriction therapy is designed to improve sleep consolidation and sleep efficiency. sleep consolidation and sleep efficiency. This is achieved by initially increasing the This is achieved by initially increasing the homeostatic drive to sleep. Sleep efficiency homeostatic drive to sleep. Sleep efficiency improves. Time in bed can then be increased. improves. Time in bed can then be increased. Difficult, but the most effective Difficult, but the most effective

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

A Therapeutic model Having discussed Sleep Hygiene, and Relaxation therapies, discuss Stimulus Control, and Bed Restriction.

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)

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

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

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

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

The Agony or the Ecstasy The Agony or the Ecstasy Familiar?

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

Snoring and Obstructive Sleep Apnoea

Consequences of Sleep Apnoea 1. Daytime fatigue, especially sleepiness 2. Bed partner sleep disturbance 3. Cardiovascular complications

Consequences of Sleep Apnoea Medical consequences :- Hypertension Insulin Resistance Cardiac Arrhythmia Heart Attack Stroke Nocturnal GORD Nocturia Depression

Risk Factors for Sleep Apnoea Male: Female 2 : 1 Increasing age Body Mass Index > 30 Neck Circumference > 42cm ( 17ins) Alcohol ( > 2 units) Smoking Post Menopausal Women Sleeping Pills

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.

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

Examination BMI Neck circumference Nasal airway: septum/ valves Tonsil size / soft palate Soft palate oedema Base of tongue

Conservative Weight loss Alcohol reduction Stop smoking Avoid sleeping tablets Keep off back

Managements Lifestyle Sleep position, i.e. Side Upright Control of Obesity Avoidance of alcohol and drugs (especially BZD’s)

Surgical Managements Adenotonsilectomy -- especially in children, rarely in adults Uvulopalatopharyngoplasty (UPPP) -- rarely helpful Nasal surgery generally unhelpful Palatal surgery

Surgical Managements Surgical Managements Other surgery Tracheostomy Weight loss surgery

Devices Mandibular Advancement Splints SomnoMed/MDSA

Devices Aveo TSD Tongue Stabilising Device

Devices External nasal splints Not helpful Internal nasal splints

Continuous Positive Air Pressure CPAP

KEY QUESTIONS: 1.Do you snore? 2.Are you sleepy?

Laugh and the world laughs with you… …snore and you sleep alone.

Thank You Dr Alex Bartle MB BS FRNZCGP Dip Obst MMed (Sleep Medicine) SLEEP WELL CLINIC Auckland Christchurch Wellington Tauranga Whangarei Nelson & Invercargill