CM II Week 6 (Sleep Disorders)

Myths vs Facts of Sleep

lots of them just to read

All Facts

•Less than 35% of US adults get the recommended 7-9 hours of sleep

•The brain CANNOT recover lost sleep

•You CANNOT “catch-up” on weekends

•Surgeons were 170% more likely to make an error w/o at least 6 hr of sleep

•Mental health and sleep are related-particularly in adolescents

•Association between amount of sleep and lifespan

•Heart disease, cancer, dementia, obesity, diabetes all worsen with decreased sleep

•One study concluded than <6 hours of sleep = 4-5x more likely to have an MI

•Sleeping less than 6 hours (instead of 7-8) doubled the risk of MI/CVA

•Sleeping improves BP (take BP meds before sleep for better outcomes)

•Sleep stabilizes mood and reactions

•Even 20 minutes of sleep loss causes trouble

•Less emotional regulation when the end of sleep is interrupted- because the end is when you are literally processing feelings.

•More traffic accidents and disasters occur in early morning hours (3 Mile Island in Pennsylvania, Chernobyl)

•Inadequate sleep costs American business $411 billion/year and countless lost creative opportunities

Sleep deprivation is how many hours of sleep

less than 6 hours

Explain the role of the optic nerve in sleep

The optic nerve is located beneath the suprachiasmatic nucleus, which signals the pineal gland to produce melatonin which tells your brain, "it's dark".

Where does sleep begin in the brain

frontal lobe

•Sleep is active, starts in frontal lobes.

What portion of the brain blocks external stimuli from reaching the cortex of the brain during sleep?

Thalamus

The thalamus blocks external stimuli form reaching the cortex. 

Thalamus function in sleep

blocks external stimuli

What factors impede sleep?

Temperature

Loud sounds

Light

Pain

Stress

Shift work

brain stem role in sleep

when asleep, the brain stem starts a cycle of awake with many other structures including prefrontal cortex and hippocampus

Role of melatonin in sleep

hormone that serves as a time cue, that it is dark and time to sleep

How to do the stages of sleep progress?

As slow waves from the front to the back of the brain

Stages 1-4 progress as slow waves synchronously move from the front of the brain to back, broken by sleep spindles

What portions of the brain begin the "wake cycle"

brainstem, prefrontal cortex, hippocampus

function of hippocampus

memory

How much of sleep is REM?

20-25%

What mental health disorder is associated with insufficient REM sleep

PTSD

What mental health disorder is associated disruptive and less deep sleep

Bipolar disorder

levels of REM sleep comparison: NB, child, teenager, adult

"Slow-wave" sleep is necessary for...

memory consolidation and learning

lack of slow wave sleep can hamper learning ability

When do the periods of REM sleep lengthen

at the end of sleep

High levels of REM sleep helps...

brain development & activity (e.g. in newborns)

What portions of the brain process sensation

sensory cortex & amygdala

sensations come in and are processed in the sensory cortex with amygdala (emotional) influence, then move to the prefrontal cortex for working memory and hippocampus for short term storage

From the hippocampus, memories are encoded and sent back to?

From the hippocampus, memories are encoded and sent back to the cortex for long term storage in declarative memory

Where are memories about movement, actions or step-by-step processes stored

basal ganglia & cerebellum

Memories about movement, actions or step-by-step processes, called procedural memories, are stored in the basal ganglia and cerebellum

Slow wave (non-REM) sleep promotes

Slow waves (non REM) sleep promotes cerebral recovery and improves cognitive functioning​

Sleep consolidates

memories!

How do we get from sleep to success?

Think of sleep as a car wash for your brain and body, like a computer defragmenting

Immune system is hard at work

Memories are consolidated (made) and cells are repaired- especially during REM. REM is also when we prune connections and regulate emotions.

7 major categories of sleep disorders

1. insomnia

2. sleep-related breathing disorders

3. central disorders of hypersomnolence

4. circadian rhythm sleep-wake disorders

5.parasomnias

6. sleep-related movement disorders

7. other sleep disorders

Insomnia

recurrent difficulty falling and staying asleep despite adequate opportunity

Sleep-related breathing disorders

respiratory abnormalities that occur during rest

Central Disorders of Hypersomnolence

daytime sleepiness not caused by disturbed sleep or misaligned circadian rhythm

Circadian rhythm sleep-wake disorders

misalignment between the endogenous circadian clock and external environment leading to sleep-wake disruptions and symptoms of insomnia or sleepiness, shift work disorder

Parasomnias

involuntary physical events and experiences occurring when falling asleeping, during sleep, or waking up

Parasomnia may lead to

injuries, adverse health effects, psychosocial effects, hypersomnia

Sleep-related movement disorders

simple movements that disturb sleep or sleep onset

HPI for sleep (long just general concept)

Listen for vague terms/complaints: sleepiness, fatigue, lack of energy, tired, lethargy, moodiness, and difficulty concentrating, sleepiness in ADLS, trouble staying awake, performance, problems driving, including near-miss accidents, sxs of obstructive sleep apnea (OSA): loud snoring alternating with quiet episodes of pauses in breathing, dry mouth, nasal congestion, nocturnal enuresis, morning headaches- may need to ask sleep partner, sleeping patterns and sleepiness: time of sleep onset and offset, sleep latency, variability on the weekends, total sleep time (including naps), chronic pain, use of hypnotics to fall asleep or stimulants to stay awake, and daytime energy

meds to consider in H&P with sleep disorders

benzodiazepines, opioids, barbiturates, anticonvulsants, antihistamines, neuroleptics, dopamine agonists, and antidepressants.

What family hx should be considered for sleep disorders

narcolepsy

obstructive sleep apnea

restless leg syndrome

periodic leg movement disorder

major depressive disorder

bipolar disorder

PE sleep

Likely unremarkable unless another cause of sleep concerns

What are the diagnostic tests for suspected sleep disorders?

Sleep logs

Actigraphy: monitor rest & activity

Polysomnography: study brain wave, breathing, HR, O2 and leg movement during sleep

multiple sleep latency test

performance eval for sleep

psychomotor vigilance test (PVT)

Oxford sleep resistance (OSLER) test

Psychomotor Vigilance Test (PVT)

Measures reaction time and alertness

-assess behavioral consequences of excessive daytime sleepiness

Oxford Sleep Resistance (OSLER)

assess vigilance and the ability to stay awake

additional factors to consider in H&P

hypothyroidism, anemia, narcolepsy type 1, or restless legs syndrome, urine toxicology, electroencephalogram (seizure), neuroimaging rarely needed

Questionnaires to detect Sleep Disorders

Epworth Sleepiness Scale (ESS)

Stanford Sleepiness Scale (SSS)

Karolinska Sleepiness Scale (KSS)

Pittsburgh Sleep Quality Index

Ullanlinna Narcolepsy Scale or Swiss Narcolepsy Scale

Epworth Sleepiness Scale (ESS)

•8 scenarios are considered for likelihood of falling asleep (sitting and reading)

•score ranges from 0 (awake) to 24 (sleepy)

What score on the ESS warrants further evaluation of sleep disorder?

10 or more

The stanford sleepiness scale (SSS) assesses

current state of sleepiness

Karolinska Sleepiness Scale (KSS) assesses

the current state of sleepiness

What two questionnaires assess the current state of sleepiness

Stanford Sleepiness Scale (SSS) and Karolinska Sleepiness Scale (KSS)

Pittsburgh Sleep Quality Index is a...

19 item self-report measure of sleep quality from the previous month, score range 0-21

Sleep Hygiene Index (to read, questions asked with ranking: Always (5), Frequently (4), Sometimes (3), Rarely (2), Never (1))

1. I take daytime naps lasting two or more hours.

2. I go to bed at different times from day to day.

3. I get out of bed at different times from day to day.

4. I exercise to the point of sweating within 1 h of going to bed.

5 .I stay in bed longer than I should two or three times a week.

6. I use alcohol, tobacco, or caffeine within 4 h of going to bed or after going to bed.

7. I do something that may wake me up before bedtime (for example: play video games, use the internet, or clean).

8. I go to bed feeling stressed, angry, upset, or nervous.

9. I use my bed for things other than sleeping or sex (for example: watch television, read, eat, or study).

10. I sleep on an uncomfortable bed (for example: poor mattress or pillow, too much or not enough blankets).

11. I sleep in an uncomfortable bedroom (for example: too bright, too stuffy, too hot, too cold, or too noisy).

12. I do important work before bedtime (for example: pay bills, schedule, or study).

13. I think, plan, or worry when I am in bed.

Sleep well: How to get better sleep quality and duration

•Cold, dark and quiet room

•Protect enough time

•No phones! (remember the suprachiasmatic nucleus)

•Little caffeine

•No meds or ETOH

•A nap before 3 if you must

•Still can't sleep? Find a sleep (CBT) therapist

True of False: People who take sleeping pills (Ambien and Temazepam) are more likely to die

true

What defines insomnia

difficulty falling or staying asleep:

1. >30 min to fall asleep

2. Awake for 30 minutes after falling asleep (cant go back to sleep)

3. Sleep efficiency <85%

4. Less than 6.5 hours of sleep

*most common sleep disorder*

First line tx for insomnia

sleep hygiene

What is the most effective treatment for insomnia

Cognitive Behavioral Therapy

Are meds recommended for insomnia

NO, last line. Only used if all else does not work

•Sleep hygiene is first line

•Sleep CBT is most effective (CBT-I)

•Can supplement with meds (benzo, hyponotics, anticholinergics) but not best options

•Non-prescription and herbal supplements not recommended

All tx regimens for insomnia

1. Sleep Hygiene

2. Treat underlying condition

3. CBT for sleep

4. Relaxation therapy, acupuncture, music relaxation

If all of the above have been tried seriously some meds with serious side effects can be tried...

If all of the above have been tried seriously some meds with serious side effects can be tried...

•short-intermediate acting benzodiazepines like temazepam, estazolam, or lorazepam

•nonbenzodiazepine hypnotic sedatives: zolpidem, eszopiclone, zaleplon

•melatonin receptor agonist: ramelteon

•sedating antidepressants (better choice if the patient also has depression and/or anxiety; trazodone, amitriptyline, doxepin, or mirtazapine)

•combination of hypnotic sedative plus sedating antidepressant

•Does the patient have epilepsy or a psychotic disorder? anticonvulsants (gabapentin, tiagabine), antipsychotics (quetiapine, olanzapine)

•Don't use antihistamines or OTC sleep aids (pain reliever+ sleep aid)

•Valerian and melatonin not recommended

Sleep Disturbances with Psychiatric Dx

•Schizophrenia, sleep architecture and clozapine (risk of agranulocytosis vs benefit)

•ADHD-stimulant meds often used, co-occurring anxiety must be treated

•Mania, Anxiety, PTSD (bipolar)- treat underlying condition first

•Anxiety can cause sleep disorders and sleep deprivation can cause anxiety disorders

•Sleep disorders can cause and exacerbate mood disorders

•Mood disorders can exacerbate sleep problems.

•Sleep problems can lead to sleep anxiety

•Anxiety= can't fall asleep vs depression= can't stay asleep (early AM)? Evidence?

What is shift work disorder

Insomnia or excessive sleepiness associated with a "nontraditional" work schedule.

Increased rates of cancer in one study!

Diagnostic workup for shift work disorder

Sleep log for +2 weeks

Actinography (measures sleep activity)

Tx for Shift Work Disorder

- Encourage sleep hygiene

- 3 mg of melatonin

- Stimulant and sedative combinations timed correctly

- Overlap workday and day off sleep

- Bright light before activities and avoid light before bed

Obstructive Sleep Apnea (OSA)

repetitive pharyngeal collapse during sleep, which leads to absence of breathing, hypoxemia, & recurrent arousal

Apnea

cessation of breathing >10 seconds

Hypopnea

partial airflow obstruction causing shallow breathing & frequent arousal

Apnea-hypopnea index

Apnea-hypopnea index is the number of apneas and/or hypopneas/ hour of sleep as measured by polysomnography study or a home sleep apnea study.

issues with OSA

Alterations in intrathoracic pressure cause sympathetic nervous activation and systemic and pulmonary arterial hypertension

chronic and sustained systemic and pulmonary HTN, arrhythmias, and associated complications.

Signs and symptoms of OSA

Snoring

Breathing pauses

Restless/ nonrefreshing sleep

Awakening caused by gasping

Insomnia

Daytime sleepiness

Risk factors for OSA

Large neck circumference

Family History

Older age

Race

Craniofacial abnormalities

Obesity

Smoking

Alcohol

What is the "gold standard" assessment for OSA

Polysomnography (PSG)

How to confirm diagnosis of OSA

Diagnosis confirmed if number of obstructive events (apnea, hypopnea, or respiratory event-related arousal) on PSG is ≥ 5 events/hour.

Modified Mallampati Score

assesses anatomy of the oral cavity for likelihood of apnea

What is examined in Modified Mallampati

Looking for low visibility of the posterior pharynx when patient opens mouth

List some examples of findings on Modified Mallampati that would increase risk of apnea

retrognathia or increased overjet (top incisor teeth ahead of bottom incisors)

lateral peritonsillar narrowing

macroglossia

tonsillar hypertrophy

elongated or enlarged uvula

high-arched or narrow hard palate

nasal abnormalities (polyps, deviation of septum, turbinate hypertrophy)

Mild OSA for RDI

mild for respiratory disturbance index (RDI) ≥ 5 events/hour and < 15 events/hour

Moderate OSA for RDI

moderate for RDI ≥ 15 events/hour and < 30 events/hour

Severe OSA for RDI

severe for RDI ≥ 30 events/hour

How to manage OSA

Weight reduction in overweight patients

CPAP

Oral Appliances (for mild to moderate that dont like CPAP or arent candidates for it)

Medications: only given to improve daytime sleepiness

What is the treatment of choice for OSA

CPAP!

for moderate-to-severe improve quality of life, reduce excessive daytime sleepiness, and decrease MVAs

What should be repeated in pts w/ OSA

polysomnography

Why give patients with OSA oral appliances than CPAP

Not all patients are candidates for CPAP

Patient preference

Unresponsive to CPAP

mandibular advancement devices (MAD) and tongue retaining devices

what meds may improve OSA sx

Medications (modafinil/Provigil) may improve daytime sleepiness

may be used in conjunction with CPAP or MAD therapy in selected cases, not as sole therapy for OSA

surgical procedures for OSA

possible, but efficacy is controversial

Restless Leg Syndrome (RLS)

definitions and causes

Uncontrollable urge to move legs, specifically at night

Can be idiopathic of secondary to neuropathy, iron deficiency, chronic renal insufficiency, pregnancy

Can interrupt sleep

Suggested treatments of RLS

Exercise

Avoid caffeine, nic, alc

Avoid every med ever (antihistamines, theophyllines, lithium, beta blockers, anti-psychs & convulsants)

labs for RLS

Check ferritin, B12, folate, thyroid

How to treat moderate to severe RLS

Alpha-2-delta ligands: gabapentin, enacarbil, and pregabalin first-line treatment.

Dopamine agonists can also be considered as first-line. **some ADRs: paradoxical increase in RLS symptom severity following initial symptom reduction, loss of impulse control, and drowsiness.

Difference between RLS and Periodic Limb Movement Disorder (PLMD)

•PLMD= Movement of feet or legs (sometimes arms) during sleep, unknown to the patient, but can wake them, disrupting sleep

•Not the same as RLS, but can co-occur

•RLS happens while the person is awake and is a crawling or tingling sensation that forces the person to move to relieve it

•Can happen minimally or up to 15 times an hour

•Can be secondary to a variety of causes like iron deficiency

What pharm tx ay help PLMD

•Add iron, improve sleep hygiene, avoid alcohol and caffeine

•Melatonin, gabapentin, bezos, dopamine agonists, GABA agonists, clonazapam

Narcolepsy

Excessive sleepiness, disturbed sleep, sleep paralysis, sleep hallucinations (not the same as dreaming) upon falling asleep and waking up.

type 1 narcolepsy

(+) cataplexy and low CSF of hypocretin

What is hypocretin

hormone made by the hypothalamus that helps regulate sleep

what is cataplexy

sudden onset of muscle weakness usually caused by intense emotional episodes

pathognomonic for narcopelspy

Type 2 Narcolepsy

(-) cataplexy, normal CSF levels of hypocretin

How to treat narcolepsy

modafinil (provigil)

Sleep hygiene, huge variety of other meds, symptoms management, specialist referral.

What are the types of parasomnia

nightmares

sleep terrors - autonomic arousal

sleep walking - arousal problem like sleep terrors

enuresis (incontinence during sleep, mostly children)

Summary

•Pay more respect to sleep as a medical risk and treatment.

•Sleep is as important as diet and probably more important than exercise in personal choices

•CBT for SLEEP is #1!

•It influences all aspects of health including our #1 cause of death (cardio, obesity, glucose regulation, behavioral med, and dementia

•Ask patients about sleep and treat thoroughly

•Sleep meds are garbage. Melatonin is too.

•Order sleep studies liberally- can be done at home

•Prioritize your own high-quality sleep.

•Respect the sleep of hospitalized patients.