September 29 & 30, 2016 Faculty/Presenter Disclosure Faculty: - - PowerPoint PPT Presentation

▶
september 29 amp 30 2016 faculty presenter disclosure
SMART_READER_LITE
LIVE PREVIEW

September 29 & 30, 2016 Faculty/Presenter Disclosure Faculty: - - PowerPoint PPT Presentation

Aug 24, 2023 11 likes •1.28k views

September 29 & 30, 2016 Faculty/Presenter Disclosure Faculty: Gail Myhr Relationships with commercial interests: Employee of Rgie de lassurance du Qubec Staff member of McGill University Health Centre Disclosure of

slide-1
SLIDE 1

September 29 & 30, 2016

slide-2
SLIDE 2

Faculty/Presenter Disclosure

  • Faculty: Gail Myhr
  • Relationships with commercial interests:
  • Employee of Régie de l’assurance du Québec
  • Staff member of McGill University Health Centre
slide-3
SLIDE 3

Disclosure of Commercial Support

slide-4
SLIDE 4

Key Learning Objectives

slide-5
SLIDE 5
slide-6
SLIDE 6
slide-7
SLIDE 7
slide-8
SLIDE 8
slide-9
SLIDE 9

CONSENSUS SLEEP DIARY-M (2011) Sun Mon Tues Wed Thurs Fri Sat What time did you get into bed? What time did you try to go to sleep? (lights out) How long did it take you to fall asleep? How many times did you awaken, not counting final one? In total, how long did these awakenings last? What was your final awakening? After your final awakening, how long did you stay in bed? What time did you get out of bed for the day? How would you rate the quality of your sleep? How refreshed did you feel when you woke up? How many times did you nap or doze? In total, how long did you nap or doze? # caffeinated drinks? Time of last one? # alcoholic drinks?Time of last one? Medications, dose & time taken. (OTC & prescription)

slide-10
SLIDE 10
slide-11
SLIDE 11

Date Day TIB (hrs) SOL (hrs) WASO (hrs) Bed Linger (hrs) TWT (hrs) TST (hrs) SE AVE

slide-12
SLIDE 12

Date Day TIB (hrs) SOL (hrs) WASO (hrs) Bed Linger (hrs) TWT (hrs) TST (hrs) SE 11/07/2016Mon

10.0 2.0 2.0 0.5 4.5 5.5 55%

12/07/2016Tues

12.0 1.0 3.0 1.0 5.0 7.0 58%

13/07/2016Wed

11.0 0.5 2.0 1.0 3.5 7.5 68%

14/07/2016Thurs

9.0 1.0 2.0 1.0 4.0 5.0 56%

15/07/2016Fri

12.0 2.0 1.0 2.0 5.0 7.0 58%

16/07/2016Sat

10.5 2.0 1.0 2.0 5.0 5.5 52%

17/07/2016Sun

10.5 1.0 2.0 1.0 4.0 6.5 62%

AVERAGE

10.7 1.4 1.9 1.2 4.4 6.3 59%

slide-13
SLIDE 13
slide-14
SLIDE 14

Age Group Recommended May be appropriate Not recommended 14-17 hrs 8-10 hrs 7 hrs 11 hrs < 7 hrs > 11 hrs 18- 25 yrs 7-9 hrs 6 hrs 11 hrs < 6 hrs > 11 hrs 26-64 yrs 7-9 hrs 6 hrs 10 hrs < 6 hrs > 10 hrs >65 7-8 hrs 5-6 hrs 9 hrs < 5 hrs > 9 hrs

National Sleep Foundation, 2015

slide-15
SLIDE 15
slide-16
SLIDE 16
slide-17
SLIDE 17
slide-18
SLIDE 18
slide-19
SLIDE 19
slide-20
SLIDE 20
slide-21
SLIDE 21
slide-22
SLIDE 22

CONSENSUS SLEEP DIARY (2011) Patient Mrs M Sun Mon Tues Wed Thurs Fri Sat What time did you get into bed? 21:00h What time did you try to go to sleep? (lights out) 22:00h How long did it take you to fall asleep? 2 h How many times did you awaken, not counting final one? 1 In total, how long did these awakenings last? 2 hr What was your final awakening? 7:30 After your final awakening, how long did you stay in bed? 0.5 h What time did you get out of bed for the day? 8:00h How would you rate the quality of your sleep? poor How refreshed did you feel when you woke up? Not at all How many times did you nap or doze? 1 In total, how long did you nap or doze? 1 hr # caffeinated drinks? Time of last one? # alcoholic drinks?Time of last one? 2/1800h Medications, dose & time taken. (OTC & prescription) 5:00h,Th

TIB= ? SOL = ? WASO = ? TWT = ? TST = ? SE = ?

slide-23
SLIDE 23
slide-24
SLIDE 24

Date Day TIB (hrs) SOL (hrs) WASO (hrs) Bed Linger (hrs) TWT (hrs) TST (hrs) SE 11/07/2016Mon

10 2 2 0.5 4.5 5.5 55%

AVERAGE

slide-25
SLIDE 25

Date Day TIB (hrs) SOL (hrs) WASO (hrs) Bed Linger (hrs) TWT (hrs) TST (hrs) SE 11/07/2016Mon

10.0 2.0 2.0 0.5 4.5 5.5 55%

12/07/2016Tues

12.0 1.0 3.0 1.0 5.0 7.0 58%

13/07/2016Wed

11.0 0.5 2.0 1.0 3.5 7.5 68%

14/07/2016Thurs

9.0 1.0 2.0 1.0 4.0 5.0 56%

15/07/2016Fri

12.0 2.0 1.0 2.0 5.0 7.0 58%

16/07/2016Sat

10.5 2.0 1.0 2.0 5.0 5.5 52%

17/07/2016Sun

10.5 1.0 2.0 1.0 4.0 6.5 62%

AVERAGE

10.7 1.4 1.9 1.2 4.4 6.3 59%

slide-26
SLIDE 26
slide-27
SLIDE 27
slide-28
SLIDE 28
slide-29
SLIDE 29
slide-30
SLIDE 30

*incr risk falls in insomnia as well (Widera 13)

slide-31
SLIDE 31

?

slide-32
SLIDE 32

Circadian rhythm sleep-wake disorder, delayed sleep phase type

slide-33
SLIDE 33

Circadian rhythm sleep-wake disorder, delayed sleep phase type

  • Proceed with: (Sleep specialist?): Schedule manipulation, use of

light/dark exposure, melatonin

slide-34
SLIDE 34

?

slide-35
SLIDE 35

Circadian rhythm sleep-wake disorder, advanced sleep phase type

slide-36
SLIDE 36

Circadian rhythm sleep-wake disorder, advanced sleep phase type

  • Proceed with: (Sleep specialist?): Schedule manipulation, use of

light/dark exposure, melatonin

slide-37
SLIDE 37

?

slide-38
SLIDE 38

Obstructive sleep apnea

slide-39
SLIDE 39

Obstructive sleep apnea

  • Proceed with: Sleep specialist, Polysomnography: CPAP. CBTi ok if

controlled

slide-40
SLIDE 40

?

slide-41
SLIDE 41

Restless Legs Syndrome

slide-42
SLIDE 42

Restless Legs Syndrome

  • Proceed with: check aggravating factors (ferritin, meds), consider

medications (DA agonists, alpha-2 delta Ca channel ligands, BZD)

slide-43
SLIDE 43
slide-44
SLIDE 44
slide-45
SLIDE 45

Parameter Adults (Cohen’s d) Adults > 55 yo (Cohen’s d) Sleep Latency

  • 0.52
  • 0.51

Sleep Quality

0.89 0.60

Wakefulness after Sleep Onset

  • 0.57
  • 0.73

Sleep Efficiency

1.00 0.38

Total Sleep Time

0.42

  • 0.19

Cohen’s d= (M1-M2)/Pooled SD 0.2 - a 'small' effect size 0.5 - a 'medium' effect 0.8 - large' effect size. *Irwin, 06.

23 RCTs Meta-analysis

slide-46
SLIDE 46
slide-47
SLIDE 47
slide-48
SLIDE 48
slide-49
SLIDE 49

Parameter Pharmacotherapy (Cohen’s d) CBTi (Cohen’s d) Sleep Onset Latency 0.45 1.05† Sleep Quality 1.20 1.44 Wakefulness after Sleep Onset 0.89 1.03 Sleep Efficiency

  • Total Sleep Time

0.84 0.46 † Significant difference *Smith, 02. Meta-analysis

21 studies, prospective, within subject

slide-50
SLIDE 50
slide-51
SLIDE 51
slide-52
SLIDE 52
slide-53
SLIDE 53
slide-54
SLIDE 54
slide-55
SLIDE 55

Awake N1 N2 N3 1 2 3 4 5 6 7 8

Hours in sleep

R E M R E M R E M R E M R E M

slide-56
SLIDE 56
slide-57
SLIDE 57

After Morin, 93

slide-58
SLIDE 58

Drug SOL WASO TST N1 N2 N3 REM SE EDS DEPRESSION SSRI, SNRI, vortiox BZD, zopiclone * trazadone doxepin (3-6 mg)

  • mirtazapine
  • **

bupropion

  • ***
  • lanzapine

caffeine alcohol †

*At high doses ** 80-89 yo, less active *** incr REM latency † decr REM early, then rebound

slide-59
SLIDE 59
slide-60
SLIDE 60
slide-61
SLIDE 61
slide-62
SLIDE 62
slide-63
SLIDE 63
slide-64
SLIDE 64

9 am 3 pm 9 pm AWAKE 3 am 9 am ASLEEP

slide-65
SLIDE 65
slide-66
SLIDE 66

Classical Conditioning (Respondant Conditioning) Operant Conditioning (Instrumental Conditioning)

slide-67
SLIDE 67

Salivation (UCR) Steak (UCS)+ Bell (CS) Salivation (UCR) Steak (UCS) Salivation (CR) Bell (CS)

slide-68
SLIDE 68

Arousal (UCR) Worry (UCS)+ Bed (CS) Arousal (UCR) Worry (UCS) Arousal (CR) Bed (CS)

slide-69
SLIDE 69
slide-70
SLIDE 70

CR: Sleeplessness C: Negative Reinforcement

CS: Bed

C: Punishment C: Positive Reinforcement

slide-71
SLIDE 71

(Classical Conditioning) cause (Operant Conditioning) maintenance Sleepless in bed Reduced Distress Bed + Arousal Sleep in chair

(-) Reinforcement of avoidance. Prevents extinction sleeplessness in bed.

slide-72
SLIDE 72

(Classical Conditioning) cause (Operant Conditioning) maintenance Sleepless in bed Reduced Distress Bed + Arousal Call in sick

(-) Reinforcement of avoidance. Prevents extinction sleeplessness in bed.

slide-73
SLIDE 73
slide-74
SLIDE 74
slide-75
SLIDE 75
slide-76
SLIDE 76

Cognitions Emotions Behaviour Event

slide-77
SLIDE 77

Oh great! Now I’ll never fall asleep! I’ll be dead for my presentation tomorrow! Annoyance, anxiety Check clock ,calculate # hrs left. Decide to skip breakfast. Hear small noise as trying to fall asleep

slide-78
SLIDE 78

Perception of event Altered information processing Automatic thoughts Activated Core beliefs/ assumptions Emotions Behaviour What we think -> How we think -> Underlying Beliefs ->

slide-79
SLIDE 79

Hear small noise as trying to fall asleep

Altered information processing

Oh great! Now I’ll never fall asleep! I’ll be dead for my presentation tomorrow!

I need 8 hrs to function. If I’m tired, it won’t be good. If something is worth doing, it’s worth doing well.

Annoyance, anxiety Check clock ,calculate # hrs left. Decide to skip breakfast.

What we think -> How we think -> Underlying Beliefs ->

slide-80
SLIDE 80
  • Confirmatory bias
  • Black/white thinking
  • Selective abstraction
  • Discounting the +
  • Overgeneralizing
  • Fortune telling
  • Catastrophizing
  • Externalizing bias
  • Jumping to conclusions
  • Labeling
  • Mind reading
  • Shoulds & musts
  • Personalizing
  • Magnification/ minimization
  • Emotional reasoning
slide-81
SLIDE 81
  • Confirmatory bias
  • Black/white thinking
  • Overgeneralizing
  • Fortune telling
  • Catastrophizing
  • Jumping to conclusions
  • Shoulds & musts
  • Magnification/ minimization
  • Misattributions
slide-82
SLIDE 82

Hear small noise as trying to fall asleep

B/W thinking, Fortune telling.

Oh great! Now I’ll never fall asleep! I’ll be dead for my presentation tomorrow!

I need 8 hrs to function. If I’m tired, it won’t be good. If something is worth doing, it’s worth doing well.

Annoyance, anxiety Check clock ,calculate # hrs left. Decide to skip breakfast.

What we think -> How we think -> Underlying Beliefs ->

slide-83
SLIDE 83
slide-84
SLIDE 84
  • If I don’t get to sleep soon, I won’t be able to perform well

tomorrow.

  • I am tired today, because I haven’t slept enough last night.
  • Insomnia reduces daytime functioning.
  • Insomnia is detrimental to my health.
slide-85
SLIDE 85
  • I have lost control of my sleep.
  • Insomnia is destroying my life.
  • I need a sleep aid to make my sleep more predictable.
  • One should be in control of one’s emotions and all aspects of one’s life.
  • I can’t be happy until my sleep is under control.
slide-86
SLIDE 86
  • My insomnia is a result of aging, and there is nothing to do about

it.

  • My insomnia is a result of my pain.
  • Disturbed sleep is a result of aging.
  • Unless my pain is corrected, there is nothing I can do to improve

my sleep.

slide-87
SLIDE 87
  • I need 8 hours of sleep each night.
  • I should fall asleep within minutes like my spouse does.
  • 8 hours of sleep is necessary to feel good and function the next

day.

  • We all sleep alike.
slide-88
SLIDE 88
  • I had little sleep last night, so I have to have a nap.
  • When I have trouble sleeping, I should stay in bed and try harder.
  • You have to make up for the sleep you lose.
  • Lying in bed, even if not sleeping, provides some rest.
  • If I get out of bed, I’ll be too awake to fall back asleep.
slide-89
SLIDE 89
slide-90
SLIDE 90

what if I can’t find parking for my doctor’s appointment . what if I die before my husband?

slide-91
SLIDE 91
slide-92
SLIDE 92
slide-93
SLIDE 93
slide-94
SLIDE 94
slide-95
SLIDE 95
slide-96
SLIDE 96
slide-97
SLIDE 97

After Manber & Carney 15

slide-98
SLIDE 98
  • If you “feel” that sleep not going to happen, or you get frustrated, get out of bed.

Don’t watch the clock.

  • Return to bed only when sleepy.
  • Don’t “Try to sleep”. Forcing sleep is counterproductive. “Falling asleep is effortless.”
slide-99
SLIDE 99
slide-100
SLIDE 100
slide-101
SLIDE 101
slide-102
SLIDE 102
slide-103
SLIDE 103
slide-104
SLIDE 104
slide-105
SLIDE 105
slide-106
SLIDE 106
slide-107
SLIDE 107
  • If you don’t sleep much, what will happen? Make more mistakes
  • If you make a mistake what will happen? Lose job.
  • If you lose your job? End up on the street, etc
  • No wonder you are so worried about your sleep!
slide-108
SLIDE 108

Where did you get the idea that you need 8 hrs of sleep? When did you last have 8 hrs of sleep? Have you been able to function on other days? What allowed you to do that? Have other factors ever made you feel unwell, besides sleep? Can you always tell what factors are responsible for how you feel?

slide-109
SLIDE 109
slide-110
SLIDE 110
slide-111
SLIDE 111

I have to sleep in the spare room to have the best quality of sleep.

Benefits Costs

I fall asleep easier I am not enjoying my nice Queen-size bed I don’t disturb my husband I am missing out on nice bedtime conversations I worry less about my sleep there Less cuddling with my husband. I feel better the next day. My husband doesn’t like this plan.

slide-112
SLIDE 112

Situation Emotions (0-100%) Automatic thoughts (Underline the “hot thought”) Evidence that supports the hot thought Evidence against the hot thought Alternative/ balanced thoughts Rate Emotions now

slide-113
SLIDE 113
slide-114
SLIDE 114
  • If you haven’t solved the problem during the day when you were at your best,

you won’t solve it now!

slide-115
SLIDE 115

if I don’t worry, I won’t be prepared for the worst I’ve always been a worrier, and can’t change now

  • Increase tolerance for uncertainty and ambiguity
  • continue to do new things
  • proceed without excessive amounts of information
  • delegate to others
  • Specialized CBT exposure techniques for hypothetical worries
  • exposure to worst case scenarios to face underlying fear (expert interventions)
slide-116
SLIDE 116

http://www.helpguide.org/articles/anxiety/how-to-stop-worrying.htm http://www.cci.health.wa.gov.au/resources/infopax.cfm?Info_ID=46

slide-117
SLIDE 117
slide-118
SLIDE 118
slide-119
SLIDE 119

CONSENSUS SLEEP DIARY (2011) Patient Mrs M Sun Mon Tues Wed Thurs Fri Sat What time did you get into bed? 21:00h What time did you try to go to sleep? (lights out) 22:00h How long did it take you to fall asleep?

2 h

How many times did you awaken, not counting final one? 1 In total, how long did these awakenings last?

2 hr

What was your final awakening? 7:30 After your final awakening, how long did you stay in bed?

0.5 h

What time did you get out of bed for the day? 8:00h How would you rate the quality of your sleep? poor How refreshed did you feel when you woke up? Not at all How many times did you nap or doze? 1 In total, how long did you nap or doze? 1 hr # caffeinated drinks? Time of last one? # alcoholic drinks?Time of last one? 2/1800h Medications, dose & time taken. (OTC & prescription)

TIB= 10 hrs SOL = 2 hrs WASO = 2 hrs TWT = 2+2+0.5 = 4.5 hrs TST = 10-4.5 = 5.5 hrs SE = 5.5/10 = 55%

ASSUMPTIONS: I need 8 hours of sleep to function If I’m tired, I can’t do my usual activities I can’t sleep if I’m worried about something. I can’t sleep if my knees hurt. Poor sleep is a part of getting old Getting old is “for the birds”.

slide-120
SLIDE 120
slide-121
SLIDE 121

CBTi Coach: Collaboration:

  • VA Centre for PTSD
  • Stanford University Medical Center
  • Dept of Defense National Center for Telehealth &

Technology

slide-122
SLIDE 122
slide-123
SLIDE 123
slide-124
SLIDE 124
slide-125
SLIDE 125

CONSENSUS SLEEP DIARY (2011) Patient Mrs M Sun Mon Tues Wed Thurs Fri Sat What time did you get into bed? 21:00h What time did you try to go to sleep? (lights out) 22:00h How long did it take you to fall asleep?

2 h

How many times did you awaken, not counting final one? 1 In total, how long did these awakenings last?

2 hr

What was your final awakening? 7:30 After your final awakening, how long did you stay in bed?

0.5 h

What time did you get out of bed for the day? 8:00h How would you rate the quality of your sleep? poor How refreshed did you feel when you woke up? Not at all How many times did you nap or doze? 1 In total, how long did you nap or doze? 1 hr # caffeinated drinks? Time of last one? # alcoholic drinks?Time of last one? 2/1800h Medications, dose & time taken. (OTC & prescription)

TIB= 10 hrs SOL = 2 hrs WASO = 2 hrs TWT = 2+2+0.5 = 4.5 hrs TST = 10-4.5 = 5.5 hrs SE = 5.5/10 = 55%

slide-126
SLIDE 126
slide-127
SLIDE 127
  • I need 8 hours of sleep to function:
  • If I’m tired, I can’t do my usual activities
  • I can’t sleep if I’m worried about something.: Soc Q. Is this true? Worry techniques.
  • I can’t sleep if my knees hurt. Soc Q. Is this true? Pain control. Knee exercises. (WebMD)
  • Poor sleep is a part of getting old
  • Getting old is “for the birds”.