 Okay, welcome to the 320 or so clinicians who have joined us for tonight's webinar. The webinar is organized by the Mental Health Professionals Network. The title of this webinar is Collaborative Mental Health Care, Older Persons and Sleep Disturbances. I'm Shantha Rajaratnam and I'll be facilitating tonight's session. I'm a professor of psychology at Monash University in Melbourne and I currently serve as the president of the Australasian Sleep Association which is the peak body representing sleep clinicians and researchers in Australia and New Zealand. We're privileged to have such a stellar group of clinicians in our panel tonight and I'd like to begin by introducing this panel to you. First I'd like to introduce Dr. Richard Kidd who is joining us from Queensland. Now you can't see Richard but he's certainly with us by phone, unfortunately his camera is not working so he's going to participate in this webinar by phone. Kidd will be providing a GP perspective on the panel. Welcome Richard. Hi. It's great to have you with us. I see that you're a GP with a special interest in aged care. Can you tell us a little bit about how this came about? Well, at one point I was actually thinking of being a geriatrician when I was a very young doctor in New Zealand and I was in an accelerated position training program and the Auckland hospital had a geriatric acute admitting unit attached to the main body of the hospital and I was admitting and discharging patients every day and the love of looking after aged people really started then and has never left me even though I've gone off and done other things like be a volunteer in Papua New Guinea. All right. Well it's great to have you with us Richard. So joining Richard is Professor Collette Browning who's a health psychologist based in Victoria and an expert in healthy aging and behavior change science. Welcome Collette. Thank you, Shanta. Can you tell us a little bit about how your research is influencing the way practitioners are managing health problems in older persons? Well, we have a longitudinal study in Melbourne on healthy aging and we've been examining what are the predictors of good outcomes in old age. And interestingly a lot of those predictors are actually health behaviors like physical activity and good eating but also we found that sleep is an important predictor of healthy aging. So I was very pleased to be invited to participate on the panel because obviously sleep is an important issue for older people and contribute significantly to their well-being in old age. Well it's great to have you on the panel Collette. In our panel is Dr. Rod McKay who is a New South Wales based psychiatrist who works with older people. I notice that you work across community residential care and inpatient settings Rod. Do you see sleep disturbances impacting on health and quality of life across all of these settings to what extent do you see it? There's no doubt but in all those settings sleep disturbance happens for many reasons and has quite a profound effect on quality of life so it's a very important issue and very important to not mismanage it. So, pleasure to be here tonight. Thanks Rod. So and last but not least I'd like to introduce Dr. David Cunnington who's a sleep physician based in Victoria, well known for his breadth of expertise in all aspects of sleep medicine. Welcome David. Thanks Arthur. David what prompted you as a physician to develop such strong expertise in behavioral and psychological treatments for sleep? Unfortunately once I got really interested in sleep it was unavoidable. There's just such interaction between how we behave, the society we live in, how we live our lives and how we sleep that I couldn't get away from it. Well it's great to have you on board David. So I note that the audience would have seen the ground rules for these webinars that are coordinated by the mental health professionals network. I'm not going to go through them again but I remind you of these particular rules. So, the learning objectives are shown on the slide there, our aim through an interdisciplinary panel discussion about this particular case study, Wayne, an older person who may be experiencing mental health issues and or sleep disturbances, we will raise awareness the link between mental health and sleep disturbances, identify the key principles of the featured panelist's approach in assessing, treating and supporting Wayne and also identify the merits, challenges and opportunities in providing collaborative care for Wayne. Now, we know that sleep loss and sleep disorders are increasingly common and are associated with a wide range of health consequences including hypertension, cognitive impairment and mood disturbances, all of which we note in the case study today. Now there's a critical need to increase knowledge among mental health practitioners about the impact of sleep disorders and appropriate management practices. So, looking specifically at the case study of Wayne, we note that he's a 67-year-old man who has retired from a job that involved shift work about five years ago. He has a history of high blood pressure, slightly overweight, snores loudly and reports being awake for much of the night. His wife is concerned about recent episodes of memory loss and his depression. Now, Wayne himself recognizes that he's tired during the day but really thinks that these health problems are a part of him becoming old. So, let's consider what our panelists recommend for Wayne and also for Bev. Now, I'll ask each panelist now to give a short, disciplined, specific response to this case study and then we'll take questions across the panel and we'll also start to look at some of the questions that you have all asked as the audience. So, I'd like to now hand over to Richard to discuss his response to the case study. Richard, over to you. Well, there are a few things as the GP with this couple coming in. The first is that Wayne is not necessarily at this point a willing participant. He's been dragged in by his wife Bev and thankfully at the end of the introduction between Bev and Wayne, there is a segue for the GP to be able to maybe get some engagement with Wayne when he turns around and says, well, Doc, I just tell her it's aging and there's nothing much you can do about it, it's there. And that's the point where the GP can say, well actually, Wayne, no, this may not just be aging. There are a number of things that you've described there and that Bev's described that we could look at and maybe we could make things a whole lot better for you and have you feeling much, much better. And so, that will give us an opportunity to then think about some investigations and involving other people and sorting things out with them. It's probably a bit too early for a differential diagnosis but clearly if there's been weight change, if he's got pain, if there's mood problems, cognition problems, if he's breathless, all of these things the GP needs to think about and that will devolve down into things like whether he might have diabetes, prostatism, maybe something a bit more sinister with his prostate, whether he's suffering with sleep apnea. So, the GP needs to think about all of those things as well as obviously dementia and depression. And the other really important thing I think is that when you have a couple presenting like this, is Bev depressed? Is she the one who's not sleeping as well? And what about her pain control? So, the GP really has to look at the dynamics of the couple. So, certainly blood and urine tests for Wayne, more history and family history around dementia and depression as well as diabetes and prostate problems and as is probably often the case, they probably didn't make a long appointment. So, part of it is trying to get the engagement for them to come back to work them up for a comprehensive mental health assessment, looking at cognition and mood and considering referrals to maybe a sleep physician, a psychologist. So, I think the GP in that first session really has to just get some engagement and explain there's a few things to sort out and there'll be a few other people to involve in the process probably. Well, thank you Richard. I think this is a great segue really into Collette's perspective as a health psychologist. So, Collette, perhaps I'll hand over to you now. Thank you, Shantha. Yes, I'm taking a health psychologist perspective but also, obviously I work in the field of gerontology so I'm also looking at some that as well. I just got a message on my machine about activating camera. Here we go. Good. I'm back again. So, I think the perspective of a health psychologist is very interesting because although we've obviously trained in psychological principles, we try and look at the interrelationships between physical, cognitive and mental health issues and in this case sleep disturbance in the context of age-related changes and expectations. So, from the gerontology perspective, what I'm interested in is looking at age-related changes and how these might impact. So, in later life sleep quality has actually been shown to be an independent risk factor for falls and depression and can actually inhibit recovery from illness. So, once again, this interrelationship between sleep and physical problems as well as mental health problems is very much in the realm of the health psychologist who would be able to assist Wayne. Also, I think Shanta has pointed out that quality, good quality sleep is also important for cognitive functioning and memory consolidation. And again, we have to look at this case from that perspective as well. A lot of older people assume that if they've got poor memory that it's because they're getting older, but it may be because they have a physical problem that's contributing to that. And also, because as we get older, we're more likely to have multiple chronic illness problems as well. It may be not the age that's impacting on poor sleep quality but a chronic illness that is impacting as well. So, the other point I think I'd like to make is that sleep occurs often occurs in the context of a personal relationship. Many of us don't sleep alone, we sleep with someone else. So, sleep patterns can actually be disruptive to the partner, Beverly in this particular case. And people who have caregiving responsibilities may have very disruptive sleep patterns as well. So, I think that we've got to consider this as a couple not just the case of Wayne. Also, Wayne attributes his health problems including his weightfulness at night as due to old age. And again, I want to highlight this issue of negative expectations that one of the things we need to do as health professionals is to maybe challenge some of those negative expectations that we all hold but also that older people themselves hold about their health issues and how it's due to old age and cannot be helped. Is that my last slide? I'm not sure. I know we're still going. So, I think from any health professional we have to reassure Wayne that in later life health problems can be treated, that there are a range of treatments that are available. Health psychologists will use evidence-based approaches and I note that there are some treatments for example using CBT approaches particularly around insomnia that have been shown to be quite successful. The other part of this case is that Wayne talks about some weight issues and management, perhaps some chronic illnesses that he may have. And again, a health psychologist is very well suited to deal with these sorts of issues because the health psychologists were trained to look at this interaction between chronic illnesses, behaviors and mental health issues. So, again, we can take a more holistic view of this case by looking at all those factors. Thanks, Collette. I mean, that's really interesting. And I think I'd like to take, you know, to pick up on one of the points that you made particularly about the extent to which Wayne has attributed a number of these problems that he's experiencing to a part of the aging process. And I'd like to, you know, in a moment ask all of you the extent to which this then is a barrier to people seeking medical treatment for, you know, such things as sleep disorders, cognitive impairment and so on. But perhaps we'll get to that after hearing the perspective of Rod as a psychiatrist. So to Rod, I might hand over to you now. Thanks, Shanta. I'll click on the camera as well and get started. I think the first thing to emphasise is each psychiatrist is going to have a slightly different way of structuring their assessment and how they'd focus on the problems in this case. But in general, they will have a structure behind that. And then the emphasis of the assessment will vary according to the training they've had, their experience with similar problems and also try to hear what Wayne's wishes are and to tailor the way the assessment occurs to meet that. And also looking at where the setting of the assessment is. This sounds like it's in your office, but often the assessments of older people aren't in the office or maybe in the person's home. They may also be in residential care and that has quite a big impact on the way that you actually carry out an assessment. And so therefore what you try to do is follow the patient's responses but move through all the elements of the assessment you'd like to do and make sure all the areas that need to be covered are. So in general, psychiatrists look at a biopsychosocial assessment. So trying to look at how will the biological, the psychological and the social factors interact and actually end up with Wayne in front of you now. And looking for what are the factors that may predispose Wayne to having problems, what's brought him now, what's precipitating it and what might be perpetuating those. I think in terms of Wayne, you can see that there's a lot we don't know about Wayne but we do know that as well as having a potential carer, he's been a carer for Bev as well and that clearly increases the risk for both sleep and mental health problems in later life. What we really don't know about to know more about Wayne is his family history and also personal history to make sure whether he's had any problems or families have problems with depression or with dementia. What we then look at is actually what were the priority assessment issues for Wayne and the most important thing is going to be rapport because Wayne has had an episode in a shopping centre which he may or may not have been worried about. His wife clearly was very worried about as brought to a GP and in this case, the GP has sent him to a psychiatrist. And so it's very likely Wayne is going to be fairly defensive coming in and so that's going to be the most important thing. Then look at the history and how much time he's spending that really depends on the quality of the referral information that you receive and mental state examination. And very much depending on how receptive Wayne is, the degree of cognitive testing you do on a first assessment or whether you negotiate doing that at a second assessment but trying to do at least some brief cognitive testing with an instrument such as a 3MS which is increasingly used in use at Wales. And then trying to develop a formulation of what the problem is both from your perspective and from Wayne's perspective as well as Bev, which I think moves on to actually what will be the priority issues to consider. One is that with any assessment is having a risk assessment in the back of your mind. Knowing that older people have, and especially over 75, have got significantly more chance of completed suicide than younger people and that you don't get as many chances to intervene. So it's important to have that in the back of your mind but particularly missed medical conditions to be what I'd be most concerned about when I was first seeing Wayne. And there's really a very broad differential diagnosis which we start to work through my mind and tailor the questions to look at those. And then think about which areas will actually impact most on initial management, which is probably in this case particularly what is it that Wayne particularly wants to see addressed. And I would suspect that either clarification or reassurance about memory problems actually might be to him come to see a psychiatrist the biggest issue. There's so much awareness raising about dementia that he's becoming a real problem about people actually becoming too worried about developing dementia. And so I'd be particularly concerned to make sure that was addressed. And then think about what are the future roles of both psychiatrists if it's required. Wayne may not have mental health issues. It could well be that it's only other issues but make sure you're negotiating what is your role and what is the role of other parties. And in terms of the principles that really will vary on who is actually involved. So mostly that treatment will be in a shared care model with the GP in an informal setting with the way that I would practice. No, I think a number of psychiatrists would practice. And then looking at in terms of an older person how do you bring in other resources to help with social needs if they're required. And so it will be a combination of direct management. I'd be reluctant to be looking on the history we've got at medication for Wayne but if you were looking at medication I think the thing I'd emphasise is because someone may have depression and sleep disturbance doesn't mean you need an antidepressant that actually is sedating. And I think it's one of the key mistakes to avoid in cases like Wayne if depression is present. And then making sure you're very clearly communicating with the patient and with the GP about not just what is proposed but what might be the side effects of what's proposed and who's going to look out for those and what to do if they occur. And that would then I think might skip the short term but to look at I think because I think it's very similar to some of the things you've heard already but I think you're very much about what are the long term priorities as well. So thinking about the fact that you may not get the diagnosis right first up. And being quite clear with Wayne and Bev that when there's a number of possibilities you might have to work through those and then come back to think about them and discuss with them whether the interventions you've suggested actually are working or not and then once they do work how do you make sure they keep working and the problems don't come back? Well thank you Rod. I think that really leads very nicely into the perspective of a sleep physician. So I'd like to ask David Cunnington to present his perspective as a sleep physician actually just before you do David. I noticed there's lots of comments from the audience that support some of the comments that were coming in before as well about different types of treatments for sleep disturbances and I think a number of you are interested in both pharmacological and non-pharmacological treatments and certainly that's something I'm going to put to the panel shortly after we hear from David. So over to you David. Yeah thanks Shanta. So I thought I'd start just actually with explaining what a sleep physician is because it's a relatively new specialty and sometimes people don't have a good understanding of what we do and sort of who we are. So we're adult physicians so trained like cardiologists, neurologists, rheumatologists, gastroenterologists in that sort of way so expert in managing physical problems in adults and then spend some time specializing specifically in sleep and manage a whole range of sleep problems not just sleep apnea. Traditionally because this has been a joint specialty with respiratory sleep medicine there has been a bit of a focus on sleep apnea but the specialty is evolving we've now got a very broad curriculum that requires trainees to train in insomnia or a range of sleep problems and that's largely been driven a bit by consumer demand. You know as we're discussing tonight people have sleep problems, sleep problems have a major impact on their general health so we need to be able to provide that sort of service and if you look really Western medicine it's not been in that space of providing good services and good help for people with sleep problems up until the last sort of 15 or 20 years. Okay so just to get on to then this specific case so rather than talk through sort of how I'd assess Wayne I've sort of just given a bit of a summary of my sort of feelings about the case and it may well come out, the other panelists may draw me out a bit later about sort of why I sort of come to these sort of conclusions and sort of thoughts about the case. But one of my thoughts about Wayne is that for me rings of a high risk of obstructive sleep apnea. We used to do case identification for sleep apnea just based on asking questions. Do you snore? Does your spouse see apneas? But what we've found is that whilst that's quite a specific strategy it's actually a very insensitive strategy. So if the spouse is seeing snoring and apneas you've got 100% hit rate. That person's got sleep apnea. So now the way we try and look for sleep apnea is actually by comorbidities. So, you know, the way I teach trainees that I talk to or other professional groups I talk to is that if you say you're an expert in managing diabetes and you look at your type 2 diabetics 60% of them will have sleep apnea snoring, not snoring apneas, no apneas, they've got sleep apnea in 60% of those patients. If you look at a population of people with depression or treatment resistant depression which is a large proportion of the waiting room often in psychiatric practices a good 60% of those patients have sleep apnea sight unseen. Not just based on symptoms of sleep apnea. So we're going much more to this comorbidity based diagnosis of sleep apnea just because that's what the prevalence data confirms and that's how we should look at it. So if you look at Wayne's comorbidities, you know, Odds to Apples he's going to have obstructive sleep apnea. And if he's got sleep apnea for me it's going to be important to treat because he's feeling tired, that sort of part of the presentation and there's this interrelationship between sleep apnea and depression. So sleep apnea itself increases the incident rate of depression, sort of new depression. So there's this relationship between having sleep apnea and the future development of depression. Where's my slides up to? Okay, so I'm up to my next slide. So I also think Wayne has insomnia and that's based on a symptom syndrome definition. So DSM4 describes insomnia as either difficulty getting to sleep, non-restorative sleep or difficulty staying asleep and symptoms for more than a month and having an impact on daytime functioning. So he meets that diagnostic criteria for insomnia and probably it's comorbid insomnia rather than just primary insomnia. And my feeling is that insomnia is important to treat because we've got good data that insomnia itself increases the risk of depression and some data that Shanta has been very involved in some of this sort of work that if we treat insomnia itself you actually get improvements in depression outcomes. So very important in this case if we think depression is part of the presenting symptomatology. David, to what extent did in your determination of high risk of obstructive sleep apnea and insomnia, what about the cognitive impairment that Richard spoke about as well? Yeah, to be honest, I don't know what to make of that. You know, there's so many potential contributing factors to the cognitive impairment that I think the only way you're going to sort of skin that is like peeling an onion and just take out one layer at a time and see does that change symptoms. And for example, that's where managing sleep apnea comes in in this case because that's potentially one layer that you can take out. Manage the sleep apnea. See the effect it has on cognitive function. Then manage the next layer, manage the depression. See the effect that has on cognitive function. I'm happy, you know, interested in the comments of Rod and Colette about whether there's more specific things you can do to try and tease out why he's got cognitive impairment. But as a physician, I find that hard to work out the why, what's causing the cognitive impairment. It's a bit hard. I think it's a bit of a chicken and egg one that too because some often older people who are depressed show signs of cognitive impairment. And also, you know, you talked about the co-morbid conditions. There's a fair bit of evidence now that some, you know, things like, you know, diabetes, for example, are contributing to cognitive problems in old age as well. So I think in this case, you know, we're looking at probably treating a number of the conditions simultaneously, maybe with some similar types of treatments. And it might be a bit difficult to know, you know, which way you're getting your effect. But I think it's important to look at the whole perspective here and look at some of those other conditions and how they might be interrelating with sleep problems. Yeah, thanks Colette. So as you can see from my slide, my plan would be referring to you. That's sort of largely my plan. So my sort of next steps for Wayne, so if I'd seen him as a new consult, my next steps would be one, do a sleep study to look at sleep apnea, but then in parallel with that, get help from a mental health professional. And because I sort of co-consult with psychologists, I've just got that availability. So it would be a health psychologist like yourself, Colette, or a clinical psychologist. But yeah, I'm also interested in the views from Rod and the rest of the panel about, well, should I refer to a psychiatrist? Or should I refer to a psychologist? And we'll get into that discussion a bit later. So thanks so much, David. I think there's lots of questions that, you know, I think we can start to ask each other. And that really opened up some of them. So I'd like to start by asking perhaps Rod to, you know, you Rod, you had a question that you'd like to pose to Colette in particular about how to consider non-medical mental health, how do non-medical mental health professionals meet the challenges and what can doctors do to assist? Would you like to ask Colette your particular question? I mean, Colette, I suspect is an exception. But I think one of the questions that I get frequently raised with me from psychologists as well as from others is actually that we've limited training about older people and about medical issues. How do they best actually, therefore, incorporate those issues in their management? And how do they know how to adapt their interventions if there's some cognitive impairment present if they haven't had formal training in how to do that? And then in terms of collaborative care, how can the psychiatrist or doctors help psychologists to encounter those issues? Look, I think this is a really good question. And as I said earlier, as health psychologists, we're really trained to look at that interaction between particularly chronic conditions and mental health issues. So I think health psychologists are well placed to understand those interactions. But I agree, in terms of the training in dealing with older people it was still quite limited in much of our training, be it psychology or other health professions. So I think part of this is to sort of understand that as we age, there's an increasing chance of various chronic conditions that may be influencing our mental health. So even very common conditions like arthritis, which is maybe causing pain in older people, are going to contribute perhaps to their difficulty in sleeping, causing restlessness at night, for example. And multiple chronic conditions are often associated with depression. So I think for a non-medical mental health professional, they just need to really be aware of what those comorbid conditions that their client may have. And I think with a collaborative care approach, a team approach, we need to be able to get information from our clients about how some of those chronic illnesses may be impacting on the particular issue that they're coming to see us about, whether it be depression and or sleep disorder, as in this case. In terms of cognitive changes, again, I think we need to adapt our interventions for that. But in reality, you know, most older people, the type of cognitive changes we're seeing is quite minor. And I was interested in the comment before about, it might have been you, Rod, actually, who said that people worry about just because they're old and they forget something one day. They think, oh my God, I'm getting dementia. Well, I think, again, this is a, we need to be able to reassure older people that forgetfulness doesn't mean you're going to get severe cognitive impairment. Well, I mean, Collette, that's a great, I mean, you, I think, were interested in this issue of, you know, the view that Wayne had put forward that perhaps, you know, this is just a part of aging. And I'd like, I understand you've got a question that, you know, you might like to ask Richard and perhaps Rod about as a perspective of GP and a psychiatrist about age of stereotypes. Yes, well, I think all health professionals need to challenge these age of stereotypes. We see them in older people themselves, as in the case we're looking at now, where older people themselves will attribute negative health issues to old age and then think, well, there's nothing much we can do about it. So I think part of what we need to do is reassure and maybe challenge older people, but yes, there are evidence-based treatments that can assist them with their concerns, but also in the training of health professionals. I'd be interested to know from you, Rod and Richard, how do you see that playing out? Have you seen any changes in the training of health professionals to help address the often-aged attitudes that health professionals have I think for old people? Yes, it's Richard. In terms of the training, as a GP supervisor, I am involved in training medical students and registrars and I have a fairly big practice and we also train nurses and we have some psychology undergraduates here and we have a few psychologists working with us as well. So we're involved in training people across the board in health professions and have a number of other specialties under our roof. And challenging ageism is certainly a very important thing and I might just quickly share one little story with you. I remember very fondly a little Scottish lady who was 104 years old and she was developing some arthritis at the age of 104 in her knee. She was a very strong matriarch. Her children were in their 70s and 80s and they still very much coutowed to mum. But anyway, she was walking using an umbrella, one of those ones with the hollow metal stems and the sharp spike on the bottom. And as a GP, I could see a disaster happening. One of these days it was going to flex and flick up and slice her leg open. And I turned around to her and said, Elizabeth, look, I think it's really time to start using a walking stick. Don't use your umbrella to support yourself. And she turned around in a nice Scottish brogue and said, Oh, doctor, I cannot be doing that. I don't want people thinking I'm old. And she was 104 and she continued to be in good shape until she was 107 or 108. And she was a beautiful example of someone who was cognitively intact, fiercely independent, still very much in control of her family, her financial affairs and everything else, up until about the age of 106. And I've got a lot of other patients who are in their 90s who are absolutely independent. They drive to my surgery and it's great for medical students, nursing students, psychology students to be able to see these healthy people coming in for check-ups. And some of them are on no medication or maybe just one or two medications. And yet at the other extreme, I've got 30 and 40 year olds who are diabetic, have got a bit of heart failure, all sorts of other problems. And some of them will be on 15 different medications. So it's not ageism. It's about recognizing what conditions people have and treating them. And one of the things you were saying before about the sleep deprivation and the cognitive impairment, I think that's a really important thing to reinforce. As a GP, I'm well aware of things like with my, I'm also involved a bit in supervising young doctors. And there's all this fatigue management around them now because we've recognized that if a person goes without significant sleep for 48, 72 hours, they basically behave like someone who's drunk. They have got significant acute cognitive impairment. So when you've got a patient who is not sleeping because of pain or because they're having to get up to pass urine frequently through the night or they've got sleep apnea or some other problems, you've got to address those problems. And quite often that apparent cognitive impairment disappears when you fix the problems and they can sleep. Yeah. I absolutely agree with that. And I think that needs to be the focus rather than the age of the person themselves. Right. I might just, we're going to sort of address some of the audience questions in a moment. Rod, did you have anything to add to direct us to resources that might be useful in addressing Collette's point about age stereotypes? Yeah. I think just briefly, I think one is just to note that actually psychiatrists do sub-train in old age and have brought in competencies for everyone. So I think you can in training address it that way. But in terms of resources, I think the most important resource is hearing from older people themselves. And so I think some of the things that people should be aware of is that COTA with Beyond Blue actually run Beyond Maturity Blues, which is a peer program. So it's older people talking to older people with reported very good outcomes. And the University of Birmingham has got videos on the web which actually older people talking about their recovery from depression in incredibly positive and powerful ways. So I think using those resources and people looking at those resources is incredibly important. And I think also trying to get a couple of positive aging figures that are in your mind yourself, I mean things like 80% of people at 80 won't have dementia. I think about the countryside or some of the negative messages that we often hold in our heads as health professionals. Thanks, Rod. I think what I might do now is one of the common threads in the discussion that's coming forward from the audience is a discussion about non-pharmaceutical, pharmacological treatments for sleep disturbances. And people are asking about yoga, about practical sleep strategies, hypnotherapy and so on. Now I might start by directing this to David Cunnington because there is a strong evidence base, David, and you're an expert in this area in terms of behavioral and psychological management of sleep disturbances. Do you want to just talk a little bit more about that evidence base? Yeah, sure. So there's a really good evidence base for a package of treatments that's bundled as Cognitive Behavioral Therapy for Insomnia, CBTI, both in healthy adults but also in elderly populations, both healthy elderly and institutionalized elderly as well. So really good data showing it's an effective strategy for improving sleep as well as improving other outcomes like general quality of life but also depression, anxiety, those types of outcomes as well. There's really five core components to CBTI and everyone talks about sleep hygiene. There's a few things in the chat box about sleep hygiene. So in meta-analysis, sleep hygiene comes fifth out of five in terms of effectiveness, so it's last. And in the last 10 years, sleep hygiene's been the control condition for most research on CBTI. So we really think that's the effect it has. And often because it's the most readily available thing that people can find, they're trying very hard with sleep hygiene. They've got a very careful pre-sleep routine and they're controlling the environment. But that actually is very counteractive and perpetuates a lot of the insomnia because it puts a lot of the focus on trying too hard to control sleep. So rather than focusing on sleep hygiene, really it's a banner of just make sure they're respectful of sleep hygiene but enough to that, you know what, that's enough. So the other four components of CBTI, the most powerful components are called sleep restriction and stimulus control. And the essence of those two components is matching the time in bed more closely to the amount of sleep people are actually getting. And stimulus control, if you're in bed and awake and don't feel like you're going to go back to bed, get up, get out of bed, wait till that feeling that you're going to sleep returns. They're really the two most powerful components, behavioral components, but they're quite challenging because it really shakes up a lot of the behavioral coping strategies people have had around sleep. If people haven't slept well, they're used to going to bed a bit earlier, sleeping in a bit later to catch a bit more sleep. And they've coped with that strategy over some time and now you're telling them to just completely throw that out and literally using something that's called sleep restriction when they're fearful about not sleeping. You know, it's quite a challenging sort of process. So we try and then incorporate that with one of the other two components of CBTI, relaxation strategies and cognitive therapy. So challenging some of those disordered cognitions people get around sleep. If I don't sleep for X amount of hours, this bad outcome will occur. Well, that's really helpful, David, and another consistent comment that we're getting is how do we know when to treat with these cognitive behavioral strategies that you've been talking about and when to treat with benzodiazepines? Of course, we know that they're widely used in general practice and more recently, melatonin as a treatment for these sorts of sleep disturbance. So, Richard, I might ask you, when a patient presents with significant insomnia, how do you make the determination of what would be the appropriate line of treatment, benzodiazepines, melatonin, cognitive behavioral? I try very fiercely to resist starting anyone on a benzodiazepine. There are a few very restricted occasions in which I will, and that's like, you know, during acute bereavement or some other fairly major trauma, and I'll make it very clear that, you know, the person in that situation where they've got very high levels of anxiety and they're hypervigilant and quite distressed, and it's an acute setting, in that setting I will, you know, be very careful in making it well understood that they shouldn't use the benzos more than three or four times a week. Otherwise, rightly or wrongly, I say that within two weeks of taking them every night, they're going to stop working and they're going to be addicted to them and they're going to find that they get increased anxiety as they start to wear off and then they're going to feel the need to take some more and have no benefit. So, I try very hard to resist the benzos and I try to get people off them who come to me. I think, particularly if we go back to Wayne, one of the things that I mentioned in response to other people is this guy is drinking a lot of tea during the day. There are a lot of times you can look at people's lifestyle and some of the things that they're doing that are actually going to interfere with their sleep and another thing with them is physical activity. A lot of people, when they have stopped working and are in retirement or semi-retirement, have given up their physical activity and if they can get back into regular exercise, that's another thing that can help reset things for them. Yes, and I would agree with that. I think some of those health behaviors are very important in terms of assisting this case, Wayne in terms of his sleep, but also, I think we noted in the case that he was slightly overweight. So, one of the approaches that health psychologists might take with this is to actually look at helping him reduce his weight through increasing his physical activity, for example. Yes, so how do you... David, do you have any comments about in your practice the decision to treat with the cognitive behavioral therapies versus the benzodiazepines? And perhaps you could also comment on when it's appropriate to use melatonin. Particularly, there was lots of questions from the audience about the use of melatonin for elderly with insomnia. Sure, so if I break it up into sort of when do I use a drug and when do I use a non-drug strategy and then I'll talk a bit about which drug. Essentially, I'd use a non-drug strategy all the time. So, always trying to give some type of CBT because there's always some type of behavioral things we can do to get sleep working a bit better and some cognitive work we can generally do. And then if people are distressed and acutely distressed about not sleeping, that's for me the role of drug as well. Not necessarily as a long-term strategy, but as a short-term strategy to help alleviate that distress. Because if people are really distressed, they find it hard to participate often in some of the behavioral change and cognitive change and lifestyle changes they need to make to sleep better. And those strategies take some time to work. Some time can be three weeks, four weeks, five weeks, that type of time. And if someone's really distressed, that they're not prepared to put in the work and wait that long. And then in terms of what drug I would use here, I really liked Richard's comments about the benzodiazepines because it's difficult. Once you start them, it can be hard to stop them. They can make sleep feel different and that changes the expectation. So people then begin to like what sleep feels like when it's a benzodiazepine sleep rather than normal sleep, which feels different to benzodiazepine sleep. And then that's part of the withdrawal thing as they associate, well, I'm not sleeping the same, it feels different. So I used to like the way it felt with the benzodiazepine. So there's potentially a role then for other sedatives and that's where melatonin is one potential medication. People are variably susceptible to the sedating effect of melatonin, which works very nicely for some, not so well for others. And so it's not necessarily your guarantee it's going to work perfectly for everybody. But it's fairly well tolerated, fairly good side effect profile. It's indicated for the treatment of insomnia in those over the age of 55 in Australia. So I think that's a good choice. But I'll also use other over-the-counter preparations like valerian, valerian and hops combinations. You know, often find those helpful and there is data for those as well. But I'll always try and use in parallel a non-drug strategy. With the talk with the patient thing, really the mainstay of treatments, the non-drug strategy, the drugs are a short-term bridge. This is a holding strategy. We're using while we're upskilling you and empowering you about self-managing so that you can manage your sleep going forward. It sounds like, David, there's times where you're going to, you know, require the expertise of one of the, you know, expertise of some of your panel members here, psychologists and psychiatrists. I think you were interested in questions of when you should refer in your practice. Do you want to put that question to your colleagues on the panel? Yeah, so Rod, I'll start. So Rod, often a patient like Wayne often finds himself as the first presentation coming to a sleep clinic. So it's not an uncommon referral for me to see with the referral being from general practice. You know, it sounds like there might be sleep apnea or insomnia, and sure, I'm comfortable sorting out that side of it. But, yeah, if I'm worried about depression, you know, when should I be referring to you? I think the key issue really is where you feel your boundaries of capacity are, and also with the GP. So keeping the GP in the loop about who the person is seeing. I think in terms of the psychiatrist, if the person's beyond what you're comfortable with, I think the thing to think about in terms of seeing a psychiatrist is, is it someone you know? So I think in terms of psychiatrists and psychologists, someone you know you can explain to the person what to expect is really important, probably more important than the professional. Also, someone who's got an interest in older people. I mean, probably one of the most important things in effective treatment of the older person is liking to work with the older person. Then if you look at specifically, I think the specific things that psychiatrists have got is they do have training in working with older people, especially the younger psychiatrist ironically enough because the training has changed. Also specifically, if you're looking at interactions with medications or what are the best medication options, that's something where a psychiatrist would see a special area. And although this overlaps between psychologists, there's the issue that psychiatrists are trained as doctors first and so particulars who are used to working with older people will be very attuned to what is that interaction between physical health, acute or chronic medical conditions and medications and mental health. So I think I'll be looking at those things. And in particular, if an older person there's any concerns about sore sodality, unless you're someone who's very comfortable working with that, it's important to get help from a health professional soon because older people, one, have an increased rate of suicide, especially over 75, but importantly, they don't tend to attempt suicide very often. They're much more successful once they decide to do it to actually do it. So if there's a concern, it's important to get that specialist help at that stage. Thanks, Rod. Perhaps, David, you might call upon expertise of others among the panel as psychologists, for example. So, Collette, you helped me out when I was talking about my views on the case. So, yeah, when should I be sending someone like Wayne to a psychologist? Well, I think the point I was making before where we're looking at what are some of the comorbidities that are occurring around the sleep problems. So if there are physical health problems, like diabetes, arthritis, those sorts of things that might be interfering with the sleep quality, then some of the things might need to be addressed like in the case of Wayne, where he's slightly overweight. You might refer to a health psychologist to help him manage his weight, get him more physically active, help him with his diet, for example, using various behavioral approaches and things like motivational interviewing, for example, which has been shown to be quite successful in helping older people change their behaviors around these sorts of issues. So I think that's the role of the health psychologist would be quite useful for those sorts of things where you're trying to address the comorbidities which will then hopefully have an impact on the primary reason that Wayne's come to see you, which is around sleep. Thank you. If I could just jump in very quickly. I think for a psychologist, if you're worried about cognition, the important thing is finding a psychologist or a psychiatrist who actually is interested and got skills in looking at that area rather than someone with more general interest. Thanks. Yeah, and I think that's the other part of it. Again, it's not clear from the case study with Wayne again whether he has severe memory problems or whether he's reporting them because he's a bit worried about his general health and he's noticed he's forgetful and is starting to worry about that. So again, I think, you know, it's an assessment around, you know, how severe this cognitive impairment is would be very useful in this case. I think just to see, hopefully, to reassure Wayne that it isn't such a problem, but if he has got significant cognitive impairment, then I think he'd have to be maybe referred into a geriatrician to deal with those sorts of issues. It's Richard here. I might asleep in as a GP seamless on a almost daily basis. There's an interesting point that you touched on and that is that it seems that very often the people who I end up diagnosing dementia and then referring them with even very early stages of dementia can fabulate and excuse any shortcomings that occur whereas a person with depression is often very worried that they're going to have dementia and are very worried about some very mild indications of some sort of cognitive issues. So I think the fact that he's been distressed and worried about it probably does point more towards depression than dementia. What would you say, Rod? I think the stereotype is right, but I think there's also a lot of exceptions to it. And in particular, there is an increased rate of suicide in people in the early stages of dementia who do have insight. So I think it's important to be cautious. So yes, there's a yes, but... Yep. So that's really helpful to understand, I guess, David. It clearly looks like there are areas where interactions with the psychologist, the psychiatrist and the important point that Rod made with really closely linking the management plan with the GP I think is crucial there. Now, a number of the members of the audience are asking or have asked before as well, what should sleep look like in someone Wayne's age? Now, is it normal for sleep need or duration of sleep to decrease? Would someone who's 67 experience awakenings and be awake through the night? I might start, Richard, because you might, I guess, have, you know, at the call face of getting people who have certain expectations of their sleep. And how do you deal with this in terms of what is normal as a part of aging? Well, it's an interesting thing. If a person doesn't have any prostate issues, if they've got good lifestyle around not drinking caffeinated drinks as this guy drinks tea all day, and they're not abusing alcohol, if there are a lot of other things not happening, they may well sleep through the night very happily. And, you know, quite a few of my patients don't have sleep problems even in their 80s and 90s. But someone in his 60s, sadly it's not uncommon for them to wake up once or twice during the night and go and have to empty their bladder. Some degree of benign prosthetic hypertrophy or, you know, basically a non-malignant problem with the prostate growing bigger is becoming quite a common issue by the time men are in their 60s. And for women, quite often there are some difficulties for them around bladder issues relating to childbirth. And they have developed a bladder that's taken control of their life. And, you know, the so-called Woolworth's bladder during the day where the first thing they do is look for the toilet when they're out shopping. But again, they're often getting up during the night. So this thing of getting up to pass urine is not an uncommon thing. It doesn't necessarily mean it's normal, but it's not uncommon. But there are things that can be done. And that's where the, you know, a GP needs to engage and say, well, let's see what we can do to improve things. So let me ask the sleep physician then. How much sleep does a 67-year-old male need, David? We hear all about how sleep is important for maintaining good health. So how do you answer that question? That's tough. Enough to feel refreshed. That's my simple answer. Because we've got population averages and we can sort of say what sleeps like across a population. But Richard made a really good point. There's a huge normal spread so that there are some people extremely elderly who sleep very well and other young people in good health who sleep very poorly. So it is a bit of a spread. As a general trend, the amount of sleep we need does reduce across life. And at the age of sort of mid-60s, I'm thinking about six and a half hours is about sort of par. We've got some data on women of the age of 50 that 3.7 awakenings per night is the average. Not one, not two. You know, it's 3.7. And so that once you're older than that, it's going to be even more. And if we look at historical writings about sleep, up until industrialization, human sleep was always written about as a first sleep, three or four hours of sleep that was deeper, followed by a bit of being awake in the middle of the night, followed by then some restlessness and dozing until the sun came up, a second sleep. And it's only since industrialization we've had this construct of eight hours of uninterrupted sleep. So that sort of information is really important for people because a lot of older people will recognize that. I have three or four hours of reasonable sleep and then I'm sort of, I'm awake and it's light, dozy sleep until the sun comes up. Historically, that's how humans sleep. Can I just ask Richard and Collette, or sorry, Rod and Collette, a number of people are asking about Wayne's history. We know that he was a shift worker. We know that he was forced to retire from his place of work. To what extent do these factors that may have triggered mood disturbance, potentially depression and so on, to what extent do you think these things brought on the sleep disturbance? Do you think the sleep disturbances are a follow-on effect of his change in life circumstances which may have triggered the depression that his wife speaks about? Perhaps, Rod, if I could ask you first. I think you could look at many hypotheses and that could be one, but I don't think you can, with the information in front of you, really say the answer is yes. There's no doubt an unhappy retirement is a risk factor for depression and that could precipitate the sleep problems. But at the same time, for most people, retirement actually, even if they weren't planning it, is actually a release and so actually 65 to 75 is probably the time of some of our best mental health. So I'd be cautious about academic interpretation, worth exploring, but wouldn't jump to it being the reason. Great, Collette. Do you have any further comments? Yeah, I would agree with that too, but I think, again, I think this issue around the planning of retirement is important because, and it's probably often in men who have had jobs that have been very engaging to them and then they find themselves in this new lifestyle of not working. I think that can be quite a stressful transition. So I think planning for what you're going to actually do when you retire is an important aspect of, in this case, with Wayne, I think as well. So as I agree, that that's one hypothesis that could be actually tested to see whether maybe talk to him a bit about that, whether he's unhappy with having retired and is missing the activities that he had before. Because it seemed like he's sitting around a fair bit and not doing much and I think this is a sign of him maybe not really thinking about what he could do in retirement because he's been used to, you know, an active job that's occupied a lot of his time. If I could just say briefly... Richard here, sorry. Okay, Richard. Yeah, I just want to make the observation that in this particular case, he retired five years earlier and it seems that they've actually been enjoying a comfortable life, a fulfilling life and been very connected with their family and it's only in recent weeks that there's been this change. So I think we're looking at something else. I agree with everything you've said about retirement and the importance of planning for it, but I think in this particular case, that may not be where this is coming from and look, it's even possibly developed a low-grade urinary tract infection or this might be the start of diabetes or something else. So I think whoever he presents to, it's very important that the GP gives him a once-over as well just to make sure there isn't something imminently treatable that's fairly acute. Richard and David, can I ask you another common question? Just briefly, because we're fast-running out of time, is the relevance of the history of shift work? To what extent, Richard, perhaps I'd start with you, to what extent would you have considered that in your management, your diagnosis and management plan? Five years ago, he retired as a shift worker. My feeling is that it's probably somewhat ancient history now. It sounds like in this case, he's only developed his sleeping difficulties relatively recently, whereas he's been retired for some five years. So I don't think in his case it's an issue, but certainly for some shift workers it is, and I think as Rod touched on before, it's really more that people get this fixation on getting a certain number of hours sleep because as a shift worker, they've got to get up at some funny time, and if they don't get to sleep when they want to get to sleep, they're not going to get to sleep, and then they're not going to function well at work, and if they're dealing with equipment that they have to be very alert for, it causes a lot of anxiety. But in this guy, that was five years ago, and it wasn't as if his type of shift work was that high-powered. He was a security guard. He wasn't operating dangerous machinery. David, I see you've posted a similar kind of a response on this. Do you want to just briefly speak to that point? I agree with Richard. I think I agree with you absolutely, Richard. I think very quickly after people have been on shift work, the circadian factors sort themselves out. You know, we travel from London and come back to Melbourne and back to work, and a week later a feeling like we're settled. But what shift work does, it teaches people that sleep's precious because they have a period in life when they're counting all those hours when am I going to get this opportunity for sleep? I'm always feeling tired. Once we start to feel like sleep is precious, then we're always sensitive to other threats around sleep. And if later on in life, five years down the track, sleep's not working well for another reason, that anxiety about sleep comes very quickly to the fore. So people who've previously worked shift work just think about sleep differently and are sort of sensitized, if you like, to getting anxiety about sleep when sleep's not working well for other reasons later in life. Sure. So look, we have rapidly run out of time, and this is a fascinating case, and it really does open up a whole range of issues. It's a complex case. I'd like to ask each of our expert panel members now to briefly, just in a minute or so, summarize from their perspective. Particularly in terms of the issues that we've been discussing about models of collaborative care or multidisciplinary input to the management of a case like Wayne. So I might start with you, Richard, to just give us your final thoughts. Sure. As I've said, I see this as a relatively acute problem. It's only really been going for some week, and I see that it's not just Wayne. There's something going on with Bev. She's somehow not coping with their relationship, and I think that we really need to explore a lot more what's been going on in their relationship. But in terms of the acute setting and what's going on as the GP, I need to involve a very extensive team. Pathologists may be radiologists as well as maybe mental health colleagues. And probably when I start sorting them out, it may well be exercise physiologists or a physiotherapist as well to help them have a safe graduated exercise program to get them back into some good routines, get rid of some of that weight, and hopefully get them a lot healthier. He may well have diabetes or some thyroid condition, maybe a low-grade urinary tract infection. He may well have depression, possibly dementia. And certainly the prostate may well need to be looked at in his case. Thank you, Richard. Collette, could I ask you for your thoughts on final responses to Wayne's case and Bev? Well, first of all, I'd just like to say that I've really enjoyed this session because I've got perspectives from the other panel members which has been very interesting. I also agree that I think this whole couple relationship is an important issue. And there's been some recent work done in this area, really, the social role of sleep, I guess, like callers. And obviously, I think Bev's being disturbed by some of the sleep issues that Wayne is having. But also, there seems to be some, maybe a little bit of friction there as well. So I think it's important in cases like this that you actually think of these relationships and how they might impact on what the presenting problem is in this case for Wayne. Also, again, from a health psychology perspective, I think looking at physical and mental health cone morbidities is very important. And I think all of the panelists have demonstrated that we've all talked about that, that we're not looking at it just from the perspective of our disciplines. But I think we all understand that, particularly in older age, there's a complexity of issues that we need to look at. So I think that's probably the main thing. And with psychologists, people don't necessarily just turn up to psychologists of their own path. They're relying on other medical professionals referring. I guess I'd just say that from that point of view, health psychologists have a lot to contribute in these areas of physical and mental health cone morbidities and assist cases like Wayne. Yes, well, I think, Collette, I certainly agree with your point. David, I think made the point earlier about non-pharmacological treatments in general for the management of sleep disturbances. The evidence base is very, very strong that these approaches that David described can be highly effective in the long term, as effective, not more effective in the long term as pharmacological treatment. So that's just one example of the clear role that the psychologists can play. Rod, over to you for your final response to Wayne's case study. I think the case emphasizes to me the importance of balancing really a healthy optimism about aging and recognizing that 67, Wayne isn't very old. I don't see many people under 75 really, but balance that with not ignoring the things which are different in old age. Be optimistic about his cognitive impairment because he's probably only got about 2% chance of having dementia, but don't ignore it. It does need following up because if he isn't at 2%, you need to do all you can to help him. And I think I do and I don't. I think one thing that hasn't been mentioned is don't use antipsychotics for sleep disturbance, which is I think a trend which is soon to start to build up to avoid the benzodiazepines. And a do which is do make sure that you help older people keep their role or keep a role in life because I think that is the one thing which helpful health professionals and helpful families often do is actually bring a support network around that actually takes away the purpose. And so if there's one thing I'd like people to think about, is really think about how we avoid doing that and encourage actually helping an older person where that has happened to refine their purpose, which is often their role in their family and helping them to recognize that again. Thank you, Rod. That's a wonderful perspective. David, can I hear from you as a sleep physician for your final response to this case we've been talking about? So a lot of the case we see a lot and Richard was saying, you know, sees many times a day even, which I believe that I find is such a hard case because unless I've really got a team and close relationships with psychologists that I know and trust or psychiatrists that I know and trust and are happy to refer patients to, this sort of case is really hard to manage and get engagement and get behavior change. And I agree with you, Rod. You know, you're quite optimistic about what the outcomes are going to be because I think we'll actually get there, but it does take a team to sort of get that engagement. That's where I've, you know, one of the things I've learned is just the luxury of if you've got a good team that you can work with in a good referral network, that just helps so much in how you can manage a case like this. Thank you, David. I think what really strikes me about this particular case and the panel's reaction to it is that it is a complex case and there are many, many aspects that require investigation and potential, you know, management approaches. I think you've all talked about the challenges that this case would pose to you in your discipline-specific roles. You've talked about the great value of multidisciplinary input and I think that's precisely the point of discussion of these sorts of case studies is to consider how we might engage other health professionals, particularly mental health professionals in the management of a case like Wayne's. Collette, your points about looking at the totality of the situation and Richard's looking at Bev as well as Wayne, looking at the relationship factors, looking at the life factors and so on are absolutely, you know, well taken and really highly relevant in the management of this case. So we have just a couple of minutes to conclude. I think the panel has provided an excellent summary of the response to this particular case. I am extremely grateful to our panel members, once again, Richard Kidd, Collette Browning, Rod McKay and David Cunnington for their absolutely, you know, insightful comments and responses to this particular case study. I'm grateful also to the mental health professionals network for coordinating a webinar on this really important topic and I think we all agree that this is an important topic and one that really does require a lot of education and reflection. So I'd like to remind you all to ensure that you complete the exit survey before you log out. This helps us a great deal in planning future webinars. Certificates of attendance for this webinar will be issued in four to five weeks. Each participant will be sent a link as well. Now, if you're interested in leading a face-to-face network in your local area with the focus on older people and mental health or sleep disturbance, the mental health professional network can help you and support you in doing so. So please fill out the expression of interest that you will receive as a link in the webinar follow-up email. Now lots of questions came up that unfortunately we didn't have time to answer all of them but a number of questions came up from the audience along the themes of practical strategies for managing sleep disturbance. And within the resources that you are directed to for this webinar, there are links to the Australasian Sleep Association website as well as the Sleep Health Foundation website. And both of these websites provide very good resources for health professionals as well as patients in terms of evidence-based strategies to manage sleep complaints, including sleep hygiene, which a number of the audience members have been discussing. So on that note, I'd like to thank the audience for their excellent questions and their participation once again to all of the members of the panel. Thank you for your contribution and participation. A pleasure. Thanks. Thank you, Shanta.