Powerpoint on causes of insomnia and its treatment

1. SLEEP DISORDERS:
INSOMNIA
DR. MARGI DESAI M.D.
CONSULTANT CLINICAL NEUROPHYSIOLOGIST
JASLOK HOSPITAL & RESEARCH CENTRE, MUMBAI

2. Insomnia and the Bard of Avon
 O sleep! O gentle sleep!
Nature’s soft nurse, how have I
frightened thee,
That thou no more wilt weigh
my eyelids down and steep my
senses in forgetfulness?
Why rather, sleep, liest thou in
smoky cribs, upon uneasy
pallets stretching thee,
And hush’d with buzzing night-
flies to thy slumber,
Than in the perfum’d chambers
of the great,under the canopies
of costly state,
And lull’d with sound of
sweetest melody?
"2 Henry IV"

3. We are sleeping less than we
used to a century ago
 The average global citizen now sleeps
about 7 hours a night…. 90 minutes less
than people did a century ago…
….Newsweek July 2002
 This means a huge `sleep debt’
 Affects performance at work and home
 Higher no. of accidents in the workplace
and on the roads

4. What do we know about sleep?
 The sleeping brain goes through
repeated cycles
Non REM sleep state REM sleep state

5. Non REM sleep state
 Divided into light sleep and deep sleep
 LIGHT SLEEP: The brain is relatively
idle but the body may still
move….occasional sudden hand or leg
jerks may occur
 DEEP SLEEP: The body may become
harder to awaken.. Brain wave activity
slows down

6. REM sleep state
 The body is essentially paralyzed but the brain
is active
 VIVID DREAMS occur in REM sleep
 The first dream episode is brief and may last
only 10 minutes
 The second REM sleep episode will be longer
 Typical sleep: 4 episodes of NonREM and
REM sleep

8. NORMALLY….
 We pass through
nonREM and REM
states several times
in the night in a
standard
pattern….`sleep
architecture’
REM REM

9. What happens when things go
wrong?
 Non REM sleep disorders
 Periodic limb movements in sleep

11. Non REM sleep disorder
 Night terrors:
 Affects mostly young children
 Frequently Wake up screaming unable
to explain why; often hand or leg
movements in bed when they are
terrified

12. REM sleep behavior disorder
 A 77-year old minister had been behaving violently in his
sleep for 20 years, sometimes even injuring his wife.
 A 60-year old surgeon would jump out of bed during
nightmares of being attacked by "criminals, terrorists and
monsters."
 A 62-year old industrial plant manager who was a war
veteran dreamt of being attacked by enemy soldiers and
fights back in his sleep, sometimes injuring himself.
 A 57-year old retired school principal was inadvertently
punching and kicking his wife for two years during vivid
nightmares of protecting himself and family from
aggressive people and snakes.

13. REM behaviour disorder
 Patients cross the boundaries between REM
and non-REM sleep
 They are dreaming but not paralyzed in REM
sleep
 Show bizarre behaviour….enact dreams in
sleep
 Often dreams are violent with the dreamer
fighting `imagined’ attacker
 Can be violent with the people they sleep with

14. How is sleep regulated?
 The sleep regulating center in the
brain… group of nerve cells near the
hypothalamus
 Control sleep by sending chemical
neurotransmitters (messengers) to the
hypothalamus , which is the brain of the
brain.
 THIS IS THE `SLEEP SWITCH’ IN
THE BRAIN

15. Sleep mechanisms are not so simple!
 The sleep switch does not work alone!!!
 It is indirectly controlled by our body’s
biological clock
 The biological clock is affected by
various factors….
 Stress, emotions, irregular work hours,
excessive alcohol, caffeine, smoking
inadequate exercise

16. WHAT CAUSES INSOMNIA?
 We now know of the sleep debt, the sleep
switch and body’s biological clock
 All three interact with emotions, stress
and cognition to influence your ability to
go to sleep

17. INSOMNIA
 Temporary phenomenon: Mumbai bomb
blasts and September 11 attacks
 When it continues for months
SEEK HELP

18. Our approach to Sleep disorders
and Insomnia
 Sleep History:
1. How long does it take to fall asleep?
2. Difficulty maintaining sleep and waking up
too early
3. Is sleep nonrefreshing?
4. Do you snore?
5. Do you have excessive sleepiness in the
daytime?
6. Do you have discomfort in your legs when
you are lying in bed trying to sleep?

19. Sleep studies in a sleep lab
 Digital machine at
Jaslok hospital
 Polysomnography
 Charts brain
activity,respiration,
heart beat and
oxygenation of blood
during sleep

20. Polysomnography
 EEG electrodes are attached to
the scalp……………………
 Electro-oculogram electrodes are
attached around the eyes and
submental under the chin for
documenting REM sleep
 Tubes under the nose check
airflow
 Bands around upper chest,
abdomen measure effort to
breathe
 Sensor around fingertips
measure oxygenation of blood

21. Information from Sleep studies
 Whether sleep cycles are normal
 Any Non REM sleep disorder
 Periodic limb movements in sleep
 Sleep apnea
 Sometimes REM sleep disorder precedes
Parkinsonian disease by 5 to 6 years
Treatable sleep disorders

22. Insomnia…. Common causes
 Depression
 Stress
 Emotional factors
 Excessive caffeine, smoking
 Too much light and noise in the bedroom
 Medical conditions that cause pain..arthritis
 Insomnia associated with sleep disorders- 40%
 Change in sleep pattern with age

23. Treatment of insomnia
 The key lies in changing your wake-sleep habits
1. Wake up at the same time every day
2. For 2 weeks, try to cut the time in bed by 1
hour and see if it helps
3. Don’t toss and turn. If you can’t get to sleep
after 20 min, get up and do something else
4. Take a relaxing bath before bed time.

24. Treatment of insomnia
5. Discontinue caffeine 4 to 6 hours before
bedtime
6. Exercise before dinner, not after
7. Avoid heavy meals, alcohol and
nicotine(smoking) just before bedtime
8. Minimize TV noise, light…move the alarm
clock away if it is distracting
9. Do not nap for more than 30 minutes in the
afternoon

25. Treatment of insomnia:
Medications
 Antidepressants
 Sleeping pills for short periods until
there’s less stress in your life
 Melatonin : helps about 10% people for
short periods,when insomnia is caused
by jet lag or working in day- night shifts

26. Treatment of insomnia
Long term
 Behavioural interventions: change bad
sleep habits
 Sleep restriction… start with 5 hours
sleep and increase by 30 minutes every
week until you sleep 8 hours in the day
 Learn to cope with stress….regular
exercise, healthy diet, breathing
exercises, identify ways to relax