Why cant I sleep like I used to Beth A Malow MD MS Professor of Neurology and Pediatrics Burry Chair in Cognitive Childhood Development Director Sleep Disorders Division Have you met Ruth and John ID: 405993
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Sleep Disorders 101“Why can't I sleep like I used to”
Beth A. Malow, M.D., M.S.Professor of Neurology and PediatricsBurry Chair in Cognitive Childhood DevelopmentDirector, Sleep Disorders DivisionSlide2
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?Slide3
“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 insomniaSlide4
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)Slide5
“Environmental” and “Behavioral” Causes of InsomniaInsomnia
Predisposing FactorsPersonalityCircadian RhythmAge
Precipitating Factors
Situational
Medical/Psychiatric
Medication-related
Perpetuating Factors
Conditioning
Substance Abuse
Poor Sleep Hygiene
3-P model of
SpielmannSlide6
“Biological” Causes of Insomnia
Why not simply prescribe hypnotics?Behavioral sleep approaches work, in many cases better than medications!They help other aspects of your patients’ lives (e.g., stress reduction)Medications have side effects as well as implications on public healthThe challenge is how to deliver behavioral treatments in ways that are both effective and cost-efficientSlide7
“Biological” Causes of Insomnia
Evidence for Behavioral Treatment of InsomniaKrypke DF, BMJ Open 2013
10529 patients and 23676 matched controls (12 classes of
comorbidity
)Slide8
Non-Pharmacological Treatment of InsomniaStimulus 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 arousalSlide9
“Biological” Causes of Insomnia
Evidence for Behavioral Treatment of InsomniaJacobs, 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. Slide10Slide11
Treatment of Insomnia- Mindfulness and Other Techniques
www.franticworld.com
Mindfulness (being in the here and now,
and acceptance of what is)Slide12
Tapering Hypnotics1- 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 stoppedSlide13
Back to RuthStarted 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. Slide14
John70 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.Slide15Slide16
Cardiovascular complicationsHypertension (High blood pressure)Atherosclerosis (Hardening of arteries)Heart attacksHeart failureHeart rhythm problemsStrokeSlide17
Other complications of OSADAY
excessive sleepinessafternoon drowsiness memory lossimpaired concentration irritability
headaches
NIGHT
snoring
and snorting
observed apneas
choking or gasping arousals unexplained tachycardia
restless sleep
sweating during sleep
nocturia
bruxism
nocturnal acid
refluxSlide18
Screening Tools: STOP-BANG
STOP (yes/no)
S
nore
T
ired
O
bstruction
P
ressure
BANG
(yes/no)
B
MI > 30
A
ge > 50
N
eck > 17"/16"
G
ender: Male
> 3
“yes”
answers suggests high risk of sleep apneaSlide19
Vanderbilt Sleep Disorders Center- Nashville (Marriott Hotel)
Established in 2003 Accredited multidisciplinary10 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)Slide20
Vanderbilt Sleep Disorders Center-Franklin (Hyatt Place Hotel)
Opened Oct 08Accredited multidisciplinary6 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)Slide21
EEG Patterns of Sleep StagesSlide22
A negative test does not exclude clinically significant sleep apnea.Slide23Slide24
The Evolution of CPAPSlide25
Treatments for Sleep Apnea
Weight Loss & Exercise
Continuous Positive Airway Pressure Therapy
Mandibular repositioning device
SurgerySlide26
ORAL APPLIANCESlide27
Happy Endings: Ruth and JohnJohn 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. Slide28
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 adjustEstimated that it takes one day per time zone for circadian rhythms to adjust to the local timeSlide29
Traveling the World without Jet Lag
Eastman CI, Burgess HJ.Sleep Med Clin. Sleep Med Clinics 2009 4(2):241-255.Slide30
Traveling from Nashville to Paris (West to East)Eastman CI, Burgess HJ.Sleep Med
Clin. Sleep Med Clinics 2009 4(2):241-255.Slide31
Summary
Sleep disorders are very commonThey are also highly treatableImproving sleep can improve a person’s functioning during the day and quality of life