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Want Of Sleep

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Evidence-based management of insomnia for the primary palliative management of patients.

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Want Of Sleep

  1. 1. { Kyle P. Edmonds, MD Fellow, Institute for Palliative Medicine San Diego Hospice
  2. 2. Absence of distress  Circadian timing (time of the day)  Sleep drive (time since last slept)  Physical comfort  Environment  Intact CNS function  Hanks et al. (2010).
  3. 3. Age 0-2 Mos 3-11 Mos 1-3 Yrs 3-5 Yrs 5-10 Yrs 10-17 Yrs Adults (inc seniors) Sleep Needs (Hours) 12-18 hours 14-15 hours 12-14 hours 11-13 hours 10-11 hours 8-9 hours 7-9 hours Adapted from Carol (2011).
  4. 4. Biological recovery  Enhanced immune function  Regulation of circadian hormones  Memory consolidation  Hanks et al. (2010).
  5. 5. Diagnostic Category Representative Diagnoses Insomnia Primary, Secondary Sleep-related breathing d/o OSA, CSA Hypersomnolence Narcolepsy Circadian rhythm disorder Shift work Movement disorder RLS Parasomnia Isolated symptoms Night terror; REM sleep behavior Primary snoring; Sleep talking Adapted from Table 10.12.1. Hanks et al. (2010).
  6. 6. General population1 9-12% Healthy seniors1 12-25% Hospital population2 23% Chronic lung disease3 50% Cancer2 70% HIV/AIDS3 75% Hemodialysis3 77% Depression3 90% (1) Bastien et al. (2003). (2) Miller & Arnold (2011). (3) Hanks et al. (2010)
  7. 7. Activated HPA axis Increased metabolic rate Increased autonomic nervous system Psychophysiologic Hyperarousal Increased sleep EEG frequency Increased cerebral blood flow Hanks et al. (2010).
  8. 8. Situation Sitting and reading Watching TV Sitting inactive in a public place (e.g. theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after a lunch without alcohol In a care, while stopped for a few minutes in traffic Miller & Arnold (2011).
  9. 9. Hygiene  Chronology  Environment  Physical Symptoms  Medical Conditions  Spiritual Concerns  Miller & Arnold (2011).
  10. 10. Persistent Medical, neurologic or psychiatric Difficulty staying asleep Nightmares, OSA Frequent awakening Medications Early morning awakening Depression Day-night reversal Delirium Miller & Arnold (2011).
  11. 11. Hugel et al. (2004).
  12. 12. Hugel et al. (2004).
  13. 13. 38% What do you think would help you sleep? • Symptom control 21% • Address worry 19% • Combination of measures 13% • Don’t know 4% • Sleep medications Hugel et al. (2004).
  14. 14. Disease Mgmt Loss, gri ef End-oflife/death mgmt Physical issues Patient/Family Characteristics Practical issues Psych & cognitive issues Social issues Spiritual issues Adapted from EPEC-O. (2007)
  15. 15. Relaxation therapies  Sleep restriction therapy  Stimulus control therapy  Cognitive behavioral therapy  BiPAP  Palatoplasty  Miller & Arnold (2011).
  16. 16. Hanks et al. (2010).
  17. 17. “Patients may be able to avoid [spiritual] concerns during the day through the distraction of daily activities but have difficulty ignoring them at night. Thus, it is important to directly address a patient’s spiritual concerns, worries, and fears about dying during the day.” Miller & Arnold (2011).
  18. 18. Consider stopping:  Steroids  Stimulant antidepressants  Bronchodilators  Diuretics 
  19. 19. Sanna & Brurera (2002).
  20. 20. Increase stage 2 (N2)  Decrease stages 3 and 4 (N3)  Interfere with slow-wave sleep  Bastien et al. (2003).
  21. 21. Medication Dosage Half-life Tmax Metabolites Comments Other benzodiazepine receptor agonists Zolpidem 5 1.5-4 1-1.5 No Zaleplon 5 1 0.5-1 No Eszopiclone 2 5-7 0.5-2 Minimal Ambien®; imidazopyridine Sonata®; pyrazolopyrimidine Lunesta®; cyclopyrrolone Melatonin agonists Ramelteon 8 1-2 0.5-1 No Rozerem®; Not a controlled substance Adapted from Table 10.12.7, Hanks et al. (2010).
  22. 22. Studied only in depressed insomniacs  25-100mg may improve sleep*  Biphasic half-life (3-6h, 5-9h) 
  23. 23. Proven phase-shifting capability  Mixed evidence for benefit in elderly  Poorly-regulated formulations 
  24. 24.  Sedative-hypnotics Falls  Hip fracture  Cognitive impairment   Preferred Zolpidem (Ambien)  Eszopiclone (Lunesta)  Ramelteon (Rozerem)  Hanks et al. (2010).
  25. 25. Great source of oracles to human kind, when stealing soft, and whispering to the mind, through sleep’s sweet silence, and the gloom of night, thy power awakes the intellectual sight; to silent souls the will of heaven relates, and silently reveals their future fates.
  26. 26. Sleep and it’s disturbance are physiologically complex  Begin with a thorough history and sleep hygiene counseling  Pharmaceuticals are only one treatment, even in palliative care 
  27. 27.   Bastien CH et al. (2003). Sleep EEG power spectra, insomnia and chronic use of benzodiazepines. Sleep. 26(3): 313-317. Carol E (2011). "How Much Sleep Do We Really Need?". National Sleep Foundation. Undated. http://www.sleepfoundation.org/article/how-sleepworks/how-much-sleep-do-we-really-need. Retrieved 2012-09-18.        Davidson JR, MacLean AW, Brundage MD & K Schulze (2002). Sleep disturbance in cancer patients. Soc Sci Med. 54: 1309-1321. EPEC-O (2007). Module 1: Comprehensive Assessment. Hanks G et al., Ed. (2010). Oxford Textbook of Palliative Medicine: Sleep in palliative care. New York, NY. 1059-1083. Hugel H, et al. (2004). The prevalance, key causes and management of insomnia in palliative care patients. J Pall Symp Mgmt. 27(4): 316-321. Maslow A (1954). Motivation and Personality. New York: Harper. Pp 236. Miller M & R Arnold (2011). Fast Facts and Conceps #101, 104, 105. Insomnia: Patient assessment, Non-parmacologic treatments & Phamacological Therapies. EPERC. Sanna P & E Brurera (2002). Insomnia and sleep disturbances. Eur J Pall Care. 9(1): 8-12.

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