Sleep is as necessary

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Sleep is as necessary as the air we breathe, the
water we drink, and the food we eat.
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Disorders of sleep are not recognized 5070
million chronic disorders of sleep 20 million
asthma 10-15 million COPD
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Medical illness disrupts sleep and problems with
sleep cause medical illness.
Depression Neurologic Cardiac Respiratory Gastroin
testinal Renal
Cognitive Cardiovascular Respiratory Metabolic
Syndrome Movement Disorder
Sleep
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We need to be alert to problems with sleep in our
patients and treat appropriately to help our
patients.
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Public Health Issues
Sleep deprivation has a major impact on Public
Health. Work absenteeism, industrial and motor
vehicle accidents, impaired cognitive and
executive function, and increased mortality due
to sleep deprivation costs society billions of
dollars in related costs.
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Public Health Concern

• Prevalence
• Incidence of Sleep Loss in the Population
• 28 of normal young adults slept 6.5 hours or
  less each weeknight
• 32 of normal young adults has an MSLT of 5 min
  or less

Bonnet and Arand, 1995
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Public Health Issues

• Industrial and Work Accidents
• Sleepiness and Industrial Errors
• Meter reading
• Chernobyl
• Three Mile Island
• Exxon Valdez
• Sleepiness and Driving
• Fatigue a factor in 57 of deaths in truck
  drivers (NTSB)
• Sleepiness and Driving
• Libby Zion Case

Mitler et al, 1988
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Public Health Issues
Industrial Accidents The Exxon Valdez oil tanker
left Valdez, Alaska on March 24, 1989, into
Prince William Sound. The taker turned out of the
shipping chanel, but did not turn back in time.
The tanker hit a reef and spilled millions of
gallons of crude oil into the Sound. It cost more
than 2 billion to clean up the spill and the
environmental damages were enormous. Although it
was initially thought that the captain was drunk,
it was subsequently determined that the cause of
the accident was the third mate, who had slept
only six hours in the previous 48 and was
severely sleep deprived.
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Public Health Issues
Motor Vehicle Crashes
Lavie et al 1986, Langlois et al, 1985
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Insomnia is Underreported and Undertreated
Hatoum et al 1998
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Medical Conditions That Can Cause Insomnia
Hyperthyroidism Arthritic Conditions Chronic
Renal Disease Chronic Lung Disease Heart
Failure Reflux Esophagitis Neurological
Disorder Hepatic Disease
This is not a complete list of medical disorders
that can produce sleep disturbance or insomnia.
Cardiovascular, cerebrovascular and neurological
disorders that affect the control of breathing
can have serious consequences and need to be
considered in any patient presenting with a
complaint of insomnia, especially elderly
patients.
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These graphs are from the National Sleep
Foundation survey that illustrate symptoms of
individuals without insomnia, occasional insomnia
and chronic insomnia patients. Note the higher
rate of symptoms in the chronic insomnia group
compared with the other groups.
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Pickwickian Syndrome
Obstructive sleep apnea was called the
Pickwickian syndrome in the past because Joe the
Fat Boy who was described by Charles Dickens in
the Pickwick papers had typical features with
snoring, obesity, sleepiness and dropsy. The
term Pickwickian syndrome was originally applied
to those patients who had sleepiness, obesity and
evidence of right heart failure. Some of the
patients probably had central alveolar
hypoventilation syndrome and obesity
hypoventilation syndrome rather than typical
obstructive sleep apnea syndrome as we now know
it.
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But . . . Most OSA patients are thin Obese
patients have hypoxemia, obesity hypoventilation,
and/or obstructive sleep apnea. A PSG is
necessary. But . . . Nasal, pulmonary, and
cardiac problems may interfere with diagnosis.
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Obstructive Sleep Apnea Syndrome
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Symptoms of Sleep Apnea Syndrome
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Obstructive Sleep Apnea Syndrome
Symptoms Excessive Sleepiness Snoring Apneic
Episodes Choking or Gasping in Sleep Nocturia Tire
dness upon Awakening
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Features of Excessive Sleepiness
Motor vehicle crashes Work related
accidents Impaired school or work
performance Marital problems Memory and
concentration difficulties Depression Impaired
quality of life
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Quality of Life in OSA
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Polysomnograpy
An Episode of Obstructive Sleep Apnea
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Upper Airway Resistance Syndrome
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Prevalence of Sleep-Disordered Breathing
Young et al, 1993
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Treatment of Obstructive Sleep Apnea Syndrome
Behavioral Treatment Medical Treatment Oral
Appliance Treatment Surgical Treatment
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Behavioral Treatments

• Attain an ideal body weight
• Sleep on the side
• Avoid sedative medication before sleep
• Avoid being sleep deprived
• Avoid alcohol before sleep
• Elevate the head of the bed
• Promptly treat colds and allergies
• Avoid large meals before bedtime
• Stop smoking

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Medical Treatments

• Weight loss
• Pharmacological
• Oxygen therapy
• Nasopharynegeal intubation
• Nasal CPAP
• BiLevel CPAP
• Automatic CPAP
• Oral Appliances
• Atrial Pacing

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Weight Loss
Response after 1 year of CPAP therapy
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Oxygen Therapy

• Improves oxygen saturation during sleep
• May prolong apneic episodes
• Reduces cardiac arrythmias
• Useful additive treatment with CPAP
• Rarely reduces apneic episodes
• Can improve daytime sleepiness
• May cause CO2 retention

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Continuous Positive Airway Pressure (CPAP
Representation of the effect of CPAP on the upper
airway in obstructive sleep apnea syndrome. The
first panel of inspiration shows the development
of the negative inspiratory pressure, muscle tone
is required to prevent collapse of the upper
airway. The second panel shows collapse when the
inspiratory negaive pressure exceeds the
counteracting muscle tone that is maintaining
airway patency. The third panel shows the
application of a positive airway pressure through
the nares which overcomes the negative
inspiratory pressure and improves airway patency.
Sullivan et al, 1981
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CPAP Compliance
Improvement Strategies

• Improved Masks
• Nasal Pillows
• Chin Strap
• Humidifier
• BiLevel Pressure Devices
• Ramping
• Nasal Decongestants

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Patient Quality of Life After nCPAP
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Crashes before/after CPAP therapy
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Surgical Treatment

• Turbinectomy / septal reconstruction
• Tonsillo-adenoidectomy
• Uvulopalatopharyngoplasty
• Laser-assisted uvulopalatoplasty (LAUP)
• Lingual tonsillectomy / Laser midline glossectomy
• Genioglossal advancement
• Hyoid myotomy and suspension
• Maxillomandibular advancement
• Radiofrequency palatoplasty
• Tongue base suspension
• Hyoidplasty
• Tracheostomy
• Gastroplasty

This section edited by Aaron E. Sher MD Albany
Medical College Albany, New York
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Adverse Effects of Tonsillo-adenoidectomy
Verse et al, 2000
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Gastroplasty Efficacy
Verse et al, 2000
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Pharmacological Therapy
Protriptyline Medroxyprogesterone Fluoxetine Antih
istamines Nasal Steroids Theophylline Acetazolamid
e Modafinil
Magalang UJ et al, 2003
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Conclusion
Obstructive sleep apnea syndrome is an important
medical disorder that warrants active
investigation by means of a clinical evaluation
and polysomnographic sleep studies. Treatment is
essential, not only to improve the symptoms that
include sleepiness, but also to prevent the
development of cardiovascular complications.
Effective treatments exist that include
behavioral, medical and surgical means dramatic
improvements in patient wellbeing can result.
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Cardiovascular Consequences
Systemic hypertension Pulmonary hypertension Cor
pulmonale Brady-tachycardia Sinus arrest Complete
heart block Atrial and ventricular
arrhythmias Myocardial infarction Sudden death
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Cardiovascular Disease
Zaninelli A. et al, 1991
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Systemic Hypertension
33 of OSA patients have systemic
hypertension 33 of Hypertensive patients have OSA
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Systemic Hypertension
Worsnop et al, 1998
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Ambulatory Blood Pressure in OSA
This illustration shows hourly blood pressure
values (mean - SEM) during ambulatory BP
recordings before (closed circles) and after
successful treatment of OSA with nCPAP (open
circles). Lower levels of blood pressure are
found during nCPAP treatment.
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Oxygen Desaturation and Atherosclerosis
Hayashi M et al, 2003
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Sudden Death
Rossner et al, 1991
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Untreated OSA is associated with an increased
risk of cardiovascular mortality in patients with
coronary artery disease (CAD). Over a five year
follow-up of 19 patients with CAD, 6 of 16
patients with OSA died compared with 4 of 43
without OSA.
Peker et al, 2000
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There is a high rate of sleep apnea in
survivors of myocardial infarction. Because of
the cardiovascular effects of obstructive sleep
apnea syndrome it is suspected that individuals
with sleep apnea have an increased risk of
developing ischemic heart disease and myocardial
infarction. This chart shows a greater rate of
apneas in patients who are survivors of
myocardial infarction that in a control group.
Hung et al, 1986
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Crashes before/after CPAP therapy
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NEXT
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Changes in Sleep with Age
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Factors Affecting Sleep in the Elderly

• 1. Circadian rhythm disturbances
• 2. Primary sleep disorders
• 3. Medical illness
• 5. Medications/polypharmacy
• 5. Dementia

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Consequences of Sleep Disturbances

• -Difficulty sustaining attention
• -Slowed response time
• -Difficulty with memory
• -Decreased performance
• MAY all be misinterpreted as dementia

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Health Care Workers

• 1. Know the diseases which interfere with sleep.
• DIMS insomnias
• DOES sleep related breathing disorders
• Parasomnias hypersomnia of central origin
• Circadian rhythm sleep disorders
• parasomnias
• sleep-related movement disorders

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HEALTH CARE WORKERS

• 2. Ask, patients will not volunteer!
• How did you sleep last night?
• Was the sleep refreshing?
• Do you snore?
• Does your sleep partner complain?