This document discusses a comprehensive, interdisciplinary approach to treating sleep disorders. It argues that insomnia and sleep-related breathing disorders (SRBD) like sleep apnea often co-occur and should be treated concurrently. Treating both disorders can improve outcomes more than treating either one alone. The document provides an overview of insomnia and SRBD, including definitions, epidemiology, consequences, evaluation methods, and treatment options like cognitive behavioral therapy and positive airway pressure. It emphasizes that multi-system sleep problems require evaluating and addressing all relevant factors through a multi-pronged treatment approach.
Poor sleep is a hallmark symptom of ME/CFS and FM. Not getting a good night’s sleep can worsen symptoms. Dive into the mechanics of good sleep with Dr. Bateman and learn why sleep disturbances occur and how to implement strategies that improve them.
Sleep and sensory balances (overload and deprivation.pptxShehlaBano3
leep deprivation is a general term to describe a state caused by inadequate quantity or quality of sleep, including voluntary or involuntary sleeplessness and circadian rhythm sleep disorders. Sleep is as important to the human body as food and water, but many of us don't get enough sleep.
Lecture given to the West of Scotland Pain Group on Wednesday 24th November 2010 in the Ebenezer Duncan Centre, Victoria Infirmary, Glasgow by Dr Paul Reading, Consultant Neurologist.
In this talk, Dr Reading describes the importance of good quality sleep and how pain and sleep interact.
www.wspg.org.uk
Pulmonologist, Jenny Kim, MD, FCCP of our Sleep Disorders Center partnered with the Livingston Health Department to present, Can’t Sleep? The ABCs of Your ZZZs to the community. During the session, Dr. Kim discussed tips for improving sleep and treatment options for common sleep disorders.
Introduction
The sleep – wakefulness cycle is genetically determined rather than learned and is established sometime after birth.Sleep is a naturally recurring state of mind and body, characterized by altered consciousness, relatively inhibited sensory activity and [inhibition of nearly all voluntary muscle during REM sleep] reduced interactions with surroundings.
Sleep can be regarded as a physiological reversible reduction of conscious awareness. Nearly one third of human life is spent in sleep. Disorders of sleep can affect activities of daily living (ADL) of an individual.
Definition
It is an easily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day.
The EEG recordings show typical features of sleep which is broadly divided into two broadly different phases:
1. D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep.
2. S-sleep (synchronised sleep), also called as NREM-sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person fifi rst passes through these stages of NREM-sleep.
Stages of sleep
The EEG recording during the waking state shows alpha waves of 8-12 cycles/sec. frequency. The onset of sleep is characterised by a disappearance of the alpha-activity.
Stage 1, NREM-sleep is the first and the ligh test stage of sleep characterised by an absence of alphawaves, and low voltage, predominantly theta activity.
Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterised by two typical EEG changes:
i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0
seconds, with a charac teristic waxing and waning amplitude.
ii. K-complexes: High voltage spikes present intermittently.
Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0 cycles/sec.
Stage 4, NREM-sleep shows predominant δ-activity in EEG. NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The EEG is characterised by a return of α-waves (α-wave sleep); other changes are similar to stage 1 NREM-sleep. One of the most characteristic features of the REM-sleep is presence of REM or rapid (conjugate) eye move ments. The other features include generalised mus cular atony, penile erection, autonomic hyperactivity (increase in pulse rate, respiratory rate and blood pressure), and movements of small muscle groups, occurring intermittently. Although it is a light stage of sleep, arousal is diffificult. These stages occur regularly throughout the whole duration of sleep. The first REM period occurs typically after 90 minutes of the onset of sleep, although it can start as early as 7 minutes after going off to sleep, e.g. in narcolepsy, in major depression, and after sleep deprivation.
It focuses on sleep medicine - sleep disorders, sleep stages, DSM classification, types, classifications, and pharmacological and non pharmacological management.
Poor sleep is a hallmark symptom of ME/CFS and FM. Not getting a good night’s sleep can worsen symptoms. Dive into the mechanics of good sleep with Dr. Bateman and learn why sleep disturbances occur and how to implement strategies that improve them.
Sleep and sensory balances (overload and deprivation.pptxShehlaBano3
leep deprivation is a general term to describe a state caused by inadequate quantity or quality of sleep, including voluntary or involuntary sleeplessness and circadian rhythm sleep disorders. Sleep is as important to the human body as food and water, but many of us don't get enough sleep.
Lecture given to the West of Scotland Pain Group on Wednesday 24th November 2010 in the Ebenezer Duncan Centre, Victoria Infirmary, Glasgow by Dr Paul Reading, Consultant Neurologist.
In this talk, Dr Reading describes the importance of good quality sleep and how pain and sleep interact.
www.wspg.org.uk
Pulmonologist, Jenny Kim, MD, FCCP of our Sleep Disorders Center partnered with the Livingston Health Department to present, Can’t Sleep? The ABCs of Your ZZZs to the community. During the session, Dr. Kim discussed tips for improving sleep and treatment options for common sleep disorders.
Introduction
The sleep – wakefulness cycle is genetically determined rather than learned and is established sometime after birth.Sleep is a naturally recurring state of mind and body, characterized by altered consciousness, relatively inhibited sensory activity and [inhibition of nearly all voluntary muscle during REM sleep] reduced interactions with surroundings.
Sleep can be regarded as a physiological reversible reduction of conscious awareness. Nearly one third of human life is spent in sleep. Disorders of sleep can affect activities of daily living (ADL) of an individual.
Definition
It is an easily reversible state of relative unresponsiveness and serenity which occurs more or less regularly and repetitively each day.
The EEG recordings show typical features of sleep which is broadly divided into two broadly different phases:
1. D-sleep (desynchronised or dreaming sleep), also called as REM- sleep (rapid eye movement sleep),active sleep, or paradoxical sleep.
2. S-sleep (synchronised sleep), also called as NREM-sleep (non-REM sleep), quiet sleep, or orthodox sleep. S-sleep or NREM-sleep is further divided into four stages, ranging from stages 1 to 4. As the person falls asleep, the person fifi rst passes through these stages of NREM-sleep.
Stages of sleep
The EEG recording during the waking state shows alpha waves of 8-12 cycles/sec. frequency. The onset of sleep is characterised by a disappearance of the alpha-activity.
Stage 1, NREM-sleep is the first and the ligh test stage of sleep characterised by an absence of alphawaves, and low voltage, predominantly theta activity.
Stage 2, NREM-sleep follows the stage 1 within a few minutes and is characterised by two typical EEG changes:
i. Sleep spindles: Regular spindle shaped waves of 13-15 cycles/sec. frequency, lasting 0.5-2.0
seconds, with a charac teristic waxing and waning amplitude.
ii. K-complexes: High voltage spikes present intermittently.
Stage 3, NREM-sleep shows appearance of high voltage, 75 μV, δ-waves of 0.5-3.0 cycles/sec.
Stage 4, NREM-sleep shows predominant δ-activity in EEG. NREM-sleep is followed by REM-sleep, which is a light phase of sleep. The EEG is characterised by a return of α-waves (α-wave sleep); other changes are similar to stage 1 NREM-sleep. One of the most characteristic features of the REM-sleep is presence of REM or rapid (conjugate) eye move ments. The other features include generalised mus cular atony, penile erection, autonomic hyperactivity (increase in pulse rate, respiratory rate and blood pressure), and movements of small muscle groups, occurring intermittently. Although it is a light stage of sleep, arousal is diffificult. These stages occur regularly throughout the whole duration of sleep. The first REM period occurs typically after 90 minutes of the onset of sleep, although it can start as early as 7 minutes after going off to sleep, e.g. in narcolepsy, in major depression, and after sleep deprivation.
It focuses on sleep medicine - sleep disorders, sleep stages, DSM classification, types, classifications, and pharmacological and non pharmacological management.
Thyroid, Adrenals, and Sex Steroids - A Balancing ActLouis Cady, MD
This was the second presentation gibven on MZarch 29, 2019 at the Manlove Psychiagtric Group and Brain Injury Institute spring conference in Rapid City, SD.
In this presentation, Dr. Cady carefully goes over the necessity of integrating and overview and awareness of hormones and their levels in the elucidation of what truly is going on with the patient.
This was an overview lecture only. Dr. Cady will be presenting a 16 hour CME program in Austin Texas on June 22 and 23 for the National Procedures Institute, and will explore all aspects of all relevant hormones and what can be done to manage and optimize them.
The ABCs of Your ZZZs - Alison S. Kole, MD, MPH, FCCP, Pulmonologist Kerry K...Summit Health
Learn from our Sleep Disorder Center experts about the basics of good sleep and the physical impact of poor sleep. We will also discuss tips for improving sleep and the treatment options for common sleep disorders, such as sleep apnea, restless legs syndrome, and insomnia, among others.
Presented by The Royal's Dr. Elliott Lee at our annual Women in Mind Conference.
Dr. Elliott Lee is an Assistant Professor and Sleep
Specialist at The Royal, where he works in both the
Sleep Disorders Clinic and the Anxiety Disorders Clinic.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
Thyroid, Adrenals, and Sex Steroids - A Balancing ActLouis Cady, MD
This was the second presentation gibven on MZarch 29, 2019 at the Manlove Psychiagtric Group and Brain Injury Institute spring conference in Rapid City, SD.
In this presentation, Dr. Cady carefully goes over the necessity of integrating and overview and awareness of hormones and their levels in the elucidation of what truly is going on with the patient.
This was an overview lecture only. Dr. Cady will be presenting a 16 hour CME program in Austin Texas on June 22 and 23 for the National Procedures Institute, and will explore all aspects of all relevant hormones and what can be done to manage and optimize them.
The ABCs of Your ZZZs - Alison S. Kole, MD, MPH, FCCP, Pulmonologist Kerry K...Summit Health
Learn from our Sleep Disorder Center experts about the basics of good sleep and the physical impact of poor sleep. We will also discuss tips for improving sleep and the treatment options for common sleep disorders, such as sleep apnea, restless legs syndrome, and insomnia, among others.
Presented by The Royal's Dr. Elliott Lee at our annual Women in Mind Conference.
Dr. Elliott Lee is an Assistant Professor and Sleep
Specialist at The Royal, where he works in both the
Sleep Disorders Clinic and the Anxiety Disorders Clinic.
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
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R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
1. intervention and treatment:
a call for a comprehensive,
interdisciplinary approach to treating
sleep disorders
emerson m. wickwire, phd, abpp, cbsm
co-director, center for sleep disorders
pulmonary disease and critical care associates
3. what you’ll learn…
I. almost everything you’ll ever need to know
about the two most common sleep disorders
II. a whole is greater than the sum of its parts
III. multi-system problems require multi-prong
treatment approaches
4. essential facts: insomnia
I. definition: what disorder looks like
II. consequences: what disorder does
III. clinical aspects: how to evaluate and treat
10. • fatigue/malaise
• attention, concentration, or memory impairment
• social/vocational dysfunction or poor school
performance
• mood disturbance/irritability
• daytime sleepiness
• motivation/energy/initiative reduction
• proneness for errors/accident at work or while driving
• tension headaches/GI symptoms
• concerns or worries about sleep
daytime consequences
11. epidemiology of the
most common sleep disorder
• 30-40% transient
• 10-15% chronic
• clinical practice: >50%
12. Foley et al, 2004
80
Number of Medical Conditions
0
10
20
30
40
50
60
70
Percent
of
Respondents
Reporting
any
Insomnia
0 1 2 or 3 4
insomnia increases with
medical problems
n=1506
age 55-84
13. Taylor et al, 2007
p values are for Odds Ratios adjusted for depression, anxiety, and sleep disorder symptoms.
Heart
Disease
Cancer HTN Neuro Pulm Urinary Diabetes Chronic
Pain
GI Any
medical
problem
%
p<.05
p<.05
p<.01
p<.01
p<.001
p<.001
p<.001
p<.001
medical problems in insomnia
n=772
age = 20 to 98
20. attentional systems are active
ARAS: activates/deactivates cortex; alertness
Hypothalamus: sleep & wake
Thalamus: sensory processing; activates/deactivates cortex
Mesial Temporal Cortex: memory; novelty detection
Cingulate: excitatory role in emotions & motivated behavior
Insular cortex: perceptions of disgust & pain
21. attentional systems are active
ARAS: activates/deactivates cortex; alertness
Hypothalamus: sleep & wake
Thalamus: sensory processing;activates/deactivates cortex
Mesial Temporal Cortex: memory; novelty detection
Cingulate: excitatory role in emotions
Insular cortex: perceptions of disgust & pain
22. • Harvey model
• sleep beliefs & worry
• insomnophobia
• battlemind
• sufferers: cognitive not somatic arousal
cognitive factors in insomnia
Harvey, 2002; Morin et al., 2007; Lichstein & Rosenthal, 1980
26. Compensatory
Behaviors
Spend more time in bed
“Try harder” to sleep
Sleep in on weekends
Take naps
Sleep outside bedroom
Overuse caffeine/stimulants
Various OTC sleep aids
Obsess/ overfocus on sleep
Insomnia
No Insomnia
Environmental
Stressor
Medical illness
Loss of loved one
Job transition
Cumulative effect
Predisposing
Risk Factors
Spielman, 1987
27. Insomnia
No Insomnia
“Compensatory”
Behaviors
Spend more time in bed
“Try harder” to sleep
Go to bed earlier
Sleep in on weekends
Take naps
Sleep outside bedroom
Overuse caffeine/stimulants
Decrease daytime activity
Various OTC sleep aids
Obsess/ overfocus on sleep
Predisposing
Risk Factors
Environmental
Stressor
Spielman, 1987
38. ask!
(doctors don’t ask & patients don’t tell)
• frequency (>3x/ week)
• intensity (>30m sol/waso, quality)
• duration (>1 mo)
• daytime sequelae
• do you snore?
39. 1. Please rate the SEVERITY of your sleep problem(s).
None Mild Moderate Severe Very Severe
Difficulty falling asleep:
Difficulty staying asleep:
Problem waking up too early:
2. How SATISFIED/dissatisfied are you with your current sleep pattern?
0 1 2 3 4
Very Unsatisfied Very Satisfied
3. To what extent do you consider your sleep problem to INTERFERE with your daily functioning
(daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.)?
0 1 2 3 4
Not at all Interfere Interfere Very Much
4. How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the
quality of your life?
0 1 2 3 4
Not at all Noticeable Very much Noticeable
5. How WORRIED/distressed are you about your current sleep problem?
0 1 2 3 4
Not at all Worried Very much Worried
clinical screening:
insomnia severity index
Bastien et al., 2001
<7 none
>7 subthreshold
>14 mod severe
>21 severe
40. use CBT-I:
• recommended 1st line treatment
• primary & comorbid insomnias
• adults of all ages & hypnotic users*
combined therapies:
• no benefit over cbt-i alone
• cbt-i aids hypnotic taper
42. essential facts: srbd
I. definition: what disorder looks like
II. consequences: what disorder does
III. clinical aspects: how to evaluate and treat
54. • 36 RCTs, N=1718
vs control
↓objective & subjective sleepiness
quality of life
neurocognitive function
vs oral appliance (OA)
↓ AHI
sleep efficiency
minimum O2
Giles, Lasserson, Smith, White, Wright & Cates, 2006
pap works
55. LESS BAD
eliminates OSA (95+%)
↓ sleepiness
↓ hospitalizations
↓ car accidents
↓ HTN (esp nocturnal)
↓ pulmonary artery pressures
↓ GERD
MORE GOOD
↑ qol
↑ cognition
↑ glucose control
↑ gas exchange
↑ heart function in heart
failure pts
↓ reduces cardiac
arrhythmias during sleep
56. srbd in ptsd
• evidence of increased srbd in ptsd
• especially uars
• hypothesis: massive sympathetic burst
alters pharyngeal muscle tone
• ↑ increased respiratory effort = EEG
• sleep: 37% of variance in symptoms
57. a whole is greater than the sum of
its parts: insomnia, srbd, or both?
I. secondary insomnia: a myth dismissed
II. frequent co-occurrence
III. hypothesized mechanisms
58. a myth…
NIH 1983 (that was then)
• insomnia is a symptom (only)
• treat the primary disorder
NIH 2005 (this is now)
• insomnia is a disorder, typically
coexisting with other disorders
• treat both conditions
• improvements insomnia can improve
other outcomes
59. a myth… dismissed
NIH 1983 (that was then)
• insomnia is a symptom (only)
• treat the primary disorder
NIH 2005 (this is now)
• insomnia is a disorder, typically
coexisting with other disorders
• treat both conditions
• improvements in insomnia can improve
other outcomes
60. • impacts quality of life
• worsens clinical outcomes
• frequently does not remit with
treatment of “primary” condition
comorbid insomnia is a disorder
61. not just a symptom
• consistency of complaints
• independent course of disorder
• responds to different treatment
than comorbid disorder
• responds to same type of treatment
across different disorders
Harvey, 2001; Lichstein et al., 2004
64. insomnia is there (and not just a symptom)
n=105
70% men
M age=53.9±14
insomnia criteria:
ISI>15
duration>6 months
PSG SOL or WASO>30m
w/daytime impairment
Smith et al., 2004
39% moderate-severe insomnia
(insomnia unrelated to SRBD)
65. (n=100, 43 men, M age=49±14)
Hagen, Patel, & McCall, 2009; Nguyen et al., 2010; Lichstein et al., 2010
half or more of patients…
61% moderate-severe insomnia (ISI)
(n=166, 138 men, M age=54.8±11.8)
49.3% moderate-severe insomnia (ISI)
84% of OSA patients also meet DSM-IV/
ICSD-2 criteria for chronic insomnia
80. multi-system problems require
multi-prong treatment approaches
I. treatment interactions & combined therapies
II. case study & clinical recommendations
III. a comprehensive practice model
81. insomnia medications can
worsen breathing
• older benzodiazepines bad
1. negatively impact breathing
2. raise arousal threshold
• newer hypnotics minimal impact AHI
• off-label meds may pose risk
82. untreated insomnia can
compromise OSA treatment
only insomnia predicted negative
outcome in oral appliance for osa
Machado et al., 2006
N=188
84. cbt-i #1 surgery #1
surgery #2 cbt-I #2
Guilleminault et al., 2009
combined treatments provide
additive benefit
85. treating both disorders improves
outcomes
Krakow et al., 2004, 2006
• in patients with symptoms of insomnia
and srbd, nasal strips improved sleep
• treatment of srbd improved outcomes
following cbt-i (8/17 remit 15/17 remit)
86. • requires additional evaluation
• srbd may be common in patients with
treatment-resistant insomnia
refractory insomnia
Guilleminault et al., 2002; Krakow et al., 2006, 2010
87. screen
– insomnia and srbd
– poor subjective sleep quality
– nonrestorative sleep/ daytime fatigue
antennae up
– older adults
– postmenopausal women
– trauma survivors
treat both conditions, concurrently if possible
clinical recommendations
88. insomnia
– be very careful w/ benzodiazepines and off-
label medications
– sleep hygiene not effective in isolation, not
effective in handout
– refer to insomnia specialist if available
srbd
– appreciate frequent co-morbidity of insomnia
– intervene early for cpap adherence
– refer to sleep specialist: snoring, obesity, htn,
dm, refractory insomnia
clinical cautions
89. • self-referred for insomnia study
• ineligible per phone screen (osa)
• discussed treatment options
• initial evaluation scheduled
Wickwire, Schumacher, Baran, Richert, & Roffwarg, 2007
the real-world: case study
90. • 61 y.o. Caucasian male
• lifelong Mississippi resident
• normal weight
• college degree
• US Army veteran
• PT VA employee w/shift work
• “happily” married 31 years
• 2 adult daughters & 2 grandchildren
patient characteristics
91. • recently diagnosed w/ OSA (AHI=31)
• GERD
• chronic knee pain
• denies past psychiatric treatment
• denies history substance abuse
• current daily meds: high blood pressure,
GERD, baby aspirin, otc sleep aid prn
medical history
92. • father had trouble falling asleep
– blamed sciatic nerve
– slept on sofa
• brother suffers PTSD
– experiences sleep problems
– takes sleep medication
• wife snores and suffers EDS
relevant family history
93. ↑ SOL
– I can’t fall asleep at night (25-year Hx)
– I don’t like to take pills (drug stupor)
OSA
– I never dreamed I had apnea… I only started
snoring two years ago… they made a mistake
– apnea is obstruction… obese people…
– PAP is frustrating, loud, straps too tight, hard
to get adjusted right
what’s on his mind?
94. • can’t concentrate or read
• can’t stay alert deer hunting
• tired & eyes irritated
• wants to nod off during work
• irritable*
assessing daytime sleepiness
95. rumination:
• grandson’s health, nephew’s safety, involved with family (softball)
• thinking about “tomorrow”
• previous day: “what someone said, what family goes through”
physical discomfort:
• pressure on feet, sensitive to physical, blankets, spouse
bedroom environment:
• tempur Pedic bed
• TV in bedroom (wife falls asleep with TV)
• wife snores; he hears her “rustling” around
assessing sleep onset insomnia
96. 307.42 Primary insomnia
327.23 Obstructive sleep apnea
Plan:
1. CBT for PAP acceptance and adherence
what, how, why
2. CBT for insomnia
diagnoses & treatment plan
102. Last meal or snack of day
END DAY ACTIVITIES- Leave work
Change pajamas/ T-shirt
Read 30- minutes (paper,
magazine, book)
Relaxation CD
Breathing exercises
Bathroom routine
EARPLUGS
Lights out/ Bed
pre-sleep routine
103. • self-report: 90-120 m/day, falling asleep
with mask on, waking and removing it
• CPAP 30m-300m (mean = 108.5m/
night over 2 week pd)
improved pap adherence
106. • definitely not as tired
• much less nodding
• less drowsy in deer stand
• no sleep aid in past 3 months
• no TV in bedroom, no late eating
• following pre-sleep routine & using
deep breathing exercises
qualitative improvement
110. MD
MOD-10
in-lab psg
at home test
MTF/PCP
or specialist
MD
PAP
oral appliance
medication
PhD
insomnia
actigraphy
PTSD/mTBI
PhD
CBT
PAP success
IRT
Follow-up Care
pap adherence data
HIPAA secure website
AHLTA friendly data
Treatment
Evaluation
prompt
scheduling
coordination
w/ referring
providers
111. in conclusion: insomnia & srbd
I. common, bad, & highly treatable
II. frequently co-occur
additive negative effects
III. combined treatments are best
demand comprehensive care
