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Information about SleepDisorders

Published on November 29, 2007

Author: Justine


Sleep Disorders :  Sleep Disorders Dr. Jeff Edmondson June 2007 Objectives:  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 Question?:  Question? Sleep apnea is known to be associated with Hypertension Respiratory muscle dysfunction Carpel tunnel syndrome Hypercalcemia Previous tonsillectomy (ISTE 2004 Question 47) Prevalence:  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 < 5% in younger adults* *Anacoli-Israel S, Cooke JR J Am Geriatr Soc 2005;53(suppl): S265-S271 Impacts:  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 partner’s sleep problems (2005 Sleep in American Poll) 25% of crashes or near crashes attributed to moderate to severe drowsiness (2004 NHSC, VA Tech Trans) Insomnia:  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) The Sleep Cycle:  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 Sleep Tracing:  Sleep Tracing Evaluation:  Evaluation H&P 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) Question?:  Question? T/F As part of the patient’s 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 Question?:  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 boy’s examination is within normal limits for his being in the > 95th percentile for weight and having 3+ tonsilar enlargement. Question?:  Question? The most reasonable plan at this point would include which one of the following: An electroencephalogram Polysomography Atomoxetine Methylphenidate (Ritalin) OSA/HAS:  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) Risks Associated With Untreated OSA/HAS:  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 Physical Features Of OSA/HAS:  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: M>F (2:1) Weaker associations: Menopause Smoking Family history HS nasal congestion Diagnosis Of OSA/HAS:  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 < 5 min Case Study:  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% Treatments For OSA/HAS:  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) CPAP:  CPAP Advantages Disadvantages Non-Compliance Up to 40% still have EDS despite therapy Questions?:  Questions? T/F Oral appliances are considered first line treatment for OSA/HAS? Answer: False. Cochraine Review T/F Laser-assisted uvulopalatopharyngoplasty is effective for alleviating the complete syndrome of OSA/HAS? Answer: False. Effective for snoring Narcolepsy:  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* Genetics:  Genetics Only 25-30% concordance in twins Strongly associated with the DQB1*0602 allele 85-95% of patients with cataplexy test homozygous for this allele DDx: OSA, RLS, Psycogenic, APSD, SWSD Cataplexy:  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 Evaluation and Diagnosis:  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 < 5 minutes is pathologic Presence of REM sleep within 15 minutes during at least 2 or more nap episodes is diagnostic (except in infants/children) Treatments:  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 Case Study:  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 RLS and PLMD:  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 Evaluation And Diagnosis:  Evaluation And Diagnosis RLS - diagnosed from the H&P PLMD requires a PSG Labs : CBC, BUN, Cr, fasting glucose, Fe, Ferritin, folate and TSH Consider EMG/NCV as indicated for neuropathy symptoms Question?:  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) Treatment For RLS And PLMD:  Treatment For RLS And PLMD Question?:  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 Circadian Rhythm Disorders:  Circadian Rhythm Disorders Advanced Sleep-Phase Syndrome Delayed Sleep-Phase Syndrome Jet Lag Shift Work Sleep Disorder (SWSD) Circadian Rhythm Disorders:  Circadian Rhythm Disorders Treatments:  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) Question?:  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 Sleep Hygiene:  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 Question?:  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) BENZODIAZEPINE Hypnotics:  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 Non-BENZODIAZEPINE Hypnotics:  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 Melatonin Receptor Agonist:  Melatonin Receptor Agonist Drug Dose (mg) Half-life (hr) Ramelteon* 8 1.0-2.6 * FDA approved without a specified time limit Case Study:  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). Case Study:  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 Case Study:  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) References And Resources:  References And Resources National Sleep Foundation American Academy of Sleep Medicine Kryger MH, Roth T, Dement WC Principles and practice of sleep medicine AAFP Monograph 286 March 2003 Sleep

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