Sleep Disorders

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Sleep Disorders

• Dr. Jeff Edmondson
• June 2007

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Objectives

• Upon completion of this presentation, the
  audience should be able to
  
• Diagnose the more common sleep disorders
• Discuss therapeutic options for individuals with
  obstructive sleep apnea
  
• Effectively counsel patients on circadian rhythm
  disorders and the components of good sleep hygiene

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Question?

• Sleep apnea is known to be associated with
• Hypertension
• Respiratory muscle dysfunction
• Carpel tunnel syndrome
• Hypercalcemia
• Previous tonsillectomy
• (ISTE 2004 Question 47)

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Prevalence

• Americans sleep 25 less than we did a generation
  ago
  
• 2/3 of Americans get less than the recommended 8
  hours of sleep per night
  
• 50 of older Americans (60) have SDB and 45
  have periodic limb movement disorders compared to
  
• Anacoli-Israel S, Cooke JR J Am Geriatr Soc
  200553(suppl) S265-S271
  

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Impacts

• 30 of adults have complaints of sleep disruption
  (NSF and NIH)
  
• 28 of American missed work due to sleep problems
  (2005 Sleep in American Poll)
  
• 25 of married couples reported losing sleep due
  to their partners sleep problems (2005 Sleep in
  American Poll)
  
• 25 of crashes or near crashes attributed to
  moderate to severe drowsiness (2004 NHSC, VA Tech
  Trans)
  

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Insomnia

• Complaints regarding the quantity, quality or
  timing of sleep at least 3 X per week for 1 month
  or more. These disruptions must result in a
  perceived impairment of daytime function
• (DSM IV)

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The Sleep Cycle

• Sleep cycle length is 90-110 minutes
• Each cycle is repeated 3 to 6 times per night
• Two stages of sleep
• Non-REM sleep
• REM sleep
• Hypnogram a recording of the sleep cycle

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Sleep Tracing
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Evaluation

• HP
• Sleep Diary for at least
  2-3 wks
  
• Diet
• Medications - to include herbals
• Alcohol and caffeine intake
• Smoking
• Physical activity
• Approximate time falls asleep and time of
  awakening
  
• Periods of excessive daytime sleepiness (EDS)
• Naps
• Epworth Sleepiness Scale (ESS)

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Question?

• T/F As part of the patients evaluation you
  administer an Epworth Sleepiness Scale
  questionnaire. The patient scores a 10. This
  indicates that he has mild sleepiness.
• Answer True
• 8-10 mild
• 11-15 moderate
• 16-20 severe
• 21-24 excessive

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Question?

• A 5-year-old overweight African-American male
  presents with behavior problems noted in the
  first 3 months of kindergarten. The mother
  explains that the child does not pay attention
  and often naps in class. He average 10 hours of
  sleep nightly and is heard snoring frequently.
  The mother has a history of attention-deficit
  disorders and take atomoxetine (Strattera). The
  boys examination is within normal limits for his
  being in the 95th percentile for weight and
  having 3 tonsilar enlargement.

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Question?

• The most reasonable plan at this point would
  include which one of the following
  
• An electroencephalogram
• Polysomography
• Atomoxetine
• Methylphenidate (Ritalin)

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OSA/HAS

• A syndrome characterized by recurrent episodes of
  partial or complete upper airway obstruction
  during sleep that usually are terminated by an
  arousal. Triad of
• Loud snoring
• Oxygen de-saturations
• Frequent arousals
• Incidence/prevalence
• 4 men
• 2 women
• (Wisconsin sleep cohort study)

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Risks Associated With Untreated OSA/HAS

• Hypertension
• Angina/CAD/MI
• Strokes/CVA
• Pulmonary HTN
• Erectile Dysfunction
• Nocturnal cardiac arrhythmias
• MVA and other injuries (3-7X)
• Chronic headaches and decreased cognitive
  functioning
  
• Premature mortality

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Physical Features Of OSA/HAS

• Small upper lip with associated overbite
• Large tongue
• Narrow hypopharyngeal airway
• Enlarged tonsils
• Large, curling and protruding lower lip
• Small chin, maxilla and mandible
• Short thick neck
• Males 17 inches in have increased risk
• Females 16 inches in have increased risk

• Central obesity with an increased BMI
• Caution 25 of patients with OSA are NOT obese
• 1 kg/m2 increase in BMI ? 30 increased RR of
  developing sleep disorder over the next 4 years
  
• Other risks MF (21)
• Weaker associations
• Menopause
• Smoking
• Family history
• HS nasal congestion

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Diagnosis Of OSA/HAS

• Overnight PSG
• Labs none routinely recommended
• In office pulse oximetry of ? benefit
• Severe OSA
• RDI 35 plus
• EDS (ESS 10) or MSLT

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Case Study

• PSG on obese 20 y/o female with EDS
• Total study time 7.9 hr
• Total sleep time 7.2 hr
• Sleep efficiency of 92
• Sleep onset (stage 1) at 8 min
• REM at 108 min

• RDI in REM 77 per hr
• PLMS 2 per hr
• Minimum oxygen saturation 85

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Treatments For OSA/HAS

• Surgical and non-surgical
• Non-surgical CPAP/Bi-PAP titrated during PSG
• Treat RDI 20 regardless of symptoms
• In the absence of symptoms, some authorities
  recommend treating only those with RDI 30
  
• Medicare covers CPAP for the following
• RDI 15 or
• RDI 5 with HTN, CAD, CVA, EDS, impaired
  cognition, mood disorders or insomnia
  
• Oral appliances intolerant of or failed CPAP
• Weight loss
• Medications stimulants (limited beneficial
  effects)

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CPAP

• Advantages

• Disadvantages
• Non-Compliance
• Up to 40 still have EDS despite therapy

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Questions?

• T/F Oral appliances are considered first line
  treatment for OSA/HAS?
  
• Answer False. Cochraine Review
  http//cochraine.org
  
• T/F Laser-assisted uvulopalatopharyngoplasty is
  effective for alleviating the complete syndrome
  of OSA/HAS?
  
• Answer False. Effective for snoring

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Narcolepsy

• Oldest described sleep
  disorder first described in 1880
  
• Incidence/prevalence - 1 in 2000
• Age of onset teenage years but reported in
  children as young as 2 yr of age
  
• Classic tetrad of
• EDS
• Sleep paralysis
• Hypnagogic hallucinations
• Cataplexy

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Genetics

• Only 25-30 concordance in twins
• Strongly associated with the DQB10602 allele
• 85-95 of patients with cataplexy test homozygous
  for this allele
  
• DDx OSA, RLS, Psycogenic, APSD, SWSD

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Cataplexy

• Most specific finding
  for narcolepsy
  
• Considered pathognomonic diagnosis of
  narcolepsy in the absence of cataplexy is
  controversial
  
• Total loss of body muscle tone
• Patients cannot move muscles voluntarily
• No loss of consciousness
• Common triggers include fatigue, emotional
  outbursts such as laughter, crying, anger
  

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Evaluation and Diagnosis

• PSG plus MSLT
• Time required to fall asleep during 4 or 5
  scheduled naps
  
• Sleep latency 10 minutes is normal
• Sleep latency
• Presence of REM sleep within 15 minutes during at
  least 2 or more nap episodes is diagnostic
  (except in infants/children)
  

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Treatments

• Behavioral sleep hygiene
• Scheduled sleep and wake periods
• 7-8 hours of sleep per night plus scheduled naps
• Scheduled physical activity
• Avoidance of daytime environments conducive to
  sleep (lectures)
  
• Medications
• Amphetamines schedule II
• Methylphenidate schedule II
• Modafinil (Provigil) schedule IV FDA approved
  in narcolepy and shift work sleep disorder.
  Residual sleepiness in OSA
  
• Gamma hydroxybutryrate (Xyrem) to treat cataplexy
  (date rape drug)?
  
• TCAs, SSRIs for cataplexy, hallucinations and
  sleep paralysis

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Case Study

• PSG on 49 y/o female referred for c/o insomnia
• Total study time 424 min
• Awake 12
• Stage 1 12
• Stage 2 60
• Stage 3 4 8
• REM 9

• Total sleep time 377 min
• Sleep efficiency 89
• REM latency 156 minutes
• Total arousal index - 5 per hr of sleep
• RDI 2 per hr
• PLMS - 18 per hr

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RLS and PLMD

• RLS is a syndrome characterized by sensory and
  motor disturbances of the lower extremities
  occurring primarily at rest
  
• Episodes are often painful and result in severe
  insomnia
  
• A desire to move the limbs, usually associated
  with parasthesias and dysesthesias
  
• Motor restlessness causing voluntary limb
  movements
  
• Nocturnal worsening of symptoms

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Evaluation And Diagnosis

• RLS - diagnosed from the HP
• PLMD requires a PSG
• Labs CBC, BUN, Cr, fasting glucose, Fe,
  Ferritin, folate and TSH
  
• Consider EMG/NCV as indicated for neuropathy
  symptoms
  

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Question?

• Which of the following is the best treatment for
  restless legs syndrome?
  
• Ropinirole (Requip)
• Continuous positive airway pressure
• Tricyclic anitdepressants (TCAs)
• SSRIs
• Cyclobenzaprine (Flexeril)
• (ISTE 2006 Question 31)

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Treatment For RLS And PLMD
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Question?

• Which one of the following sleep disorders is in
  the general class of circadian sleep disorders
  and may respond to bright light therapy?
  
• Shift-work insomnia
• Alcohol dependent sleep disorder
• Inadequate sleep hygiene
• Sleep-related myoclonus

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Circadian Rhythm Disorders

• Advanced Sleep-Phase Syndrome
• Delayed Sleep-Phase Syndrome
• Jet Lag
• Shift Work Sleep Disorder (SWSD)

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Circadian Rhythm Disorders
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Treatments

• Sleep hygiene
• Light therapy limited studies using 2 hour
  exposure to 2500 lux light from 7 am to 9 am
  advanced circadian pattern by 1.4 hours
  
• Medications
• Benzodiazepines
• Non-Benzo hypnotics
• Melatonin - at least 3 mg HS for jet lag
• Modafinil SWSD (also for Narcolepsy)

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Question?

• Promoting good sleep hygiene is basic in the
  treatment of insomnia. Which one of the following
  measures will aid in promoting healthy sleep
  habits?
• Vigorous evening exercise
• Taking an enjoyable book or magazine to bed to
  read
  
• Drinking a glass of wine as a sedative close to
  bedtime
  
• Eating the heaviest meal of the day close to
  bedtime
  
• Maintaining a regular sleep/wake schedule

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Sleep Hygiene

• Avoid excessive time in bed and naps
• Exercise regularly in the morning or afternoon
• Maintain regular sleep and wake up times
• Increase exposure to bright light
• Avoid eating a heavy meal or drinking 3 hours
  before bedtime

• Keep the room dark
• Maintain a comfortable room temperature
• Avoid caffeine in the afternoon and evening
• Do not drink alcohol or smoke to help with sleep
• Avoid unfamiliar sleep environments

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Question?

• Which one of the following benzodiazepines has
  the shortest half-life?
  
• Flurazepam (Dalmane)
• Alprazolam (Xanax)
• Cloazepate (Tranxene)
• Diazepam (Valium)
• Clonazepam (Klonipin)
• (ISTE 2004 Question 129)

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BENZODIAZEPINE Hypnotics

• Drug Half-life (hr)
• Flurazepam (Dalmane) 50 hours
• Alprazolam (Xanax) 12 hours
• Cloazepate (Tranxene) 50 hours
• Diazepam (Valium) 50 hours
• Clonazepam (Klonipin) 25 hours

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Non-BENZODIAZEPINE
Hypnotics

• Drug Dose (mg) Half-life (hr)
• Zolpidem 5-10 2-3
• Zolpidem CR 6.25-12.5 2.8
• Zaleplon 5-10 1-2
• Eszopiclone 1-3 6
• Indiplon (IR and CR)
• FDA approved without a specified time limit
• Not yet FDA approved

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Melatonin Receptor Agonist

• Drug Dose (mg) Half-life (hr)
• Ramelteon 8 1.0-2.6
• FDA approved without a specified time limit

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Case Study

• At a routine office visit, a 55 year old female
  tells you about a long history of intermittent
  crawling sensation in her legs at night, which
  has become more frequent in the past year. She
  says that the sensation is difficult to describe,
  but when pressed says it feels like worms
  crawling under my skin. After taking additional
  history, you suspect the diagnosis of restless
  leg syndrome (RLS).

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Case Study

• Which of the following would be consistent with
  this syndrome?
  
• Stereotyped, repetitive flexion of the limbs
• A compelling urge to move the limbs, usually
  associated with parasthesias /dyesthesias
  
• Symptoms that are worse at rest, or present only
  at rest
  
• Involvement of only one leg at a time during most
  episodes, but not necessarily the same leg each
  time
  
• A normal neurologic examination

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Case Study

• Which of the following would be consistent with
  this syndrome? T or F
  
• Stereotyped, repetitive flexion of the limbs (F)
• A compelling urge to move the limbs, usually
  associated with parasthesias /dyesthesias (T)
  
• Symptoms that are worse at rest, or present only
  at rest (T)
  
• Involvement of only one leg at a time during most
  episodes, but not necessarily the same leg each
  time (F)
  
• A normal neurologic examination (T)

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References And Resources

• National Sleep Foundation
• http//www.sleepfoundation.org
• American Academy of Sleep Medicine
• http//www.aasmnet.org
• Kryger MH, Roth T, Dement WC Principles and
  practice of sleep medicine
  
• AAFP Monograph 286 March 2003 Sleep