|Sponsored by the HealthcareTrainingInstitute.org providing Quality Education since 1979|
The basic sleep-wake cycle is governed by a biological clock in the brain. Light information is transmitted from the eye via the retino-hypothalamic tract to the suprachiasmatic nuclei embedded deep in the brain in the hypothalamus. Neuronal pathways from these nuclei then activate secretion of a neurohormone called melatonin from the pineal gland. This hormone has a central function in the sleep-wake cycle, its level rising just before bedtime to reach a peak between 2am and 4am and then decreasing in the early morning. Melatonin secretion is reduced by bright light and by substances that can interfere with sleep — such as caffeine-containing drinks. In some studies, treatment with melatonin has been shown to improve sleep in patients with sleep disorders. With age, there is reduced responsiveness to melatonin and melatonin levels may decline, particularly in patients with Alzheimer's disease — explaining some of the sleep disturbances in such patients. While most people sleep for about seven to eight hours, there is a variable need for sleep — some people function with less sleep than others, even as little as four hours a night. Insomnia is more common in women, as well as in the elderly, and there may be a genetic component. You need less sleep as you get older (generally above the age of 65) — commonly about six hours rather than eight.
Step One: The first task is to understand what the patient's actual problem is. The six questions to ask are:
Step Two: Once you have documented there is a problem to address, the next step is to try and identity an underlying cause. For short-term insomnia, the causes are usually a stressful event. The main causes of insomnia are listed below. Therefore, you need to explore recent stressful events, any symptoms of anxiety and/or depression that may have been precipitated by recent events, any physical symptoms and any drugs used (including excess alcohol, tea or coffee consumption). Of patients reporting a sleep problem, 52% have a well-defined mental disorder and 54% report a physical disorder. If a specific cause has been identified, then this should clearly be targeted. A counselor in the practice may help with psychological issues, antidepressants may he needed to treat depression and referral to a specialist may be needed for a severe psychiatric illness. Physical symptoms need to he treated, and advice on alcohol, tea and coffee given. A look at the patient's list of prescriptions may reveal drugs that interfere with sleep. In some patients, you will not identify a specific cause for the insomnia — this group of people are said to have primary insomnia.
Step Three: The next step is to provide advice to try and re-establish a sleep routine. The first task is to dispel unrealistic expectations — many people feel they must have a full eight hours sleep, even as they age. Readjusting expectations may he all that is needed. It is important to try and break any "anxiety/sleep cycle' — that is, (he worry about not getting to sleep, or getting insufficient sleep compounding the problem. There are numerous tips you can give a patient to improve their sleep pattern and these are listed in the box above.
Main causes of insomnia
Tips to aid sleep
Reflection Exercise #3
Others who bought this Sleep Disorders Course