nkhani

Kusagona tulo ndi vuto lofala kwambiri la kugona, lomwe limatanthauzidwa ngati vuto la kugona lomwe limachitika mausiku atatu kapena kuposerapo pa sabata, limakhala kwa miyezi yoposa itatu, ndipo silimayambitsidwa ndi kusowa kwa mwayi wogona. Pafupifupi 10 peresenti ya akuluakulu amakumana ndi vuto la kusowa tulo, ndipo ena 15% mpaka 20% amafotokoza za vuto la kugona. Odwala omwe akusowa tulo kwa nthawi yayitali amakhala pachiwopsezo chowonjezeka cha kupsinjika maganizo, kuthamanga kwa magazi, matenda a Alzheimer's, ndi kulephera kugwira ntchito.

Mavuto azachipatala

Makhalidwe a kusowa tulo ndi khalidwe labwino kapena nthawi ya kugona kosakwanira, limodzi ndi vuto la kugona kapena kugona, komanso kuvutika maganizo kwakukulu kapena kusokonezeka kwa masana. Kusagona tulo ndi vuto la kugona lomwe limachitika mausiku atatu kapena kuposerapo pamlungu, limatenga miyezi yoposa itatu, ndipo silimayamba chifukwa cha kuchepa kwa mpata wogona. Kusowa tulo nthawi zambiri kumachitika nthawi imodzi ndi matenda ena amthupi (monga kupweteka), matenda amisala (monga kupsinjika maganizo), ndi matenda ena ogona (monga matenda a miyendo yopumula ndi kupuma movutikira).

Kusagona tulo ndi vuto lofala kwambiri la kugona pakati pa anthu ambiri, ndipo ndi limodzi mwa mavuto omwe amatchulidwa kawirikawiri pamene odwala amapita kuchipatala choyambirira, koma nthawi zambiri samalandira chithandizo. Pafupifupi 10 peresenti ya akuluakulu amakumana ndi vuto la kusowa tulo, ndipo ena 15% mpaka 20 peresenti ya akuluakulu amawonetsa zizindikiro za kusowa tulo. Kusagona tulo kumakhala kofala kwambiri mwa amayi ndi anthu omwe ali ndi vuto la maganizo kapena thupi, ndipo chiwerengero chake chidzawonjezeka m'zaka zapakati ndi zaka zapakati, komanso mu perimenopause ndi menopause. Tikudziwabe pang'ono za ma pathological and physiological mechanisms of kusowa tulo, koma pakali pano akukhulupirira kuti psychological and physiological overstimulation ndiye maziko ake.

Kusagona tulo kungakhale kochitika kapena mwa apo ndi apo, koma odwala oposa 50% amakhala ndi kusowa tulo kosalekeza. Kusowa tulo koyamba nthawi zambiri kumachokera ku malo opsinjika, zovuta zaumoyo, nthawi zantchito, kapena kuyenda modutsa nthawi zingapo (kusiyana kwa nthawi). Ngakhale kuti anthu ambiri amagonanso bwinobwino atazolowera zinthu zimene zawayambitsa, anthu amene amakonda kusowa tulo amakhala ndi vuto losagona tulo. Zamaganizo, khalidwe, kapena zakuthupi nthawi zambiri zimayambitsa vuto la kugona kwa nthawi yaitali. Kusowa tulo kwa nthawi yayitali kumatsagana ndi chiwopsezo chowonjezeka cha kupsinjika kwakukulu, kuthamanga kwa magazi, matenda a Alzheimer's, komanso kuchepa kwa ntchito.

Kuwunika ndi kuzindikira kwa kusowa tulo kumadalira kufunsa mwatsatanetsatane mbiri yachipatala, kujambula zizindikiro, matenda, comorbidities, ndi zina zomwe zimayambitsa. Kujambula kwa mawola 24 akugona kutha kuzindikira zolinga zambiri zamakhalidwe ndi chilengedwe. Zida zowunikira zomwe odwala ananena komanso zolemba zakugona zimatha kupereka chidziwitso chofunikira chokhudza kuopsa kwa zizindikiro za kusowa tulo, kuwunikira chithandizo chazovuta zina za kugona, ndikuwunika momwe chithandizo chikuyendera.

Njira ndi Umboni

Njira zamakono zochizira kusowa tulo ndi monga mankhwala olembedwa ndi dokotala komanso ogulira, psychotherapy ndi khalidwe therapy (yomwe imadziwikanso kuti cognitive-behavioral therapy [CBT-I] ya kusowa tulo), ndi adjuvant ndi njira zina zothandizira. Njira yochiritsira yokhazikika kwa odwala ndikuyamba kugwiritsa ntchito mankhwala osagulitsika kenako ndikugwiritsa ntchito mankhwala omwe adalembedwa ndi dokotala atalandira chithandizo chamankhwala. Odwala ochepa amalandira chithandizo cha CBT-I, mwina chifukwa cha kusowa kwa akatswiri ophunzitsidwa bwino.

CBTI-I
CBT-I imaphatikizapo njira zingapo zomwe cholinga chake ndi kusintha machitidwe ndi zochitika zamaganizo zomwe zimayambitsa kusowa tulo, monga kuda nkhawa kwambiri ndi zikhulupiriro zoipa za kugona. Mfundo yaikulu ya CBT-I imaphatikizapo njira zowonetsera khalidwe ndi kugona (kuletsa kugona ndi kuwongolera mphamvu), njira zotsitsimula, malingaliro ndi chidziwitso (kapena zonse ziwiri) zomwe zimayang'ana kusintha zikhulupiriro zoipa ndi nkhawa zambiri zokhudzana ndi kusowa tulo, komanso maphunziro a ukhondo wa tulo. Njira zina zothandizira m'maganizo monga Acceptance and Commitment Therapy ndi Mindfulness Based Therapy zagwiritsidwanso ntchito pochiza kusowa tulo, koma pali chidziwitso chochepa chothandizira mphamvu zawo, ndipo ziyenera kupitirizidwa kwa nthawi yaitali kuti zipindule. CBT-I ndi chithandizo chamankhwala chomwe chimangoyang'ana kugona ndipo chimakhala ndi zovuta. Nthawi zambiri amatsogozedwa ndi akatswiri azamisala (monga katswiri wazamisala) pamakambirano a 4-8. Pali njira zosiyanasiyana zogwiritsira ntchito CBT-I, kuphatikizapo mawonekedwe afupikitsa ndi mawonekedwe a gulu, ndi kutenga nawo mbali kwa akatswiri ena azachipatala (monga anamwino ogwira ntchito), komanso kugwiritsa ntchito telemedicine kapena nsanja za digito.

Pakadali pano, CBT-I ikulimbikitsidwa ngati chithandizo choyambirira pamalangizo azachipatala ndi mabungwe angapo akatswiri. Mayesero azachipatala ndi kusanthula kwa meta kwawonetsa kuti CBT-I imatha kusintha kwambiri zotsatira zomwe zanenedwa za odwala. Mu meta-kuwunika kwa mayeserowa, CBT-I idapezeka kuti ikuwongolera kuopsa kwa zizindikiro za kusowa tulo, nthawi yoyambira kugona, komanso nthawi yodzuka pambuyo pogona. Kusintha kwa zizindikiro za masana (monga kutopa ndi kutengeka maganizo) ndi khalidwe la moyo ndilochepa, mwina chifukwa cha kugwiritsa ntchito njira zowonongeka zomwe sizinapangidwe makamaka pofuna kusowa tulo. Ponseponse, pafupifupi 60% mpaka 70% ya odwala ali ndi vuto lachipatala, ndi kuchepa kwa 7 mfundo mu Insomnia Severity Index (ISI), yomwe imachokera ku 0 mpaka 28 mfundo, ndi zotsatira zapamwamba zomwe zimasonyeza kusowa tulo koopsa. Pambuyo pa masabata a 6-8 a chithandizo, pafupifupi 50% ya odwala kusowa tulo amapeza chikhululukiro (chiwerengero chonse cha ISI, <8), ndipo 40% -45% ya odwala amapeza chikhululukiro chosalekeza kwa miyezi 12.

Pazaka khumi zapitazi, digito ya CBT-I (eCBT-I) yakhala yotchuka kwambiri ndipo pamapeto pake ikhoza kuchepetsa kusiyana kwakukulu pakati pa zofuna za CBT-I ndi kupezeka. ECBT-I imakhala ndi zotsatira zabwino pazotsatira zingapo za kugona, kuphatikizapo kuopsa kwa kusowa tulo, kugona mokwanira, kugona mokwanira, kukhala maso mukagona, nthawi yogona, nthawi yogona, komanso kuchuluka kwa kudzutsidwa usiku. Zotsatirazi ndi zofanana ndi zomwe zimawonedwa pamasom'pamaso ndi mayesero a CBT-I ndipo zimasungidwa kwa masabata a 4-48 pambuyo potsatira.

Kuchiza matenda obwera chifukwa cha kupsinjika maganizo ndi kupweteka kosalekeza kumatha kuchepetsa zizindikiro za kusowa tulo, koma nthawi zambiri sikungathetseretu vuto la kusowa tulo. M'malo mwake, kuchiza kusowa tulo kumatha kusintha kugona kwa odwala omwe ali ndi comorbidities, koma zotsatira za comorbidities pawokha sizofanana. Mwachitsanzo, chithandizo cha kusowa tulo chingathe kuchepetsa zizindikiro za kuvutika maganizo, kuchepetsa chiwerengero cha zochitika ndi kubwerezabwereza kwa kuvutika maganizo, koma sikukhudza kwambiri ululu wosatha.

Njira ya chithandizo chamagulu angapo ingathandize kuthana ndi vuto la kuchepa kwazinthu zofunikira pazamankhwala am'maganizo ndi machitidwe. Njira imodzi imasonyeza kugwiritsa ntchito maphunziro, kuyang'anira, ndi njira zodzithandizira pa mlingo woyamba, digito kapena gulu lamaganizo ndi khalidwe lachidziwitso pa mlingo wachiwiri, chithandizo chamaganizo ndi khalidwe la munthu pa mlingo wachitatu, ndi chithandizo chamankhwala monga chithandizo cha nthawi yochepa pa mlingo uliwonse.

Chithandizo chamankhwala
Pazaka 20 zapitazi, kachitidwe ka mankhwala ogodomalitsa ku United States asintha kwambiri. Kuchuluka kwa mankhwala a benzodiazepine receptor agonists akupitirirabe kuchepa, pamene chiwerengero cha trazodone chikupitirirabe, ngakhale US Food and Drug Administration (FDA) sinatchule kusowa tulo ngati chizindikiro cha trazodone. Kuphatikiza apo, otsutsana ndi chilakolako chofuna kudya adayambitsidwa mu 2014 ndipo akhala akugwiritsidwa ntchito kwambiri.

Zotsatira za kukula kwa mankhwala atsopano (nthawi ya mankhwala,

Njira za Beers (mndandanda wamankhwala omwe amawonedwa ngati osayenera kwa odwala azaka 65 kapena kupitilira apo) amalimbikitsa kupewa kugwiritsa ntchito mankhwalawa.

Mankhwalawa sanavomerezedwe ndi FDA pochiza kusowa tulo. Mankhwala onse omwe ali patebulo amatchulidwa kuti Mimba Kalasi C ndi US FDA, kupatulapo mankhwala otsatirawa: Triazolam ndi Temazepam (Kalasi X); Clonazepam (Kalasi D); Diphenhydramine ndi docetamine (kalasi B).
1. Benzodiazepine receptor agonist class hypnotic mankhwala
Benzodiazepine receptor agonists akuphatikizapo mankhwala a benzodiazepine ndi mankhwala omwe si a benzodiazepine (omwe amadziwikanso kuti mankhwala a Z-class). Mayesero azachipatala ndi kuwunika kwa meta awonetsa kuti benzodiazepine receptor agonists amatha kufupikitsa nthawi yogona, kuchepetsa kudzutsidwa kwa kugona, ndikuwonjezera pang'ono nthawi yonse yogona (Table 4). Malinga ndi malipoti a odwala, zotsatira za benzodiazepine receptor agonists zimaphatikizapo anterograde amnesia (<5%), sedation tsiku lotsatira (5% ~ 10%), ndi makhalidwe ovuta panthawi yogona monga kulota, kudya, kapena kuyendetsa galimoto (3% ~ 5%). Zotsatira zomaliza ndi chifukwa cha chenjezo la bokosi lakuda la zolpidem, zaleplon, ndi escitalopram. 20% mpaka 50% ya odwala amakumana ndi kulolerana kwamankhwala ndi kudalira kwakuthupi atamwa mankhwala usiku uliwonse, zomwe zimawonetsedwa ngati kusagona tulo komanso kukomoka.

2. Sedative heterocyclic mankhwala
Mankhwala osokoneza bongo, kuphatikizapo tricyclic mankhwala monga amitriptyline, demethylamine, ndi doxepin, ndi heterocyclic mankhwala monga olanzapine ndi trazodone, kawirikawiri amapatsidwa mankhwala ochizira kusowa tulo. Doxepin yokha (3-6 mg tsiku lililonse, yotengedwa usiku) yavomerezedwa ndi US FDA pochiza kusowa tulo. Umboni wapano ukusonyeza kuti mankhwala ochepetsa kupsinjika maganizo amatha kusintha kugona bwino, kugona mokwanira, komanso kutalikitsa nthawi yogona, koma sakhudza nthawi yogona. Ngakhale kuti US FDA satchula kusowa tulo ngati chisonyezero cha mankhwalawa, madokotala ndi odwala nthawi zambiri amakonda mankhwalawa chifukwa ali ndi zotsatira zochepa pa mlingo wochepa komanso zochitika zachipatala zasonyeza kuti akugwira ntchito. Zotsatira zake ndi monga sedation, pakamwa pouma, kuchedwa kwa mtima conduction, hypotension, ndi matenda oopsa.

3. Otsutsana ndi chilakolako chofuna kudya
Mitsempha yomwe ili ndi orexin mu lateral hypothalamus imayambitsa ma nuclei mu ubongo ndi hypothalamus zomwe zimalimbikitsa kugalamuka, ndikuletsa ma nuclei mu ventral lateral ndi medial preoptic malo omwe amalimbikitsa kugona. M'malo mwake, zoletsa chilakolako zimatha kulepheretsa kuwongolera kwa mitsempha, kuletsa kugalamuka, ndikulimbikitsa kugona. Otsutsa atatu a orexin receptor antagonists (sucorexant, lemborxant, ndi daridorexint) avomerezedwa ndi US FDA pofuna kuchiza kusowa tulo. Mayesero azachipatala amathandizira mphamvu yawo pakugona komanso kukonza. Zotsatira zake ndi monga sedation, kutopa, ndi kulota kwachilendo. Chifukwa cha kuchepa kwa amkati chilakolako mahomoni, zomwe zingachititse kuti narcolepsy ndi cataplexy, chilakolako timadzi antagonists ndi contraindicated odwala amenewa.

4. Melatonin ndi melatonin receptor agonists
Melatonin ndi timadzi timene timapangidwa ndi pineal gland pansi pamdima usiku. Exogenous melatonin imatha kufika m'magazi kupitirira msinkhu wa thupi, ndi nthawi yosiyana malinga ndi mlingo wake ndi mapangidwe ake. Mlingo woyenera wa melatonin pochiza kusowa tulo sunadziwike. Mayesero olamuliridwa okhudza akuluakulu asonyeza kuti melatonin ili ndi zotsatira zochepa pakuyamba kugona, ndipo sizimakhudza kudzuka panthawi yogona komanso nthawi yogona. Mankhwala omwe amamangiriza ku melatonin MT1 ndi MT2 zolandilira avomerezedwa kuti azichiza kusowa tulo (ramelteon) ndi circadian sleep wake disorder (tasimelteon). Monga melatonin, mankhwalawa sakhudza kudzuka kapena kugona kwathunthu mukagona. Kugona ndi kutopa ndizo zotsatira zofala kwambiri.

5. Mankhwala ena
Antihistamines mu mankhwala ogulitsidwa (diphenhydramine ndi docetamine) ndi mankhwala (hydroxyzine) ndi mankhwala omwe amagwiritsidwa ntchito kwambiri pochiza kusowa tulo. Zomwe zimachirikiza mphamvu zake ndizochepa, koma kupezeka kwawo ndi chitetezo chodziwika kwa odwala kungakhale zifukwa za kutchuka kwawo poyerekeza ndi benzodiazepine receptor agonists. Sedative antihistamines ingayambitse kukhumudwa kwambiri, zotsatira za anticholinergic, ndikuwonjezera chiopsezo cha dementia. Gabapentin ndi pregabalin amagwiritsidwa ntchito pochiza kupweteka kosalekeza komanso ndi mankhwala oyamba ochizira matenda a mwendo wopumula. Mankhwalawa amakhala ndi sedative, amawonjezera kugona kwapang'onopang'ono, ndipo amagwiritsidwa ntchito pochiza kusowa tulo (kupitirira zisonyezo), makamaka akamayenda ndi ululu. Kutopa, kugona, chizungulire, ataxia ndizo zotsatira zoyipa kwambiri.

Kusankhidwa kwa hypnotic mankhwala
Ngati mankhwala asankhidwa kuti alandire chithandizo, ma benzodiazepine receptor agonists afupipafupi, orexin antagonists, kapena mankhwala otsika kwambiri a heterocyclic ndiwo kusankha koyenera koyamba m'zochitika zambiri zachipatala. Benzodiazepine receptor agonists angakhale chithandizo chokondedwa kwa odwala kusowa tulo omwe ali ndi zizindikiro zoyamba kugona, odwala achikulire, ndi odwala omwe angafunike mankhwala osakhalitsa (monga kusowa tulo chifukwa cha kupsinjika kwakukulu kapena nthawi zina). Pochiza odwala omwe ali ndi zizindikiro zokhudzana ndi kugona kapena kudzuka msanga, anthu okalamba, ndi omwe ali ndi vuto la kugwiritsa ntchito mankhwala osokoneza bongo kapena kupuma movutikira, mankhwala otsika kwambiri a heterocyclic kapena kupondereza chilakolako angakhale choyamba.

Malingana ndi ndondomeko ya Beers, mndandanda wa mankhwala omwe ali osayenera kwa odwala a zaka 65 kapena kuposerapo amaphatikizapo benzodiazepine receptor agonists ndi heterocyclic mankhwala, koma samaphatikizapo doxepin, trazodone, kapena orexin antagonists. Mankhwala oyamba nthawi zambiri amaphatikiza kumwa mankhwala usiku uliwonse kwa masabata a 2-4, ndikuwunikanso zotsatira zake ndi zotsatira zake. Ngati mankhwala a nthawi yayitali akufunika, limbikitsani mankhwala apakati (2-4 pa sabata). Odwala ayenera kutsogoleredwa kuti amwe mankhwala 15-30 mphindi asanagone. Pambuyo pa mankhwala kwa nthawi yayitali, odwala ena amatha kudalira mankhwala, makamaka akamagwiritsa ntchito benzodiazepine receptor agonists. Pambuyo pakugwiritsa ntchito nthawi yayitali, kuchepetsedwa kokonzekera (monga kuchepetsa 25% pa sabata) kungathandize kuchepetsa kapena kusiya mankhwala osokoneza bongo.

Kusankha pakati pa kuphatikiza mankhwala ndi monotherapy
Maphunziro angapo oyerekeza omwe alipo akuwonetsa kuti pakapita nthawi yochepa (masabata a 4-8), CBT-I ndi mankhwala ogodomalitsa (makamaka mankhwala amtundu wa Z) ali ndi zotsatira zofananira pakuwongolera kugona, koma chithandizo chamankhwala chimatha kuwonjezera nthawi yayitali yogona poyerekeza ndi CBT-I. Poyerekeza ndi kugwiritsa ntchito CBT-I ndekha, mankhwala osakaniza amatha kugona mofulumira, koma ubwino umenewu umachepa pang'onopang'ono mu sabata lachinayi kapena lachisanu la chithandizo. Kuonjezera apo, poyerekeza ndi mankhwala kapena mankhwala osakaniza, kugwiritsa ntchito CBT-I ndekha kungapangitse kugona kosalekeza. Ngati pali njira ina yabwino yogwiritsira ntchito mapiritsi ogonetsa, kutsata kwa odwala ena ku uphungu wamakhalidwe kungachepe.