Managing Sleep Health in the Primary Care Setting

§  Paul Doghramji, MD Family PhysicianCollegeville Family PracticeCollegeville, PA

Faculty

2

Disclosures

§  Paul Doghramji, MD has the following relevant financial relationship(s) with one or more commercial interests to disclose:§  Merck: Speakers Bureau, Faculty, Peer Reviewer

3

Learning Objectives1.  Define sleep health and summarize its clinical

importance

2.  Identify common sleep disorders in primary care

3.  Use appropriate diagnostic tools to assess patients’ sleep health

4.  Describe approaches to improve sleep health

4

PRE-TEST QUESTIONS

5

Pre-test ARS QuestionHow confident are you in your ability to manage insomnia? 1.  Not at all confident2.  Not very confident 3.  Somewhat confident4.  Pretty much confident 5.  Very confident

6

Pre-test ARS QuestionHow often do you ask patients about sleep problems? 1.  Never2.  Rarely3.  Sometimes4.  Often 5.  Always

7

Part 1

Sleep 101: What We All Need to Know

8

Sleep Perspectives Behavioral

§  Reversible §  Perceptual

disengagement from, and unresponsiveness to, the environment

NREM = non-rapid eye movement; Carskadon et al. (2005). Normal human sleep: an overview. In: Principles and Practice of Sleep Medicine, 4th ed., Kryger MH et al., eds. Philadelphia: Elsevier/Saunders, pp13-23. Science vol 342, 18 Oct 2013

Neurophysiological §  Two distinct states: REM sleep

and NREM§  Actively produced, not a result of

passive inactivity§  Highly regulated by homeostatic

and circadian processes§  Produces changes in the entire

organism, not just the CNS

Teleological§  Necessary for survival; deprivation leads to functional

impairments and eventual death§  Important for clearance of neurotoxic waste products (eg,

beta amyloid) that accumulate in the brain during wakefulness

9

Why is Sleep Important?§  Cognition and

performance

§  Mood regulation

§  Mental health

§  Physical health

§  Safety

Four Rs:§  Rest§  Restore§  Rejuvenate§  Repair

SLEEP ≠ REST10

Two States of SleepRapid eye movement (REM) sleep§ When dreaming occurs§ “Active brain in a paralyzed body”

Hours 1

N 1 & REM

N 2

N3

2 3 4 5 6 7 8

Non-REM sleep§  3 stages §  Based primarily on EEG

Typical Sleep Architectural Pattern of a Young Human Adult

Adapted from Hauri P. The Sleep Disorders. Kalamazoo, Mich: Upjohn;1982:8.

Stage I & REM sleep (red) are graphed on the same level because their EEG patterns are very similar 11

Sleep Across the Life Span

0

100

200

300

400

500

600

700

Tota

l Sle

ep T

ime

(min

)

Age (years)

Total Time in BedAwake in BedNREM N 1REM

NREM N 2

NREM N310 20 30 40 50 60 70 8050

Adapted from Williams RL, et al. Electroencephalography of Human Sleep: Clinical Applications. New York, NY: John Wiley & Sons; 1974.

12

13

Orexin = Hypocretin§  Hypothalamic peptides (OX1 and OX2)§  Localized in the dorsolateral hypothalamus§  Wide projections throughout brain and spinal

column§  Peptide neurotransmitters involved in§  Arousal §  Locomotion§  Metabolism (energy and appetite control)§  Increase blood pressure & heart rate

Peyron et al. J Neurosci. 1998;18:9996. Moore et al. Arch Ital Biol. 2001;139:195. Silber & Rye. Neurology. 2001;56:1616. 14

Part 2

Sleepiness

15

Sleepiness: How Do Patients Describe It?

§  “I’m tired all the time”§  “I have no energy”§  “I feel fatigued”§  “I feel depressed”§  “I don’t feel rested”§  “I don’t sleep well”

The International Classification of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005; Chervin RD. Chest 2000;118:372-379; Shen J, et al. Sleep Med Rev 2006;10:63-76.

16

Patients Also Mean Other Things by “TIRED”

Sleepiness Fatigue Lack of

motivation

Tendency to fall asleep or inability to stay awake

Sensation of weariness, tiredness, exhaustion, loss of energy; the desire to rest

“I don’t feel like doing anything…”

Improved by sleep Improved by rest, exertion makes it worse

17

Sleepiness in America

37%

16%

0%

10%

20%

30%

40%

At least a few days per month At least a few days per week

% of US Adults Reporting that They Are So Sleepyit Interferes with Their Daily Activities

National Sleep Foundation. “Sleep in America” Poll. March 2002.18

Assessment Options: Sleep Parameters

§  Subjective: based on self-report§ Epworth§ Insomnia Severity Scale§ Diaries§ Often do not reflect objective sleep measures

§  Objective: §  Sleep lab or home sleep monitor

§  Wearable technology (eg, Fitbit):§  Increasingly capable of more objective sleep assessment:

total sleep time, slow wave sleep, REM sleep§ Not reimbursable, not validated in clinical practice

19

Johns MW. Sleep. 1991;14:540-545.

Rate the chances of dozing in sedentary situations Never Slight Moderate High

Sitting and reading 0 1 2 3

Watching television 0 1 2 3

Sitting, inactive in a public place (eg, a movie theater or a meeting) 0 1 2 3

As a passenger in a car for an hour without a break 0 1 2 3

Lying down to rest in the afternoon when circumstances permit 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quietly after lunch without alcohol 0 1 2 3

In a car, while stopped for a few minutes in the traffic 0 1 2 3

Epworth Sleepiness Scale

Score >=10 Prompts Further Evaluation 20

Categories of Sleepiness§  Insufficient sleep

§  Factitious§  Insomnia

§  Poor quality sleep§  Obstructive sleep apnea§  Restless Legs Syndrome

§  Disturbed timing of sleep§  Circadian rhythm

disorders

§  Medications and substances§  Rx, OTC, herbals§  Illicit drugs, alcohol

§  Brain “damage”§  MS, Parkinson’s, TBI,

stroke, Alzheimer's§  Narcolepsy

21

Sleep-Wake Disorders: Prevalence in Adults

*Among night and rotating shift workers; †Prevalence of hypersomnias such as narcolepsy without cataplexy may be higher. 1. Young T, et al. Am J Respir Crit Care Med. 2002;165:1217-1239. 4. Ohayon MM. Sleep Med Rev. 2002;6:97-111.2. Drake CL, et al. Sleep. 2004;27:1453-1462. 5. Silber MH, et al. Sleep. 2002;25:197-202.3. Strine DP, et al. Sleep Med. 2005;6:23-27. 6. Merlino G et al. Neurol Sci. 2007;28:S37-S46. †Mignot E, et al. Brain. 2006;129:1609-1623. †Singh M, et al. Sleep. 2006;29:890-895.

Restless Legs Syndrome6

10%-15%

Comorbid Insomnias4

6%

Narcolepsy5

0.06%†

Obstructive Sleep Apnea1

3%-28%Shift Work Disorder2

8%-32%* Insufficient Sleep Syndrome3

26%

22

How to Diagnose the Cause of Sleepiness

§  Get detailed sleep/wake history§  Differentiate sleepiness, fatigue, or depression

§  Quantify degree of sleepiness: ESS

§  Start probing for causes, looking for clues§  Insufficient Sleep Syndrome: doesn’t get enough sleep§  OSA: loud snoring, waking up choking, witnesses apneas,

waking with sore throat, headache, enuresis, nocturia§  RLS: uncomfortable feelings in legs prevent sleep, need to

move them to relieve symptoms§  PLMD: no clues except excessive sleepiness§  Narcolepsy: hypnogogic/hypnopompic hallucinations, sleep

paralysis, cataplexy23

Obstructive Sleep ApneaSymptoms

§  Loud Snoring§  Gasping, choking§  Witnessed

apneas§  Morning

headaches, sore throat

§  Enuresis/nocturia

Physical Findings

§  Large neck§  Crowded

pharynx§  Obesity§  Micrognathia,

short chin

Treatment

§  CPAP/BiPAP/Auto-PAP

§  Oral appliance§  Surgery§  Weight loss§  Positioning§  “Provent”§  “Inspire”

24

Screening for OSA: STOP-BANG MethodSTOP Questionnaire*

§  Snoring

§  Tiredness (daytime)

§  Observed you stop breathing during sleep

§  High blood Pressure

BANG†

§  BMI > 35

§  Age > 50 years

§  Neck circumference > 40 cm (~ 16 in)

§  Gender: Male

* High risk = Yes to > 2 of 4 STOP items † High risk = Yes to > 3 of 8 STOP-BANG items

Chung F, et al. Anesthesiology 2008;108:812-821.25

Airway Assessment: OSA Mallampati Scale

Nuckton TJ, et al. Sleep. 2006;29:903-908.

Odds of OSA increase >2-fold for every 1-point increase

Class I Class II Class III Class IV

26

Restless Leg SyndromeSymptoms

• Irresistible urge to move legs usually with unpleasant sensations• Relief with

movement• Worse at night• Worse with rest

Etiology

• Dopaminergic dysfunction• Iron deficiency• Renal

insufficiencies• Peripheral

neuropathies• 25% secondary

Treatment

• Dopaminergic agents• Iron if deficient• Sedative

hypnotics• Anticonvulsants• Opiates• Sleep hygiene

Allen RP, Sleep Med, 2003. 27

Periodic Limb Movement Disorder Compared to RLS

§  Substantial overlap§  Up to 85% of RLS patients have PLMD§  30% of PLMD patients have RLS

§  RLS diagnosis is made clinically

§  PLMD diagnosis is made via PSG§  No other daytime clues, just sleepiness

§  Treatments are the same28

Part 3

Impact of Insomnia

29

InsomniaDefinition as a disorder:§  Trouble getting to sleep and/or§  Trouble staying asleep and/or§  Waking up too early

§  Occurring more days of the week than not§  Ongoing for >3 months

30

Why Should PCPs Be Proactive About Insomnia?

§  Highly prevalent in primary care§  But patients don’t tell

you§  Serious consequences

§  Day-to-day life§  Poor outcome on mental

and physical health§  Insomnia is a clue

§  Most insomnia is co-morbid

§  Easy to identify

Treatment§  Relieves an upsetting

symptom

§  Improves next day consequences

§  Improves outcome of co-morbidity§  Psychiatric§  Medical

§  Majority done by PCP31

Insomnia Screening and Follow-up§  Sleep Schedule: Do you have trouble getting to sleep, staying

asleep, or waking up too early?§  Daytime consequences: Do you feel like you have slept well

throughout the day?

§  Sleep timing: When do you go to bed? …Wake up? …Middle of the night awakening? …How long does it take you to fall back to sleep?

§  Treatments: What remedies have you tried? Any previous Rx’s?§  Sleep hygiene/lifestyle issues: Alcohol? Smoking? Exercise?

Medications that cause insomnia? §  Duration, frequency, prior: How long has this been going on?...How

often?...Have you had it before?...

Sateia MJ, Doghramji K, Hauri PJ, Morin MM. Sleep. 2000;23:1-66. Erman MK. In: Sleep Disorders: Diagnosis and Treatment. Totowa, NY: Humana Press; 1998:21-51.

32

How Frequent are Comorbidities?

35

28

19 17 15 14 11

0

10

20

30

40

50

30

47

37 39

50

3842

106

17

2522

1215

0

10

20

30

40

50

InsomniaSevere insomnia

Terzano MG, et al. Sleep Med. 2004;5:67-75. Katz DA, McHorney CA. (1998). Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med 158(10):1099-1107.

Prev

alen

ce %

Medical Conditions in Primary Care Patients

with Insomnia

Insomnia with Medical Conditions

33

How Does Inadequate Sleep Increase CVD?

Total sleep time <5 hours compared to >5 hours: § Higher glucose & cortisol levels§ HPA-associated endocrine & metabolic imbalances§ Hypercholesterolemia, even after controlling for other risk factors

§  Nighttime BP: Nighttime SBP higher and day-to-night SBP dipping lower (-8% vs -15%, P < 0.01) in insomniacs

§  Atherosclerosis: Total sleep time (P = 0.005), and sleep quality (P = 0.05) contributed to increased carotid intima-media thickness

§  Inflammation: Serum CRP levels higher and increased at a steeper rate

Lanfranchi, PA, et al. (2009). Nighttime blood pressure in normotensive subjects with chronic insomnia: implications for cardiovascular risk. Sleep 32(6): 760-766. Nakazaki, C, et al. (2012). Association of insomnia and short sleep duration with atherosclerosis risk in the elderly."Am J Hypertens 25(11): 1149-1155. Parthasarathy, S, et al. (2015). Persistent insomnia is associated with mortality risk. Am J Med 128(3): 268-275 e262. Lin, CL, et al. (2016). The relationship between insomnia with short sleep duration is associated with hypercholesterolemia: a cross-sectional study. J Adv Nurs 72(2): 339-347. Farina, B., et al. (2014). Heart rate and heart rate variability modification in chronic insomnia patients. Behav Sleep Med 12(4): 290-306. de Zambotti, M., et al. (2011). Sleep onset and cardiovascular activity in primary insomnia. J Sleep Res 20(2): 318-325.

34

How Much Does Insomnia Add to CV Mortality?

Health Professionals Follow-Up Study

§ US men free of cancer§ Insomnia symptoms in 2004, followed through 2010

§ Adjusted for age, lifestyle factors, and common chronic conditions

Metaanalysis§ N=122,501 over 3-20 yrs§ Insomnia ↑ risk of CVD or CVD mortality 45% : RR 1.45, 1.29-1.62; p < 0.00001

Li, Y, et al. (2014). "Association between insomnia symptoms and mortality: a prospective study of U.S. men." Circulation 129(7): 737-746. Sofi, F, et al. (2014). Insomnia and risk of cardiovascular disease: a meta-analysis. Eur J Prev Cardiol 21(1): 57-64.

1.25

1.091.04

1

1.25

1.5

Total Mortality CVD Mortality

Difficulty Initiating & NonrestorativeDifficulty initiatingDifficulty maintainingEarly-morning awakenings

1.55 (1.19-2.04)

1.32 (1.02-1.72)

Adjusted Hazards Ratio

35

Does Treating Insomnia Help Comorbidities?

0102030405060708090

100

4 Months 16 Months

Poor Good

0

20

40

60

80

100

4 Months 16 MonthsControl Tai Chi

By Sleep Quality% Remaining at High Risk

%

4 monthsCBT 0.21 (.

03-1.47) p<.10

TCC NS16 months

CBT 0.06 (.005-.669) p<.01

TCC 0.10 (.008-1.29) p<.

05

OR of Remaining at

High Risk

2-hour group sessions weekly for 4 mo with a

16-mo evaluation

Carroll, JE, et al. (2015). Psychoneuroendocrinology 55: 184-192

Risk score based on HDL, LDL, triglycerides, CRP, fibrinogen, A1C, glucose, insulin

•  High risk = 4 or more abnormal

By Intervention

36

Does Insomnia Increase Risk of Psychiatric Disorders?

31.135.9

30

14.4

5

2118

10

05

10152025303540

Major depression

Any anxiety disorder

Alcohol abuse/dep

Drug abuse/dep

Patie

nts

(%)

Breslau et al. Biol Psychiatry. 1996;39:411-418.

Incidence (%) over 3.5 yearsInsomnia (n=240) No Insomnia (n=739)

37

Part 4Treatment of Insomnia

38

Patient Education: Most Powerful Tool§  Inform WHY management is so important

§  Consequences§  Emphasize keeping regimented sleep schedule

§  Wake up same time every day§  Naps usually not a good idea

§  Emphasize sleeping long enough§  Can’t catch up on weekends

§  Emphasize lifestyle measures§  Alcohol, exercise, smoking, caffeine, diet (no large

meals)

39

Treatments: CBT and/or Medications?§  Address the comorbid condition as well as the

insomnia§  Discuss with patient pros + cons of meds and CBT

§  Medications: §  Which are best applicable?§  Habit forming?§  How long to use?§  Side effects?

§  CBT: §  At your discretion—ability, time, interest

§  Allow patient to voice his/her concerns, fears, and needs 40

CBT Compared to Pharmacotherapy

Adapted from: Jacobs GD, et al. Arch Intern Med. 2004;164:1888-1896; Schutte-Rodin S et al. J Clin Sleep Med. 2008;4(5):487-504. Morin CM, et al. Sleep 1999;22:1134-56.

CBT-I Components§  Sleep hygiene education§  Cognitive therapy§  Sleep restriction therapy§  Stimulus control therapy§  Relaxation training

Sleep Hygiene §  Regular wake time§  Limit time awake and in bed§  Limit napping during the day§  Avoid clock watching if awake§  Avoid caffeine after 2 PM, alcohol after

dinner, or eating dinner just before bedtime

§  Avoid stressful activities in the evening 41

Melatonin: Meta-analysis in Primary Sleep Disorders §  19 placebo-controlled studies, N=1683

§  Melatonin demonstrated efficacy for: §  Reducing sleep latency (WMD= 7.06 minutes)§  Increasing total sleep time (WMD = 8.25 minutes)

§  Effects magnified with longer duration and higher doses§  Improved sleep quality (standardized mean difference =

0.22)§  No significant effects of trial duration and melatonin dose

Ferracioli-Oda E, et al. PLoS One. 2013;8:e63773. 42

Prescription Agents for Insomnia§  NOT FDA approved for insomnia

§  Sedating antidepressants§  Antipsychotics like quetiapine§  Anticonvulsants

§  FDA-approved hypnotics§  Benzodiazepine-receptor agonists

§  Benzodiazepines§  Non-benzodiazepines

§  Melatonin-receptor agonist§  H1-receptor antagonist§  Orexin-receptor antagonist

43

Benzodiazepines

Medication Dosage Range† (mg)

Onset of Action

Half-life (h)

Short-term

Limitation?

Estazolam 0.5 – 2 Rapid 10 - 24 Yes

Flurazepam 15 – 30 Rapid 47 - 100 Yes

Quazepam 7.5 – 15 Rapid 39 - 100 Yes

Temazepam 7.5 – 15Slow/ Inter-

mediate9.5 -12.4 Yes

Triazolam 0.25 – 0.50 Rapid 1.5 - 5.5 Yes

†Normal adult dose. Dosage may require individualization MICROMEDEX. Available at: http://www.micromedex.com. Prescriber’s Digital Reference. Available at: www.PDR.net.

44

Selective Benzodiazepine-Receptor Agonists

Zaleplon Zolpidem Zolpidem ER Eszopiclone

Dose – mg [elderly]

5, 10, 20 [5] 5, 10 [5] 6.25, 12.5

[6.25] 1, 2, 3 [1]

Tmax (hours) 1 1.6 1.5 1Half-life [elderly] (hrs.) 1 2.5 [2.9] 2.8 [2.9] 6 [9]

Sleep latency ↓ ↓ ↓ ↓

Wake After Sleep Onset -- -- ↓ ↓

Total sleep time↑

(20 mg)↑ ↑ ↑

Schedule IV IV IV IV

Prescriber’s Digital Reference. Available at: www.PDR.net. 45

Newer HypnoticsRamelteon Doxepin Suvorexant

Mechanism Melatonin agonist H1 antagonist Orexin antagonist

Dose – mg [elderly] 8 3, 6 [3] 10, 20Tmax (hours) 0.75 3.5 2

Half-life (hrs.) 1‒2.6 15.3 12

Sleep latency ↓ -- ↓

Wake After Sleep Onset -- ↓ ↓

Total sleep time -- -- ↑

Schedule None None IV

Prescriber’s Digital Reference. Available at: www.PDR.net. 46

Suvorexant§  Novel mechanism of action

§  Highly selective antagonist of orexin receptors OX1R and OX2R

§  Approved to help sleep onset and to maintain sleep§  Dosing:

§  10 mg within 30 minutes of bed ≥7 hours before awakening§  Can be increased to 20 mg if necessary

§  Exposure to suvorexant is increased in:§  Obese compared to non-obese patients§  Women compared to men

§  In 2 phase 3 clinical trials comparing suvorexant to placebo:§  Improved time to sleep onset at 1 month: 8-10 min§  Increased total sleep time at 1 month: 16-21 min

Belsomra® (suvorexant) Prescribing Information. Merck & Co., Inc. Whitehouse Station, NJ. May 2016. 47

Choosing the Right Pharmacotherapy§  Trouble with sleep initiation only: rapid- and short-acting

§  Ramelteon, triazolam, zaleplon, zolpidem§  Trouble staying asleep with sleep initiation problems: rapid- and

long-acting§  Eszopiclone, temazepam, zolpidem ER, zolpidem (if awakes early

in evening), suvorexant§  Trouble staying asleep withOUT sleep initiation problems:

§  Doxepin (taken at sleep onset), sublingual zolpidem (taken if one awakens)

§  Issues with controlled substances: both unscheduled§  Ramelteon, doxepin

§  Generic medications:§  Temazepam, triazolam, zaleplon, zolpidem, eszopiclone

48

When to Consider Referral an Expert

1. Doghramji P. J Clin Psychiatry. 2001;62(suppl 10):18-26.2. Sateia MJ, Owens J, Dube C, Goldberg R. Sleep. 2000;23:243-308.3. Kushida CA, Littner MR, Morgenthaler T, et al. Sleep. 2005;28:499-521.

§  Suspected obstructive sleep apnea or narcolepsy1-3

§  Violent behaviors or unusual parasomnias1-3

§  Daytime tiredness (sleepiness) that you can’t figure out1

§  Insomnia fails to respond to behavioral and/or pharmacologic therapy after an appropriate interval1,3

§  You don’t feel comfortable treating the condition

49

Summary

50

Take-home Messages§  Insomnia is highly prevalent and can impact the general

well-being of patients§  Poor sleep quality can increase the risk of chronic medical

conditions (eg, diabetes, hypertension, depression)

§  Evaluation of sleep should be routine part of acute care and well visits

§  Patient education and non-pharmacologic approaches can be effective initial strategy to improve sleep

§  When needed, pharmacologic therapy should be tailored to patient’s needs and preferences

§  Follow-up and therapeutic adjustment important parts of sleep management 51

Additional Resources

§  For additional resources, visit:§  Sleepfoundation.org§  Sleep.org§  Sleephealthjournal.org

52

POST-TEST QUESTIONS

53

Post-test ARS QuestionAfter participating in this program, how confident are you now in your ability to manage insomnia? 1.  Not at all confident2.  Not very confident 3.  Somewhat confident4.  Pretty much confident 5.  Very confident

54

Post-test ARS QuestionAfter participating in this program, how often do you plan to ask patients about sleep problems? 1.  Never2.  Rarely3.  Sometimes4.  Often 5.  Always

55