Sleep and ADHD

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Sleep disorders in adults with ADHD

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Sleep and ADHD

  1. 1. Dr Yasir Hameed (MRCPsych) Specialist Registrar Norfolk and Suffolk NHS Trust 28 March 2014 Yasir Hameed (MRCPsych) Digitally signed by Yasir Hameed (MRCPsych) DN: cn=Yasir Hameed (MRCPsych) gn=Yasir Hameed (MRCPsych) c=United Kingdom l=GB o=Norfolk and Suffolk NHS Trust ou=Norfolk and Suffolk NHS Trust e=yasirmhm@yahoo.com Reason: I am the author of this document Location: Date: 2014-03-29 11:44Z
  2. 2. » Sleep and its importance » Sleep disorders in adults with ADHD (focus on Delayed Sleep Phase Disorder DSPD) » Assessment » Treatment 2
  3. 3. Upon completion of this educational activity, participants should be able to: » Recognise the delayed sleep phase in adults with ADHD. » Explain the consequences for health in general of late and short sleep on the long term and how to treat the delayed sleep phase. 3
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  6. 6. Sleep
  7. 7. » Restorative/homeostatic » Thermoregulation/energy conservation » Consolidation of learning and memory
  8. 8. » Cyclic nature of sleep is reliable » REM periods every 90 – 120 minutes » First REM period is shortest » Most deep sleep (Stage 3 & 4) occurs early » Most REM occurs late
  9. 9. » All variety of sleep disorders are more common amongst children and adults with ADHD than healthy controls, controls with other psychiatric illness, and health siblings » The DSM-III considered excessive movements during sleep to be a criterion for hyperactivity in children » Sleeping disorder (predominantly delayed sleep phase disorder) prevalence in clinical studies of adults is 80 % and in clinical studies in children – 73 % » Kooij, JJS. Adult ADHD Diagnostic Assessment and Treatment. Third edition. 2013. Pearson publication.
  10. 10. » - (Very) late Chronotype » - A chronic pattern of (very) late sleep and preference for late rise » - May result in daytime sleepiness and/or insomnia » - May be compensated for by an irregular sleep pattern » - Leads to dysfunctioning due to increased inattentiveness and/or social problems » - Main complaint is sleep onset insomnia 11
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  13. 13. » Partners having different bedtimes is another common problem for having sex » High rates of divorce and separation (Biederman J, Faraone SV, Keenan K, et al. 1992) » 4 times more likely to have complaints of poor quality relationships (Biederman J, Faraone SV, et al 2006)
  14. 14. » Clinical history ˃ Sleep initiation, maintenance, duration; refreshed and alert in AM; bedtime routine; anxiety/depression; unusual night-time behaviours » Sleep log ˃ 2-3 weeks to document sleep-wake patterns ˃ Munich Chronotype Questionnaire (MCTQ) » Smartphone apps ˃ Sleep Cycle Calculator » Actigraphy and Polysomnography ˃ Needed for OSAS, RLS, or nocturnal seizures
  15. 15. » Management is “diagnostically driven”, and depends on thorough assessment and a formulation to include the likely underlying cause or causes.
  16. 16. » Interventions: ˃– Sleep diary ˃– Sleep hygiene ˃– Switch of medication ˃– Dose reduction ˃– Other medication ˃– Drug holiday
  17. 17. » In a randomized, crossover study in children with ADHD, results indicated that, relative to baseline, immediate-release MPH increased sleep-onset latency statistically significantly more than did atomoxetine (p<.001), consistent with the time to onset of persistent sleep and mean time to onset of first sleep epoch (p<.001 for both) » No difference in ADHD rating scale IV-Parent Version » Sangal et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD. Sleep. 2006;29(12):1573-1585 19
  18. 18. » Medication is rarely the first and only choice » Behavioural strategies aiming to sustain improvement and minimise adverse effects
  19. 19. » Melatonin has both immediate and extended- release forms (Circadin®) » Evidence? » In practice, adverse effects are relatively uncommon and self-limiting. There is increasingly reassuring evidence that this is a safe medication in hypnotic doses of up to 10mg . Bendz L.M.,and Scates A.C. Melatonin treatment for insomnia in pediatric patients with attention deficit hyperactivity disorder. Ann Pharmacother 2010 44(1) 185-191 Weiss M.D., Wasdell M.B., et al Sleep hygiene and melatonin treatment for children and adolescents with ADHD and initial insomnia. J Am Acad Child Adolesc Psychiatry 2006 45(5) 512-519 Rossignol D.A., and Frye R.E. Melatonin in autism spectrum disorders : a systematic review and meta-analysis. Dev Med Child Neurol 2011. 9.(783-792)
  20. 20. » Promethazine » Clonidine » Benzodiazepines » Z hypnotics » Antidepressants
  21. 21. » Whatever medication is tried, periodic breaks from treatment are prudent to assess whether ongoing treatment is necessary. » Most hypnotics will remain ineffective in the presence of poor sleep routines, overstimulation at bedtime or the challenges of nocturnal multimedia. » Always give advice on sleep hygiene 23
  22. 22. • Sleep difficulties are highly prevalent in ADHD, are often multifactorial in origin, and significantly impair quality of life • Sleep difficulties exacerbate daytime ADHD symptoms • Shared biological dysregulation in ADHD may contribute to disordered sleep • Assessment of ADHD is incomplete without a sleep history (pre- and post-treatment) • Sleep diaries are particularly useful in assessment
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