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Hello. I'm Norman Swan.
Welcome to this program on Sleep and Health - A Wake-up Call.
Sleep disorders have a significant impact on our health
and they contribute to a variety of other problems,
including increased workplace and traffic injuries.
The costs are somewhere between $3 billion to $7 billion,
not to mention the $40 million bucks or so
that we spend each year on sleep medications.
In this program,
we'll be looking at the latest research in sleep and sleep medicine,
the range of sleep disorders, and their health consequences,
and the latest treatments, including some simple tools.
We're coming to you across Australia
through the Rural Health Education Foundation's satellite network.
As usual, there are a number of useful resources available to you
on the Rural Health Education Foundation's website, and that's at:
Now let's meet our expert panel.
Dr Nick Antic is a sleep physician
at the Adelaide Institute for Sleep Health in Adelaide.
- Welcome. - Thank you, Norman.
Not quite sure where else the Adelaide Sleep Centre would be,
but it's certainly there.
Nick's particularly interested in developing simplified diagnostic
and management strategies for sleep apnoea,
particularly for use in a primary care setting.
Dr Delwyn Bartlett is a research psychologist
at the Woolcock Institute of Medical Research in Sydney in NSW.
- Welcome, Delwyn. - Hi.
Delwyn's an expert on insomnia
and the use of cognitive behavioural therapy
to help people get a better sleep.
Dr Bandana Saini is a lecturer in pharmacy at the University of Sydney.
Welcome.
Her many research interests include the use of pharmacists
in screening for sleep disorders
and in actively promoting good sleep habits.
And Dr Tim Peacock is a general practitioner
based in Tintenbar in northern NSW.
Do you get much sleep, Tim, in a busy rural general practice?
- I get enough, yeah. - Get enough?
Welcome to you all.
Nick, what are we talking about here
in terms of the range of problems that we're looking at?
Well, there's a variety of fairly common problems, really.
I mean, the two clinically we deal with more than most
is obstructive sleep apnoea and insomnia.
And... but there are other rarer conditions,
including restless legs and narcolepsy as well, that we may deal with,
and there's the bigger community issue of getting enough sleep,
and some of the occupational health and safety and driving safety issues
that might go with good sleep,
which we're increasingly recognising is important for good health.
Let's look at directionality here.
In terms of bad sleep causing health problems, what do we know about that?
'Cause there's a bit of mythology in there, isn't there?
Well, look, I mean, there is a little bit.
And it's a tricky dynamic actually
because people who are unwell for a variety of reasons, chronic illness,
often don't sleep very well
but, of course, that doesn't mean
that they're a cause for their chronic illness.
There's a study in the US, a nurses' health study,
which has suggested that people that sleep very little
or people who sleep too much
might actually both do worse in terms of outcomes.
NORMAN: What sort of outcomes?
Well, in terms of mortality and other various health problems as well.
I mean, that might be, again, getting back to the cause and effect question,
might be that people who have got chronic illness
might actually sleep a lot
and therefore that might be the reason they're unwell.
It may not be only the health issues, though.
There is increasing evidence a good sleep's important
for good quality of life.
It can be important for driving safety, neurocognitive function.
It can be important for mood as well.
So, you know, there's a variety of implications for health.
And what about health problems causing sleep disorders,
apart from the sleep disorders themselves?
Well, yeah, look, certainly, that can be a problem.
And a variety of chronic medical conditions can cause sleep problems.
Chronic pain of course is one that might.
And the link between psychiatric disturbance and sleep disturbance
is a very strong and powerful one in both directions.
And then other chronic medical conditions -
people with heart failure
often will have problems with breathing during sleep.
There's a variety of chronic medical conditions that can affect sleep.
Bandana, what are the medications that GPs need to look out for,
and indeed pharmacists?
I guess, well, there's an over-the-counter variety,
which includes antihistamines and some herbal medications
that people often walk into pharmacies for.
Then there's also the prescription medications...
That cause sleepiness or cause lack of sleep?
Ah... people come in...
The ones that cause sleeplessness,
again, there's a whole variety -
there's probably those that are used for common conditions
such as hypertension.
So for example, beta-blockers,
especially the ones that can cross the blood-brain barrier.
There are certain antidepressants,
for example, the serotonin selective reuptake inhibitors
that can actually keep people awake
if they're taken too late in the evening.
Some other medications,
for example, diuretics people use for heart failure or for hypertension,
can also cause sleep problems
just because people have to wake up in the night
so if they're not taken at the correct time.
And there's a whole variety of others
that if you look at the literature on side effects,
it will say they will cause sleep problems,
but those are the most common, for example.
Tim, as a GP, what are the commonest things you see?
Look, I'd agree with Nick,
that we probably most commonly see sleep apnoea and insomnia
as, you know, primary presentations.
But sleep will enter our consultations in various other areas -
mood disorders, anxiety,
you know, people who are generally stressed.
Might be part of a workplace situation type of problem.
Um... so, yeah, look, you know,
it's often not necessarily a primary presenting problem...
NORMAN: And it can cut both ways. - What's that? Sorry?
- And it can cut both ways. - Yeah. Absolutely. Yeah.
Delwyn, is there any such thing as good quality sleep? Can we define that?
Oh, I think so.
NORMAN: You know a good night's sleep when you've had one.
Well, yes, and people can say it can change their lives.
But most people, perhaps,
when they have been good sleepers just accept it
and a good sleeper doesn't know how to sleep.
They just go to bed and go to sleep.
Whereas somebody who has had any sleep difficulties
can put a lot of time and effort into their sleep, worry about it,
and it becomes something that is quite difficult to attain.
So why don't you give us a primer on normal sleeps
before we start getting into the abnormal stuff?
So this is the young person.
DELWYN: This is the young,
healthy person who's 24.
So down the Y-axis we've got coloured boxes.
And across the bottom on the X-axis
we've got hours of sleep.
And I think it's important to stress
a number of points.
One, that the black boxes
represent wakefulness.
And being awake
is a very normal part of sleep.
So we will wake
at least 2-3 times a night...
NORMAN: Will we know that?
DELWYN: Well, most people don't
when they're young and healthy.
So sometimes it has to do with
the length of the wake
and sometimes it has to do with
the timing of the wake
and our memory of it.
There are a number of different factors.
We also cycle through the stages
of sleep approximately every 90 minutes.
We don't start the night in light sleep
and finish the night in deep sleep.
Most of our brain rest sleep
is in the first one-third of the night.
So if we go back and we look at
that hypnogram or diagram,
black is awake and green is asleep.
And the yellow boxes,
they're representing the transition
from being awake to going to sleep.
And you spend about 5% of the night
when you're healthy and young
in that sort of transitional sleep.
Now, the green boxes are Stage 2 sleep.
And it's light sleep.
So we spend 45% to 55% of the night
in light sleep,
which is quite a remarkable
piece of information
for a lot of people,
because they believe that good sleepers
are in deep sleep for most of the night.
So after we've been asleep
for about 25-35 minutes,
we go into deep sleep,
or slow-wave sleep,
and that's the lighter blue box
and the dark blue boxes.
And during slow-wave sleep,
children will walk, talk
and have night terrors,
but they'll also secrete growth hormone.
And adults will secrete...
NORMAN: So it's a growing experience.
It's a growing experience.
Then we go back up and you have Stage 2 sleep again
and you go right back up to REM sleep,
and that's the red box.
And REM sleep is dream sleep
and it's almost the same as being awake.
And during dream sleep,
your brain is very active.
You have small EEG waves.
And the other interesting thing that
happens is your body's semiparalysed,
so you don't get up
and act out your dreams.
So...
NORMAN: So your brain pulls the plug on the body.
DELWYN: It does.
So this is when you can get that sort of feeling when you're asleep
and you got a dream where you're being chased,
you're running and you can't run, your limbs simply won't move.
Yes. And we tend to get longer dream periods towards morning
and more lighter sleep of Stage 2 sleep.
So if you wake from a dream
particularly after about the second sleep cycle,
about three hours of sleep,
you can sometimes wake and feel absolutely wired.
- You're ready for action. - Yes, you are.
And does it matter where you wake in the cycle?
Well, if you wake, say, which is not that usual, from deep sleep,
it's very easy for you to go back into deep sleep or to go back to sleep.
Whereas if you wake after dream sleep,
it may take you about 15 minutes sometimes to go back to sleep
if you start thinking when you wake.
And is there such a thing as a normal night's sleep, lengthwise?
Most of the epidemiological studies
suggest that if we get somewhere between about 6.5 and 8.5 hours
that that's a pretty a good sleep.
It's generally a U-shaped curve.
So it follows along to what Nick was saying,
is that if you get too little sleep or too much sleep,
then that's associated with other complications,
morbidity and increased mortality.
OK, so those are the cycles.
But if your alarm is set to a time
and you wake up at 6am,
and that happens to hit your deep cycle or your light cycle,
or your light part of your cycle,
does it actually matter to your sense of tiredness
or refreshment during the day?
Well, if it was 6am in the morning,
it's highly unlikely that you would be in deep sleep,
unless you only went to bed at sort of 3:00 in the morning.
And then you would wake up feeling awful -
jet-lagged and a woolly brain.
Whereas if you woke, from lighter stages of sleep, such as Stage 2,
it's easier to wake up.
NORMAN: Less distance to travel. - Yes.
NICK: You might be interested to know that there's a company in America
promoting an alarm clock that can wirelessly measure your EEG
and tell you what stage of sleep you're in
and not wake you until it's safe to wake you, if you like,
which brings a whole new spectrum to being late for work.
I was gonna say, what do you say to your boss?
NICK: 'My alarm clock said it wasn't safe.'
'You want me fresh? That's when you gotta take me.'
What do they call it - a gen Y clock, do they?
- So, when you're older, it changes. DELWYN: Yes.
NORMAN: So let's look at the cycle when you're older.
DELWYN: And I really think what is showing up there on that hypnogram
is that there's a lot more transitional sleep,
there are a lot more boxes that are black,
so we get more wakes.
And you don't get the same length of time
in deep sleep, or slow-wave sleep.
And so a question I often ask groups when I'm talking about sleep
is that, if you have a pattern like that, are you doomed?
And the answer is no.
It's really reflecting all the changes of age
that are happening to the rest of our body and brain.
NORMAN: Sounds depressing. DELWYN: No.
You can still play golf.
(Laughs) Play golf? I'll fall asleep.
But some people are more aware of these wake cycles.
Yes, they are.
They feel they're not getting a good night's sleep.
And sometimes when you're older, if people aren't active,
mentally and physically,
then they may be sleeping more than what is perhaps a good idea
during the daytime.
So therefore, their quality of sleep and their sleep debt will also be reduced.
And, again, you need less sleep, or it's just the fact that you're waking more?
Is that a bit of a myth?
I think it is a bit of a myth. And Nick can make a comment about this.
But generally with increasing age, we need about the same amount of sleep.
It's the quality of our sleep that changes.
NORMAN: And you've just gotta live with it.
Nick, what changes that... If you take exercise or whatever,
can you change that pattern back to a more youthful look?
I think... I think that would be difficult.
I think that would be difficult.
And I think education is an important process here
to explain to people what is normal sleep as they get older,
because if we have people come
and they're waking one or two or three times and complaining about it,
you might have to explain to reassure them.
Keeping active during the day is important for good health
and important for good sleep as well.
So, some exercise.
And... I mean, falling asleep for a couple of hours in the afternoon
will take away from sleep pressure in the evening and fragment sleep.
And we certainly get patients who get into that cycle
of sleeping during the day and then not sleeping well at night
and then napping during the day.
And that will need to be avoided, I think.
A power nap would be OK, but a prolonged sleep not so good.
Now, some people talk about,
when talking about treating people's insomnia,
they talk about light therapy -
that it's important to get light in the morning
to reset your melatonin.
Tell me a little bit about body clocks and sleep.
We have... I always like to tell people the story
that a French astronomer in the 18th century
put a plant in a dark cupboard and watched it.
And the plant opened and closed its leaves for a number of days
in total darkness,
which is not what I was taught in biology.
And really what comes from that
is that most living organisms have an internal clock mechanism
that regulate patterns of behaviour.
And that's applicable to human beings.
And our clock mechanism was not identified formally until 1972.
NORMAN: So this is the 'suprachiasmatic nucleus', or whatever they call it.
Yes, and we all call it the SCN 'cause it's much easier.
Which sits under the pineal gland.
Well, it doesn't. It actually sits on top of the optic chiasm
in front of the hypothalamus.
And so really what it does
is that, with light,
and the light message goes via the retina
to the SCN,
it then gets relayed to the pineal gland,
and when the pineal gland gets a light message,
it suppresses the night-time sleep hormone - melatonin.
And if it's suppressed
at the same time each day or most days,
then the brain gets an idea
of what to do X number of hours in the future.
Because our human sort of clock mechanism
and timing of our sleep-wake patterns
are slightly longer than the 24 hours that we live in.
So exposure to light and dark
actually reset it into our normal 24-hour environment.
NORMAN: And does any light do that?
DELWYN: Well, it needs to be of a certain strength
and we generally look at about 3,000 lux,
which is outside light
first thing in the morning.
And it doesn't need to be a sunny day.
And so we know also that if you're very close to an external artificial light,
then that will have a similar effect,
but you have to sit very close to the light, and it's pretty boring.
NORMAN: There are some alarm clocks that turn on a light for you, isn't there?
I don't think we've developed that technology yet, in Adelaide.
NORMAN: Bit behind, but we'll tell you about it later.
And the core body temperature story?
Well, the core body temperature goes along with the light and dark,
but perhaps I need to say a little bit more -
increasing darkness is the trigger for the release of melatonin.
And melatonin does two things -
one, it has a slight hypnotic effect,
and, more importantly,
what it does is it lowers the core body temperature.
Now you can't go to sleep or stay asleep
unless your body temperature starts to fall
and continues to fall.
NORMAN: So being hot is a bad idea.
DELWYN: Yes. And sleeping with an electric blanket in winter
is not such a good idea.
It's going to wake you up frequently.
And let's now then translate all this to good, healthy sleep habits.
'Cause what my understanding is,
it's, you know... bed's for sleeping or sex.
You're allowed to have sex wherever you like, but bed is for that.
No television or computers or work - that sort of thing.
There's also this thing about core temperature,
that you can take a hot bath but it's gotta be two hours beforehand
so that you get that body temperature drop.
Take us through some of the things that you talk about.
I think you've been summarising that very well.
One of the things to avoid
is exercise close to bedtime
because you can get an elevated
internal, or core, body temperature,
and then it makes it different
for sleep onset to occur.
So you need a gap
to cool down and slow down
so that sleep onset will occur.
Perhaps most importantly,
we need some time-out or wind-down time
so that we can have a demarcation line
between work and sleep.
And sleep needs to be something
that we can do
without putting effort into it,
without thinking about it,
because it's a really nice thing to do -
not that 'I have to get sleep in order to be able to perform the next day.'
You're putting pressure on yourself.
Is insomnia a real thing
or just somebody who's worried about the fact they're not sleeping?
Well, often insomnia is triggered by somebody worrying about something.
And then that worry may actually be resolved
and the person is left worrying about the poor sleep.
So we're really looking at triggers,
we're looking at things that maintain the poor sleep,
and that's an ongoing problem.
And, Nick, we've been confused about insomnia
'cause a lot of the research is getting poor university students
and sleep-depriving them,
and saying that's equivalent to insomnia,
where a lot of the story about insomnia being bad for you comes from.
Yeah, look, I think sleep deprivation is a whole different area, really.
And if you're going to sleep-deprive university students or anybody,
you will see decrements in performance over a period of time.
I think the story of insomnia is different. You're absolutely right.
And, I mean, there is this issue sometimes
of people misperceiving their sleep,
and they think that they're sleeping very poorly,
but when you measure it, they're actually sleeping really quite well.
And I think sometimes that can be a helpful adjunct to their therapy.
And when you study people with insomnia, they're performing extremely well.
- Some call them overachievers. DELWYN: Yes.
And we wonder whether it's because they have high levels of cortisol and ACTH.
Now, we know from research studies
where they've done half-hourly blood assays
that individuals with insomnia do have high levels of cortisol and ACTH.
So is that the trigger for the insomnia?
Or is it an adaptation to poor quality sleep,
so that they can maintain their performance during the daytime?
But perhaps more recently was a paper that was published this year
that shows that individuals with insomnia
are actually faster at short-reaction-time tasks
than people who sleep well.
NORMAN: So almost hyper-aroused. - Yes.
And then if you put them through a cognitive behavioural treatment program,
they then become slower.
- But prior to... NORMAN: So you cause car accidents.
(Laughs) No. No.
Car accidents perhaps, with most individuals with insomnia
are probably due to inattention
and the difficulty of just sort of being aware
and having an awareness that's safe for you to drive.
But the interesting thing about the study that I started to talk about
is that complex tasks that are quite involved
are often very difficult for individuals with insomnia.
Put them in a treatment program,
and their performance actually improves on the complex tasks.
So there's lots of different things happening.
What about sleep medications, Bandana?
I mean, they've got a bad rap and we still prescribe them by the bucketload.
Yes, I think we do see quite a lot of prescriptions in the pharmacy.
Well, I guess the ones that are prescribed
are... have shown efficacy
but there are cautions that go along with them.
So, for example, they shouldn't be used for longer durations.
They shouldn't be used in populations who are at risk,
for example, the elderly
because of a varied metabolism or because they've got other conditions,
or in people who may have another condition
that will interact with that particular medication.
So I think we need to exercise a lot of caution
when we dispense these medications,
but we certainly do see a lot of prescriptions.
Tim, do you think there's ever a case for prescribing sleep medications?
I mean, if you read the literature,
you think, 'Well, why would you ever do it?'
Certainly I think as a short-term adjunctive treatment
for improving sleep,
particularly in people with mental health problems.
I think it's certainly indicated there needs to be a very firm guideline
about short-term use
and good information about the potential for tolerance and dependence
that goes along with that.
NORMAN: What's your advice on sleep medications, Delwyn?
I'd agree with Tim.
I think that, particularly in the case of bereavement or an accident
or something like that,
that people do just need to have a little bit of help.
But as long as it is for a short term
and then you're able to step in and say,
'OK, so now let's look at what's actually happening
with your sleep patterns.
Have you gone into a sort of pattern where you're spending many hours in bed
because you feel so awful and you're grieving?'
And it's to be able to talk through the underlying problem
and then wean somebody slowly off the medication.
Let's go to our first case study:
Your patient, Tim.
Yeah, well, look, you know, on the face of it,
you'd certainly be wondering about a picture of sleep apnoea,
with the snoring
and the story of occasionally stopping breathing overnight.
But you'd certainly want to be, as always, taking a good history
and performing examination to look for other problems -
depression, anxiety, congestive cardiac failure.
It would seem less likely in this sort of case.
Um... and...
..you know, that's the general sort of approach we should be taking
in initially assessing this chap.
NORMAN: Nick?
I think that it's a very fair summary of the whole situation.
I mean, I think the clinical history certainly sounds
like obstructive sleep apnoea's a possibility,
but you need to consider all things,
and just not getting enough sleep might be an issue.
I guess the stop-breathing episodes make you wonder.
And, you know, the potential link between sleep apnoea and hypertension
and the fact that he's put on weight
would again make you wonder about sleep apnoea.
I think there'd be an indication
for probably doing a sleep study in this sort of situation
to further investigate.
NORMAN: And if you're in a country town and can't get access to sleep studies?
Which I would imagine is a fairly common problem, issue.
Well, yeah, no, look, I think it is.
I mean, I think the access to sleep studies has improved on where it was,
but it's a complicated test and the access is not always there...
NORMAN: But does it change your management
if he doesn't score high on a depression scale
and you've got this story?
Hasn't he got it until proved otherwise, and just whack him on a CPAP?
Well, look, I mean, some would say that's a reasonable step. I don't...
NORMAN: The CPAP manufacturers would.
I think the CPAP manufacturers... some may, yeah.
I think this is an important condition to diagnose
and it's important to think about the range of treatment options,
the severity of sleep apnoea.
CPAP is a challenging therapy.
Is it the right option in this situation?
Does he need to go to that extent?
Can he just do some of these lifestyle things
and lose some weight, and so on?
I think there is some other treatment options
apart from CPAP for sleep apnoea,
so I think it's a bit of a simplistic way of dealing with things, really.
And I think we need to make the diagnosis in this situation.
Because if it is sleep apnoea,
it's potentially a lifelong diagnosis here
and we need to work our way through it in a logical way.
Delwyn, what would happen if he scored high on depression
and you suspected sleep apnoea?
What would you be starting to think of here, if anything?
Well, there are a percentage of individuals
who have obstructive sleep apnoea and insomnia and are depressed.
NORMAN: Understandably so. - Yes.
Yes.
So your approach would be to treat both,
or treat the sleeping problem first and then see what happens to the depression,
or what?
Sometimes it's useful to treat the insomnia first
and then the obstructive sleep apnoea.
But if somebody has a severe obstructive sleep apnoea,
then we're looking at a life-threatening situation
and you would be wanting to perhaps do them in tandem at the same time.
NORMAN: What do you do in a sleep study?
Well, patients will come in to a sleep laboratory and... usually -
there is a bit of a push now
towards doing some home sleep studies as well,
where people will come in and be wired up and go home.
They'll be attended by a technician and they'll have a series of monitoring,
which would include EEG and oxygen saturations
and thoracic and abdominal bands.
It's quite complex measurements.
Might take about eight hours or so of recording time.
They'll be analysed by a technician the following morning,
or soon after, and scored.
And then a physician will come in and review the data
and try and make an overall interpretation
of the clinical situation.
So it is quite a time-consuming and labour-intensive process.
And I think one of the ways we've got to go
is to find some simpler ways to help access for the condition.
We'll come back to that in a moment.
So how common is it?
How common is obstructive sleep apnoea?
Well, it depends on how you define it, of course.
I mean, if you talk about breathing pauses during sleep,
it can be very common.
If you're talking about obstructive sleep apnoea/hypopnoea syndrome,
which is breathing pauses during sleep and daytime sleepiness,
the study from Busselton in Western Australia
suggests it's 3% of adults.
Now, that's about a 10- to 15-year-old study
and the population is heavier since that time,
so it's almost certainly more.
And similar sort of studies in India have suggested a prevalence of 7%.
So I think if we were working in that sort of framework
we'd say that it's quite a common condition.
But there's a spectrum of disease severity of course
and not everybody with sleep apnoea will need treatment.
NORMAN: I think we've got a graphic
of one of your hypnograms,
or whatever you call it,
looking at the sleep... what happens.
NICK: Yeah, well, it's to give an idea
of the complexity of the measurements
and show how wonderfully wise we are.
That's the main reason I put it up.
But apart from that...
This is somebody with very severe
sleep apnoea.
This is a 20-minute recording.
And if you look at the line
third from the bottom,
there are brief pauses you can see there
that are apnoeas - cessations of breathing.
And the line directly above that
is the oxygen saturation,
which you can see dropping repeatedly.
So this person is stopping breathing,
their oxygen saturation is falling
and then they're having
a brief wakefulness episode from sleep.
Some of which they may perceive
and many they may not.
And the cycle is repeating itself.
And in this 20 minutes,
this person's woken every minute.
And they've had about 20 apnoeas.
And it can be...
..you can see 100 arousals from sleep
per hour in the most severe of cases.
And that would be
a very symptomatic patient.
NORMAN: What are the risk factors?
Well, in adults, weight is a major factor.
Probably the major factor.
Other things that can predispose people,
certainly in younger adults,
tonsillar and adenoid hypertrophy.
And in children, that's a big factor.
It's an anatomical disease
more in children.
Various skeletal and craniofacial abnormalities
might be an issue -
retruded chin and so on.
But there are some people, their breathing is more unstable,
particularly in lighter stages of sleep
and it can be a condition where you see sometimes
in people of near-normal or normal body weight.
It's not always associated with weight.
NORMAN: So an abnormal anatomy in the upper airways?
Well, potentially, for some.
I mean, it's not only really the anatomy of the upper airway,
it's the collapse of the upper airway by external forces sometimes.
NORMAN: So the fat in the neck.
Potentially. Or even fat in the tongue as well.
That might be also a factor.
Maybe fat lining the airway.
And some people's airways are inherently more collapsible than others as well.
So it's quite a varying disease in that respect.
Not everybody who has a BMI of 50 will have sleep apnoea.
So if Tim says, 'There's a holding pattern,
we're gonna try get you to lose some weight, Charles,'
and Charles says, 'Well, I've tried before.
What's the buy-in here... pay-off here if I lose weight?'
What's the statistic?
Well, if they've got sleep apnoea,
the rule of thumb is if they can lose 10% of their body weight,
the sleep apnoea severity will drop by about 30% to 35% or so.
So if we're talking about a 100kg male, 10kg weight loss can be very helpful.
We don't have the advantage here
of knowing if this man has got sleep apnoea,
'cause he hasn't had a sleep study.
But weight loss is always helpful.
It's helpful to snoring as well, of course.
And it's of course important for good health as well.
So I agree. I think it would be an important thing.
And I think probably something
that we don't always well do when they come to us is
that we can treat them, but we really need to focus on a primary factor here,
and that's weight reduction,
which is not easy, of course.
Got a question from Graham, a GP from Warren in New South Wales.
'Once a patient has had a sleep study and been diagnosed,
how does he access a CPAP machine?'
Well, that would depend a little bit on the circumstances -
the state and the different funding opportunities.
But not to bore you with too long an answer,
usually in most states, if they've got a health care card,
there'd be public access through various clinics
to publicly-funded CPAP.
That would be the case in our laboratory -
our CPAP nurses would set them up.
If they're privately insured or they don't have a health care card,
there are a variety of private suppliers that will supply CPAP,
usually and ideally, on doctor's prescription.
And they will then help patients learn how to use the device,
fit the mask and so on.
More and more pharmacists are doing it, aren't they?
Yes, there are quite a few pharmacists who are retailing CPAP
through their pharmacies.
I just have a quick comment to make.
There's no legal prescription required for CPAP,
so if you have patients that walk into a pharmacy
that's retailing a CPAP machine
and that patient requests CPAP,
the ideal response would be that you should get a proper diagnosis
'cause otherwise it's hard to set them on a pressure.
Look, I'd agree with that.
I think really this whole process needs to be supervised
and carefully thought through.
I don't think CPAP is a great therapy if you only snore.
Now, it can be helpful, but I just think it's a fairly significant treatment
for simple snoring, for example,
and that may be the situation presenting there.
So, look, I think most of our CPAP suppliers
will insist on a doctor's prescription
and some sort of supervision of the whole process.
It's a safe treatment, CPAP.
NORMAN: So just take us through it. What happens?
Well, let's take this patient here - Charles.
He would come to see us, he would have a sleep study.
We would review the data and make a clinical decision.
And if we thought CPAP was indicated,
we would do one of two things -
either they would have a CPAP titration in a laboratory,
where the CPAP pressure is manually titrated by the technical staff,
or they may take a home...
NORMAN: So this is via a nose mask?
Via nose or full-face mask, yes.
So there is a mask that fits over the nose and mouth.
There's a third mask option that goes into the nostrils as well.
There's a variety of masks out there.
The other option is to use a home auto-titrating CPAP device
to... which will automatically adjust the pressure
depending on changes in upper airway size to set a pressure,
or that may be in fact the device that people prefer to use,
although that's a lot more costly.
One of those ways to set the pressure
and then they would go and usually have a trial of therapy.
Almost always they can rent the machine for a month or so.
They need very good support through the process to fit the mask
and work through some of the side effects - nasal blockage
and a dry mouth or a mouth falling open.
It's got its challenges. It can be a very effective treatment.
But it needs to be carefully thought through and carefully managed,
particularly in the first month or so.
NORMAN: Tim, any issues?
- Uh... with gaining CPAP machine or...? NORMAN: Yep.
No, I mean, it's useful that Nick's outlined it for us,
because really, again, from a general practice perspective,
the transition between your sleep study and gaining a CPAP machine
can sometimes be a bit of a mystery,
something that tends to happen at their end.
And certainly, again, you know, maintaining support
once the CPAP has been titrated and started to be used is very useful.
What about mandibular splints,
'cause they're almost as effective, aren't they?
No, I don't think they're almost as effective,
but they can be very effective.
I mean, they're a top and bottom plate that bring the lower jaw forwards,
compared to the upper jaw.
They need to be very carefully made
and a careful assessment
of how much protrusion is possible.
For people who snore, they can be a very effective therapy,
for simple snorers, and for mild sleep apnoea as well.
NORMAN: You've got to be properly fitted with it by a dentist.
NICK: I think it's a really important thing.
They have to be very carefully made.
There are some boil-and-bite devices
that really probably aren't terribly effective
that people will see available out there -
the old football mouthguard sort of thing.
Not terribly effective.
As you get towards a more moderate-to-severe sleep apnoea,
they're not as effective as CPAP in most patients.
You can occasionally have a win, of course.
And some patients like them
because they're not quite as intrusive, if you like.
So you'll sometimes use a mandibular splint on the way to CPAP.
Well, we might sometimes.
I mean, again, if you've got more moderate-to-severe sleep apnoea,
we would usually go down the line of CPAP first.
But not everybody tolerates CPAP.
And a mandibular advancement splint can be a second-line therapy.
If you've got more mild sleep apnoea,
well, then a dental splint is absolutely in play.
And if you only snore, that can be a very effective therapy.
Now, I think I recently covered a story in fact from Adelaide
suggesting that we're not very good at selecting patients for surgery
and often they're ending up with surgery too quickly,
without going through the hoops.
Well, yeah, I mean, that study was from Adelaide
but not about Adelaide, 'cause we're actually very good in that process.
NORMAN: The best. - Yeah, thank you.
The, um... Look, surgery and sleep apnoea, it's different.
In children, very effective -
removing tonsils and/or adenoids can be curative in the right patients.
In the adult population, it needs very careful consideration.
Our approach really is, dare I say it,
last-ditch sort of stuff most of the time -
when other therapies have failed and you have severe untreated sleep apnoea.
NORMAN: And there's several operations in play.
NICK: There are a variety of operations -
I should say that if you've got big tonsils,
even as a 20- or 30-year-old, that can be curative sometimes.
And I think you need to look in the airway
and see if there's anything there.
The more complicated operations,
be they palatal advancement,
or various maxillomandibular advancement surgeries
are very complicated surgeries.
- And multi-stage. - Multi-stage, often.
Not available widely, and need a very skilled surgeon.
I think it's a real niche area, in terms of sleep apnoea at the moment.
NORMAN: Don't jump into surgery too early.
Probably not tonight, no.
Let's go to our next case study who's James.
He's in his 50s,
and asks his local pharmacist
for a good... it was you, Bandana,
for a good vitamin supplement
saying he's suffering fatigue
during the day and often feels hyped up.
He manages a large rural property.
He's having difficulty concentrating and performing his tasks,
especially in the early afternoon.
But he tries to drink a fair bit of coffee to stay alert.
He gets off to sleep quite well,
but wakes up and has difficulty getting back to sleep.
His wife tells him he occasionally snores,
but his breathing seems normal.
In other words, he's not stopping breathing.
What will you do with him in your pharmacy?
OK, he's probably standing
close to the vitamin shelf.
I might take him to a little corner where we can talk without...
NORMAN: Away from the valerian. - Away from the valerian.
I would probably want to ask a few questions
about when his symptoms started,
is there a pattern, how lately has this occurred,
what else is happening in his life,
probably get a feel for any other medical conditions
that he's diagnosed with.
He's talking about being wired, so he may be having some stress issues.
Maybe check his medication history on our dispensing computer
to see if he's got any medications that might be affecting...
Being 50, he might have some of the usual cardiovascular type medications.
And then try and build a picture of what's happening.
I might dissuade him from the vitamins, if he's having an adequate diet.
He doesn't really need to supplement,
and that's not gonna really help him sleep.
He says that he can get into sleep quickly, but he wakes up,
so that's kind of bordering into the definition of insomnia,
which is, you know, having difficulty initiating sleep, or maintaining,
or getting up unrefreshed.
So, to my mind, I would probably feel, you know, talk to him about this issue,
and maybe send him off to my colleague here.
NORMAN: How collegial of you. Tim, what are you going to do for him?
NORMAN: Send him back to the pharmacist for valerian.
Quite possibly.
Look, you know, again, he needs a good general approach.
You know, he's a farmer in his 50s.
We wanna know that he's not depressed,
that the... the drought hasn't had too much of an effect, and...
NORMAN: Do you have any favourite screening tools for this,
or do you use anything... to assess him?
Um... well, probably not routinely,
but, you know, things like the Epworth sleep score
is something that would come to mind as a useful tool.
And whether you have the time to go through that
in general practice is up to the individual.
But, certainly, you know, a general approach to him,
and you want to make sure nothing else is going on.
Then you really need to sit down and get a decent sleep history from him as well,
find out when it is that he goes to bed,
how long does it take to go to sleep once he's there,
when does he next wake, what happens then, does he toss and turn?
NORMAN: So, Delwyn, what do you think about him?
First of all, tell us about this Epworth score.
Epworth sleepiness score is something
that we use in sleep clients on a very frequent basis.
It's looking at sleepiness
in specific situations.
And Nick would use it a lot
in his practice as well.
We define sleep...
NORMAN: Shows great confidence in Nick.
NICK: I've never even heard of it actually.
(Laughter)
We define somebody as being sleepy
if they've got a score of greater than ten.
So, we're looking at a situation of zero where this does not occur,
one has a slight chance of occurring...
- ..two will occur quite frequently... NORMAN: So what will occur?
Being sleepy in a given situation,
such as... after lunch without alcohol, sitting down reading.
The ones we get most concerned about
is when somebody goes to sleep at the traffic lights.
- And they score a three. NORMAN: Right.
So you'd be looking at something like that,
and thinking, 'Well, this person's got a high probability
of having obstructive sleep apnoea.'
So you'd like to do something about it.
Now, if you had somebody who you perceived might have insomnia,
they generally score very low on an Epworth sleepiness score,
because they usually are hyper-aroused.
So they're not sleepy during the daytime.
This comes back to our overachiever, high performance...
Yeah, but maybe the 'wired' infliction,
perhaps sometimes more than the overachiever.
And so they tend to score very low scores,
usually about two or three on the Epworth score.
We just call it the ESS.
And if they had a score of greater than eight,
not as high as what you first start to look at somebody
with obstructive sleep apnoea,
then I would be looking at the possibility that somebody with insomnia
had some other sleep disorder,
such as restless legs syndrome, obstructive sleep apnoea,
or they may be very depressed.
And tell me about depression, anxiety and insomnia,
and how you disentangle all that.
If I could disentangle all of those things,
I would probably be somebody with a magic wand.
NORMAN: Like Nick? - Yes.
(Laughter)
NORMAN: OK, so how do you assess him, apart from the...
..apart from this, what's the...
I think one of the difficulties is, until 1996,
if you were looking at anybody who had insomnia,
you didn't have anybody in your study who had anxiety or depression.
And if you were looking at somebody with depression,
you would perhaps not describe
their sleeping difficulties to any great extent.
So it's only in the last few years that we have any studies
where you have individuals with anxiety, depression and sleep.
And so it's quite hard to pull out what is really happening,
and which is the chicken and which is the egg.
It is a bi-directional problem.
I mean, until recently, it was thought
that if you had insomnia, you had depression,
fix the depression then the sleep problem will go away.
And now we know untreated insomnia
will lead to depression in many individuals.
- So how do you manage this man? - How do we manage this man?
Well, I think you would spend some time, as Bandana was saying,
and also Tim, finding out what's really happening for him.
Because he goes to sleep in a reasonable time,
and he's waking in the middle of the night,
it's quite possible that he's waking after his second sleep cycle.
He may be waking then at the end of dream sleep,
so his brain will be very active and it's very easy for him then to go from
dreaming to thinking and worrying.
And, in the middle of the night, when you're alone,
and you're the only person awake,
it's often when all the problems
of whatever's happening to you descend upon you.
It's the great, sort of, cloud of doom.
NORMAN: So what do you do for him?
Well, one of the interesting things is when we try very hard to go to sleep,
it's quite difficult.
So, what you may suggest to him is that he sits up in bed,
and focuses on a point on the opposite wall in his bedroom,
and tries to stay awake in the dark.
That is very boring and it's very difficult to do,
because the little voice that's been keeping you awake now says,
'But you're trying to stay awake, don't you want to go to sleep now?'
My understanding also is that there's quite good evidence that sleep...
that good sleep habits that we discussed before -
dealing with your core temperature,
what other people call have a sleep hygiene in the bedroom,
and those sorts of things does work for insomnia.
Not alone. So if you just did those, sort of... those sorts of things,
like reducing alcohol and caffeine, and not having your computer,
and all those sorts of things in the bedroom,
they definitely help.
But what we do know is that treatments for insomnia,
such as reducing the time that you spend in bed to increase your sleep debt,
or getting up when you're tossing and turning in bed,
they're the treatments that are the most effective long-term.
NORMAN: So tell me about sleep restriction.
Well, what we often do when you're not sleeping,
is spend more time in bed trying to sleep.
And the rationale is, 'Well, if I'm not sleeping, at least I'm resting.'
And inadvertently, the individual is training themselves to be awake in bed.
So bed becomes a place of being awake instead of a place of sleeping.
It becomes a very uncomfortable, unpleasant place to be.
So the person can go to sleep in front of the television,
they can put their head on their computer board.
Go to bed and they're wide awake. And so it's a learned response.
And, so, if you can reduce the time that you spend in bed,
you will increase your sleep debt
because you're spending less time in bed,
and you're only really, sort of, going there when you can't stay awake,
as opposed to lying in bed and trying to sleep.
Then what we need to do will generally...
NORMAN: Tell me the instructions you give him for sleep restriction.
OK. You'd probably ask somebody to keep a sleep diary for one to two weeks.
You'd then look at how long they actually spend in bed each night,
and how long they actually sleep.
And this is the individual's assessment of their own sleep.
So then you would put the assessed sleep time,
and you'd divide it by the time that they spend in bed,
and multiply it by 100 over 1.
That gives you a thing called sleep efficiency,
and a good sleep efficiency is around about 85% or more.
But if somebody has insomnia, you're aiming initially for about 80%.
So you would reduce the time that they spend in bed,
so that their sleep time is going to be...
NORMAN: So don't go to bed till a certain time,
then get out of bed always at this time in the morning.
Yes, and you can adapt it to the individual's needs.
NORMAN: There's always getting up at the same time each morning.
As much as possible. If you've got somebody who's a morning person,
they might want to get up really early, and go to bed earlier.
Or you might want to do going to bed later,
and getting up at the same time as they were before.
So you can mix and match that depending on what type the person is
in terms of morning or evening type.
So sleep restriction and then you can extend it slowly
as they start to sleep for a higher percentage of the time.
Often by about a quarter of an hour at a time.
NORMAN: And what was the other thing you said that was important?
It's called stimulus control therapy.
So, basically, what you're trying to do is to take all stimulation,
or anything that keeps a person awake.
You want to take the person away from the bedroom,
and you want to take the things away from the bedroom that keep them awake.
And so if you are having difficulties going to sleep,
or going back to sleep within about, sort of... more than about 30 minutes,
and it's sort of a guess, but most people actually go to sleep
within about 10 to 15 minutes.
So we tend to say, 'Look, if you're not able to go to sleep
in around about 15 to 20 minutes and your brain is working overtime,
it's probably a really good idea to get up and do something else for a while,
something that's very boring, and do it in very dim light,
so you're not stimulating, or preventing the suppression or the...
secretion, sorry, of melatonin at night.
OK, and what about cognitive behavioural therapy?
Cognitive behavioural therapy is helping the individual
to be aware of how they think about something.
So if you believe that your sleep has gone away,
and it's never going to come back,
that's a pretty daunting... you know, thought to have.
And that means that you're then going to be experiencing
poor sleep for a very long time.
But if you start to have an understanding of sleep and sleep stages,
and what you may have inadvertently done
to train yourself into those poor sleep patterns,
then you're able to set boundaries.
And it gives you the option of relearning sleep.
Because sleep doesn't go away, we often train it away.
That's been shown to work in randomised trials?
Yes, it's been shown to be very effective
over the last, sort of, 20 to 30 years.
It's been around for a long time.
We have some very large randomised controlled trials.
And now the American Academy of Sleep Medicine
see cognitive behavioural therapy as the first line of treatment.
Nick, what's the correct advice with caffeine?
We just had a question from a general practitioner in Queensland.
Well, look, I think caffeine can be a significant sleep disrupter,
and I think it's best advi... well, avoid it in the late evening.
Again, it's a bit idiosyncratic.
I mean, some people can tolerate it fine, you know.
Personally, I can have a cup of coffee at ten o'clock at night,
and go to sleep straightaway afterwards.
I think, probably as people get older, they don't tolerate it quite as well,
and certainly, we would be taking a sleep history here,
and try to identify if caffeine was a contributor to their sleep disruption.
NORMAN: Delwyn, alcohol is the same? It's a bit idiosyncratic.
It can be, but generally what we suggest to people
is that they think about if they want to have alcohol,
have it earlier in the evening, because it helps you to go to sleep
but it tends to fragment your sleep in the second half of the night.
Then if you have obstructive sleep apnoea,
that will make the soft tissue at the back of the throat more lax.
You're likely to snore more,
and you're more likely to have hypopnoeas or apnoeas.
TIM: Not to mention dehydrate you and make you go to the toilet.
And drug interactions with some of the medication that you might be taking
to put you to sleep as well.
- So no coffee, no ***. And... DELWYN: No, diminished.
NORMAN: Diminished.
We spoke about hypnotics earlier,
but when is the right time to give sleep medication, if ever. Nick?
I think what Tim said earlier was pretty much spot on, really.
Short-term usage in difficult situations, absolutely.
I mean, I think it can be useful, but...
I think there are a group of patients
with very severe psychiatric disease that may...
The reality might be that they may need a hypnotic medication.
But, certainly as a long-term therapy,
we would absolutely try and avoid it if we possibly could.
It'd be a very small number of patients who'd end up on that sort of therapy.
NORMAN: Delwyn? - One of the comments I'd like to make
in terms of hypnotic medication which I think people often forget,
is that if you're taking a hypnotic medication,
you often start to lose the confidence that you can sleep,
and you become very dependent.
And confidence about sleeping is a very healthy thing to have.
So it's a mind game.
DELWYN: It is a mind game, and a very important mind game.
Some of the medications have been at least partly associated
with some unusual behaviours during sleep.
- The Stilnox story. - Well, yes. In parts.
And it's a difficult cause-and-effect relationship.
But when you get a patient talking about sleep eating or other things,
it does catch your attention, really.
They eat things like butted cigarettes and cat food,
and all those sort of things that you wouldn't normally expect people to eat,
and it's quite a striking history actually.
It's probably not an unusual situation
to have the long-term benzodiazepine users
who have had several failures in reduction of their medication
that really, at the end of the day, are better off staying on them,
so they don't run into problems, you know, withdrawing,
or having rebound insomnia,
or also going to multiple different practitioners to get prescriptions.
I think even with the over-the-counter ones, the antihistamines, the Unisom,
and the rest of it that people come in to buy,
again, they've only ever been shown to work in very mild forms of insomnia,
not in the moderate-severe and certainly not with people
who have this crossover between
depression, insomnia and other disorders.
And again, if you see the elderly population,
there's issues with using antihistamines as well.
So it's hard to recommend something, really, spot-on, for this gentleman.
Let's go to our next case study, who's Jane.
35-year-old nurse at an aged-care facility and works shifts.
She has two young children and she comes to see you, Tim,
because she actually fell asleep at the wheel on the road home.
She's had similar incidents before,
and crossed over to the other side of the road.
She's pretty scared about this.
She's not sleeping well generally, and she's asking for possible medication.
Yeah, I guess your first instinct would be not to leap to the medication
as the answer to this problem.
Shift work's clearly a part of this lady's life,
and, you know, there's got to be a degree of adaptation to that,
and so exploring, you know, the approach she takes to...
you know, how she structures her working life and sleep
is gonna be important to try and work out, you know,
how she should best go about improving that situation.
You also wanna make sure, again, that there's nothing else going on,
that she's got no other medical problems or psychiatric problems
that might be leading to sleep problems also.
NORMAN: Delwyn, what's the story with shift work?
Well, what we know from mainly case histories
is that when somebody is a night-shift worker,
they generally do not become nocturnal.
So they're sleepy at night and they're more wakeful during the daytime.
NORMAN: So, it's your 'astronomer in the darkroom' again.
Yes, it is, and one case history suggests
that it takes 70 days and 70 nights for a human being to become nocturnal,
and the average shift worker does not want to do that.
They want to see their family and friends,
they want to have a life when they're not working.
NORMAN: And not sleep in a coffin and worry about stakes through the heart.
Yes. So, that's a very big problem.
We know that a lot of our major disasters worldwide
tend to occur in the middle of the night,
and because we're not so good at making good decisions,
and it depends on what we're doing.
So, having a drowsy driving situation on the way home
is not unusual for night-shift workers.
So what can we do about it? That's probably your next question.
NORMAN: That was going to be my next question.
We can use light to an extent.
So that if you have afternoon bright light...
So if Jane is sleeping... Now, she's got two young children,
so you'd want to know how old her children were,
and how you can adapt this into what's happening for her.
But if she could have bright light in the afternoon,
and the problem is when she wakes up, if she gets a reasonable sleep,
she's likely to have gritty eyeballs and want to put her sunglasses on
because it's very uncomfortable.
So she needs bright light before she goes to work,
and she needs bright light when she's at work,
particularly in the first couple of hours of her shift.
NORMAN: So her employers need to know that.
They do need to know that, and what would be useful too
when she has a break, if she could actually have a ten-minute power nap.
And even putting your head down on a pillow at night
can sometimes make a big difference to somebody's alertness.
So by having the light in the early part of the shift,
you can delay sleep onset.
So somebody's then more likely to be safer driving home
because their body temperature is... what we're really trying to do is
keep them more alert and we're trying to sort of keep the body temperature
down a bit lower so that they've got more chance of getting into bed,
and having a better quality sleep before it starts to rise.
It's a coincidence, we've got James from Mount Isa asking this very question.
So, what about the problem with the young kids?
She's getting home, her husband's got to get to work,
kids have got to get to school or preschool,
and she just can't do all that.
No, and that's very difficult, because if she's a working mum and she is,
she's likely to put a load of washing on,
she'll take the children to preschool, she'll talk with people,
and she may not even get into bed till 10 or 11 o'clock in the morning.
And what you'd like to do in... in an ideal situation
is to really encourage her to go to bed as soon as she possibly can.
You'd also be encouraging her to wear glasses, sunglasses, on the way home,
and sunglasses at home.
So that she doesn't get the light in the morning,
which will then suppress that melatonin and wake her up,
and make her sleep more difficult.
She needs a sympathetic partner when she's on night shift.
DELWYN: She does and it's very hard.
NORMAN: And what about the fit-to-drive issue
if she's told you she's got problems with sleepiness?
That's gonna vary slightly from state to state,
in terms of, you know, mandatory reporting.
But... And in fact, I would actually even say
that perhaps this presentation might be slightly unusual.
A lot of people that rely on, you know, driving for their...
..you know, their mobility,
might not want to tell you that they've had a drowsy episode at the wheel,
even though it's contrary to their health.
But, certainly, 'fit to drive' comes back to
us being aware of what the guidelines are,
and in our respective fitness to drive.
NORMAN: Nick, does medication help in this situation?
Medication? Oh, well, look, I mean, I think very rarely.
Occasionally melatonin might be helpful
to get people into a normal sleep-wake cycle...
There's probably no randomised trial evidence to support that.
There certainly isn't.
I think what this lady needs to do,
and I think Delwyn's touched on it, is really take her sleep very seriously,
try and make an effort to try and get an adequate amount of sleep in a week,
because I would be very confident she's not getting enough sleep,
and she probably needs to focus on that more than anything.
Maybe her employer does as well.
There have been some very nice studies following doctors around
who are sleep-deprived and documenting their errors.
It's a very significant problem.
And, I mean, I know it... from our own days of training, you know,
at the end of 14 hours or so,
you weren't as sharp as you were at the beginning of the shift.
- Big problem. - Let's go on to our next case study.
Mary brings her five-year-old son Joey to see you, Tim.
Busy day today.
He's got a poor attention span, easily distracted,
and his teacher thinks he might have ADHD.
Mary says he's often irritable, difficult to control,
hyperactive, doesn't stay with tasks, doesn't sleep well, tosses and turns,
and she thinks she hears him snoring at times.
TIM: Hm. Yeah, look...
NORMAN: And he's tearing around your surgery as you speak now.
That's not uncommon.
He certainly... That paints a picture which certainly might sound like ADHD.
However, you know, the story of snoring loudly,
poor sleep and irritability during the day,
might be a way that a child like that presents with sleep apnoea.
And, you know, often in that situation, large tonsils, adenoids are a cause,
and, you know, surgical treatment might come first.
NORMAN: Nick?
Yeah, I think it's a fair summary.
You may well be able to do a sleep study in some situations,
but the access to that could be a problem.
I think the point here, as Tim's saying,
is that children present a bit differently with sleep apnoea.
They tend to be more hyperactive,
adults tend to be more sleepy as a general rule.
It's a different disease in many...
So are some cases with ADHD misdiagnosed and they've really got a sleep problem?
Look, many children with ADHD have a sleep problem, absolutely.
But I think some have sleep apnoea, really.
So it cuts both ways? ADHD, sleep problems,
or sleep problems causing what looks like ADHD?
Look, I think both things here,
and I think it should be considered anyway in situations, you know.
Straight examination, looking for large tonsils and large adenoids.
Even snoring alone in children might actually be
somewhat detrimental to their neurocognitive development.
So it's an important issue.
You might want to treat that before you whack them on to Ritalin.
You want to consider it, I think, absolutely.
And what do stimulants do for sleep?
Well, it depends.
I mean, in the right circumstances for rarer conditions such as narcolepsy,
stimulants can be a very important part of getting people back on track.
They can be a sedative, Bandana, in ADHD?
BANDANA: In rare cases, yes.
But, certainly, for example, you don't want to be using them
in the late afternoon or evening,
because, of course, they can disrupt sleep significantly.
They prevent people getting to sleep and further exacerbate the problem.
OK, let's go to our final case study and that's about Joan, who's 48.
She presents with symptoms of an irresistible urge
to move her legs in the evening, making it difficult to get to sleep at night.
Her husband complains that when she's asleep, she kicks her legs repeatedly,
and she says she's tired the following day.
She has had these symptoms before
and each time it was when she was pregnant,
particularly late in pregnancy,
and she thinks her mother had the same problem.
She's recently been started - because she's been feeling a bit low -
on Cipramil. Tim?
Well, look, I mean, I would say this is relatively uncommon.
I don't know how many GPs would agree, but a relatively uncommon degree
of this problem that would present to a GP.
It's perhaps not uncommon that the term 'restless legs' would be passed
at some stage during consultation every now and then,
but not be a big part of it.
Um... so... yeah, that would be my initial comment, I think.
And...
I'd probably be interested in what Nick has to say about this.
Look, we see a bit of this, obviously, and there are a couple of comments.
The pregnancy - there is a link between restless legs and pregnancy,
iron deficiency and restless legs.
I think if you've got a patient with restless legs,
I'd be checking their iron levels and looking at their ferritin.
If it's low, I'd obviously be investigating the cause,
but also iron replacement can be a very effective therapy.
Some medication, Cipramil's one.
The SSRI's tricyclics can worsen the situation.
There can be a family history. It's not an uncommon problem.
People probably don't present for medical help all that often.
There are some patients that find this very disruptive.
I mean, it's a late nights, or evening late night problem,
urge to kick or move their legs, relief with movement.
That follows the circadian rhythm pathway
for being an afternoon, evening and night problem.
It can be very disruptive sometimes.
There's a small subgroup that would do very well with dopaminergic therapy.
- Only a small subgroup. NORMAN: So this is L-dopa?
Potentially L-dopa, possibly the dopamine agonists
would be the first-line therapies,
and nonergot dopamine agonists, the older ones -
cabergoline and pergolide - had a lot of problems with nausea,
but also with some cardiac valve abnormalities.
So the newer drugs - ropinirole, pramipexole -
can be very effective sometimes.
NORMAN: But it's got to be low dose. You can get augmentation of symptoms.
You can, and the augmentation, when symptoms can come on earlier in the day
and involve the arms as well, can be quite distressing.
It can lead to people further increasing the dose and exacerbating the problem.
So caution is needed.
For the right patients though, it can be quite significant symptomatic relief,
and they may go on, this group of patients,
to have leg kicks during sleep, periodic movements of sleep,
but may further disrupt their sleep as well.
So they may have difficulty getting to sleep, or disruptive sleep as well.
NORMAN: Bandana? - Yes, that's right.
There's also some possibility of drug interaction.
If you are on pramipexole or ropinirole, they're also authority prescriptions,
so it's not an easy prescription to get by.
They're costly for people who choose to buy it off the PBS.
Um... also sometimes they can interact
if you're also taking some antipsychotic medications
because they work in exactly the opposite way.
Do you have any, sort of, things up your sleeve
in terms of restless legs from a psychological point of view?
Well, I guess, one of the things is there's a fear then of going to sleep
because they feel so uncomfortable, or they wake in the middle of the night,
and they're going to have very uncomfortable legs.
So sometimes standing up can help.
Going to bed at times
having the shower head on the back of the legs can be useful.
NORMAN: The what?
Using the shower head on the back of your legs.
NORMAN: Kicking it or...?
(Laughter) - No.
DELWYN: As much pressure as you have and lucky to have pressure,
which is probably not that helpful in rural communities.
But, again, heat can be a slight...
..you know, it helps a little bit in terms of improvement,
and then some good healthy sleep habits.
But it's a difficult one,
because often you have insomnia and restless legs syndrome.
So... it's not easy for the individual.
Give us 90 seconds on narcolepsy and parasomnias, Nick, before we have to go.
Right, I'm on the clock starting now.
NORMAN: Couple of people have asked questions about them.
Look, narcolepsy is a fascinating condition.
- Probably autoimmune NORMAN: Autoimmune?
Well, potentially autoimmune in nature, there's a HLA link there.
Tends to come on in late teenage years and there's a classic tetrad of symptoms
which involves daytime sleepiness,
hypnagogic hallucinations, very vivid hallucinatory dreams at sleep onset,
cataplexy - which is the loss of muscle tone -
elicit with laughter or emotion,
or sleep paralysis - waking up and being aware you're awake,
but being unable to move,
that many people would have normally in the community anyway.
Very disabling, in the right circumstances sleepiness is a problem.
Cataplexy tends to come on later in the condition, sleepiness first.
The stimulant medications can be very effective there.
Parasomnias - they...
I mean, sleepwalking and talking are common in childhood,
can persist into adulthood.
NORMAN: Not a sign of epilepsy? - Not usually a sign of epilepsy, no.
Nocturnal epilepsy comes into your differential
for all parasomnias, but rarely.
Complex but stereotype behaviour would make you think about epilepsy.
In older individuals, particularly with neurological disease,
and Parkinson's disease in particular,
REM behaviour disorder can be a very distressing condition
where there's violent, aggressive punching, kicking, screaming at night.
Good for marriages.
Not terribly good for marriages on the whole, no.
Many sleep conditions are not that good for marriages.
Snoring's pretty annoying too.
But this is a condition that's quite responsive to the drug clonazepam,
so I think if you've got a patient with Parkinson's disease,
it might even develop, first of all, before Parkinson's disease.
We're thinking about if you've got somebody
exhibiting violent dreams during sleep later in life.
95 seconds. Perfect. Thank you all very much.
What are your take-away messages for those watching? Tim?
Look, I think being aware of the range of sleep problems
is important for us as GPs.
Taking a good history, including a sleep history,
making sure you're excluding significant medical problems,
you know, attending to healthy sleep practice,
and learning how to inform people and get them to use resources,
and recognising the usefulness of sleep studies.
NORMAN: Bandana? - I think pretty much the same.
Pharmacy's a very front-line profession.
We're often the first port of call that people come to with problems.
The easy solution is not simply to provide them
with what they're asking for, but to get a little bit of history,
be aware of the different risk factors for the different sleep disorders.
Pharmacists are also privy to...
I guess, a medication history of patients,
so they know what medications people are taking.
Be aware which medications affect sleep, or could possibly be affecting sleep.
Also it gives you an indication of what other medical conditions a person has.
So if you're putting two plus two together,
and it looks like this person has some risk factors
would be a very strong referral,
I guess, for moving on to get a proper diagnosis
from a GP or a sleep physician.
NORMAN: Delwyn?
I think it's setting boundaries for your sleep.
So, having a constant waking time is extremely important,
and that means getting up regardless of what your quality
of night-time sleep has been like, or how you feel.
And along with setting boundaries is actually letting sleep happen,
not trying too hard, not worrying about it,
and knowing that most times your brain and body really do try very hard
to work together to give you a good health when it can.
NORMAN: Let it happen. - Let it happen.
NORMAN: Nick? - They're all good points.
One thing I'd just like to add is, I think we're hearing increasingly
that access to diagnosis and treatment is not always available.
I think the challenge for us is to try and build
the skilled health-professional workforce,
be they all of my colleagues here, nurses as well,
to try and use simplified techniques to diagnose and manage
sleep apnoea in particular, but sleep generally.
I think good sleep has been underestimated -
it's important for good health generally.
Thank you all very much. Fascinating program.
I hope you've enjoyed this program on sleep and health.
If you're interested in obtaining more information
on the issues raised tonight, there are resources available
on the Rural Health Education Foundation's website
and that's at rhef.com.au.
Don't forget to complete and send in your evaluation forms,
and please register for CPD points by completing the attendance sheet.
Thanks to the Department of Health and Ageing for making the program possible,
but thanks also to you for taking the time to attend and contribute.
I'm Norman Swan. I'll see you next time.
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