DESERT PALMS MEDICAL

ASSOCIATES TEAM

CARE MANAGER
DR. FARAH TALIBI
CARE FACILITATORS
AMNA ANAM SIDDIQUI
KHURRAM HUMAYUN
SHAHNAZ BANO
SHAROZE MUGHAL
CHRONIC INSOMNIA
 WHAT IS
SLEEP ?
 Sleep is a necessary restorative
process that affects all aspects of
Functioning

 Sleep is an active process of the

brain

 Early in sleep slow rolling eye

movements occur, known as Non
Rapid Eye Movement

 Later – deeper in sleep, Rapid Eye

Movement are associated with
increased heart rate and irregular
breathing
SLEEP PHASES THROUGHOUT LIFE:
Childhood and adolescence
- Sleep needs range form 18 hours a day for infants to about 9 hours a
day for teenagers.
Adulthood
- Amount of deep sleep drop dramatically between age 20 and 40, and
average sleep time is 7.5 hours
- Women’s reproductive cycles affect sleep
- especially pregnancy (sleepier first trimester)
- Also affected by menstrual cycle
 
 LACK OF SLEEP: INSOMNIA
The term insomnia is used for a disorder with the following diagnostic
criteria:
 - Difficulty falling asleep, staying asleep or nonrestorative sleep;
 - this difficulty is present despite adequate opportunity and circumstance
to sleep;
 - this impairment in sleep is associated with daytime impairment or
distress;
 - this sleep difficulty occurs at least 3 times per week and has been a
problem for at least 1 month.
For further elaboration, Insomnia can be divided in three types:
EARLY INSOMNIA – Increased sleep latency (trouble falling asleep)
MIDDLE INSOMNIA – Disrupted sleep (trouble staying asleep)
LATE INSOMNIA – Insufficient duration of sleep (waking up too early)
Chronic Insomnia Defining
Qualities  Complaint of poor sleep
causing distress or
impairment for 6 months
or longer
 Averages less than 6.5
hours sleep per day
 Or 3 episodes per week
of:
 Taking longer than 30
minutes to fall asleep
 Waking up during the
night for at least an hour
 Not accounted for by
another sleep disorder,
mental disorder, medical
condition or substance
use.
PHYSICAL, EMOTIONAL
AND COGNITIVE
EFFECTS OF INSOMNIA
 Mood changes,
irritability, poor
concentration, memory
defects etc
 Impairs creative
thinking, verbal
processions, problem
solving
 Risk of errors, accidents
due to excessive
daytime sleepiness –
markedly increases if
awake for more than
16-18 hours (micro
sleep attacks)
 Increased appetite,
deceased body
temperature
 CAUSES
Causes of insomnia without the involvement of an underlying health condition
include:
• Stress related to big life events, like a job loss or change, the death of a loved
one, divorce, or moving
• Things around you like noise, light, or temperature
• Changes to your sleep schedule like jet lag, a new shift at work, or bad habits
you picked up when you had other sleep problems

Causes of insomnia in addition to an underlying health disorder include:

• Mental health issues like depression and anxiety
• Medications for colds, allergies, depression, high blood pressure, and asthma
• Pain or discomfort at night
• Caffeine, tobacco, or alcohol use
• Hyperthyroidism and other endocrine problems
• Other sleep disorders, like sleep apnea or restless legs syndrome
 RISK FACTORS
 Age: greater prevalence in
older individuals
 Female gender especially
post and perimenopausal
women
 Divorce/Separation/Death
of spouse
 Psychiatric illness (mood
and anxiety disorders)
 Medical conditions
 Cigarette smoking
 Alcohol and coffee
consumption
 Certain prescription drugs
Sleep Deprivation Effects
 SLEEP
EXPERIMENTS
 SLEEP DEPRIVED PUPPIES: In 1894,
Russian physician Maria Manaceina
conducted an odd experiment
meant to determine whether or not
sleep is more important than food.
To help her figure it out, Manaseina
forced four puppies to stay awake
by constantly walking and handling
them. The first puppy died after 96
hours, while the rest perished
shortly after. Manaseina repeated
her experiment on six additional
puppies, only to find that they all
died as well, thereby proving her
theory that sleep is indeed more
important to immediate survival
than food.
 SLEEP DEPRIVED HUMANBEINGS:

 A research scientist observed

three men as they stayed awake
for a total of 90 hours straight.
Though the men experienced
some confusion after the first 24
hours, it was not until the second
night of sleep deprivation that
the hallucinations began. One
man reported that the floor was
covered in “greasy looking
molecular layer of particles,”
and began to have trouble
walking as he attempted to step
over these particles. After the 90
hours was up, all three men fell
asleep without a problem. In
fact, they slept so deeply that
not even the electric shock they
were then subjected to could
wake them.
MEASURING BEAUTY SLEEP:

To conduct this experiment, they kept 10 from sleeping for a total

of 31 hours. Afterwards, they asked 40 additional people to
compare before and after photos of the test subjects. The
feedback received found that the after photos had “more hanging
eyelids, redder eyes, more swollen eyes, darker circles under the
eyes, paler skin, more wrinkles…” and even “looked sadder” than
the photos taken before the experiment began.
HEALING THROUGH SLEEP:

A 2015 study done by German scientists found that during periods of deep
sleep, the body’s immune system actually encodes “memories” of infections in
order to learn how to fight off those infections later.
A group of rats which received plenty of sleep, but on a 20-hour schedule,
exhibited immune responses that were subpar compared to those on a regular
schedule. These two studies suggest that not only does the well-rested brain
play a role in maintaining health, but those who sleep in “shifts,” as do those
who are employed in “shift work,” are more prone to sickness.
INSOMNIA AND NEUROTICISM:

According to a recent study

done in Holland, those with
neurotic tendencies tend to
suffer from insomnia much
more frequently than their
peers. To study
this, researchers polled 2,089
volunteers between the ages of
18 and 84. The study found
that neuroticism led to
increased difficulty in falling
asleep and functioning during
the day, while those who tend
to be overly conscientious tend
to have increased trouble
staying asleep throughout the
night.
 THE RUSSIAN SLEEP
EXPERIMENT
This is an urban legend based upon an experiment set in a late–
1940s Soviet test facility. In a military-sanctioned scientific
experiment, five political prisoners were kept in a sealed gas chamber,
with a continually administered airborne stimulant for keeping the
subjects awake for 30 consecutive days. The prisoners were falsely
promised that they will be set free from prison if they complete the
experiment.
In the course of the five days, the situation went out of control - the
subjects blocked observation and went all kinds of crazy, screaming
and moaning. Then they turned completely silent for several days, and
when the scientists broke into the chamber, they saw the unspeakable:
the subjects tore most of their skin off of their bodies; blood covered
the floor.
Somehow, the mutilated prisoners remained alive, pleading to turn the
stimulant gas back on, screaming that they “must stay awake”. When
the research group tried to immobilize them, the subjects showed
astonishing strength, even killing some of the soldiers who were
helping the scientists.
Eventually, the subjects were pacified. One of them, instructed to
asleep, died immediately after his eyes closed. The rest were killed
while trying to break out.
Before shooting the last subject, one researcher screamed: “What are
you?!” And that mutilated, blood-covered body answered with a
terrifying smile:  “We are you. We are the madness that lurks within
you all, begging to be set free at any moment in your deepest animal
mind. We are what you hide from in your beds every night. We are
what you sedate into silence and paralysis when you go to the
nocturnal haven where we cannot tread.” So he said, before the
researcher shot him in the head.
 DIAGNOSIS
Doctors use tools which involve asking the patient questions in the office, having
them fill out logs and questionnaires, performing certain blood tests, or doing an
overnight sleep study.
 Sleep log: A sleep log is a simple diary that keeps track of details about our
sleep. In a sleep log, the patient is asked to record details like their bedtime,
wake up time, how sleepy they feel at various times during the day, and
more. A sleep log can also help the doctor figure out what might be causing
insomnia. 
 Sleep inventory: A sleep inventory is an extensive questionnaire that gathers
information about the patient’s personal health, medical history, and sleep
patterns.
 Blood tests: The doctor may perform certain blood tests to rule out medical
conditions such as thyroid problems, which can disrupt sleep in some people.
 Sleep study: The doctor may suggest that the patient should do an overnight
sleep study, or polysomnography, to gather information about their nighttime
sleep. In this exam, the patient sleeps overnight in a lab set up with a
comfortable bed. During the exam they are connected to an EEG, which
monitors the stages of sleep. A sleep study also measures things like oxygen
levels, body movements, and heart and breathing patterns. A sleep study is a
non-invasive test.
 POLYSOMNOGRAPHY (SLEEP STUDY)

 Polysomnography, also called a

sleep study, is a test used to
diagnose sleep disorders.
Polysomnography records your
brain waves, the oxygen level
in your blood, heart rate and
breathing, as well as eye and
leg movements during the
study.
Polysomnography is
usually done at a
sleep disorders unit
within a hospital or
at a sleep center.

Polysomnography
may be used to help
adjust your
treatment plan.
 MEDICATION & TREATMENT
 Initial treatment for insomnia may involve nonmedical therapy,
such as developing better sleep habits or psychotherapy, and
sometimes medications. If a medical condition like diabetes or
menopause is causing insomnia, treating those conditions may
help. If insomnia is a side effect of a medication, changing the
medication or its timing or reducing the dose may help.

 Short-term insomnia, often caused by travel or stress, usually

improves once the stress is removed or after your body has
adjusted to the new schedule. Short-term use of over-the-counter
sleep remedies may help. Chronic insomnia, which disrupts sleep
for extended periods of time, may call for a thorough physical
exam, alteration of some lifestyle habits, medical treatment, and,
perhaps, psychotherapy to identify a hidden cause. It is most
important to treat any problem that is producing insomnia
symptoms. Just treating insomnia symptoms without dealing with
the main cause will not be helpful.
Relaxation
Many poor sleepers simply need help relaxing. If you're a habitual insomniac
and trying to get to sleep just makes you more anxious and awake, try these
alternative choices to help reduce your worry about sleep while relaxing
your body and mind. If the root cause of insomnia is stress, any treatment
must address the problem of stress in your life.

Breathing exercises can promote relaxation. Here's a routine you can do

anywhere, anytime:

Exhale completely through your mouth.

Inhale through your nose to a count of four.
Hold your breath for a count of seven.
Exhale through your mouth for a count of four.
Repeat the cycle three times.

Moderate exercise can help you sleep better and give you more energy
while awake. Aim for a 20- to 30-minute routine three or four times a week.
Tailor the workout to your physical condition, and exercise in the morning
or afternoon, not close to bedtime.
 Mind/Body Medicine

 Meditation, yoga, and biofeedback may reduce tension and

promote better sleep. Visualization or guided imagery,
during which you hold a peaceful image in your mind before
bedtime, can also be an effective path to relaxation. You can
learn these techniques from an instructor, online sites, a
how-to book, or an instructional tape.
TREATMENT OF INSOMNIA IN THE
GERIATRIC PATIENT  Educational, Behavioral, and
Cognitive Interventions:

Prior to initiating symptomatic

therapy for insomnia, clinicians are
advised to provide patients with
educational, behavioral, and
cognitive interventions aimed at
introducing adaptive behaviors.

 Stimulus-control therapy,
Patients are instructed to go to bed
only when they feel tired, to get out
of bed after 20 minutes of being
unable to fall asleep, and to return
to bed when they feel sleepy.
Patients are also advised to avoid
looking at the clock, to shorten
daytime naps, to use the bed only
for sleep, and to rise at a consistent
time in the morning.
Various sleep-hygiene recommendations that may be helpful
in elderly patients are shown below:

o Avoid caffeine, alcohol, and nicotine

o Increase exposure to bright light during the
day
o Perform regular exercise (preferably in the
morning or early afternoon)
o Avoid exposure to bright light during the night
o Avoid heavy meals within 2-3 hours of bedtime
o Avoid large amounts of fluids 2-3 hours before
bedtime
o Allow for a comfortable sleep environment
o Minimize excessive noise, temperature, and
light in the bedroom;
 SLEEP MEDICATIONS
Benzodiazepine sedatives such as triazolam (Halcion), estazolam, lorazepam
(Ativan), temazepam (Restoril), flurazepam, and quazepam (Doral) and non-
benzodiazepine sedatives such as zolpidem (Ambien, Intermezzo), eszopiclone
(Lunesta), and zaleplon (Sonata) are drugs that can help induce sleep. However,
these medicines may be addictive with extended use. Also they can be dangerous
if you take them with alcohol or other drugs that depress the central nervous
system. They can cause morning sleepiness, although side effects are generally
less severe with the non-benzodiazepines.

Belsomra (suvorexant) is the first approved orexin receptor antagonist. Orexins

are chemicals that are involved in regulating the sleep-wake cycle and play a role
in keeping people awake.
Doxepin (Silenor) is approved for treating people who have trouble staying
asleep. Silenor may help with sleep maintenance by blocking histamine receptors
Antidepressant drugs may be used in people with
depression to help with sleep. They are not approved
for the treatment of insomnia.
Ramelteon (Rozerem) is an insomnia medication that is
less likely to cause morning sleepiness or to be
addictive.

Over-the-counter sleep drugs usually

contain an antihistamine. Antihistamines
are often used for allergies, but they have
a side effect of drowsiness. These
medications may cause daytime sleepiness
and dry mouth along with other side
effects.
PREVENTION & MANAGEMENT
 QUESTIONS TO ASK AS A CARE COORDINATOR
• What do your sleep difficulties look like: do you have trouble falling asleep, staying
asleep, or do you wake up too early? How many times a week do you have trouble sleeping
like this?
• What is your sleep schedule: what time do you go to bed, wake up, and nap during the
day? (even short naps count)
• Is your weekend sleep schedule different from your weekday schedule? Does your work
schedule require you to adjust your sleep at all?
• What do you do when you can’t sleep—get out of bed, read, watch TV, work on your
laptop? Is there anything you’ve done in the past that has helped you sleep?
• Do you lie awake feeling anxious or worrying about responsibilities and tasks?
• What is your sleep environment like: Do you sleep alone or with a partner? Is your room
dark and quiet? Is your bed comfortable? Do you have any sleep disruptions during the
night, for example, young children in the house?
• How long have you had trouble sleeping? Have you had trouble sleeping on and off for as
long as you can remember, or is this a new issue?
• Have you had any major changes (a move, a new job), or any stressful circumstances in
your life recently (a breakup, financial troubles)?
• Do you have any medical conditions?
 INSOMNIA AND CHRONIC DISORDERS
CORELATION
As chronic diseases have assumed an increasingly common role in
premature death and illness, interest in the role of sleep health
in the development and management of chronic diseases has
grown. Notably, insufficient sleep has been linked to the
development and management of a number of chronic diseases
and conditions, including type 2 diabetes, cardiovascular
disease, obesity, and depression.

 DIABETES
Research has found that insufficient sleep
is linked to an increased risk for the
development of type 2 diabetes.
Specifically, sleep duration and quality
have emerged as predictors of levels
of Hemoglobin A1c, an important marker
of blood sugar control. Recent research
suggests that optimizing sleep duration
and quality may be important means of
improving blood sugar control in persons
with type 2 diabetes.
CARDIOVASCULAR DISEASE

Persons with sleep apnea have been found

to be at increased risk for a number of
cardiovascular diseases. Notably,
hypertension, stroke, coronary heart
disease and irregular heartbeats (cardiac
arrhythmias) have been found to be more
common among those with disordered
sleep than their peers without sleep
abnormalities. Likewise, sleep apnea and
hardening of the arteries (atherosclerosis)
appear to share some common
physiological characteristics, further
suggesting that sleep apnea may be an
important predictor of cardiovascular
disease.
 OBESITY

Laboratory research has found that

short sleep duration results in
metabolic changes that may be
linked to obesity. Epidemiologic
studies conducted in the
community have also revealed an
association between short sleep
duration and excess body weight.
This association has been reported
in all age groups—but has been
particularly pronounced in children.
It is believed that sleep in
childhood and adolescence is
particularly important for brain
development and that insufficient
sleep in youngsters may adversely
affect the function of a region of
the brain known as
the hypothalamus, which regulates
appetite and the expenditure of
energy.
 DEPRESSION

The relationship between sleep and depression is

complex. While sleep disturbance has long been held
to be an important symptom of depression, recent
research has indicated that depressive symptoms
may decrease once sleep apnea has been effectively
treated and sufficient sleep restored. The
interrelatedness of sleep and depression suggests it is
important that the sleep sufficiency of persons with
depression be assessed and that symptoms of
depression be monitored among persons with a sleep
disorder.