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?
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.
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.
How can we help Ruth and John sleep better at night and enjoy life more?
“Medical”
“Biological”
“Environmental/Behavioral”
Teasing out the Root Causes (first step in treatment)
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
Primary hormonal product of the hypothalamic-pituitary-adrenocortical (HPA) axis
Mediates basal metabolic and stress-related processes
Cortisol 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
InsomniaInsomnia
Predisposing FactorsPersonality
Circadian RhythmAge
Predisposing FactorsPersonality
Circadian RhythmAge
Precipitating FactorsSituational
Medical/PsychiatricMedication-related
Precipitating FactorsSituational
Medical/PsychiatricMedication-related
Perpetuating FactorsConditioning
Substance AbusePoor Sleep Hygiene
Perpetuating FactorsConditioning
Substance AbusePoor Sleep Hygiene
3-P model of Spielmann
“Biological” Causes of Insomnia
Why not simply prescribe 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
“Biological” Causes of Insomnia
Evidence for Behavioral Treatment of Insomnia
Krypke DF, BMJ Open 2013
10529 patients and 23676 matched controls (12 classes of comorbidity)
Non-Pharmacological Treatment of Insomnia
Stimulus control (use bedroom only for sleep)Sleep restriction (and related tactic of delaying
bedtime)Relaxation techniquesSleep hygiene: avoiding caffeine, alcohol, iPad use
at night. Physical exercise.Cognitive therapy: identifying and changing stressful
and distorted sleep cognitions that exacerbate insomnia by elevate psychophysiologic arousal
“Biological” Causes of Insomnia
Evidence for Behavioral Treatment of Insomnia
Jacobs, Arc Intern Med, 2004
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.
Treatment of Insomnia- Mindfulness and Other Techniques
www.franticworld.com
Mindfulness (being in the here and now, and acceptance of what is)
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 2nd 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
Started on gabapentin 100 mg at bedtime for sleep. Titrated up to 200 mg.
Eliminated caffeine after noon, limited alcohol use to weekends. Started running in the mornings before work.
Ruth is sleeping a little better, but there is a missing piece to consider.
John
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.
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 attacks• Heart failure• Heart rhythm problems• Stroke
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)
SnoreTiredObstructionPressure
BANG (yes/no)
BMI > 30Age > 50Neck > 17"/16"Gender: Male
> 3 “yes” answers suggests high risk of sleep apnea
Vanderbilt Sleep Disorders Center- Nashville (Marriott Hotel)
Established in 2003
Accredited multidisciplinary10 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)
Vanderbilt Sleep Disorders Center-Franklin (Hyatt Place Hotel)
Opened Oct 08
Accredited multidisciplinary6 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)
EEG Patterns of Sleep Stages
A negative test does not exclude clinically significant sleep apnea.
The Evolution of CPAP
Treatments for Sleep Apnea
• Weight Loss & Exercise
• Continuous Positive Airway Pressure Therapy
• Mandibular repositioning device
• Surgery
ORAL APPLIANCE
Happy Endings: Ruth and John
John was diagnosed with sleep apnea and treated with continuous positive airway pressure.
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.
Both Ruth and John are feeling much more alert during the day, and are able to spend more time on activities they enjoy.
In fact, things are so much better that they are planning a trip to Paris this summer.
Jet Lag Disorder
Complaint of insomnia or daytime sleepiness, accompanied by a reduction in total sleep time, associated with transmeridian jet travel across at least 2 time zones.
Impairment of daytime function, general malaise, or somatic symptoms (GI disturbance), within 1-2 days after travel.
An individual’s innate circadian preference may confer a greater or lesser ability to adjust
Estimated 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 Clin. Sleep Med Clinics 2009 4(2):241-255.
Traveling from Nashville to Paris (West to East)
Eastman CI, Burgess HJ.Sleep Med Clin. Sleep Med Clinics 2009 4(2):241-255.
Summary
Sleep disorders are very common
They are also highly treatable
Improving sleep can improve a person’s functioning during the day and quality of life