Sleep Disorders 101“Why can't I sleep like I used to”

Beth A. Malow, M.D., M.S.

Professor of Neurology and Pediatrics

Burry Chair in Cognitive Childhood Development

Director, Sleep Disorders Division

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?

“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 insomnia

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)

“Environmental” and “Behavioral” Causes of Insomnia

InsomniaInsomnia

Predisposing FactorsPersonality

Circadian RhythmAge

Predisposing FactorsPersonality

Circadian RhythmAge

Precipitating FactorsSituational

Medical/PsychiatricMedication-related

Precipitating FactorsSituational

Medical/PsychiatricMedication-related

Perpetuating FactorsConditioning

Substance AbusePoor Sleep Hygiene

Perpetuating FactorsConditioning

Substance AbusePoor Sleep Hygiene

3-P model of Spielmann

“Biological” Causes of Insomnia

Why not simply prescribe hypnotics?

1.Behavioral sleep approaches work, in many cases better than medications!

2.They help other aspects of your patients’ lives (e.g., stress reduction)

3.Medications have side effects as well as implications on public health

The challenge is how to deliver behavioral treatments in ways that are both effective and cost-efficient

“Biological” Causes of Insomnia

Evidence for Behavioral Treatment of Insomnia

Krypke DF, BMJ Open 2013

10529 patients and 23676 matched controls (12 classes of comorbidity)

Non-Pharmacological Treatment of Insomnia

Stimulus 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 arousal

“Biological” Causes of Insomnia

Evidence for Behavioral Treatment of Insomnia

Jacobs, 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.

Treatment of Insomnia- Mindfulness and Other Techniques

www.franticworld.com

Mindfulness (being in the here and now, and acceptance of what is)

Tapering Hypnotics

1- 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 stopped

Back to Ruth

Started 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.

John

70 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.

Cardiovascular complications

• Hypertension (High blood pressure)• Atherosclerosis (Hardening of arteries)• Heart attacks• Heart failure• Heart rhythm problems• Stroke

Other complications of OSA

DAY

excessive sleepiness afternoon drowsiness memory loss impaired concentration irritability headaches

NIGHT

snoring and snorting observed apneas choking or gasping

arousals unexplained tachycardia

restless sleep sweating during sleep nocturia bruxism nocturnal acid reflux

Screening Tools: STOP-BANG

STOP (yes/no)

SnoreTiredObstructionPressure

BANG (yes/no)

BMI > 30Age > 50Neck > 17"/16"Gender: Male

> 3 “yes” answers suggests high risk of sleep apnea

Vanderbilt Sleep Disorders Center- Nashville (Marriott Hotel)

Established in 2003

Accredited multidisciplinary10 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)

Vanderbilt Sleep Disorders Center-Franklin (Hyatt Place Hotel)

Opened Oct 08

Accredited multidisciplinary6 bed lab, 7 nights a week (neurology, pulmonary, pediatrics)

EEG Patterns of Sleep Stages

A negative test does not exclude clinically significant sleep apnea.

The Evolution of CPAP

Treatments for Sleep Apnea

• Weight Loss & Exercise

• Continuous Positive Airway Pressure Therapy

• Mandibular repositioning device

• Surgery

ORAL APPLIANCE

Happy Endings: Ruth and John

John 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.

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 adjust

Estimated that it takes one day per time zone for circadian rhythms to adjust to the local time

Traveling the World without Jet Lag

Eastman CI, Burgess HJ.Sleep Med Clin. Sleep Med Clinics 2009 4(2):241-255.

Traveling from Nashville to Paris (West to East)

Eastman CI, Burgess HJ.Sleep Med Clin. Sleep Med Clinics 2009 4(2):241-255.

Summary

Sleep disorders are very common

They are also highly treatable

Improving sleep can improve a person’s functioning during the day and quality of life