Nitun Verma MD MBAMedical Director

Washington Center for Sleep Disordershttp://www.washingtonsleep.com

Presenter Background

Tufts University MD MBAGeorgetown University ResidencyStanford University FellowshipBoard Certified in adult / pediatric sleep medicine

Washington Center for Sleep Disorders

There are only 2 accredited sleep centers in the East Bay

Established relationships with surgeons, dentists, equipment providers for a multidisciplinary treatment approach

Washington Center for Sleep Disorders

Conditions Treated

Changes in sleep associated with adolescence, menopause, retirement

Obstructive Sleep Apnea (OSA)InsomniaRestless Legs Syndrome (RLS)Delayed/Advanced Sleep Phase SyndromeNarcolepsy

Drowsy Driving

QUIZ:How many US drivers fall asleep at

the wheel every day?

80,000

Drowsy DrivingWho is at risk?

Young people, particularly males Work requires long or odd hoursCommercial driversPersons with undiagnosed or untreated sleep disorders Those

who have consumed alcohol People taking prescription medication that contain sedatives

http://www.aasmnet.org/Resources/FactSheets/DrowsyDriving.pdf

QUIZ:How many sleep-related motor vehicle accidents are there each

year ?

250,000

Drowsy DrivingWho is at risk?

Get enough sleep Take breaks while driving Short nap, preferably 15 to 20 minutes in length.Do not drink alcohol Do not drive late at night

http://www.aasmnet.org/Resources/FactSheets/DrowsyDriving.pdf

QUIZ:How many people in the US have a

sleep disorder?

30,000,000

Obstructive Sleep Apnea

Only 1 out of 10 people with OSA are diagnosed by their doctor.

Is obstructive sleep apnea and snoring the same thing?

Obstructive Sleep ApneaWhat is it?

Airway narrowingCrisis and shocksShallow sleepCan’t remember it

Obstructive Sleep ApneaWhat is it?

Obstructive Sleep ApneaWhat is it?

Obstructive Sleep ApneaWhat is it?

Airway narrowingCrisis and shocksShallow sleepCan’t remember it

Is obstructive sleep apnea and snoring the same thing?

Obstructive Sleep ApneaWhat happens if you have it?Heart and blood vessels

Obstructive Sleep ApneaWhat happens if you have it?Heart and blood vessels

Neurocognitive Effects of OSAHyperactivity, rebelliousness, aggression more common

in SDB childrenInattentionDifficulty regulating emotionsLower grades than unaffected childrenDecreased performance on IQ tests

Insomnia

Insomnia

30% of adults have symptoms of insomnia 10% of adults have insomnia that is severe enough to cause

daytime consequences Almost 10% of adults are likely to have chronic insomnia

http://www.aasmnet.org/Resources/FactSheets/Insomnia.pdf

InsomniaEffectsFatigue Moodiness Irritability or anger Anxiety about sleep Lack of concentration Poor Memory Poor quality performance at school or work Lack of motivation or energy Headaches or tension Upset stomach Mistakes/accidents at work or while driving

http://www.aasmnet.org/Resources/FactSheets/Insomnia.pdf

InsomniaTypesAdjustment Sleep DisorderPsychophysiologic InsomniaParadoxical InsomniaInsomnia due to a mental disorderIdiopathic InsomniaInadequate Sleep HygieneBehavioral Insomnia of ChildhoodInsomnia due to a drug or substanceInsomnia due to a medical condition

Sleep Hygiene

Good sleep habits = good sleep without medsRegular sleep schedulePrevent heart burn at nightAvoid stimulants in afternoon / eveningAvoid naps after 3pm

Cognitive Behavioral TherapyStimulus Control Therapy

Stimulus Control TherapyGo to bed only when sleepy-not just fatigued, but sleepy.Get out of bed when unable to sleep (e.g., after 20 min), go to

another room, and return to bed only when sleep is imminent.Curtailing all sleep-incompatible activities (overt and covert); no

eating, TV watching, radio listening, planning or problem solving in bed.

Arise at a regular time every morning regardless of the amount of sleep the night before.

Avoid daytime napping.

Restless Legs Syndrome

Restless Legs Syndrome

“Creepy crawling” sensations in legs at night (rarely arms and rarely pain)

Sensations decrease with movement or massageDelay sleep time

10% of people have symptoms of RLSWomen have 1.5 – 2x increased riskMost people are treated after many years of symptoms

Restless Legs SyndromeFactors that make it worse

Medical conditions: iron deficiency, kidney diseaseMedications: antihistamine, antidepressant, tranquilizerAlso: obesity, sleepiness, pregnancy, smoking

Risk increased if other sleep disorders also present

Restless Legs SyndromeTreatments

Massage, compresses, movement

Medications: some for intermittent use, others for daily use

Specific to iron deficiency: Iron replacement

Narcolepsy

Common Vignette:19 year old male presents with symptoms of sleepiness for over 3 months.

When telling a joke or surprised, his jaw becomes slack, but consciousness is maintained. A few times he has had to hold on to the wall or railing for support. These episodes last between 30 seconds to 2 minutes. Also when waking up from sleep, he occasionally feels paralyzed, unable to move. This is very frightening to him, but resolves spontaneously. Because of sleepiness, his school performance has deteriorated.

Narcolepsy Summary

EDS / Cataplexy / Sleep HallucinationsEtiology unclear but genetics / environment / autoimmune possibleTreat both EDS and Cataplexy

Prevalence

0.05% general population (1 out of 2,000)55% of narcoleptics are ever diagnosed (some sources 1 out of

4)10 years is the time to diagnosis2nd decade of life is peak onsetSymptoms are rare before 5 years of ageEDS before cataplexyJapan 0.16% Israel <0.01%

Signs and Symptoms

EDS (excessive day time sleepiness)CataplexySleep ParalysisSleep Hallucinations

Signs and Symptoms

EDS Can also occur while activeCan occur as a sleep attackCan occur several times a dayNaps are refreshing (important to distinguish from idiopathic

hypersomnia)Can result in poor work / school performanceNeed to monitor driving safety

Signs and Symptoms

Cataplexy (60% of patients with narcolepsy have it)Abrupt / reversible loss of voluntary muscle toneTendon reflexes inhibited30 seconds – 2 minutesUsually bilateralConsciousness usually maintainedSeverity and frequency vary

Common= muscle tone decreases, slurred speech Severe= total body collapse

Important to identify triggers

Signs and Symptoms

Sleep ParalysisUpon awakening or falling asleepFrightening to patient(affects 3-5% of non-narcoleptic population as well)

Signs and Symptoms

HallucinationsSleep onset (hypnagogic) Upon waking (hypnopompic)

Mignot E. Narcolepsy: A Guide for Understanding , Diagnosing, and Treating Narcolepsy.

Obstructive Sleep ApneaQuizzesSleep Apnea QuizSleepiness QuizInsomnia Quiz

Online quizzes at www. washingtonsleep. com

that do the scoring for you

Nitun Verma MD MBAMedical Director