Sleep Disorders 101 Why cant I sleep like

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Sleep Disorders 101 “Why can't I sleep like I used to” Beth A. Malow,

Sleep Disorders 101 “Why can't I sleep like I used to” Beth A. Malow, M. D. , M. S. Professor of Neurology and Pediatrics Burry Chair in Cognitive Childhood Development Director, Sleep Disorders Division

Have you met Ruth and John? Ø Ruth is a 67 -year-old retired nurse.

Have you met Ruth and John? Ø Ruth is a 67 -year-old retired nurse. Presents with difficulty falling asleep and early morning wakings for last month. She has neuropathy. Also admits to having anxiety about her husband John’s heart condition and his loud snoring at night. Ø John is a 70 -year-old retired engineer. He falls asleep easily but snores loudly all night, and is very sleepy during the day. His sleepiness interferes with Ruth and his participating in social activities. Ø How can we help Ruth and John sleep better at night and enjoy life more?

Teasing out the Root Causes (first step in treatment) ü“Medical” ü“Biological” ü“Environmental/Behavioral” Disclaimer: This

Teasing out the Root Causes (first step in treatment) ü“Medical” ü“Biological” ü“Environmental/Behavioral” Disclaimer: This is simplistic. Anxiety can be both “medical” and “biological. ” Relaxation techniques at night used to relieve anxiety work on the biological, medical or environmental/behavioral aspects of insomnia

Hyperarousal Theory of Insomnia. Neuroendocrine Cortisol üPrimary hormonal product of the hypothalamic-pituitary-adrenocortical (HPA) axis

Hyperarousal Theory of Insomnia. Neuroendocrine Cortisol üPrimary hormonal product of the hypothalamic-pituitary-adrenocortical (HPA) axis üMediates basal metabolic and stressrelated processes üCortisol typically reaches its lowest levels in the evening. Dysregulation of the cortisol rhythm, with blunting of the expected fall in cortisol in the evening, has been observed in insomnia Vgontzas et al. , J Clin Endo Metab, 2001)

“Environmental” and “Behavioral” Causes of Insomnia Perpetuating Factors Conditioning Substance Abuse Poor Sleep Hygiene

“Environmental” and “Behavioral” Causes of Insomnia Perpetuating Factors Conditioning Substance Abuse Poor Sleep Hygiene Insomnia Predisposing Factors Personality Circadian Rhythm Age 3 -P model of Spielmann Precipitating Factors Situational Medical/Psychiatric Medication-related

Why not simply prescribe “Biological” Causes of Insomnia hypnotics? 1. Behavioral sleep approaches work,

Why not simply prescribe “Biological” Causes of Insomnia hypnotics? 1. Behavioral sleep approaches work, in many cases better than medications! 2. They help other aspects of your patients’ lives (e. g. , stress reduction) 3. Medications have side effects as well as implications on public health The challenge is how to deliver behavioral treatments in ways that are both effective and cost-efficient

Evidence for Behavioral Treatment “Biological” Causes of Insomnia Krypke DF, BMJ Open 2013 10529

Evidence for Behavioral Treatment “Biological” Causes of Insomnia Krypke DF, BMJ Open 2013 10529 patients and 23676 matched controls (12 classes of comorbidity)

Non-Pharmacological Treatment of Insomnia ü Stimulus control (use bedroom only for sleep) ü Sleep

Non-Pharmacological Treatment of Insomnia ü Stimulus control (use bedroom only for sleep) ü Sleep restriction (and related tactic of delaying bedtime) ü Relaxation techniques ü Sleep hygiene: avoiding caffeine, alcohol, i. Pad use at night. Physical exercise. ü Cognitive therapy: identifying and changing stressful and distorted sleep cognitions that exacerbate insomnia by elevate psychophysiologic arousal

Evidence for Behavioral Treatment “Biological” Causes of Insomnia 63 young and middle-aged adults with

Evidence for Behavioral Treatment “Biological” Causes of Insomnia 63 young and middle-aged adults with chronic sleep-onset insomnia randomized to CBT, zolpidem (10 mg 30 minutes before bedtime). Sleep diaries and home sleep monitoring showed significant improvements in CBT groups. Jacobs, Arc Intern Med, 2004

Treatment of Insomnia. Mindfulness and Other Techniques üMindfulness (being in the here and now,

Treatment of Insomnia. Mindfulness and Other Techniques üMindfulness (being in the here and now, and acceptance of what is) www. franticworld. com

Tapering Hypnotics 1 - Implement a behavioral sleep medicine plan 2 - Choose 1

Tapering Hypnotics 1 - Implement a behavioral sleep medicine plan 2 - Choose 1 day of the week (Saturday often a good choice) to cut sleep aid in half. 3 - One week later, choose a 2 nd day of the week (Tues, Wed, or Thurs) to cut sleep aid in half. 4 - Each week, add another day of the week to take half of sleep aid. 5 - When down to half of a pill every night, start the process again by discontinuing sleep aid one night a week until it is completely stopped

Back to Ruth Ø Started on gabapentin 100 mg at bedtime for sleep. Titrated

Back to Ruth Ø Started on gabapentin 100 mg at bedtime for sleep. Titrated up to 200 mg. Ø Eliminated caffeine after noon, limited alcohol use to weekends. Started running in the mornings before work. Ø Ruth is sleeping a little better, but there is a missing piece to consider.

John Ø 70 year old man with coronary artery disease, who had a heart

John Ø 70 year old man with coronary artery disease, who had a heart attack last year. He snores heavily and often stops breathing, especially on his back. Ø He falls asleep right away and sleeps 8 hours, unaware that he is restless and stopping breathing in his sleep. He is sleepy during the day and feels like he hasn’t had a refreshing night’s sleep. He wakes up with a dry mouth and sore throat.

Cardiovascular complications • • • Hypertension (High blood pressure) Atherosclerosis (Hardening of arteries) Heart

Cardiovascular complications • • • Hypertension (High blood pressure) Atherosclerosis (Hardening of arteries) Heart attacks Heart failure Heart rhythm problems Stroke

Other complications of OSA DAY �excessive sleepiness �afternoon drowsiness �memory loss �impaired concentration �irritability

Other complications of OSA DAY �excessive sleepiness �afternoon drowsiness �memory loss �impaired concentration �irritability �headaches NIGHT �snoring and snorting �observed apneas �choking or gasping arousals unexplained tachycardia �restless sleep �sweating during sleep �nocturia �bruxism �nocturnal acid reflux

Screening Tools: STOP-BANG STOP (yes/no) BANG (yes/no) Snore Tired Obstruction Pressure BMI > 30

Screening Tools: STOP-BANG STOP (yes/no) BANG (yes/no) Snore Tired Obstruction Pressure BMI > 30 Age > 50 Neck > 17"/16" Gender: Male > 3 “yes” answers suggests high risk of sleep apnea

Vanderbilt Sleep Disorders Center. Nashville (Marriott Hotel) üEstablished in 2003 ü Accredited multidisciplinary 10

Vanderbilt Sleep Disorders Center. Nashville (Marriott Hotel) üEstablished in 2003 ü Accredited multidisciplinary 10 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)

Vanderbilt Sleep Disorders Center. Franklin (Hyatt Place Hotel) Opened Oct 08 Accredited multidisciplinary 6

Vanderbilt Sleep Disorders Center. Franklin (Hyatt Place Hotel) Opened Oct 08 Accredited multidisciplinary 6 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)

EEG Patterns of Sleep Stages

EEG Patterns of Sleep Stages

A negative test does not exclude clinically significant sleep apnea.

A negative test does not exclude clinically significant sleep apnea.

The Evolution of CPAP

The Evolution of CPAP

Treatments for Sleep Apnea • Weight Loss & Exercise • Continuous Positive Airway Pressure

Treatments for Sleep Apnea • Weight Loss & Exercise • Continuous Positive Airway Pressure Therapy • Mandibular repositioning device • Surgery

ORAL APPLIANCE

ORAL APPLIANCE

Happy Endings: Ruth and John Ø John was diagnosed with sleep apnea and treated

Happy Endings: Ruth and John Ø John was diagnosed with sleep apnea and treated with continuous positive airway pressure. Ø Ruth is sleeping more soundly at night, and is not awoken by John’s snoring. The CPAP provides a level of white noise that is soothing. Ø Both Ruth and John are feeling much more alert during the day, and are able to spend more time on activities they enjoy. Ø In fact, things are so much better that they are planning a trip to Paris this summer.

Jet Lag Disorder üComplaint of insomnia or daytime sleepiness, accompanied by a reduction in

Jet Lag Disorder üComplaint of insomnia or daytime sleepiness, accompanied by a reduction in total sleep time, associated with transmeridian jet travel across at least 2 time zones. üImpairment of daytime function, general malaise, or somatic symptoms (GI disturbance), within 1 -2 days after travel. üAn individual’s innate circadian preference may confer a greater or lesser ability to adjust üEstimated that it takes one day per time zone for circadian rhythms to adjust to the local time

Traveling the World without Jet Lag Eastman CI, Burgess HJ. Sleep Med Clinics 2009

Traveling the World without Jet Lag Eastman CI, Burgess HJ. Sleep Med Clinics 2009 4(2): 241 -255.

Traveling from Nashville to Paris (West to East) Eastman CI, Burgess HJ. Sleep Med

Traveling from Nashville to Paris (West to East) Eastman CI, Burgess HJ. Sleep Med Clinics 2009 4(2): 241 -255.

Summary üSleep disorders are very common üThey are also highly treatable üImproving sleep can

Summary üSleep disorders are very common üThey are also highly treatable üImproving sleep can improve a person’s functioning during the day and quality of life