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Section 17
Brief Consultation Strategies with Sleep Disordered Clients

Question 17 | Answer Booklet | Table of Contents

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.

Management
If a patient presents with insomnia or volunteers it us a major problem in their life, the use of a structured approach based on four steps should ensure a successful outcome to the consultation.

Step One: The first task is to understand what the patient's actual problem is. The six questions to ask are:
Is there difficulty getting off to sleep? In this case, anxiety/worry is a common cause.
Is there difficulty maintaining sleep, perhaps with early morning waking? Early morning waking is a common symptom of depression.
Are there any particular sleep disturbances — for example, nightmares, restless legs, jerking limbs?
Duration of the problem. Is this a short-term insomnia after a stressful event such as an exam or a death in the family, or is it long-term (more than six months' duration)? If not handled well, short-term insomnia can turn into a long-term problem.
Docs the insomnia significantly interfere with functioning in the day — is the patient tired or irritable in the day through lack of sleep at night? Patients presenting with tiredness may well have a sleep disorder as the cause.
Is the patient a shift-worker (where the whole circadian rhythm of sleep may be disturbed)?
These six questions will allow you to judge the problem. If you wish to further document the insomnia, you can ask the patient to complete a sleep diary, noting when they went to bed, how long they took to get off to sleep, how many times they woke in the night and the total hours of sleep.

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
Psychiatric: anxiety, stress, bereavement, depression, dementia
Physical: breathlessness, cough, pain, nocturia, hot flushes associated with the menopause
Environmental: partner who snores, noise outside, bedroom being too hot, too cold or too bright
Alcohol and alcohol withdrawal
Smoking
Caffeine-containing drinks — tea, coffee
Prescribed drugs — for example, beta-blockers, theophylline, SSRIs, steroids, levodopa
Use of stimulant drugs
Shift-work

Tips to aid sleep
Establish a regular routine by having a set time each day for waking up
Go to bed when tired but not if you are not
Avoid sleeping in the day
Ensure you have a comfortable bedroom, with no noise, good curtains, a comfortable bed, and check that the room is the correct temperature
Exercise in the day but not late at night before sleep
Don't undertake mentally stressful tasks at night — instead, do something you find relaxing and enjoyable before you go to sleep
Avoid alcohol, tea, coffee and large meals before sleep
Stop smoking
Try and relax before going to sleep — don't tax your brain just before going to sleep!
Some prescription medicines may affect sleep — check with your doctor

Practical points
To document the problem, ask the patient to complete a sleep diary
Short-term insomnia is usually caused by a stressful event such as bereavement
When treating insomnia target specific causes
As many as 30% of patients become physically dependent on benzodiazepines when they use them for more than two to four weeks
- Mead, Mike; Ten minute consultation: Four steps to insomnia management; Update, 1/19/2006, Vol. 72 Issue

Personal Reflection Exercise #3
The preceding section contained information about brief consultations with sleep disordered clients.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 17
According to Mead, what is one technique that can help a therapist gain insight into the exact nature of the client’s sleep disturbances? To select and enter your answer go to Answer Booklet.

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