Dr Darren Mansfield: Thank you very much, Andrew, and thank you for coming tonight. It's great to see a really good turnout. Sleep Health as part of wellbeing is really getting a lot more attention and more and more I'm seeing interesting people coming along wanting to hear a bit about presentations on Sleep Health and why it's important. If I tried to do this 10 years ago, I'd probably have maybe two people and a Rottweiler in the room, but now we've got 80 people in the room for this sort of thing, so it's really, really good because I think there is a lot more public recognition coming to this field.

And we're even starting to get governments interested. Just 3 years ago we managed to convince our Federal Government to commit to a parliamentary inquiry into the healthy sleep of Australians and that was not an easy task for us to convince them to do that because governments, as you might expect, they've got an awful lot of key public health priorities and it's very hard for them to deal with a new kid on the block trying to convince them they've got an extra public health priority to start investing in. So they have been very receptive. I won't say they've been gushing us with money, but at least they've really started to come to a level of recognition.

And one of the reasons that the governments are coming around and the general public and the communities are coming around to an understanding around sleep is that we could reasonably expect that 40% of people, and maybe 40% of people in this room, over their lifetimes will have a sleep disorder. So when I talk on sleep topics, I'm usually talking to somebody who either has a sleep disorder or that they're very closely connected to somebody else who does. So it becomes a very relevant topic for most people.

And tonight, I'm going to talk on sleep apnoea and I'll have some time to talk a bit about insomnia because they are 2 of the most prevalent sleep disorders. I am happy in question time to just throw it open to any type of sleep problem that comes to mind. I can probably have a go at most of them, and body clock disorders, particularly among adolescents, is a very other important subject, so if that's something I haven't got in my slide preparation, but I can certainly talk to it in question time if you wish. And I think we can go to our first slide.

So this is what sleep apnoea is all about. If you take somebody's upper airway, on the left that you can see here where the tongue is sitting in that forward position and the airflow can either work its way through the nose or the mouth and down into the lungs through the windpipe or the trachea. In our upper airways, however, we have a lot of circumferential muscles around them and the tongue that sits there is actually a large floppy muscle. As we fall asleep, we lose muscle tone and our tongue and other pharyngeal muscles become rather floppy and that airway can become quite collapsible.

And you can see here in the case of somebody who's having obstructive sleep apnoea is that the airway can actually occlude. And it's often a transition. So an airway that's narrowing will set up snoring. So that means that the air is being squeezed through a very narrow space in that upper airway right behind the tongue and the tongue will flutter and the soft palate will flutter and will make that snoring noise. So snoring is telling us that the airway is becoming compromised. However, there is still air moving in and out, and people are ventilating and their oxygen levels are usually maintained.

If, however, that tongue was to drop back further and the other muscles around it were to collapse a bit further, that's when we can have this scenario of the occlusion of the upper airway. Now, as you all might imagine, we now have an unsustainable situation. So the person that's doing that is going to need to respond and they'll do so by wakening. And in wakening, that episode may be just milliseconds to several seconds long and that might be all it is and that would be enough to regain muscle tone, allow that airway to reopen, start ventilation again and that person would go back to sleep and, in most instances, they would have little or no awareness that had occurred.

But, of course, as soon as they're back to sleep, then they're at risk of the same thing happening again and this becomes a repetitive cycle. And by this being repeated across the night and in some instances many times per hour, sometimes 60, 70, even 80 times an hour we'll see people occlude their airway, it leads to significant amounts of sleep fragmentation, and as you might imagine, a certain percentage of these people will wake feeling very tired and have variable degrees of tiredness and drowsiness throughout the day.

And one of the key problems of sleep apnoea, apart from the noises they may make at night and apart from the concern that they may give to their partners that see these big long apnoea episodes or apnoeic episodes which is really just a medical word for saying stopping breathing, and it can create a lot of apprehension for partners that are observing this, is that non-restorative sleep and all the consequences that may come from that and I'll talk a little bit more about that. 

Next slide.  OK, so why is it that humans are so predisposed to this? So this is an upper airway of a human and next to it is a chimpanzee [the image on screen at this time shows a chimpanzee and a human side by side, both facing to the left. Both the human and chimpanzee airways are superimposed on the images. The human airway is much longer and more cylindrical than that of the chimpanzee. The chimpanzee airway is shorter and stubbier]. And humans are particularly prone to sleep apnea because of this really long cylindrical upper airway that we have and I'll point to it here. From there all the way down to here is unusually long and cylindrical compared to other animal species.

And that is something that developed over many hundreds of thousands of years so that our upper airways can do quite sophisticated things and allows us to create very sophisticated sounds. So humans phonate. They can communicate in very sophisticated ways and make all kinds of sounds in ways that other animal species cannot. So we have created this long cylindrical airway for communication purposes, but a long cylindrical upper airway is also an unstable upper airway compared to a short, stubby upper airway that something like a chimpanzee might have, for example. Now, chimpanzees, they can squeal, they can grunt, but they can't make anything like the range of sounds that we can. So that's what we've sacrificed – a stable upper airway for the purposes of communication. And that's the trade-off, is that humans are much more likely to snore, much more likely to occlude their airway at night than most other animal species. So there are some dog species, and the bulldog is the classic example of an animal that can have sleep apnoea, but most others, it's actually pretty uncommon or, for that matter, it might be mild.

Next slide [the slide shows an older male who has a round tummy].  I'm going to use a stereotype to then perhaps to some extent dispel the stereotype. So when I grew up in this field, we thought of somebody who's having sleep apnoea might look like this chap. First of all, he is a chap, so there is a male predominance, a little bit older and a little bit rounder than some other people, and that extra weight, particularly weight around the upper airway, and it will get into the tongue itself, and it even gets into the soft palate. So fat tissue finds its way into all kinds of places which narrows the upper airway. And by narrowing that upper airway, you can imagine that predisposes it to occluding.

However, I think it's important to point out that if you are only looking at somebody like that to try and make a diagnosis of sleep apnoea, you're going to miss nearly a third of it. So, women have sleep apnoea commonly. Probably about one third of the frequency of men. But that's still being a common condition. It's common amongst women. It is common also in leaner people when they may have some upper airway, an anatomical predisposition. So people with short jaws, for example, might be people that will have a narrow or smaller upper airway and will predispose them to sleep apnoea. So we look for all of these sorts of things as well as your conventional sort of weight-related sleep apnoea which it’s, as I say, common, but think beyond that because a third of them will not necessarily be overweight.

So if you're going to the doctor or even more commonly when in my practice, the sleep apnoea sufferer is marched in, usually dragged by the ear by somebody else, most commonly a partner, to have their condition looked at. And we have to stop thinking why it is that, that people may choose to come or, for that matter, why a partner may choose or encourage, sometimes strongly encourage, their partner to come along and see somebody like myself.

Next slide [the slide is not shown on the video, it keeps focus on the speaker].  OK. And this is one of the more common reasons, is just that snoring is quite disruptive. It's socially disruptive. And bothers bed partners. So I'm far more likely to see somebody in my practice turn up if they have a partner as opposed to somebody who sleeps alone simply because they just get that encouragement about and that feedback about how loud their snoring might be or, for that matter, apnoea episodes are observed at night.

Snoring possibly is not a true health problem. It's a social problem. So loud snoring all by itself, perhaps in the absence of sleep apnoea, if they're able to ventilate sufficiently, but it's just noisy ventilation, is often thought of as more of a social concern than a true health concern. There's been some evidence to link just snoring in the absence of sleep apnoea with higher rates of stroke and perhaps heart disease, although I don't think the evidence is really stacking up as better data comes through. So, think of it more as a social problem, but we do see some snorers that perhaps are just a little tired even though they may not necessarily have much sleep apnoea. And just that loud vibration probably in subtle ways does affect their sleep quality sometimes in ways that we can't even measure. And as a result, we will see a degree of tiredness in these people and therefore it's important to treat, certainly if they're tired. But otherwise, I think our reason to treat this condition is in part in consideration for how disruptive they are to other people.

This is the second reason that we often have people come and see us is they're tired and they're often sleepy. And the sleepiness is often in passive situations more so than active situations. So, for example, if I had sleep apnoea and if I was a tired and a generally sleepy person, I could probably still reasonably likely stay awake throughout the rest of this presentation. However, if people in the audience have got sleep apnoea, you have a much higher chance than me of falling asleep. We may have the same condition. So sleepiness is very situational. Very hard thing to measure if it's highly situational. So, a sleepy person in a stimulating context will still generally stay awake. Sleepy person in a more passive or boring or inactive context, far more likely to fall asleep.

But if it's really severe, it still will actually start to be intrusive even when they are trying to do more stimulating tasks. But in the workplace, if these people can be in a meeting, the sorts of questions I ask, in a workplace, what are you like in a meeting? What are you like in a meeting, in particular, if you aren't doing much of the talking? What are you like in a presentation of somebody else? What are you like in a car as a passenger? What are you like even if you're the driver? Because for many people, driving can be a fairly relaxed and passive task because they're so used to it. Not everybody. Some people concentrate on their driving and for them it's a very stimulating task. But many people it's a passive task and therefore they are at risk of falling asleep driving. And falling asleep at the traffic lights is actually very common, and falling asleep on a highway, as you might imagine, much more likely than falling asleep around the streets of Glenferrie.

But this is one of the things that I have to spend a lot of my time thinking about, the implications of sleepiness. Not just how it may affect performance in the workplace, but safety. And this was a truck driver who did fall asleep and these are the sorts of things that I have to think about with anybody who comes to see me in relation to sleepiness is: could they create a safety risk, particularly on the road. And so, driving is one of those things that there is an obligation to be fit to drive and we have to push the issue a little bit more strongly if we have sleepy people who we believe might be at increased risk of creating this sort of scenario, as you might see.

But sleepiness is not just around could it affect your productivity or your safety or the safety of others. It has a lot of effect on mood.  So tired people are probably not as resilient as alert people. And we think that that has an impact on anxiety levels and mood disorders like depression and so forth. So, there are very strong links now between degrees of tiredness and sleepiness and the implications it may have on mood and mood disorders. We are in the business of improving people's mental health and very, very importantly in young people who are sleepy. And we have some young sleep apnoea sufferers, but young people can be sleepy for other reasons and other conditions too which we can touch on in question time if you choose. But resilience, I think, is very strongly related to fatigue and drowsiness levels. So that's one of our goals.

And the third reason that people might come to see us is the implications around long-term health. So, if there's occluding of the airways going on repeatedly at night, just imagine that somebody is standing over you, if you happen to have sleep apnoea, with a pillow and just dropping that pillow over your face and holding it there for 20 seconds, then lifting it up, and then waiting a little while, then dropping a pillow over your face. That's what sleep apnoea is like and you can imagine it creates a stress response. When people asphyxiate, their oxygen levels will fall. Then they'll have this abrupt arousal. Their blood pressure will go up, their heart rate will go up in response to that. So, you can see each of these episodes of asphyxia causes a stress response and if this is happening repeatedly across the night, could this have long-term health implications? And the answer is yes. It does. It affects blood pressure. It affects the risk of heart disease and later in life, higher rates of stroke. And there's now good emerging evidence to suggest also that it may affect cognitive function later in life. And it makes sense if you stop breathing and your oxygen levels fall, neurons or brain cells, they don't like a low oxygen environment. Our 30-year-old neuron is pretty resilient and can probably cope with it. What about a 70-year-old neuron or an 80-year-old neuron? And there is some evidence to suggest that you can increase rates of neuronal death later in life with sleep apnoea, particularly if the oxygen levels are dropping a long way.

So, this slide here is a graph that looks at the longer term survival of those that have severe sleep apnoea and compares mild sleep apnoea as a group, snorers without sleep apnoea as a group, and healthy people that neither have sleep apnoea and snore. And I'll go one side or another, but you can see all of those other groups, their longer term death rate as shown here. And time, over here, cluster together [on the graph, snorers, those with mild sleep apnoea, sleep apnoea with a CPAP machine and the control group have lower risks of fatal and non-fatal cardiovascular disease (between 5-10%). Those with sever sleep apnoea have higher risks of disease (30-35% for non fatal cardiovascular events, 15-20% risk of fatal cardiovascular events). So, the likelihood of these people dying of any cause is rather clustered together. But this group over here is severe sleep apnoea. We would suggest that the moderate through to the severe end of sleep apnoea has higher rates of cardiovascular disease and, as a result, higher rates of death, more so than just the snorers or the snorers with a very mild sleep apnoea.

So, if we're treating for longer term health, we might suggest that the moderates to severes are the ones that we might target. If we're going to treat mild ones, you'd probably use a little bit more around assessing the extent to which the related snoring is disruptive to others, the extent to which mild sleep apnoea might make people tired. And it does. Mild sleep apnoea can still make people quite tired and drowsy during the day in some circumstances. There's a lot of variability in that, but the more severe the sleep apnoea, the more likely you are indeed to be tired and drowsy during the day. Next slide [the slide is not shown on the video, it keeps focus on the speaker]. 

OK, so if we're looking at sleep, this is a conventional way of investigating for sleep apnoea and it's a bit cumbersome. We have to ask people to sleep over for a night and we stick a whole bunch of wires and bands and then we ask them to peacefully go off to sleep and we'll wake you up in the morning and you'll enjoy the experience and have a great night out. And, I'm sure there's people in this room that have had sleep tests and if you have, you probably haven't quite seen it that way. There's a lot of stuff that's stuck on you. It is disruptive to the sleep. It seems a bit ridiculous that the very thing that we're trying to measure is interfered with by all the stuff that we put all over you. But that's how we've conventionally done it.

Historically, it was always coming to a facility or a hospital and have all of this stuff put all over you and we'll monitor your brainwave activity, bands around the chest will measure your ventilation, your breathing measurements on that sit under the nose. You can't see there, but there's a little probe that sits on the finger which measures oxygen levels and heart rate and body position. So there's a lot of information that we get from these tests, but for the customer, it's a lot of stuff put on them and they don't especially enjoy the experience. If I've had somebody who's had one of these before and I'm suggesting they need another one, it's a bit of a pitch. They don't want to come back because they don't really feel that they sleep as well as normal. But we can make an allowance for that and we very usually will get a satisfactory result even though people may perceive they don't sleep as well as they would in their home setting. And there are portable systems now whereby these can be done in the home. Still lots of bits and pieces are stuck on, but, nonetheless, it is simplified, it can be done in the home context.

But there is hope of making this easier again and some of the newer technologies out are condensing a whole sleep test into something that sits on your finger. And this device is actually available currently and there are other devices similar to it and it just measures oxygen level and pulse rate and one or 2 other fancy signals on the finger alone. And it makes an interpretation from how the pulse rate works as to whether this person is awake or asleep and even attempts to work out what stage of sleep they might be from the pulse rate and they can measure pulse rate and oxygen levels and estimate the likelihood of somebody actually having sleep apnoea from something as simple as this. This might be our future and we think that we can convince people to do this test more readily than the full laboratory test. They're not quite as good yet. I mean, they do make some estimates and some inferences. So, they're not as accurate. But they probably are a little bit of a step forward for a lot of people.

OK. So, if you've seen the GP or the specialist, you have a diagnosis of sleep apnoea and we would think about why are we going to treat this? Is it something to do about the disruptive nature of the snoring? Is it something to do with the symptoms of non-restorative sleep, drowsiness and fatigue? Do we think it's severe enough to impact your long-term health risk? And they're the 3 fundamental things going through my mind when I decide we're going to treat this condition. There is a little bit of overtreatment in milder forms of sleep apnoea that are perhaps not that symptomatic. Maybe they live by themselves. Maybe nobody's complaining about the snoring. Maybe the health risks aren't that severe. Sometimes we may not always need to treat those, but there can be a bit of a tendency to still want to treat them. So, keep that in your mind. Even ask yourselves or if it's relevant to you or you know somebody, think about why you would want to have this condition treated.

And then we can talk a little bit briefly about what sort of treatments there are. This is the most well-known treatment, so these are called CPAP machines, continuous positive airway pressure devices [the slide on screen shows a man lying down on a bed with his head on a pillow. There is a machine placed on the bedside table with a hose that connects to an air mask on the man’s face]. So that little mask that's sitting on the nose attached to an air pump on the bedside table and it is just room air just sucked out and delivered under a little bit of pressure. And that pressurised air going into that airway will literally expand or effectively inflate that upper airway and prevent that airway from occluding. So I would practically guarantee 98% of patients with sleep apnoea, I would say to them, we're hooked up to one of these devices, you will stop snoring almost completely and the apnoea or the airway occlusions would stop almost completely. So, it's extremely effective. So, doctors like treatments that work. It's fair to say not every patient who comes through the rooms is jumping out of their skin to get hooked up to one of these devices. It's pretty cumbersome. So, you've got to think through this fairly carefully. Is this the right treatment? Is the problem severe enough to go to this kind of trouble to be hooked up to one of these devices? If the symptoms are significant, the patients do like it. They're always ambivalent to start with. They're always guarded. It's always a bit of a "give it a go" and rent one and have a shot for just a few weeks. But if the patients are quite symptomatic and they suddenly wake up the next day and it's the first time, sometimes in years, they actually feel like they've had a good night's sleep, they will take to it pretty quickly and then forget all the cosmetic implications of this and the hassles of carting these things around. They feel better and so it can make the world of difference.

For those that aren't terribly symptomatic, and we do see that, people sometimes even fairly severe, and they're not terribly tired. It is a little bit harder to convince people that this is the solution for them and we have to look at other options.

And things like this is a little mouth guard [slide shows an image of a jaw mould with teeth, with a clear transparent mouthguard sitting over the teeth]. So, these devices are usually made up by dentists and they sit on the teeth like a mouth guard that somebody might wear playing sport to protect the teeth, but it's got an upper and a lower dentition. It's just designed to reposition the bottom jaw slightly forward. And the tongue being attached to the bottom jaw is pulled forward and will actually create a little bit of room at the back of the throat and in doing so reduce the likelihood of snoring and sleep apnoea. And these can work really well for mild to moderate sleep apnoea sufferers and snorers, but it's not terribly good for severe. We just can't get enough jaw advancement for the severe ones to overcome that occlusion. So, we're cautious about who we may select for this. But they certainly can work for a sizeable number of people.

Next slide [slide shows an image of a face from the nose down. The mouth is open wide and you can see the person’s tonsils. The tonsils are enlarged]. Think about other things, which I haven't touched on, is that's a big set of tonsils there and sometimes we get 16-year-olds that are snoring furiously and they are lean and we think, "What's going on? Let's have a look down their throat" and we might see something like this. So, it's not the tongue that's doing all the occluding of the airway. It's those fat tonsils that you can see. So, tonsillectomies can work really well for snorers and sleep apnoea. So, we always make sure we have a good look down there and we will recommend to take the tonsils out if we think that that's what the cause is.

Next slide [slide shows text saying “Aim 10% weight reduction from diet and exercise. Can cure mild OSA. Bariatric surgery for more significant weight loss. Improves but does not resolve moderate to severe OSA. New drugs]. OK, weight loss. Body weight is something that significantly contributes to sleep apnoea risk and progression over time. Weight loss is hard. For the number of times I've had the discussion, every now and then we get somebody that's done a fantastic job with weight loss through diet and exercise, but it's really tricky. People, when you put on a bit of weight, it resets the whole system and it's almost like we want to just maintain this weight. Every time you diet, the metabolism adjusts to try and get you back up to that weight you started at. It's extremely difficult to maintain weight loss. But 10% is achievable. Much more than that, it's really hard work. 10% of weight loss, that is. And so, we look at other things and that's where bariatric surgery. So, things about lap bands and gastric sleeves have become increasingly popular in the last 15 or so years because they work. But, again, it's a big procedure and it's not without risk and there might be evidence to suggest that 15 or so years on, that weight does start to work its way back up again. Although they are very effective for a good while.

And there's some new drugs on the scene. Many of you will have heard about Ozempic and similar drugs to that which is now actually, so popular, we can't get it in Australia. But it is probably the most exciting weight loss drug that we've had to work with for, well, ever. And we might see on average eight to ten kilos weight loss with that injectable medication once a week. Watch this space. It's not available in the pharmacies anymore and I'm not sure when it's coming back. They promised March, but they could be talking March next year.

Next slide [the slide shows an armadillo lying on the ground with a beer can up against its mouth]. And alcohol reduction. Alcohol is a muscle relaxant. We don't tell people they have to be tea-totallers, but just we do encourage people to drink in moderation, particularly if you're a known snorer and we think that you've got sleep apnoea.

And finally body repositioning [the slide shows an image of a tennis ball on the left, and on the right an image of a woman sleeping on her side while wearing a device around her chest that has a large lump on the back side]. So, if you think the tongue's dropping backwards, and many people will know this, the snorers are worse on their back than on their side and that's the same with people who occlude their airway completely with an apnoea, often it's worse on the back than the side. And there are devices that can be used to keep people on the side-on position. When I first entered this game, it was just get a tennis ball, stick it in a sock, wear a T-shirt, safety pin that sock to the T-shirt right in the middle of the back and then you've got a tennis ball sitting there. That generally keeps you off your back, so that works. And there are other commercial devices like big cushions that you can wear and there are now even electronic devices that work as body position sensors that will actually buzz or vibrate or something like that when you get onto your back and tip you back onto your side. And they work quite well. Some people like them. I won't say that they're enormously popular. But it is one of the options that we do run through with people.

So I'm going to wind up on sleep apnoea and I'm just going to, if I've got time, talk a little bit about, insomnia or talk a bit about it in question time if you like. So, it's a really common problem. We might say 5-10% of the adult population can be expected to have sleep apnoea. That's how common it is. If we're going to treat it, think about why we're going to treat it. Is it because of its disruption to others? Is it because of the daytime symptoms of fatigue and drowsiness and the risks that that entails? Or are we concerned about the long-term health? We don't treat it just because it's there. We try and encourage our doctors to actually say, "Hang on, get back to why we're treating it.  And then move from that position, not just the number on the page." But it is fair to say doctors are guilty of seeing something and then feeling compelled to treat it. But you can hold them to account next time you go there and say, "Hang on, why are we doing this?"

I'm going to talk a little bit, just a few minutes, about insomnia and I'll just race through it pretty quickly, because it's probably our second most common sleep disturbance that I would see. Insomnia is interesting that the vast majority of people who suffer from insomnia will not get help or if they get help, they might go to the GP or they might go to a store and just get some natural sedatives or something like that. So, some self-help strategies, perhaps a visit to the GP, but as a specialist in this area, it always surprises me, that we're really only just seeing a fraction of the problem that are finding their way to us. People really do just put up with this problem, not necessarily convinced or aware of what solutions might be in play. So, I see predominantly people with chronic insomnia. They're the ones that would have symptoms of difficulty getting off to sleep or maintaining sleep when there is opportunity to sleep. These are not the people that are just spending not enough time in bed because they're out and about on a Saturday night having a late night. We're talking about people that are in bed but can't sleep for a period of that night. And it would have to be 3 nights a week and a chronic insomnia sufferer would mean that it has to have been going on for 3 months.

Next slide [the slide shows an image of a young man lying on a pillow with his eyes wide open with stress. Over the image are the words “the thing that I said 5 years ago was very stupid”]. And there's a model that's been described which explains why this might actually arise in predisposed individuals and there's 3 components. There is, in fact, the predisposing factors, the, precipitating, then finally the perpetuating factors. And I'll just quickly go through those. So, these are the ruminators. These are the people that spend a lot of time thinking about things that, and we all do it and some of us do it more than others, but that sort of thinking about the day that's just gone, thinking about the week or the month or what's on tomorrow or what's on next week, whatever it might be, rumination is one of the predisposing factors for having difficulty either getting off or maintaining sleep.

A stressful event can be a precipitating factor. And this is the most common scenario that I see is in a predisposed person, something happens. They might lose their job, they might have a relationship breakdown, they could have a car accident. It could be just a single one-off event, whatever it might be. But, of course, it creates stress. Anybody who's stressed will have more difficulty falling asleep or maintaining sleep. That's quite normal. Many or most will make a recovery from that over time and you would expect their sleep would therefore be restored. So when you're treating those short-term insomnias, that's where medication can be quite useful and I think that's what medication is really designed for – people with stress, short-term insomnia, short-term use of medication can be quite effective and there is less fear or worry that this will turn into a long-term strategy.

However, the ones that are likely to see me are exactly that when that happens. So when the insomnia does not go away as the stress goes away or they get over the stressful scenario but they're left with a persistent insomnia.

And that's where we talk about the perpetuating factors. What's happened that's caused this insomnia to start to be perpetuating? And that's when we start to turn the stress into the stress about sleep itself. It starts to be worried about. If I go to bed tonight, will I fall asleep? Or if I wake up, I'm worried now, will I get back to sleep? And I've got all this stuff on tomorrow and I've got this busy schedule. I've got all these things that I've got to pull off and now I can't get back to sleep. So, I'm going to actually change the stress to whatever it was beforehand into sleep itself. And as you might imagine, then that becomes a self-perpetuating problem – worrying about sleep. I see people that worry about their sleep so much, they design their whole daily schedule or redesign their whole schedule around trying to figure out a solution that's going to help them to sleep that subsequent night. Some people even give up their jobs, because they feel that they just can't do it anymore because of this lack of sleep. So, we really try and turn that on its head. Sleep is only there to restore you so that you can be a productive person during the day. We don't want to have people withdraw from their daily activities in order to get some sleep. It's got to be the other way around. And we talk to people a bit about that. And people can sometimes go into their bedroom and think their bed looks like this. You know, this is a dreadful place to be. "I hate the bedroom." Some people get anxious going past the bedroom. So, it becomes a conditioned response. Either going to bed or thinking about bed creates a stress response. So, you can see how we’ve now got a perpetuating cycle.

Next slide [slide is not shown, the video focuses on the speaker]. Now, excessive time in bed. If you aren't sleeping well, you are more likely to say, "I'm going to go to bed a little bit earlier to give myself my best chance." I might wake up at 2 or 3 in the morning and lie awake for 2 or 3 hours and then fall back to sleep at 5 in the morning and you might get 2, 3, 4 hours then. And you think, "If I don't get those extra 2 or 3 hours from 5 am, I'll just fall the pieces." But guess what that's turned into? That's 9 hours in bed in some instances. So I have a simple view. If you are spending 9 hours in bed and your body does not need 9 hours of sleep, it's this simple - you are going to lie awake and you are going to perpetuate wakefulness because of that extra time in bed. And that's one of our key focuses. The vast majority of people I see with insomnia are in bed more hours than the average in the community and we're going to change that. We're going to do something that's quite counter-intuitive and make that less hours in bed.

Now it's really common. It's certainly at least as common as sleep apnea, but, as I say, most people just suffer through this and manage on their own.

Next slide [The slide shows text with the title “Insomnia Treatment CBT-I. Beneath the title it lists behavioural techniques including sleep hygiene, stimulus control therapy and sleep restriction. It also lists cognitive techniques including attitudes to sleep and relaxation and mindfulness]. OK, and I might speed up over that one and go on to, some treatments. So how do we treat this? When you all hear about the 10 healthy tips for a good night's sleep and some of them can be really helpful, but once it's fairly severe, we have to do some slightly more dramatic things and one of the things that we really focus on, or 2 things that we focus on, is a thing called sleep restriction. It's reversing this long time in bed. If you are in bed 9 hours, we might make it 7. Sometimes we might even make it 6 hours. And that's quite a shock to people when they come in. The sleep doctor says 6 hours in bed. It's absolutely the opposite of what you might expect. They would be told at a sleep clinic to actually reduce your sleep opportunity. What happens is that we build up a little bit of sleep debt.

So we'll go to the next slide if we can [The slide has the title “Sleep Restriction”. There is a graph that is a straight horizontal line. On the left hand side, the start of the line is labelled 10:30 pm. On the right hand side the end of the line is labelled 7:30 am. There are 4 separated blue bars sitting on top of the line. Underneath the line, there is the text “Sleep efficiency = Total sleep time/Time in bed = eg. 65%”. So it might be, those blue bars might be somebody's sleep pattern across 4 blocks of sleep and, interspersed with periods of wakefulness. Let's just say it might look like that. And let's just say it might be 9 hours in bed. So, we're going to then ask this person when they're ready and when they've planned it to reduce that time in bed.

Next slide [The slide shows the same horizontal line as the slide before including the 4 blue blocks. There are 2 additional vertical lines placed along the horizontal line]. And we'll put some vertical bars there to indicate when we're going to ask them to go to bed and when we're going to ask them to wake up and we plan this. We don't say, "I want you to start tonight." I said, "Let's look at your schedule. When are you not too busy? When are you having holidays? When can we do this? And I'd rather you do this in 2 months when you're ready than do it tomorrow night when you're not ready. Because you've got a big schedule." Because we're going to make that person initially more tired than what they currently are. If all we're going to do is shorten the time in bed. But we are going to build a little bit of sleep debt and we're going to use that sleep debt to our advantage as it accumulates over about 10 days to 14 days and it builds sleep pressure. Sleep pressure is what we're looking for. We want to make these people a little bit more sleepy. As opposed to the sleep apnoea sufferer, we want them to actually build a little bit of sleepiness. Sometimes they say they start getting sleepy during the day and I say, "Great. That's what I want." I don't want you to actually be sleepy during the day when you're doing things, but it's great to hear that you're building a little bit of sleepiness. Don't have a nap because that will dissipate and will lose the effect of it. But hang in there and wait till bedtime and we'll actually find it starts to turn into much more continuous sleep at night for a short time in bed. And when that's achieved and those people will, there's a lot of psychology in this, they'll suddenly feel, "I can do this. I'm back in control. I'm not so fearful about going to bed. It's going to be a short time in bed, but at least I'm starting to have confidence that it'll be mostly sleep." So, all of those negative thoughts and associations start to disappear and you can bring it back out. These people will start to increase their time in bed and it will hold together. And at some point down the track, if it unravels again, they've learnt the strategy and they can re-implement it. So, if this works really well, I rarely see people again. They self-manage this. If there's another stress or another factor later on that causes their sleep to be disturbed, they just implement this themselves and it works very, very well. Sleep restriction as a strategy is something that takes a bit of time to talk people through. A bit of time to convince people it's the right thing to do. And a bit of planning around, "We're going to make you tired. We're going to make you feel worse before you feel better. And we have to have a strategy around that." So, it's a little bit of relationship building. Because the patient has got to have confidence that this is a good idea because it wasn't what I was expecting. So, you can see how this is hard to implement in a 15-minute GP practice. There are online tools that recommend this sort of stuff. And, again, that is also hard to be convinced that it's the right solution if it's just an online tool or an app telling you this is what you need to do. So, this is possibly one of the reasons why some of the really good strategies around long-term insomnias are not out there broadly applied in the community.

One of my jobs is to make people a little bit more aware that these sorts of solutions are in place and they're not drugs. It's a behavioural strategy and it's not even particularly a cognitive strategy. We can do relaxation techniques and meditation techniques and they do help a bit, but they don't help as much as sleep restriction and that's what we focus a lot on and we use all the cognitive state around relaxation to supplement that, but it's not the main part of the solution. Short times in bed for insomnia is really what we focus on. And we'll make it complex. We'll get people to follow diaries and various other things to actually track whether they're able to maintain this or implement it.

But there are some times that we just can't get by without a medication and some people do still need to be supplemented with the medication. The really severe ones, we don't always succeed with that strategy and we will introduce some medication. When somebody has a medication, we are trying to think, "Well, who needs one? What type of medication? And how long might we need to use it for?" Because it could be a long time. And that doesn't always sit well with GPs, pharmacists or, for that matter, even the patients necessarily. Most people come and see me because they're trying to get off medication or avoid medications, but there's a percentage of times we still have to use it and it's OK. And if we do it in a supervised way, we rarely run into problems and we try and give people some permission that this is actually an acceptable strategy. And about a quarter of our people that we see with chronic insomnia will still have to be supplemented with some form of medication. But 3 quarters of them, we can get by with just a behavioural strategy and a little bit of some cognitive techniques as well. I'm going to stop there.