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Dr Yasir Hameed (MRCPsych) Specialist Registrar Norfolk and Suffolk NHS Trust 28 March 2014 This presentation was presented at ADHD Training Day at Dunston Hall in Norwich on 28 March 2014. The day is free for all staff and is kindly sponsored by Eli Lilly Neuroscience plus is supported by the Trust NDD Steering Group and the Postgraduate Department.
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Dr Yasir Hameed (MRCPsych)Specialist RegistrarNorfolk and Suffolk NHS Trust28 March 2014
» Sleep and its importance
» Sleep disorders in adults with ADHD (focus on DelayedSleep Phase Disorder DSPD)
» Assessment
» Treatment
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Upon completion of this educational activity,participants should be able to:
» Recognise the delayed sleep phase in adultswith ADHD.
» Explain the consequences for health ingeneral of late and short sleep on the longterm and how to treat the delayed sleepphase.
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Sleep
» Restorative/homeostatic» Thermoregulation/energy conservation» Consolidation of learning and memory
» Cyclic nature of sleep is reliable» REM periods every 90 – 120 minutes» First REM period is shortest» Most deep sleep (Stage 3 & 4) occurs early» Most REM occurs late
» All variety of sleep disorders are more common amongstchildren and adults with ADHD than healthy controls,controls with other psychiatric illness, and health siblings
» The DSM-III considered excessive movements during sleepto be a criterion for hyperactivity in children
» Sleeping disorder (predominantly delayed sleep phasedisorder) prevalence in clinical studies of adults is 80 % andin clinical studies in children – 73 %
» Kooij, JJS. Adult ADHD Diagnostic Assessment and Treatment. Third edition. 2013. Pearsonpublication.
» - (Very) late Chronotype
» - A chronic pattern of (very) late sleep and preference forlate rise
» - May result in daytime sleepiness and/or insomnia
» - May be compensated for by an irregular sleep pattern
» - Leads to dysfunctioning due to increasedinattentiveness and/or social problems
» - Main complaint is sleep onset insomnia11
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» Partners having different bedtimes is anothercommon problem for having sex
» High rates of divorce and separation(Biederman J, Faraone SV, Keenan K, et al. 1992)
» 4 times more likely to have complaints of poorquality relationships (Biederman J, Faraone SV,et al 2006)
» Clinical history˃ Sleep initiation, maintenance, duration; refreshed and
alert in AM; bedtime routine; anxiety/depression; unusualnight-time behaviours
» Sleep log˃ 2-3 weeks to document sleep-wake patterns˃ Munich Chronotype Questionnaire (MCTQ)
» Smartphone apps˃ Sleep Cycle Calculator
» Actigraphy and Polysomnography˃ Needed for OSAS, RLS, or nocturnal seizures
» Management is “diagnostically driven”, anddepends on thorough assessment and aformulation to include the likely underlyingcause or causes.
» Interventions:
˃– Sleep diary˃– Sleep hygiene˃– Switch of medication˃– Dose reduction˃– Other medication˃– Drug holiday
» In a randomized, crossover study in children withADHD, results indicated that, relative to baseline,immediate-release MPH increased sleep-onsetlatency statistically significantly more than didatomoxetine (p<.001), consistent with the time toonset of persistent sleep and mean time to onset offirst sleep epoch (p<.001 for both)
» No difference in ADHD rating scale IV-Parent Version
» Sangal et al. Effects of atomoxetine and methylphenidate on sleep in children with ADHD.Sleep. 2006;29(12):1573-1585
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» Medication is rarely the first and only choice
» Behavioural strategies aiming to sustainimprovement and minimise adverse effects
» Melatonin has both immediate and extended-release forms (Circadin®)
» Evidence?
» In practice, adverse effects are relativelyuncommon and self-limiting. There isincreasingly reassuring evidence that this is asafe medication in hypnotic doses of up to10mg .
Bendz L.M.,and Scates A.C. Melatonin treatment for insomnia in pediatric patients with attention deficit hyperactivitydisorder. Ann Pharmacother 2010 44(1) 185-191Weiss M.D., Wasdell M.B., et al Sleep hygiene and melatonin treatment for children and adolescents with ADHD andinitial insomnia. J Am Acad Child Adolesc Psychiatry 2006 45(5) 512-519Rossignol D.A., and Frye R.E. Melatonin in autism spectrum disorders : a systematic review and meta-analysis. DevMed Child Neurol 2011. 9.(783-792)
» Promethazine» Clonidine» Benzodiazepines» Z hypnotics» Antidepressants
» Whatever medication is tried, periodic breaksfrom treatment are prudent to assess whetherongoing treatment is necessary.
» Most hypnotics will remain ineffective in thepresence of poor sleep routines,overstimulation at bedtime or the challenges ofnocturnal multimedia.
» Always give advice on sleep hygiene23
• Sleep difficulties are highly prevalent in ADHD, are oftenmultifactorial in origin, and significantly impair quality of life
• Sleep difficulties exacerbate daytime ADHD symptoms
• Shared biological dysregulation in ADHD may contribute todisordered sleep
• Assessment of ADHD is incomplete without a sleep history (pre-and post-treatment)
• Sleep diaries are particularly useful in assessment
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