Sleep Disorders

Question 1

How common are sleep disorders?

Answer 1

• 9% general population
• 50-90% chronic pain
• 50% heart failure patients
• 36-50% cancer patients

Question 2

Describe normal physiology of sleep

Answer 2

• 1/3 life asleep
• purpose unknown
• induction period, decrease skeletal muscle activity, cardiac and resp rhythm, lower core temp and arterial pressure.
• non REM:
  
  • Phase 1 and 2 lighter sleep
  • Phase 3 and 4 deeper sleep
• REM:
  
  • active sleep, dreaming
• 4-6 sleep cycles of 90 min
• 7-10 hours /day adults
• quality is subjective

Question 3

Why is sleep disruption important?

Answer 3

• mood
• cognition
• concentration
• memory
• anxiety
• fatigue
• physical discomfort
• poor treatment compliance
• treatment outcomes
• survival
• pain control
• immune/metabolic functions
• QOL
• caregivers – increased hospitalization

Question 4

Sleep history

Answer 4

• anxiety
• pain
• symptoms
• other medical problems
• timing of sleep - initiation or maintenance
• alcohol
• caffeine
• medications
• mood

Question 5

Diagnosis of Sleep disorders

Answer 5

• Primary
• Secondary
• Sleep-related breathing disorders
• movement disorders

Question 6

What is insomnia?

Answer 6

• Subjective symptom related to inadequate quality or quantity of sleep
• Difficulty falling asleep (initiation)
• Diffculty staying asleep (maintenance)
• Both

Question 7

List factors that cause insomnia

Answer 7

• Environmental
  
  • light, noise, heat, mattress, cold
• Psychological
  
  • Anxiety, fear
• Physical
  
  • pain
  • GI
  • urinary frequency (meds, tumour effect)
  • pruritis
  • resp symptoms
  • myoclonus
  • delirium
  • excessive daytime sleep
• Pharmacological
  
  • medication
  • caffeine, smoking, etoh, withdrawal
  • steroids
  • stimulants
  • bronchodilators

Question 8

List other medical conditions that cause sleep disorders

Answer 8

• COPD
• OSA
• asthma
• renal
• endocrine
• infectious diseases

Question 9

Management of sleep disorders

Answer 9

• treat underlying cause when able
• Non Pharm
  
  • CBT, sleep restriction, hypnosis, relaxation, stimulus control (get out of bed if not sleepy)
  • Sleep hygiene
• Pharm (no systematic studies)
  
  • Benzos and z drugs:
    
    • SE: cog impairment, delirium, falls, depression
    • tolerance
    • long term use makes sleep worse
  • SSRI if also depression
    
    • choose sedating one : mirtazapine
  • Atypical antipsychotic if anxiety
    
    • olanzpaine, quetiapine

Question 10

Tips with Benzodiazepines for sleep

Answer 10

• Short duration of action : alprazolam
  
  • sleep onset
• Intermediate duration (8-15 hours) : temazepam, lorazepam, oxazepam)
  
  • depression early morning awakening
  • high daytime anxiety
• Long acting and variable metabolism : clonazepam
  
  • anxiolytic
  • careful titration

Question 11

Sleep hygiene for palliative care

Answer 11

• Personal habits:
  
  • regular sleeping times
  • bright light during day
  • avoid naps
  • avoid alcohol
  • avoid stimulants 4-6 hours before bed
  • exercise but not right before bed
• Sleep environment
  
  • comfortable bedding
  • no bright lights
  • block noise
  • cool temp
  • bed for sleep and sex
• Before bed time
  
  • light snack, warm milk
  • relaxation technique
  • avoid stimulating activities
  • pain relief with long acting analgesic