iindaba

Ukuphuthelwa yeyona nto ixhaphakileyo yokungalali, ichazwa njengengxaki yokungalali eyenzeka ngobusuku obuthathu okanye ngaphezulu ngeveki, ihlala ngaphezu kweenyanga ezintathu, kwaye ayibangelwa kukunqongophala kwamathuba okulala. Malunga ne-10% yabantu abadala bahlangabezana nemilinganiselo yokungalali, kwaye enye i-15% ukuya kwi-20% ichaza iimpawu zokungalali ngamaxesha athile. Izigulana eziphuthelwa ixesha elide zisemngciphekweni omkhulu wokuba noxinzelelo olukhulu, uxinzelelo lwegazi, isifo sika-Alzheimer, kunye nokuphelelwa ngamandla emsebenzini.

Imiba yeklinikhi

Iimpawu zokungalali bubuthongo obungonelisiyo okanye ubude bexesha, buhamba nobunzima bokulala okanye ukugcina ubuthongo, kunye nokukhathazeka okukhulu kwengqondo okanye ukungasebenzi kwasemini. Ukuphuthelwa kukungalali kakuhle okwenzeka ngobusuku obuthathu nangaphezulu ngeveki, okuqhubeka ngaphezu kweenyanga ezintathu, yaye akubangelwa kukungalali ngokwaneleyo. Ukuphuthelwa kuhlala kwenzeka ngaxeshanye nezinye izifo zomzimba (ezifana neentlungu), izigulo zengqondo (ezifana nokudakumba), kunye nezinye iingxaki zokulala (ezifana nesifo somlenze ongapheliyo kunye ne-apnea yokulala).

Ukuphuthelwa yeyona nto ixhaphakileyo yokungalali phakathi kwabemi ngokubanzi, kwaye ikwayenye yeengxaki ezikhankanywa kakhulu xa izigulana zifuna unyango kumaziko ezonyango, kodwa zihlala zinganyangwa. Malunga ne-10% yabantu abadala bahlangabezana nemilinganiselo yokungalali, kwaye enye i-15% ukuya kwi-20% yabantu abadala bachaza iimpawu zokungalali ngamaxesha athile. Ukuphuthelwa kuxhaphake kakhulu kubasetyhini nakubantu abaneengxaki zengqondo okanye zomzimba, kwaye izinga leziganeko zalo liya kwanda kwiminyaka ephakathi nasemva kweminyaka ephakathi, kunye nakwixesha lokuyeka ukuya exesheni kunye nokuyeka ukuya exesheni. Sisazi kancinci kakhulu malunga ne-pathological and physiological mechanisms yokuphuthelwa, kodwa okwangoku kukholelwa ukuba ukunyanzeliswa ngokwasengqondweni nangokwempilo ziimpawu zayo eziphambili.

Ukuphuthelwa kusenokuba yimeko okanye ngamaxesha athile, kodwa ngaphezulu kwe-50% yezigulane zifumana ukuphuthelwa okuzingisileyo. Ubuthongo bokuqala buhlala buvela kwimeko yokuhlala ecinezelayo, imiba yezempilo, iishedyuli zomsebenzi ezingaqhelekanga, okanye ukuhamba kwiindawo ezininzi zamaxesha (umahluko wexesha). Nangona uninzi lwabantu lubuyela kubuthongo obuqhelekileyo emva kokuziqhelanisa neziganeko eziqalayo, abo batyekele ekuphuthelweni basenokungalali okungapheliyo. Izinto zengqondo, zokuziphatha, okanye zomzimba zihlala zikhokelela kubunzima bokulala ixesha elide. Ukungalali ixesha elide kukhatshwa yingozi enkulu yokudakumba, uxinzelelo lwegazi, isifo sika-Alzheimer, kunye nokuphelelwa ngamandla emsebenzini.

Uvavanyo kunye nokuxilongwa kokuphuthelwa kuxhomekeke kuphando oluneenkcukacha lwembali yonyango, iimpawu zokurekhoda, ikhosi yokugula, ukugula, kunye nezinye izinto ezibangelayo. Ukurekhodwa kokuziphatha kokulala kweeyure ezingama-24 kunokuchonga iinjongo zokungenelela kokuziphatha kunye nokusingqongileyo. Izixhobo zovavanyo ezixeliweyo zesigulana kunye needayari zokulala zinokubonelela ngolwazi oluxabisekileyo malunga nobume kunye nobukhulu beempawu zokuphuthelwa, isikrini soncedo kwezinye iingxaki zokulala, kunye nokubeka iliso kwinkqubela yonyango.

Iqhinga kunye nobungqina

Iindlela zangoku zokunyanga ukuphuthelwa zibandakanya amayeza kagqirha kunye ne-counter-the-counter, unyango lwengqondo kunye nokuziphatha (ekwaziwa ngokuba yi-cognitive-behavioral therapy [CBT-I] yokuphuthelwa), kunye ne-adjuvant kunye nolunye unyango. Indlela eqhelekileyo yonyango kwizigulana kukusebenzisa amayeza afumaneka ekhawuntareni kuqala uze usebenzise amayeza kagqirha emva kokufuna unyango. Zimbalwa izigulana ezifumana unyango lwe-CBT-I, ngokuyinxenye ngenxa yokungabikho kwabanyangi abaqeqeshwe kakuhle.

I-CBTI-I
I-CBT-I ibandakanya uluhlu lwezicwangciso ezijoliswe ekutshintsheni iipatheni zokuziphatha kunye nezinto zengqondo ezikhokelela ekuphuthelweni, ezifana nokuxhalaba ngokugqithiseleyo kunye neenkolelo ezingalunganga malunga nokulala. Umxholo ongundoqo we-CBT-I uquka izicwangciso zokuziphatha kunye nokulala (ukuthintela ukulala kunye nokulawula ukuvuselela), iindlela zokuphumla, ukungenelela kwengqondo kunye nengqondo (okanye zombini) ezijoliswe ekutshintsheni iinkolelo ezingalunganga kunye nokukhathazeka ngokugqithiseleyo malunga nokulala, kunye nemfundo yokucoceka kokulala. Ezinye iindlela zongenelelo ngokwasengqondweni ezifana noNyango loKwamkeleka kunye nokuZibophelela kunye noNyango oluSekwe kwiMindfulness nazo zisetyenzisiwe ukunyanga ukuphuthelwa, kodwa kukho idatha enyiniweyo exhasa ukusebenza kakuhle kwazo, kwaye kufuneka ziqhubeke ixesha elide ngokwentelekiso ukuze zixhamle. I-CBT-I lunyango lonyango olujolise ebuthongweni kwaye lujolise kwingxaki. Ngokuqhelekileyo ikhokelwa yingcali yezempilo yengqondo (njengengqondo yengqondo) kwii-4-8 zokubonisana. Kukho iindlela ezahlukeneyo zokuphunyezwa kwe-CBT-I, kubandakanywa ifom emfutshane kunye nefom yeqela, kunye nokuthatha inxaxheba kwabanye abaqeqeshi bezempilo (njengabahlengikazi abaqhubayo), kunye nokusetyenziswa kwe-telemedicine okanye iiplatifti zedijithali.

Okwangoku, i-CBT-I iyacetyiswa njengonyango lomgca wokuqala kwizikhokelo zeklinikhi yimibutho yeengcali ezininzi. Izilingo zeklinikhi kunye nohlalutyo lwe-meta lubonise ukuba i-CBT-I inokuphucula kakhulu iziphumo ezichazwe kwisigulane. Kwi-meta-uhlalutyo lwezi zilingo, i-CBT-ndiye ndafunyanwa ukuba ndiphucule ubunzima beempawu zokulala, ixesha lokulala, kunye nexesha lokuvuka kokulala. Ukuphucuka kweempawu zasemini (ezifana nokudinwa kunye neemvakalelo) kunye nomgangatho wobomi buncinci ngokwentelekiso, ngokuyinxenye ngenxa yokusetyenziswa kwamayeza enziwe afana nalawo enziwe afana nalawo aveliswe ngabenzi angaphuhliswanga ngokukodwa ukuphuthelwa. Ngokubanzi, malunga ne-60% ukuya kwi-70% yezigulane zineempendulo zeklinikhi, kunye nokuncipha kwamanqaku e-7 kwi-Insomnia Severity Index (ISI), ukusuka kwi-0 ukuya kwi-28 amanqaku, kunye namanqaku aphezulu abonisa ukungalali kakhulu. Emva kweeveki ze-6-8 zonyango, malunga ne-50% yezigulane zokulala zifumana ukuxolelwa (i-ISI iyonke amanqaku, <8), kunye ne-40% -45% yezigulane zifumana ukuxolelwa okuqhubekayo kwiinyanga ezili-12.

Kule minyaka ilishumi idlulileyo, i-CBT-I yedijithali (eCBT-I) iye yanda kakhulu kwaye inokunciphisa umsantsa obalulekileyo phakathi kwemfuno ye-CBT-I kunye nokufikeleleka. I-ECBT-I inempembelelo entle kwiziphumo ezininzi zokulala, kubandakanya ubunzima bokungalali, ukusebenza kakuhle kokulala, umgangatho wokulala, ukuphaphama emva kokulala, ixesha lokulala, ubude bexesha lokulala, kunye nenani lokuvuka ebusuku. Ezi ziphumo zifana nezo zibonwa kwizilingo zobuso be-CBT-I kwaye zigcinwe kwiiveki ze-4-48 emva kokulandelwa.

Ukunyanga i-comorbidities ezifana nokudakumba kunye neentlungu ezingapheliyo kunokunciphisa iimpawu zokuphuthelwa, kodwa ngokubanzi azikwazi ukusombulula ngokupheleleyo iingxaki zokulala. Ngokuchasene noko, ukunyanga ukuphuthelwa kunokuphucula ukulala kwezigulane ezine-comorbidities, kodwa umphumo kwi-comorbidities ngokwawo awuhambelani. Ngokomzekelo, unyango lokungalali lunokunciphisa iimpawu ezixinzelelekileyo, ukunciphisa izinga leziganeko kunye nokuphindaphinda ukudandatheka, kodwa kunempembelelo encinci kwiintlungu ezingapheliyo.

Indlela yonyango enenqanaba inokunceda ukujongana nomba wemithombo engonelanga efunekayo kunyango lwengqondo kunye nokuziphatha. Enye imo iphakamisa ukusebenzisa imfundo, ukubeka iliso, kunye neendlela zokuzinceda kwinqanaba lokuqala, unyango lwe-digital okanye lweqela lwengqondo kunye nokuziphatha kwinqanaba lesibini, unyango lwengqondo kunye nokuziphatha komntu kwinqanaba lesithathu, kunye nonyango lweyeza njengexesha elifutshane elihambelanayo kwinqanaba ngalinye.

Unyango lwamayeza
Kule minyaka ingama-20 idlulileyo, ipateni kagqirha ye-hypnotic e-United States iye yatshintsha kakhulu. Isixa somyalelo we-benzodiazepine receptor agonists siqhubeka sihla, ngelixa inani le-trazodone liqhubeka nokunyuka, nangona i-US Food and Drug Administration (i-FDA) ayizange ibhale ukungabikho kokulala njengento ebonisa i-trazodone. Ukongezelela, abachasi be-appetite be-receptor antagonists baqaliswe kwi-2014 kwaye baye basetyenziswa ngokubanzi.

Ubungakanani besiphumo samayeza amatsha (ubude beyeza,

Iikhrayitheriya zeBeers (uluhlu lwamachiza athathwa njengelungafanelanga izigulane ezineminyaka engama-65 okanye ngaphezulu) cebisa ukuba kuthintelwe ukusetyenziswa kweli yeza.

Ichiza alivunywanga yi-FDA kunyango lokungalali. Zonke iziyobisi ezidweliswe kwitheyibhile zihlelwa njengeKlasi yokukhulelwa kwe-C yi-US FDA, ngaphandle kwezi ziyobisi zilandelayo: i-Triazolam kunye neTemazepam (iKlasi X); I-Clonazepam (iKlasi D); I-Diphenhydramine kunye ne-docetamine (iklasi B).
1. Benzodiazepine receptor agonist class iziyobisi ze-hypnotic
I-Benzodiazepine receptor agonists ibandakanya iziyobisi ze-benzodiazepine kunye neziyobisi ezingekho ze-benzodiazepine (ezaziwa ngokuba ziziyobisi ze-Z-class). Izilingo zeklinikhi kunye nohlalutyo lwe-meta lubonise ukuba i-benzodiazepine receptor agonists inokunciphisa ngokufanelekileyo ixesha lokulala, ukunciphisa ukuvuswa kokulala emva kokulala, kunye nokwandisa kancinci ubude bokulala (Itheyibhile 4). Ngokweengxelo zesigulane, iziphumo ezichaphazelekayo ze-benzodiazepine receptor agonists ziquka i-anterograde amnesia (<5%), i-sedation ngosuku olulandelayo (5% ~ 10%), kunye nokuziphatha okunzima ngexesha lokulala njengokuphupha emini, ukutya, okanye ukuqhuba (3% ~ 5%). Isiphumo secala lokugqibela singenxa yesilumkiso sebhokisi emnyama ye-zolpidem, zaleplon, kunye ne-escitalopram. I-20% ukuya kwi-50% yezigulane zifumana ukunyamezela kweziyobisi kunye nokuxhomekeka komzimba emva kokuthatha amayeza ubusuku bonke, kubonakaliswe njenge-rebound insomnia kunye nesifo sokuyeka.

2. Iziyobisi ze-heterocyclic ze-sedative
Ama-antidepressants e-sedative, kubandakanywa neziyobisi ze-tricyclic ezifana ne-amitriptyline, i-demethylamine, kunye ne-doxepin, kunye neziyobisi ze-heterocyclic ezifana ne-olanzapine kunye ne-trazodone, ngokuqhelekileyo zichazwe ngamachiza okunyanga ukuphuthelwa. Kuphela i-doxepin (i-3-6 mg yonke imihla, ithathwe ebusuku) ivunywe yi-US FDA yonyango lokungalali. Ubungqina bangoku bubonisa ukuba i-antidepressants ye-sedative inokuphucula umgangatho wokulala, ukulala kakuhle, kunye nokwandisa ubude bexesha lokulala, kodwa ibe nefuthe elincinci kwixesha lokulala. Nangona i-US FDA ingakudwelisi ukuphuthelwa njengophawu kula machiza, oogqirha kunye nezigulana zihlala zikhetha la machiza kuba aneziphumo ebezingalindelekanga ezingephi kwiidosi eziphantsi kwaye namava eklinikhi abonakalise ukusebenza kwawo. Iziphumo ebezingalindelekanga ziquka ukuthomalalisa, umlomo owomileyo, ukulibaziseka kokwenziwa kwentliziyo, i-hypotension, kunye noxinzelelo lwegazi.

3. Abachasi be-appetite receptor
I-neurons equkethe i-orexin kwi-hypothalamus esecaleni ivuselela i-nuclei kwi-brainstem kunye ne-hypothalamus ekhuthaza ukuvuka, kwaye inqanda i-nuclei kwindawo ye-ventral lateral kunye ne-medial preoptic ekhuthaza ukulala. Ngokuchasene noko, izinto ezithintela umnqweno wokutya zinokunqanda ukuhamba kwemithambo-luvo, zicinezele ukuphaphama, kwaye zikhuthaze ukulala. Abachasi abathathu be-orexin receptor antagonists (i-sucorexant, i-lemborxant, kunye ne-daridorexint) baye bavunywa yi-US FDA yonyango lokungalali. Izilingo zeklinikhi zixhasa ukusebenza kwazo ekuqaleni kokulala kunye nokugcinwa. Iziphumo ebezingalindelekanga ziquka ukuthomalalisa, ukudinwa, nokuphupha ngokungaqhelekanga. Ngenxa yokunqongophala kwehomoni ye-endogenous appetite, enokuthi ikhokelele kwi-narcolepsy nge-cataplexy, abachasi be-hormone ye-appetite bayachaswa kwizigulane ezinjalo.

4. I-Melatonin kunye ne-melatonin receptor agonists
I-Melatonin yihomoni ekhutshwe yi-pineal gland phantsi kweemeko ezimnyama ebusuku. I-melatonin yangaphandle inokufikelela kugxininiso lwegazi ngaphaya kwamanqanaba omzimba, ngamaxesha ahlukeneyo ngokuxhomekeke kwidosi ethile kunye nokwakheka. Idosi efanelekileyo ye-melatonin yokunyanga ukuphuthelwa ayikamiselwa. Ulingo olulawulwayo olubandakanya abantu abadala lubonise ukuba i-melatonin inesiphumo esincinci ekuqalekeni kokulala, phantse akukho siphumo sokuvuka ngexesha lokulala kunye nobude obupheleleyo bokulala. Amayeza abopha kwi-melatonin MT1 kunye ne-MT2 receptors avunyiwe kunyango lwe-refractory insomnia (ramelteon) kunye ne-circadian sleep wake disorder (tasimelteon). Njenge-melatonin, la machiza aphantse angabinampembelelo ekuvukeni okanye ekuleleni ixesha elipheleleyo emva kokulala. Ukulala kunye nokudinwa zezona ziphumo zixhaphakileyo.

5. Amanye amayeza
I-Antihistamines kwi-over-the-counter drug (i-diphenhydramine kunye ne-docetamine) kunye neziyobisi ezichazwe ngugqirha (i-hydroxyzine) ziziyobisi ezisetyenziswa ngokuqhelekileyo kunyango lokungalali. Idatha exhasa ukusebenza kwayo ibuthathaka, kodwa ukufikeleleka kwabo kunye nokhuseleko olubonwayo kwizigulane kunokuba zizathu zokuthandwa kwabo xa kuthelekiswa ne-benzodiazepine receptor agonists. I-antihistamine ye-sedative inokubangela ukuxhatshazwa ngokugqithisileyo, imiphumo emibi ye-anticholinergic, kunye nokunyusa umngcipheko we-dementia. I-Gabapentin kunye ne-pregabalin ziqhele ukusetyenziselwa ukunyanga iintlungu ezingapheliyo kwaye zingamachiza onyango lokuqala lwe-syndrome yomlenze ongaphumli. La machiza anesiphumo sokuthomalalisa, ukwandisa ukulala okucothayo, kwaye asetyenziselwa ukunyanga ukuphuthelwa (ngaphaya kwezibonakaliso), ngakumbi xa ehamba nentlungu. Ukudinwa, ukozela, isiyezi, kunye ne-ataxia zezona ziphumo bezingalindelekanga.

Ukukhethwa kwamachiza e-hypnotic
Ukuba iyeza likhethwa unyango, i-benzodiazepine receptor agonists emfutshane, i-orexin antagonists, okanye i-dose ephantsi ye-heterocyclic iziyobisi zikhetho lokuqala olufanelekileyo kwiimeko ezininzi zeklinikhi. I-Benzodiazepine receptor agonists ingaba yonyango olukhethiweyo lwezigulane zokulala kunye neempawu zokulala, izigulane ezincinci ezikhulileyo, kunye nezigulane ezinokufuna unyango lwexesha elifutshane (njengokungalali ngenxa yoxinzelelo olunzima okanye lwexesha). Xa kunyangwa izigulane ezineempawu ezinxulumene nokugcina ubuthongo okanye ukuvuka kwangoko, abantu abadala, kunye nabo baneengxaki zokusetyenziswa kweziyobisi okanye i-apnea yokulala, i-heterocyclic ye-dose ephantsi okanye i-suppressants ye-appetite ingaba yinto yokuqala yokukhetha.

Ngokwe-criteria yeBeers, uluhlu lweziyobisi ezingafanelekanga kwizigulane ezineminyaka eyi-65 okanye ngaphezulu zibandakanya i-benzodiazepine receptor agonists kunye neziyobisi ze-heterocyclic, kodwa azibandakanyi i-doxepin, i-trazodone, okanye i-orexin antagonists. Iyeza lokuqala lidla ngokubandakanya ukuthatha amayeza ubusuku ngabunye kwiiveki ezi-2 ukuya kwezi-4, kwaye emva koko kuvavanywe iziphumo kunye neziphumo ebezingalindelekanga. Ukuba amayeza exesha elide ayadingeka, khuthaza amayeza aphakathi (2-4 amaxesha ngeveki). Izigulane kufuneka zikhokelwe ukuba zithathe amayeza 15-30 imizuzu ngaphambi kokulala. Emva kweyeza lexesha elide, ezinye izigulane zinokuhlakulela ukuxhomekeka kweziyobisi, ngakumbi xa usebenzisa i-benzodiazepine receptor agonists. Emva kokusetyenziswa kwexesha elide, ukunciphisa okucwangcisiweyo (okufana nokunciphisa i-25% ngeveki) kunokunceda ukunciphisa okanye ukuyeka izidakamizwa ze-hypnotic.

Ukhetho phakathi konyango oludibeneyo kunye ne-monotherapy
Izifundo ezimbalwa ezikhoyo zentloko ukuya kwintloko zibonise ukuba kwixesha elifutshane (iiveki ze-4-8), i-CBT-I kunye neziyobisi ze-hypnotic (ikakhulukazi iziyobisi ze-Z-class) zineempembelelo ezifanayo ekuphuculeni ukuqhubeka kokulala, kodwa unyango lweziyobisi lunokwandisa kakhulu ubude bexesha lokulala xa kuthelekiswa ne-CBT-I. Xa kuthelekiswa nokusebenzisa i-CBT-I yedwa, unyango oludibeneyo lunokuphucula ukulala ngokukhawuleza, kodwa le nzuzo iyancipha ngokuthe ngcembe kwiveki yesine okanye yesihlanu yonyango. Ukongezelela, xa kuthelekiswa namayeza okanye unyango oludibeneyo, ukusebenzisa i-CBT-I yedwa kunokuphucula ukulala ngokuqhubekayo. Ukuba kukho enye indlela elunge ngakumbi yokuthatha iipilisi zokulala, ukuthobela kwezinye izigulane iingcebiso zokuziphatha kunokwehla.