Sleep Disorders Medicine for Non-Sleep Specialists William H. Noah, MD Brian M. Wind, PhD.

Sleep Disorders Medicinefor Non-Sleep Specialists

William H. Noah, MD Brian M. Wind, PhD

Sleep Disorders

• There are 92 different sleep disorders

• We are going to update three areas:– Restless Legs Syndrome (RLS)– Insomnia– Obstructive Sleep Apnea (OSA)

Restless Legs Syndrome (RLS)

Restless Leg Syndrome

• Urge to move or unpleasant leg sensations (“creepy-crawling,” “burning,” or “itching”) that interfere with sleep onset

• 80% of RLS patients also have Periodic Limb Movements (PLMs) which disrupts sleep

• Up to 15% of the population - increases with age (women > men)

Secondary RLS

• CNS Iron deficiency (possibly 80% of all cases)– Symptoms occur with Ferritin levels <80 (not 30)

• A common medication side effect– Antihistamines, antidepressants, antiemetics and

antipsychotics (dopamine depletion)• Renal failure

Treatment Pearls

• Replace iron to Ferritin >80 (not 30)– Best results with iron citrate combination at night

• Change antidepressant to bupropion (Wellbutrin)• Avoid carbidopa/levodopa (Sinemet) because of

augmentation • Use ropinirole (Requip) and pramipexole (Mirapex) • May use benzodiazepines and narcotics short term

Insomnia

• Definition– Trouble getting to sleep– Trouble staying asleep– Often have both

• Two broad subtypes– Short term (acute/transient)– Long term (chronic)

• Prevalence - >50% Americans will meet diagnostic criteria

Insomnia

• Differential diagnosis– Paradoxical insomnia (aka sleep state misperception) – Circadian rhythm disorders (e.g., jet lag, shift work

disorder, delayed sleep phase)– Medical conditions– Medications– Other sleep disorders (e.g., OSA)

• Use of “tools” to diagnose – consultation (including sleep, medical, physical, psychosocial histories) sleep logs, actigraphy

Insomnia

• Consequences- Fatigue - Somatic complaints (e.g., GI, h/a’s, pain) - Stress about poor sleep- Mood disturbances- Poor concentration- Impaired performance- Health problems (e.g., HTN, weight gain)

Insomnia

• Short term (acute/transient) insomnia– Symptoms exist for < 30 days– Medication may be appropriate– Various “anticipated” circumstances (e.g., life

stressors, grief/bereavement, health issues, travel)

Insomnia

• Long term (chronic) insomnia– Symptoms exist for > 30 days– Often “psychophysiological” in nature– Medication is not appropriate, usually

contraindicated– Intervention of choice is Cognitive Behavioral

Treatment (CBT)

Insomnia

• Cognitive Behavioral Treatment (CBT)– Sleep hygiene (education re: healthy sleep habits)– Stimulus control (bed = stimulus for sleep)– Sleep restriction (to make TIB congruent with TST)– Relaxation training (to reduce stress at bedtime)– Medication taper

• Done in 2-3 office visits• Covered by insurance• High efficacy, effectiveness, lasting effect (SCMT

Obstructive Sleep Apnea (OSA)

If patients don’t wear the machine, it’s all a waste of money and time.

Obstructive Sleep Apnea

• SCMT PAP Internal Compliance Summary

Year PAP Pts Compliant %2009 477 354 74%2010 411 341 83%2011 383 309 81%

Last Full Quarter: 3rd Qtr 2011 86%

Prevalence of OSA• Estimated 20-25% of population has OSA

(using an AHI > 5)• 42% of nursing home patients• 60% of stroke patients• 60% of hypertensive patients (83% if on

multiple HTN medications)• >90% of DMII patients have sleep apnea• 80% of cases undiagnosed

Young T, N Engl J Med 1993; 328Kapur V, Sleep Breath 2002; 6

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Source: CDC Behavioral Risk Factor Surveillance System.

No Data <10% 10%–14%

No Data <10% 10%–14% 15%–19%

No Data <10% 10%–14% 15%–19% ≥20%

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

• New concepts in pathophysiology– Anatomic features

• Mallampati score• Tonsilar Hypertrophy

– Pharyngeal dilator muscle activity– Low arousal threshold– Unstable ventilatory control (high loop gain)

Why Treat OSA?

• Improved quality of life• Decreased morbidity/mortality

• He, Chest 1988, 94

• Improvement of OSA related diseases• Hypertension• Diabetes / insulin resistance• Cardiovascular disease

– CAD– CHF– Arrhythmias—AFIB

• Stroke• Pulmonary hypertension• Gastroesophageal reflux disease• Nocturia and enuresis

• COPD (Overlap Syndrome)• Fibromyalgia • Obesity / weight related complications• Depression / mood disorders• Sexual dysfunction• Sleep related accidents

Cardiovascular Consequences: Hypertension

Odds Ratio

0 0.1 - 4.9 5 - 14.9 > 15Apnea / Hypopnea Index (AHI)

Prospective Study of Association Between OSA and Hypertension

Adjusted for age, sex, BMI, neck circ., cigs., ETOH, baseline HTN

Adapted from Peppard PE et al. N Engl J Med 2000;342. The Wisconsin Cohort Study

N > 700Eval at 1 & 4 yr

Increased risk for HTN in OSA

•OSA pts with hypertension: 40% • Pepperell et al Lancet 2002

•Hypertension pts with OSA: 40% • Rauscher et al Chest 1992

•As high as 60% in other studies • Hedner, Eur Respir J 2006, 203• Silverberg, Curr Hypertens Rep 2001, 3

•Other References:• Guilleminault, Annu Rev Med 1976, 27• Lavie, Am Heart J 1984, 108• Kales, Lancet 1984, 1005-8• Fletcher, Ann Intern Med 1985, 103• Hla, Ann Intern Med 1994, 120• Carlson, Am J Respir Crit Care Med 1994, 150• Young, Arch Intern Med 1997, 157 • Smith, Chest 2002, 121

HTN & OSA: Intervention

Becker et al. Circ 2003; 107:68

Therapeutic vs. Subtherapeutic CPAP

N = 32 Treat x 2 months

Reduction in HTN with OSA Treatment – The Evidence

Schotte, Arch Intern Med 1990, 150 Pepperell et al. Lancet 2002; 359:204 Lund-Johansen, Am J Med 1990, 88 Mayer, Cardiology 1991, 79 Suzuki, Sleep 1993, 16 Wilcox, Sleep 1993, 16 Rauscher, Thorax 1993, 48 Davies, Clin Res 1994, 86 Faccenda, Am J Respir Crit Care Med 2001, 163 Duran-Cantolla, BMJ 2010; 341: 599

The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7)

Recommended screening patients for OSA when they have new onset hypertension

ORRefractory hypertension1

1 Chobanian, A., et al., Hypertension 2003; 42:1206-1252

The Link Between OSA and Hypertension

Coronary Artery Disease and OSA

Sleep Apnea patients 3 - 4.5 times as much ischemic heart disease

Strohl, Am J Respir Crit Care Med 1996,154Mooe, Am J Med 1996, 101Mooe, Chest 1996, 109

OSA independent predictor of CAD (OR=3.1)Peker Y, Eur Respir J, 1999, 14

OSA and Congestive Heart Failure OSA may contribute to the development of

congestive heart failure (CHF) OSA is associated with increased mortality in CHF CPAP improves objective measures of cardiac

function in patients with CHF and OSA /CSA:– Takasaki, Am Rev Respir Dis 1989, 140

– Malone, Lancet 1991, 338– Naughton, Am J Respir Crit Care Med 1995, 151– Naughton, Circulation 1995, 91– Tkacova, J Am Coll Cardiol 1997, 30– Tkacova, Circulation 1998, 98

OSA and Heart Failure

• CPAP lowers hospitalization and expenditure rates– Javaheri, Am J Respir Crit Care Med 2011, 539-46

• Men with AHI ≥30 were 58% more likely to develop heart failure than those with AHI <5– Circulation 2010; 122: 352-360

OSA and Arrhythmias

Guilleminault, Am J Cardiol 1983, 52 400 OSA patients - 2% V-Tach, 10.8% Sinus Arrest,

7.8% Sec Deg AV block Mehra et al. AJRCCM 2006

Non-sustained V-Tach = 3.40, Complex ventricular ectopy =1.74, Atrial fibrillation = 4.02

Other references: Smith, Chest 2002, 121 Fichter, Chest 2002, 122 Harbinson, Chest 2000, 118

Kanagala et al. Circulation 2003~Double the rate at 12 months

Recurrence of Atrial Fibrillation at 12 months after Cardioversion

Marin et al. Lancet 365:1046-53, 2005

Cardiovascular Outcomeswith or without CPAP Treatment

TIA and Stroke in Patients with OSA

• Doppler techniques to show a decrease in middle cerebral artery flow at the termination of obstructive events– Balfors, AJRCCM 1994,150,1587– Hajak, Chest 1996,10,670

• Case-control study: OSA was 5x more frequent in stroke patients as in the control group– Dyken, Stroke 1996,27,401

• Prevalence in 187 consecutive OSA patients = 7%– Schulz, Pneumologie 2000, 5, 575

OSA and Stroke

– Stroke survivors have 50% of having significant sleep apnea

– 3x risk of stroke or death with untreated sleep apnea

• Yaggi HK, V Mohsenin, Obstructive sleep apnea as a risk factor for stroke and death. New England Journal of Medicine, 2005; 353:2034-41.

Questions?

Sleep Disorders Medicine for Non-Sleep Specialists William H. Noah, MD Brian M. Wind, PhD.

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