Greg Matwiyoff MD CAPT MC USN Pulmonary Critical Care amp Sleep Medicine Naval Medical Center San Diego November 14 th 2018 Disclosure I wish Objectives Normal Sleep Physiology ID: 733429
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Sleep Disorders for the Operational Provider
Greg Matwiyoff, MDCAPT MC USNPulmonary, Critical Care, & Sleep MedicineNaval Medical Center San DiegoNovember 14th, 2018Slide2
Disclosure
I wish!Slide3
Objectives
Normal Sleep PhysiologyInsomniaObstructive Sleep ApneaRestless Legs SyndromeSomnambulismParasomniasOh and a little on asthmaSlide4
Sleep disorders Broadly classified
(ICSD 3)InsomniaSleep related breathing disordersCentral Disorders of HypersomnolenceCircadian rhythm disordersParasomniasSleep related movement disordersOtherSlide5
Sleep ArchitectureSlide6
How much sleep is normal?
No exact numberRange is 6-9 hours with significant individual variability>10 hours seen in long sleeper<5 hours probably abnormal with symptoms of sleep deprivationSlide7
Chronic Insomnia Disorder icsd-3
Difficulty initiating or maintaining sleep or waking up earlier than desired Adequate opportunity for sleep, Associated with daytime impairments such as fatigue, irritability, school/work impairmentsPresent for over 3 monthsSymptoms at least 3 times per weekNo other disorder to explain symptomsCo-morbid with other conditions (depression)Slide8
Epidemiology
50 percent of primary care patients have occasional insomnia10-30 percent of primary care patients have chronic insomniaMore prevalent in women than menIncreases with age and medical co-morbiditiesDisorder of increased arousal Slide9Slide10
Maladaptive Behaviors
Extending time in bedNapsSleeping earlierLying in bedAlcohol or drug useIrregular wake timesClock-watching, TV in bed, Laptops and iPads in bedSlide11
Evaluation
Sleep habit historyBed timeWake timeNon workdaysNapsAwakeningsSleep DiaryActigraphySleep testing or polysomnograms are not recommended for initial evaluation of insomnia (AASM Guidelines)Slide12
Sleep DiarySlide13Slide14
Behavioral Therapy
Stimulus Control-extinguish the negative association between the bed and anxietyGo to bed only when sleepyLeave the bed if unable to sleep in 20 subjective minutesEngage in non-stimulating activity until sleepy then return to bedRepeat 2 and 3Slide15
Behavioral Therapy
Relaxation trainingProgressive muscle relaxationGuided imageryAbdominal breathingSlide16
Cognitive behavioral therapy for insomnia (CBT-I)
Common cognitive distortions are identified and addressed in the course of treatment. These include: Structured program to reset the brain’s sleep system and increase sleep drive.Essentially it’s controlled sleep deprivationTeaching patients a skill that can be used over and over if necessaryRequires tremendous self discipline Slide17
Stepped Care ModelSlide18
Date of download: 9/6/2012
Copyright © 2012 American Medical Association. All rights reserved.
From:
Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison
Arch Intern Med. 2004;164(17):1888-1896. doi:10.1001/archinte.164.17.1888
Slide19
Date of download: 9/6/2012
Copyright © 2012 American Medical Association. All rights reserved.
From:
Cognitive Behavior Therapy and Pharmacotherapy for Insomnia: A Randomized Controlled Trial and Direct Comparison
Arch Intern Med. 2004;164(17):1888-1896. doi:10.1001/archinte.164.17.1888
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Pharmacologic Therapy
Most efficacy studies are short-duration (2-5 weeks) Longer studies have looked at zaleplon1 and ramelteon2FDA indications: all agents are for short-term use except Eszopiclone, zolpidem extended-release, and ramelteon1 Ancoli-Israel S, et,. Al., Long-term use of sedative hypnotics in older patients with insomnia. Sleep Med. 2005;6:107-113
2
DeMicco M, et. Al., Long-term therapeutic effects of
ramelteon
treatment in adults with chronic insomnia: a 1 year study. Sleep. 2006;29(
suppl
):A234Slide21
Sedating low-dose antidepressantstrazodone, amitriptyline, nortriptyline
Not recommended as first line therapy for insomnia (consider after CBTi and two BzRAs) Poor efficacy dataHigh side-effect profileWeight gainDaytime sedationTolerance, rebound insomniaIneffective alone in depression and insomniaSlide22
Insomnia Summary
Chronic insomnia is a behavioral problem and generally responds well to behavioral treatmentAssess all insomnia patients for depression and anxietyPharmacotherapy alone is not as effective and benefits are not sustained long-termAnn Intern Med. Published online 3 May 2016 doi:10.7326/M15-2175Slide23Slide24
Cervicomental
angle predicts OSA as well as neck circumference >17”/43 cm in menSlide25Slide26Slide27
Prevalence of osa
Overall prevalence of OSA 10-25% (30+ million Americans)Males are affected more commonly (2x risk)Obesity (body-mass index>30) increases risk 4-foldIncreases after menopause in womenRuns in familiesSlide28
Risk factors
Male gender RR=2Obesity RR=4Age (highest increase from age 40-60)Asians tend to have more OSA lower BMI than Caucasians Daytime sleepiness (Epworth) is not strongly correlated with OSANo screening tool is available to exclude OSASlide29
Mechanisms
Anatomic factorsLoss of airway dilator muscle toneDamage due to vibrationFatigue due to increased tone during wakeLoss of lung volume (FRC) from obesity, supine positionArousal thresholdSlide30
HST Process FlowSlide31
Apnea-hypopnea index (AHI)
AHI is all the apneas+hyponeas divided by the recording timeFor example: (17 apneas + 66 hypopneas)/7 hours recording = AHI of 11.8AHI<5 is considered normal
AHI
SEVERITY
TREATMENT
5-14
MILD
OPTIONAL
15-30
MODERATE
RECOMMENDED
>30
SEVERE
HIGHLY
RECOMMENDEDSlide32
Moderate-Severe OSA
Moderate and severe OSA increases risk of developing hypertension (high blood pressure)No significant increase seen with mild OSA, howeverMarin, JAMA, May 2012; 307,20Slide33
Continuous Positive Airway
Pressure (CPAP)The most effective treatment for OSA is continuous positive airway pressure (CPAP)A machine is used to generate air pressure to maintain airway patency during sleepIt usually takes some effort to acclimate to CPAP but it is generally well-toleratedSide effects include dry nose or mouth, gas or bloating, mask discomfort and clausterphobiaSlide34
Data download exampleSlide35
Data download exampleSlide36
Oral Appliance Therapy (OAT)
Custom-fitted dental deviceAdvances mandible during sleep to open airwaySuitable for mild-moderate OSAReduces snoringSlide37
Oral appliances
Fitted by sleep dentistsGradual adjustment increases advancement of jawTakes 2-3 weeks to fabricate and a few weeks for adjustmentsSlide38
CPAP vs OAT
CPAPSlightly cumbersomeRequires electricityMonitors and adjusts pressure depending on apneas and hypopneasObjective dataRecommended for severe OSARapid issueOATPortableNo need for electricity
No need for supplies
No monitoring of apneas during sleep
Subjective data
Not recommended for severe OSA
May take a few weeks to fabricateSlide39
Summary
Home testing and Lab testing strategies have similar outcomes in managing OSACPAP is the best tolerated, most effective therapy for OSAOral appliance is a good alternative treatment for mild-moderate OSASurgery is reserved for very special casesSlide40
Restless Legs Syndrome (RLS)
Clinical diagnosis (PSG not required)Should cause sleep disturbancesFamily history often positive (50%)Associated with periodic limb movements but not required for diagnosisArms often affected as well as legsRLS-NOT diagnosed by a sleep study (PSG not required)Slide41
RLS Diagnostic Criteria
Uncomfortable sensation in legsUrge to move legsWorse at rest, improves with movementWorse at night (circadian pattern)Causes significant impairment of sleep or other functioningExclude other causes (neuropathy, nervous foot tapping, cramps, myalgias)40% of people without RLS-will report some urge to move their legs at nightSlide42
RLS
U – Uncomfortable feeling in extremitiesR – Rest makes symptoms worseG – Getting up and moving makes symptoms betterE – Evening symptoms are worse Slide43
RLS-Risk Factors
Family history (single nulceotide polymorphisms-SNPs)Iron deficiency (ferritin <50 mcg/L)Antidepressants (except bupropion)Antihistamines TCAsDopamine antagonists (risperidone)Pregnancy (2-3x) increases with parityChronic kidney disease (2-5x)Gastric bypassSlide44
Pathophysiology
Decreased CNS iron levels in substantia nigraDecreased dopaminergic activityIncreased glutamate activity or imbalanceGenetic factors (BTBD9, MEIS1, MAP2K5/LBXCOR may alter iron homeostasis)Slide45
RLS-Treatment
Iron replacement (ferritin >75 mcg/L, transferrin 20-50%)Dopaminergic agentsPramipexoleRopiniroleRotigotineWarn about impulsivity and nauseaGabapentin extended releaseRelaxation techniques, massage, warm baths, external counter pulsationOpioidsSlide46
Sleepwalking (Somnambulism)
4% Adults, 22% lifetime prevalenceLeaving the bed during N3 sleep (first half of the night)May have multiple episodes per nightMore complex and goal-directed behavior than in confusional arousals but similar in natureTypical duration <10 minutesLittle or no recallSlide47
Sleepwalking (Somnambulism)
Increase seen with z-drugs (zolpidem), stimulants, antihistamines, SSRIs.Increase seen with N3 sleep rebound after sleep deprivationIncrease with stress, illness, anxiety, alcohol use, bladder distensionIncrease with sleep fragmentation from other sleep disorders (OSA)Slide48
Somnambulism Treatment
Reassurance and address contributing factorsSafety (lock keys, firearms, windows)Gently guide patient back to bedScheduled awakeningsAdequate sleep durationAvoid antihistaminesMedications generally not used but can consider TCAs or Klonopin.Referral to Sleep medicine at NMCSDWe usually do a formal sleep study to exclude exacerbating diagnoses.Not a MEDBOARD able condition.Slide49
Military Service and Hypersomnia
“To constitute a physical disability, the medical impairment or physical defect must be of such a nature and degree of severity as to interfere with the member’s ability to adequately perform his or her duties.”Narcolepsy mandates a PEBSleep apnea and idiopathic hypersomnolence may mandate a PEB depending on severity, response to treatment ,and patient’s occupationSleepwalking does not merit PEB and is disqualifying for military service (ADSEP)Slide50
Parasomnias
Adverse behavioral or experiential phenomena that occurs during sleep or during the transition to and from sleep Slide51
Categories
Non-REM related parasomniasConfusional arousalsNight terrorsSomnambulismREM related parasomniasREM Behavior DisorderNightmare disorderRecurrent isolated sleep paralysisOther ParasomniasSlide52
Asthma
Reactive Airways Disease and asthma are not the same. Asthma: atopy with reversible airways obstructionRAD: irritant asthma-a condition that results from a single or multiple exposures to an irritant (i.e.) cleaning product, chlorine gas attack.All that wheezes is NOT asthmaSome patients can be treated intermittentlyCornerstone of treatment is Inhaled CorticosteroidsSlide53
Asthma
Always enquire about exacerbating conditionsTobacco useAllergic RhinitisGERDWhat is VCDThink about VCDCan complicate about 40% of asthma casesCan masquerade as asthmaSlide54
Questions?