HELPING YOUR PATIENTS GET THE SLEEP OF THEIR DREAMS OCFP 51 ST ANNUAL SCIENTIFIC ASSEMBLY NOVEMBER...

HELPING YOUR PATIENTS GET THE SLEEP

OF THEIR DREAMS

OCFP 51ST ANNUAL SCIENTIFIC ASSEMBLY

NOVEMBER 2013

Dr. CAROLE LAMARCHE, C. Psych.

DECLARATION REGARDING CONFLICT OF INTEREST I DO NOT HAVE AN AFFILIATION

(FINANCIAL OR OTHERWISE) WITH A PHARMACEUTICAL, MEDICAL DEVICE OR COMMUNICATIONS ORGANIZATION

copyright Dr. Carole Lamarche, C. Psych.

OBJECTIVES OF TODAY’S SEMINAR

PROVIDE A BRIEF OVERVIEW OF COMMON SLEEP DISORDERS INCLUDING INSOMNIA, OBSTRUCTIVE SLEEP APNEA, AND RESTLESS LEGS SYNDROME.

UNDERSTAND THE COMPONENTS OF COGNITIVE-BEHAVIOURAL TREATMENT FOR INSOMNIA

PROVIDE EXAMPLES OF BRIEF ASSESSMENT AND INTERVENTION STRATEGIES FOR SLEEP DISORDERS

UNDERSTAND WHEN TO REFER TO A SLEEP CLINIC OR PSYCHOLOGIST


INSOMNIA: BRIEF ASSESSMENT STRATEGIES

FOR THE PHYSICIAN

REVIEW HEALTH HISTORY FOR COMMON COMORBID DISORDERS:– DEPRESSION – ANXIETY– SUBSTANCE USE– PHYSICAL PAIN– HEART AND LUNG PROBLEMS



FOR THE PHYSICIAN HAVE PATIENT KEEP A SLEEP

DIARY OBTAIN COLLATERAL INFORMATION

FROM BEDPARTNER ASK ABOUT RECENT LIFE EVENTS ASK ABOUT PHYSICAL PAIN ASK ABOUT MOOD AND INTEREST



FOR THE PHYSICIAN

ASK PATIENTS HOW MUCH ALCOHOL THEY USE PER DAY

ASK PATIENTS ABOUT CAFFEINE USE

ASK PATIENTS ABOUT NAPPING



PSYCHOLOGICAL TREATMENT OF INSOMNIA

STIMULUS CONTROL THERAPY

SLEEP RESTRICTION THERAPY

COGNITIVE THERAPY

STIMULUS CONTROL

GO TO BED ONLY WHEN SLEEPY IF UNABLE TO FALL ASLEEP OR STAY ASLEEP

WITHIN 20 MINUTES, LEAVE BEDROOM RETURN TO BED WHEN SLEEPY REPEAT AS OFTEN AS NECESSARY MAINTAIN REGULAR WAKETIME DO NOT NAP USE BEDROOM ONLY FOR SLEEP AND SEX



SLEEP RESTRICTION

ESTIMATE TOTAL SLEEP TIME FROM SLEEP DIARY

PRESCRIBE ESTIMATED TOTAL SLEEP TIME AS NEW TIME TO STAY IN BED

AS SLEEP IMPROVES, ADD 15 ADDITIONAL MINUTES TO TIME IN BED

COGNITIVE THERAPY

IDENTIFY MALADAPTIVE THOUGHTS, PREDICTIONS AND BELIEFS ABOUT SLEEP

CHALLENGE THESE WITH FACTS ABOUT SLEEP AND EVIDENCE FROM PATIENT’S LIFE


INSOMNIA: ADDITIONAL PSYCHOLOGICAL INTERVENTIONS

RELAXATION TRAINING– PROGRESSIVE MUSCLE RELAXATION– DIAPHRAGMATIC BREATHING– IMAGERY AND VISUALIZATION– AUTOGENICS


MEDICAL INTERVENTIONS FOR INSOMNIA

MEDICATIONS– BENZODIAZEPINES– BENZODIAZEPINE RECEPTOR

AGONITSTS– ANTI-DEPRESSANTS– ANTI-PSYCHOTICS


WHAT ABOUT MEDICATIONS?

MEDICATIONS ARE APPROPRIATE FOR SHORT-TERM OR INTERMITTENT USE BUT NOT FOR CHRONIC USE

MANY IMPACT SLEEP ARCHITECTURE, HAVE ADDICTION POTENTIAL, CAN CAUSE DAYTIME SLEEPINESS AND CREATE REBOUND INSOMNIA UPON WITHDRAWAL


INSOMNIA: BRIEF INTERVENTIONS FOR THE

PHYSICIAN ASK PATIENT TO MAKE TO-DO LIST ASK PATIENT TO JOURNAL HAVE PATIENT LEARN RELAXATION ASK PATIENT TO GET OUT OF BED

WHEN AWAKE ASK PATIENT TO GO TO BED LATER/

WAKE UP EARLIER


INSOMNIA: BRIEF INTERVENTIONS FOR THE

PHYSICIAN ENCOURAGE PATIENTS TO ONLY

SLEEP AND HAVE SEX IN BED, NOTHING ELSE

ENCOURAGE A REGULAR WAKE-UP TIME, REGARDLESS OF SLEEP QUANTITY OR QUALITY

HAVE PATIENTS INCREASE AFTERNOON PHYSICAL ACTIVITY


DSM-5 BREATHING-RELATED DISORDERS

OBSTRUCTIVE SLEEP APNEA HYPOPNEA (OSAH)

CENTRAL SLEEP APNEA

SLEEP-RELATED HYPOVENTILATION


OSAH: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN: HISTORY

SPECIFIC FACTORS:

– OBESITY– CROWDED

PHARYNGEAL AIRWAY

– AGE– GENDER– MENOPAUSE

COMMON COMORBIDITIES:– HYPERTENSION– CORONARY

ARTERY DISEASE– HEART FAILURE– STROKE– DIABETES– DEPRESSION


OSAH: BRIEF ASSESSMENT STATEGIES FOR THE PHYSICIAN: HISTORY

NON-SPECIFIC FACTORS:– MORNING HEADACHES– HEARTBURN– NOCTURIA– REDUCED LIBIDO– DRY MOUTH– ERECTILE DYSFUNCTION


OSAH: BRIEF ASSESSMENT STRATEGIES FOR THE

PHYSICIAN DO THEY SNORE? DOES A BEDPARTNER COMPLAIN

OF SNORING OR OTHER LOUD NOISES?

DO THEY FALL ASLEEP DURING THE DAY WITHOUT TRYING?

ANY ACCIDENTS OR NEAR MISSES?


INTERVENTIONS FOR OBSTRUCTIVE SLEEP

APNEA HYPOPNEA CONTINUOUS POSITIVE AIRWAY

PRESSURE (CPAP) BILEVEL POSITIVE AIRWAY

PRESSURE (BiPAP) ORAL APPLIANCES POSITIONAL STRATEGIES (I.E.

TENNIS BALL)


INTERVENTIONS FOR OBSTRUCTIVE SLEEP

APNEA HYPOPNEA

SURGERY OPTIONS:– TISSUE REMOVAL (UPPP, TONSILS,

ADENOIDS– JAW REPOSITIONING– NASAL SURGERY– IMPLANTS INTO THE SOFT PALATE


OSAH: ADDITIONAL BRIEF INTERVENTIONS FOR THE

PHYSICIAN

ENCOURAGE HEALTHY EATING AND PHYSICIAL ACTIVITY IN ORDER TO PROMOTE WEIGHT LOSS

ENCOURAGE SMOKING CESSATION ENCOURAGE MODERATION WITH

ALCOHOL USE TREAT COMORBID MENTAL AND

PHYSICAL HEALTH CONDITIONScopyright Dr. Carole Lamarche, C.

Psych.

RESTLESS LEGS SYNDROME (RLS): BRIEF ASSESSMENT

STRATEGIES FOR THE PHYSICIAN

RULE OUT OTHER CAUSES OF MOVEMENTS:– ARTHRITIS– LEG EDEMA– LEG CRAMPS– PERIPHERAL ISCHEMIA– HABITUAL FOOT TAPPING– POSITIONAL DISCOMFORT– MEDICATION EFFECTS


RLS: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN: HISTORY

SPECIFIC FACTORS:– FEMALE GENDER– PREGNANCY– AGE– FAMILY HISTORY– IRON DEFICIENCY– GENETIC RISK FACTORS


RLS: BRIEF ASSESSMENT STRATEGIES FOR THE PHYSICIAN: HISTORY

COMMON COMORBIDITIES:– DEPRESSION– ANXIETY DISORDERS– ATTENTIONAL DIFFICULTIES– CARDIOVASCULAR DISEASE– CHRONIC RENAL FAILURE– PERIODIC LIMB MOVEMENT DISORDER


INTERVENTIONS FOR RESTLESS LEGS

SYNDROME MEDICATIONS:

– DOPAMINERGICS (E.G. REQUIP (ROPINIROLE), MIRAPEX (PRAMIPEXOLE) AND NEUPRO PATCH (ROTIGOTINE)

– ANTICONVULSANTS– OPIOIDS– MUSCLE RELAXANTS


ADDITIONAL INTERVENTIONS FOR

RESTLESS LEGS SYNDROME

LIGHT THERAPY STRETCHING YOGA RELAXATION TEACHNIQUES


RLS: ADDITIONAL BRIEF INTERVENTIONS FOR THE

PHYSICIAN

ENCOURAGE DECREASE IN CAFFEINE, ALCOHOL AND NICOTINE USE

ENCOURAGE USE OF MASSAGE OR WARM BATH

ENCOURAGE USE OF HEAT OR ICE IDENTIFY VITAMIN AND MINERAL

DEFICIENCIES (IRON, MAGNESIUM, ETC.)


WHEN TO REFER TO A SLEEP CLINIC

WHEN YOU SUSPECT THERE IS A SLEEP DISORDER THAT NEEDS POLYSOMNOGRAPHY TO BE CORRECTLY DIAGNOSED– SLEEP APNEA– NARCOLEPSY– REM SLEEP BEHAVIOUR DISORDER


WHEN TO REFER TO A PSYCHOLOGIST

WHEN YOU SUSPECT A PSYCHOLOGICAL DISORDER THAT IS MODERATE TO SEVERE (MOOD DISORDER, ANXIETY DISORDER, SUBSTANCE USE DISORDER)

WHEN THE PATIENT HAS CHRONIC PHYSICAL PAIN

WHEN THE PATIENT IS HAVING DIFFICULTY IMPLEMENTING YOUR SUGGESTIONS



SOME USEFUL WEBSITES

Canadian Sleep Society: www.css.to Mayo Clinic:

www.mayoclinic.com/health/insomnia American Sleep Apnea Association:

www.sleepapnea.org Restless Legs Syndrome Foundation:

www.rls.org

USEFUL REFERENCES

SINK INTO SLEEP. 2013. J. DAVIDSON THE INSOMNIA WORKBOOK. 2009. S.

SILBERMAN & C. MORIN SAY GOODNIGHT TO INSOMNIA. 2009 G.

JACOBS QUIET YOUR MIND AND GET TO SLEEP.

2013. C. CARNEY & R. MANBER INSOMNIA 1993. C. MORIN


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HELPING YOUR PATIENTS GET THE SLEEP OF THEIR DREAMS OCFP 51 ST ANNUAL SCIENTIFIC ASSEMBLY NOVEMBER...

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