izindaba

Ukuqwasha kuyisifo esivame kakhulu sokulala, esichazwa njengesifo sokulala esenzeka ubusuku obuthathu noma ngaphezulu ngeviki, esihlala isikhathi esingaphezu kwezinyanga ezintathu, futhi asibangelwa ukuntuleka kwamathuba okulala. Cishe u-10% wabantu abadala uhlangabezana nemibandela yokuqwasha, kanti abanye abangu-15% kuya ku-20% babika izimpawu zokuqwasha ngezikhathi ezithile. Iziguli ezihlala isikhathi eside ezingalali zisengozini enkulu yokuba nokucindezeleka okukhulu, umfutho wegazi ophakeme, isifo i-Alzheimer's, nokulahlekelwa ikhono lokusebenza.

Izinkinga zomtholampilo

Izici zokuqwasha ziyikhwalithi yokulala engagculisi noma ubude besikhathi, obuhambisana nobunzima bokulala noma ukungalali kahle, kanye nokucindezeleka okukhulu kwengqondo noma ukungasebenzi kahle kwasemini. Ukuqwasha yisifo sokulala esiba khona ubusuku obuthathu noma ngaphezulu ngesonto, esithatha isikhathi esingaphezu kwezinyanga ezintathu, futhi asibangelwa amathuba alinganiselwe okulala. Ukuqwasha kuvame ukwenzeka kanyekanye nezinye izifo ezingokomzimba (ezifana nobuhlungu), izifo zengqondo (njengokucindezeleka), nezinye izinkinga zokulala (njenge-rerestless leg syndrome kanye nenkinga yokulala).

Ukuqwasha yisifo sokulala esivame kakhulu phakathi kwabantu abaningi, futhi kungenye yezinkinga ezivame ukukhulunywa lapho iziguli zifuna ukwelashwa ezikhungweni zezokwelapha eziyinhloko, kodwa ngokuvamile zingelashwa. Cishe u-10% wabantu abadala uhlangabezana nemibandela yokuqwasha, kanti abanye abantu abadala abangu-15% kuya ku-20% babika izimpawu zokuqwasha ngezikhathi ezithile. Ukuqwasha kuvame kakhulu kwabesifazane nakubantu abanezinkinga ezingokwengqondo noma ezingokomzimba, futhi izinga lakho lokugula lizokhula lapho esekhulile ngeminyaka nangemuva kweminyaka ephakathi nendawo, kanye nasenkathini yokunqamuka kokuya esikhathini nokuya esikhathini. Kuncane kakhulu esikwaziyo mayelana nezinqubo ze-pathological kanye ne-physiological zokuqwasha, kodwa okwamanje kukholakala ukuthi ukweqisa okungokwengqondo nokwengqondo yizici zayo eziyinhloko.

Ukuqwasha kungase kube ngokwesimo noma ngezikhathi ezithile, kodwa ngaphezu kwe-50% yeziguli ziba nokuqwasha okungapheli. Ukuqwasha kokuqala kuvame ukuvela endaweni yokuhlala enengcindezi, izinkinga zempilo, izinhlelo zokusebenza ezingavamile, noma ukuhamba ezindaweni eziningi zesikhathi (umehluko wesikhathi). Nakuba abantu abaningi bezobuyela ebuthongweni obuvamile ngemva kokujwayela izenzakalo ezivusa amadlingozi, labo abathambekele ekubeni nokuqwasha bangase babe nokuqwasha okungapheli. Izici ezingokwengqondo, zokuziphatha, noma zomzimba ngokuvamile ziholela ebunzimeni bokulala isikhathi eside. Ukuqwasha isikhathi eside kuhambisana nengozi eyengeziwe yokucindezeleka okukhulu, umfutho wegazi ophakeme, isifo i-Alzheimer's, nokulahlekelwa ikhono lomsebenzi.

Ukuhlolwa nokuxilongwa kokuqwasha kuncike ekuphenyweni okuningiliziwe komlando wezokwelapha, izimpawu eziqoshiwe, inkambo yokugula, ukugula, nezinye izici eziyimbangela. Ukurekhodwa kokuziphatha kokuvuka kokulala kwamahora angama-24 kungakhomba imigomo eminingi yokungenelela yokuziphatha nemvelo. Amathuluzi okuhlola abikwe isiguli kanye nedayari yokulala inganikeza ulwazi olubalulekile mayelana nemvelo nobukhulu bezimpawu zokuqwasha, isikrini sosizo sezinye izinkinga zokulala, nokuqapha ukuqhubeka kokwelashwa.

Isu kanye nobufakazi

Izindlela zamanje zokwelapha ukuqwasha zihlanganisa imithi kadokotela nemithi ethengwayo, ukwelashwa kwengqondo nokuziphatha (okubuye kwaziwe ngokuthi ukwelapha kwengqondo-yokuziphatha [CBT-I] yokuqwasha), kanye ne-adjuvant nezinye izindlela zokwelapha. Indlela evamile yokwelapha ezigulini iwukusebenzisa izidakamizwa ezitholakala ekhawuntareni kuqala bese zisebenzisa imithi kadokotela ngemva kokuthola usizo lwezokwelapha. Zimbalwa iziguli ezithola ukwelashwa kwe-CBT-I, ngokwengxenye ngenxa yokuntuleka kwabelaphi abaqeqeshwe kahle.

I-CBTI-I
I-CBT-I ihlanganisa uchungechunge lwamasu ahloselwe ukushintsha amaphethini okuziphatha kanye nezici ezingokwengqondo eziholela ekuqwaleni, njengokukhathazeka ngokweqile nezinkolelo ezingezinhle mayelana nokulala. Okuqukethwe okuyinhloko kwe-CBT-I kuhlanganisa amasu okuhlela ukuziphatha nokulala (imikhawulo yokulala nokulawula ukuvuselela), izindlela zokuphumula, ukungenelela kwengqondo nokuqonda (noma kokubili) okuhloswe ekuguquleni izinkolelo ezingezinhle nokukhathazeka ngokweqile mayelana nokuqwasha, kanye nemfundo yokuhlanzeka kokulala. Ezinye izindlela zokungenelela ezingokwengqondo ezifana ne-Acceptance and Commitment Therapy kanye ne-Mindfulness Based Therapy nazo ziye zasetshenziswa ekwelapheni ukuqwasha, kodwa kunedatha elinganiselwe esekela ukusebenza kahle kwazo, futhi zidinga ukuphikelela isikhathi eside uma kuqhathaniswa ukuze kuzuze. I-CBT-I iwukwelashwa okushiwo udokotela okugxile ekulaleni futhi kugxile enkingeni. Ivamise ukuqondiswa umelaphi wezempilo yengqondo (njengodokotela wezengqondo) ngokubonisana okungu-4-8. Kunezindlela ezihlukahlukene zokusebenzisa i-CBT-I, okuhlanganisa ifomu elifushane nefomu leqembu, ngokubamba iqhaza kwabanye ochwepheshe bezempilo (njengabahlengikazi abasebenzayo), kanye nokusetshenziswa kwe-telemedicine noma amapulatifomu edijithali.

Njengamanje, i-CBT-I iyanconywa njengokwelashwa komugqa wokuqala kuzinkombandlela zomtholampilo yizinhlangano eziningi zobungcweti. Ukuhlolwa kwemitholampilo nokuhlaziywa kwemeta kubonise ukuthi i-CBT-I ingathuthukisa kakhulu imiphumela ebikiwe yesiguli. Ekuhlaziyweni kwe-meta yalezi zivivinyo, i-CBT-I yatholwa ithuthukisa ubukhali bezimpawu zokuqwasha, isikhathi sokuqala kokulala, nesikhathi sokuvuka ngemva kokulala. Ukuthuthukiswa kwezimpawu zasemini (njengokukhathala nomoya) kanye nezinga lempilo lincane uma kuqhathaniswa, ngokwengxenye ngenxa yokusetshenziswa kwezinyathelo ezijwayelekile ezingakhelwanga ngokuqondile ukuqwasha. Sekukonke, cishe i-60% kuya ku-70% yeziguli zinempendulo yomtholampilo, ngokuncipha kwamaphuzu angu-7 ku-Insomnia Severity Index (ISI), esukela ku-0 kuya kumaphuzu angu-28, amaphuzu aphezulu abonisa ukuqwasha okunzima kakhulu. Ngemuva kwamaviki angama-6-8 okwelashwa, cishe amaphesenti angama-50 eziguli eziqwasha athola ukuxolelwa (inani eliphelele le-ISI, <8), kanti ama-40% -45% eziguli athola ukuxolelwa okuqhubekayo izinyanga eziyi-12.

Kule minyaka eyishumi edlule, i-CBT-I yedijithali (eCBT-I) isiye yaduma kakhulu futhi ingase ekugcineni inciphise igebe elibalulekile phakathi kwesidingo se-CBT-I nokufinyeleleka. I-ECBT-I inomthelela omuhle emiphumeleni eminingana yokulala, okuhlanganisa ubunzima bokuqwasha, ukusebenza kahle kokulala, ikhwalithi yokulala eqondile, ukuphaphama ngemva kokulala, ubude besikhathi sokulala, ubude besikhathi sokulala, kanye nenani lokuvuka ebusuku. Le miphumela ifana naleyo ebonwa ekuhlolweni kobuso nobuso kwe-CBT-I futhi igcinwa amaviki angu-4-48 ngemva kokulandelela.

Ukwelapha izifo ezihambisana nokucindezeleka nobuhlungu obungapheli kunganciphisa izimpawu zokuqwasha, kodwa ngokuvamile akukwazi ukuzixazulula ngokuphelele izinkinga zokuqwasha. Ngokuphambene nalokho, ukwelapha ukuqwasha kungathuthukisa ukulala kweziguli ezinezifo ezihambisanayo, kodwa umthelela kuma-comorbidities ngokwawo awuguquki. Isibonelo, ukwelashwa kokuqwasha kunganciphisa izimpawu zokucindezeleka, kunciphise izinga lezigameko kanye nezinga lokuphindaphinda lokucindezeleka, kodwa kunomphumela omncane ebuhlungu obungapheli.

Indlela yokwelapha enezigaba ingasiza ekuxazululeni inkinga yezinsiza ezinganele ezidingekayo ekwelapheni ngokwengqondo nokuziphatha ngendlela evamile. Imodi eyodwa iphakamisa ukusebenzisa izindlela zemfundo, ukuqapha, kanye nezindlela zokuzisiza ezingeni lokuqala, ukwelashwa kwengqondo yedijithali noma yeqembu kanye nokuziphatha ezingeni lesibili, ukwelapha kwengqondo nokuziphatha komuntu ngamunye ezingeni lesithathu, kanye nokwelashwa kwemithi njenge-adjunct yesikhashana esifushane ezingeni ngalinye.

Ukwelashwa ngemithi
Eminyakeni engu-20 edlule, iphethini kadokotela yezidakamizwa eziluthayo e-United States ibe nezinguquko ezinkulu. Inani lemithi ye-benzodiazepine receptor agonists liyaqhubeka nokuncipha, kuyilapho inani le-trazodone lencwadi kadokotela liqhubeka nokukhuphuka, nakuba i-US Food and Drug Administration (FDA) ingazange ibale ukuqwasha njengophawu lwe-trazodone. Ngaphezu kwalokho, abaphikisi be-receptor abacindezela ukudla baqalwa ngo-2014 futhi basetshenziswe kabanzi.

Ubukhulu bomphumela wemithi emisha (ubude besikhathi somuthi,

I-criteria yamabhiya (uhlu lwezidakamizwa ezibhekwa njengezingafaneleki ezigulini ezineminyaka engu-65 noma ngaphezulu) zincoma ukugwema ukusetshenziswa kwalo muthi.

Umuthi awugunyazwanga yi-FDA ekwelapheni ukuqwasha. Zonke izidakamizwa ezisohlwini lwethebula zihlukaniswa njenge-Pregnancy Class C yi-US FDA, ngaphandle kwalezi zidakamizwa ezilandelayo: I-Triazolam ne-Temazepam (Ikilasi X); I-Clonazepam (Ikilasi D); I-Diphenhydramine ne-docetamine (ikilasi B).
1. Izidakamizwa ze-hypnotic zekilasi le-Benzodiazepine receptor agonist
I-Benzodiazepine receptor agonists ihlanganisa izidakamizwa ze-benzodiazepine kanye nezidakamizwa ezingezona ze-benzodiazepine (ezaziwa nangokuthi izidakamizwa ze-Z-class). Ukuhlolwa kwemitholampilo kanye nokuhlaziywa kwe-meta kubonise ukuthi i-benzodiazepine receptor agonists ingafinyeza ngokuphumelelayo isikhathi sokulala, ukunciphisa ukuvuswa kokulala ngemva kokulala, nokwandisa kancane ubude besikhathi sokulala (Ithebula 4). Ngokwemibiko yesiguli, imiphumela emibi ye-benzodiazepine receptor agonists ihlanganisa i-anterograde amnesia (<5%), i-sedation ngosuku olulandelayo (5% ~ 10%), nokuziphatha okuyinkimbinkimbi ngesikhathi sokulala njengokuphupha emini, ukudla, noma ukushayela (3% ~ 5%). Umthelela oseceleni wokugcina ungenxa yesixwayiso sebhokisi elimnyama le-zolpidem, zaleplon, ne-escitalopram. U-20% kuya ku-50% weziguli uzwa ukubekezelelwa kwezidakamizwa kanye nokuncika ngokomzimba ngemva kokuthatha imithi njalo ebusuku, okubonakaliswa ukuqwasha okuphindaphindiwe kanye nesifo sokuyeka.

2. Izidakamizwa ze-heterocyclic ezidambisayo
Ama-antidepressants adambisayo, okuhlanganisa izidakamizwa ze-tricyclic ezifana ne-amitriptyline, i-demethylamine, ne-doxepin, nezidakamizwa ze-heterocyclic ezifana ne-olanzapine ne-trazodone, ziyimithi evame ukunikezwa ukwelapha ukuqwasha. I-doxepin kuphela (3-6 mg nsuku zonke, ethathwa ebusuku) egunyazwe yi-US FDA yokwelapha ukuqwasha. Ubufakazi bamanje buphakamisa ukuthi ama-antidepressants adambisayo angathuthukisa ngokuphelele ikhwalithi yokulala, ukusebenza kahle kokulala, futhi andise ubude besikhathi sokulala, kodwa abe nomthelela omncane esikhathini sokulala. Nakuba i-US FDA ingakufaki ukuqwasha njengenkomba yale mithi, odokotela neziguli bavame ukukhetha le mithi ngoba inemiphumela engemihle ngemithamo ephansi futhi ulwazi lomtholampilo lubonise ukusebenza kwayo. Imiphumela engemihle ihlanganisa ukuqunjelwa, umlomo owomile, ukubambezeleka kokwenziwa kwenhliziyo, i-hypotension, nomfutho wegazi ophakeme.

3. Abamelene ne-appetite receptor
Ama-neurons aqukethe i-orexin ku-lateral hypothalamus ashukumisa i-nuclei ku-brainstem kanye ne-hypothalamus ekhuthaza ukuphaphama, futhi avimbele i-nuclei ezindaweni ze-ventral lateral ne-medial preoptic ezikhuthaza ukulala. Ngokuphambene nalokho, izidakamizwa ezicindezela ukudla zingavimbela ukuqhutshwa kwemizwa, zicindezele ukuphaphama, futhi zikhuthaze ukulala. Izimbangi ezintathu ze-orexin receptor antagonists (i-sucorexant, i-lemborxant, ne-daridorexint) zigunyazwe yi-US FDA ukuze zelashwe ukuqwasha. Izivivinyo zemitholampilo zisekela ukusebenza kahle kwazo ekuqaleni kokulala nokunakekelwa. Imiphumela engemihle ihlanganisa ukuqunjelwa, ukukhathala, nokuphupha okungavamile. Ngenxa yokuntuleka kwama-hormone esifiso sokudla, okungaholela ekwandeni kwe-narcolepsy nge-cataplexy, abaphikisi be-hormone ye-appetite bayaphikiswa ezigulini ezinjalo.

4. I-Melatonin ne-melatonin receptor agonists
I-Melatonin iyi-hormone ekhishwa yi-pineal gland ngaphansi kwezimo ezimnyama ebusuku. I-melatonin yangaphandle ingafinyelela ekugxilweni kwegazi okungaphezu kwamazinga okuphila, ngezikhathi ezihlukahlukene kuye ngomthamo othize kanye nokwakheka. Umthamo ofanele we-melatonin wokwelapha ukuqwasha awukanqunywa. Izivivinyo ezilawulwayo ezibandakanya abantu abadala zibonise ukuthi i-melatonin inomthelela omncane ekuqaleni kokulala, cishe ongenawo umthelela wokuphaphama phakathi nokulala kanye nobude besikhathi sokulala. Imithi ebophezela kuma-melatonin MT1 kanye nama-receptors e-MT2 igunyazelwe ukwelashwa kokuqwasha okuphikiswayo (i-ramelteon) kanye ne-circadian sleep wake disorder (tasimelteon). Njenge-melatonin, lezi zidakamizwa cishe azinawo umthelela ekuphaphameni noma ubude besikhathi sokulala ngokuphelele ngemva kokulala. Ukulala nokukhathala kuyimiphumela emibi kakhulu.

5. Ezinye izidakamizwa
Ama-Antihistamine ezidakamizwa ezithengwayo (i-diphenhydramine ne-docetamine) kanye nemithi kadokotela (i-hydroxyzine) imithi yokwelapha yokuqwasha esetshenziswa kakhulu. Idatha esekela ukusebenza kwayo ibuthakathaka, kodwa ukufinyeleleka kwazo nokuphepha okucatshangwayo ezigulini kungase kube izizathu zokuduma kwazo uma kuqhathaniswa nama-agonists e-benzodiazepine receptor. Ama-antihistamine e-sedative angabangela ukuthuthumela ngokweqile, imiphumela emibi ye-anticholinergic, futhi andise ingozi yokuwohloka komqondo. I-Gabapentin ne-pregabalin zivame ukusetshenziselwa ukwelapha ubuhlungu obungapheli futhi ziyimithi yokwelapha yokuqala ye-rerestless leg syndrome. Le mithi inomphumela wokulalisa, yandisa ukulala kwegagasi elihamba kancane, futhi isetshenziselwa ukwelapha ukuqwasha (ngaphezu kwezinkomba), ikakhulukazi uma kuhambisana nobuhlungu. Ukukhathala, ukozela, isiyezi, kanye ne-ataxia yimiphumela emibi evame kakhulu.

Ukukhethwa kwezidakamizwa ze-hypnotic
Uma imithi ikhethelwa ukwelashwa, ama-agonists ama-benzodiazepine receptor amafushane, ama-orexin antagonists, noma izidakamizwa ze-heterocyclic ezinedosi ephansi ziyizinketho zokuqala ezinengqondo ezimweni eziningi zomtholampilo. I-Benzodiazepine receptor agonists ingase ibe ukwelashwa okuthandwayo kweziguli zokuqwasha ezinezimpawu zokulala, iziguli ezikhulile ezincane, kanye neziguli ezingase zidinge imithi yesikhashana (njengokuqwasha ngenxa yokucindezeleka okukhulu noma ngezikhathi ezithile). Lapho ukwelapha iziguli ezinezimpawu ezihlobene nokugcina ubuthongo noma ukuvuka kusenesikhathi, abantu asebekhulile, nalabo abanezinkinga zokusebenzisa izidakamizwa noma i-apnea yokulala, izidakamizwa ze-heterocyclic ezinedosi ephansi noma izicindezeli zesifiso sokudla kungase kube ukukhetha kokuqala.

Ngokwenqubo yamaBeers, uhlu lwezidakamizwa ezingafaneleki ezigulini ezineminyaka engu-65 noma ngaphezulu luhlanganisa i-benzodiazepine receptor agonists nezidakamizwa ze-heterocyclic, kodwa alubandakanyi i-doxepin, trazodone, noma i-orexin antagonists. Umuthi wokuqala ngokuvamile uhlanganisa ukuphuza imithi njalo ebusuku amaviki angu-2-4, bese uhlola kabusha imiphumela nemiphumela engemihle. Uma imithi yesikhathi eside idingeka, khuthaza imithi yesikhashana (izikhathi ezingu-2-4 ngesonto). Iziguli kufanele ziqondiswe ukuthatha imithi 15-30 imizuzu ngaphambi kokulala. Ngemuva kwemithi yesikhathi eside, ezinye iziguli zingase zibe nokuncika emithini, ikakhulukazi uma zisebenzisa i-benzodiazepine receptor agonists. Ngemuva kokusetshenziswa isikhathi eside, ukwehlisa okuhleliwe (njengokunciphisa ngo-25% ngesonto) kungasiza ukunciphisa noma ukuyeka izidakamizwa zokulutha.

Ukukhetha phakathi kokwelashwa okuhlangene kanye ne-monotherapy
Izifundo ezimbalwa ezikhona zokuqhathanisa ikhanda nekhanda ziye zabonisa ukuthi esikhathini esifushane (amaviki angu-4-8), i-CBT-I kanye nezidakamizwa ze-hypnotic (ikakhulukazi izidakamizwa ze-Z-class) zinemiphumela efanayo ekuthuthukiseni ukuqhubeka kokulala, kodwa ukwelapha izidakamizwa kungandisa kakhulu ubude besikhathi sokulala uma kuqhathaniswa ne-CBT-I. Uma kuqhathaniswa nokusebenzisa i-CBT-I yodwa, ukwelashwa okuhlangene kungathuthukisa ukulala ngokushesha, kodwa le nzuzo iyancipha kancane kancane evikini lesine noma lesihlanu lokwelashwa. Ukwengeza, uma kuqhathaniswa nemithi noma ukwelashwa okuhlangene, ukusebenzisa i-CBT-I kuphela kungathuthukisa ukulala ngokuqhubekayo. Uma kunenye indlela elula yokuthatha amaphilisi okulala, ukuthobela kweziguli iseluleko sokuziphatha kungase kwehle.