Thank You !!!Thank You !!!Dr. Constance Kay, MS Support GroupDr. Constance Kay, MS Support GroupAWAKE Group of the VillagesAWAKE Group of the VillagesPhillip Ratliff & Lois Brach, CoordinatorsPhillip Ratliff & Lois Brach, CoordinatorsHeather Ellington, Office Manager, VSL Heather Ellington, Office Manager, VSL John Crawford, Technical Director, VSLJohn Crawford, Technical Director, VSLThomas Chaput, Sleep Technologist, VSLThomas Chaput, Sleep Technologist, VSLMiyoshi Scott, Nurse, VSLMiyoshi Scott, Nurse, VSL

Sleep & Multiple Sleep & Multiple SclerosisSclerosis

Juan A. Albino, MD, FCCPJuan A. Albino, MD, FCCPBoard Certified in Sleep MedicineBoard Certified in Sleep Medicine

Village Sleep Lab 751-4955Village Sleep Lab 751-4955 Accredited by the AASM, 1/08Accredited by the AASM, 1/08

Common Sleep DisordersCommon Sleep Disorders

InsomniaInsomnia: wants to sleep but cannot : wants to sleep but cannot Sleep DeprivationSleep Deprivation: does : does notnot want to sleep want to sleep

but can; problem of sleep but can; problem of sleep quantityquantity Sleep ApneaSleep Apnea: sleepy during day, snores : sleepy during day, snores

(throat obstruction) problem of sleep (throat obstruction) problem of sleep qualityquality Restless Legs SydromeRestless Legs Sydrome: leg discomfort, : leg discomfort,

relieved by movement, symptoms day and relieved by movement, symptoms day and night night

Parasomnias: Parasomnias: abnormal sleep behaviorsabnormal sleep behaviors Circadian Rhythm Disorders: Circadian Rhythm Disorders: sleep clock sleep clock

not in harmony with the environmentnot in harmony with the environment

Restless Legs Syndrome Restless Legs Syndrome (RLS)(RLS)

Urge to move legs, discomfort at rest, Urge to move legs, discomfort at rest, worse at night, relieved by movementworse at night, relieved by movement

Affects 10% of population, women moreAffects 10% of population, women moreSeverity: mild, 7%, to incapacitating, 3%Severity: mild, 7%, to incapacitating, 3%Familial or Primary, often begins in Familial or Primary, often begins in

childhood; 2ary: other disorders presentchildhood; 2ary: other disorders presentDisruptive of social activities and sleepDisruptive of social activities and sleepCommon, easily diagnosed, and treatableCommon, easily diagnosed, and treatable

RLS and PLMDRLS and PLMD

Periodic Leg Movement Disorder, PLMDPeriodic Leg Movement Disorder, PLMD Involuntary leg movements while Involuntary leg movements while asleepasleepRLS occurs while RLS occurs while awakeawake, but 80% PLMD, but 80% PLMDBoth PLMD and RLS can disrupt sleepBoth PLMD and RLS can disrupt sleepLeg movements are common during sleepLeg movements are common during sleepNeed sleep study to diagnose PLMD but Need sleep study to diagnose PLMD but

not RLSnot RLSSame treatment for PLMD and RLSSame treatment for PLMD and RLS

Good Sleep Hygiene: BasicsGood Sleep Hygiene: Basics

Regular times for sleeping and awakeningRegular times for sleeping and awakening Maintain bedroom dark, quiet, coolMaintain bedroom dark, quiet, cool Use bed only for sleep and sexUse bed only for sleep and sex Avoid late daytime napsAvoid late daytime naps Avoid at night: alcohol, caffeine, nicotineAvoid at night: alcohol, caffeine, nicotine Sleep around 7 to 8 hours every nightSleep around 7 to 8 hours every night Prudent exercise and eating Prudent exercise and eating Avoid stressful situations at bedtimeAvoid stressful situations at bedtime Test: spontaneous bedtime and rise timeTest: spontaneous bedtime and rise time

Multiple SclerosisMultiple Sclerosis & Sleep Problems & Sleep Problems

Sleep Problems present before MS: Sleep Problems present before MS: can worsencan worsen

Sleep Problems caused by MS: can Sleep Problems caused by MS: can be managedbe managed

Sleep Problems develop independent Sleep Problems develop independent of MS: often complicated by MSof MS: often complicated by MS

Multiple SclerosisMultiple Sclerosis & Sleep Problems & Sleep Problems

Insomnia & Sleep ApneaInsomnia & Sleep ApneaDaytime Sleepiness & FatigueDaytime Sleepiness & FatigueDisruptions during SleepDisruptions during SleepAnxiety and DepressionAnxiety and DepressionNeurological complications of Neurological complications of

MSMS

MS & InsomniaMS & Insomnia

Primary Insomnia: present before MSPrimary Insomnia: present before MS Insomnia due to MS: improves with better Insomnia due to MS: improves with better

treatment of MS symptoms at nighttreatment of MS symptoms at nightDepression / insomnia: before or after MSDepression / insomnia: before or after MSUrge to urinate: bladder, prostate, etc.Urge to urinate: bladder, prostate, etc.Sleep apnea sometimes causes insomniaSleep apnea sometimes causes insomniaMedications: some antidepressants, Medications: some antidepressants,

stimulantsstimulants

Insomnia due to MS: CausesInsomnia due to MS: Causes

Leg and bladder spasticityLeg and bladder spasticityPain syndromesPain syndromesRespiratory muscle weakness: Respiratory muscle weakness: upperupper

airway (airway (throatthroat): aspiration, sleep apnea): aspiration, sleep apneaRespiratory muscle weakness: Respiratory muscle weakness: lowerlower

airway (airway (lungslungs): ventilation (hypoxemia)): ventilation (hypoxemia)Environmental: temperature & humidityEnvironmental: temperature & humidity

Frequent UrinationFrequent Urination

Causes: light sleep, bladder problem, Causes: light sleep, bladder problem, prostate problem, drugs, infectionsprostate problem, drugs, infections

Light sleep: insomnia, Sleep Apnea, Light sleep: insomnia, Sleep Apnea, PLMDPLMD

Consider urological evaluationConsider urological evaluationAvoid too much fluids, salt, diuretics, Avoid too much fluids, salt, diuretics,

alcohol, caffeinealcohol, caffeineConsider sleep study (polysomnogram)Consider sleep study (polysomnogram)Medicines for bladder (Detrol, Ditropan) Medicines for bladder (Detrol, Ditropan)

or prostateor prostate

Depression and AnxietyDepression and Anxiety

Anxiety: difficulty going to sleep, worriesAnxiety: difficulty going to sleep, worries Depression: difficulty going or staying Depression: difficulty going or staying

asleep, or waking up early; hopeless, asleep, or waking up early; hopeless, helpless, no fun, sad helpless, no fun, sad

Depression: before or after MS; problem Depression: before or after MS; problem recognizing, admitting to illnessrecognizing, admitting to illness

Drugs are effective in treating bothDrugs are effective in treating both Treat chronic insomnia: behavioral therapyTreat chronic insomnia: behavioral therapy Beware: anti-anxiety drugs & sleepiness; Beware: anti-anxiety drugs & sleepiness;

anti-depressants & insomniaanti-depressants & insomnia

Drugs and InsomniaDrugs and Insomnia

Anti-depressants: Prozac, Celexa, Anti-depressants: Prozac, Celexa, Zoloft, Paxil, take in the morning or Zoloft, Paxil, take in the morning or add sedating one at night: trazodoneadd sedating one at night: trazodone

Stimulants for fatigue: Stimulants for fatigue: methylphenidate, though modafinil methylphenidate, though modafinil betterbetter

Coffee, alcohol, tobacco: avoidCoffee, alcohol, tobacco: avoid

Primary Insomnia: Before MSPrimary Insomnia: Before MS

Insomnia: inability to get to sleep, stay Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime asleep, wakes up early, with daytime impairmentimpairment

Acute Insomnia (<4 weeks): stress, illnessAcute Insomnia (<4 weeks): stress, illness Sleep medicines work well in acute stageSleep medicines work well in acute stage Chronic Insomnia: >4 weeks, often yearsChronic Insomnia: >4 weeks, often years Treat basic problem: >60% psychologicalTreat basic problem: >60% psychological Psychotherapy and behavioral therapy Psychotherapy and behavioral therapy

better than medicines, not easy to treat better than medicines, not easy to treat Psychologists, Psychiatrists, PCPPsychologists, Psychiatrists, PCP

Treatment of Chronic Treatment of Chronic InsomniaInsomnia

Sleep Hygiene: avoid coffee & alcohol, sleep in Sleep Hygiene: avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before beda quiet, dark, cool room, eat lightly before bed

regular sleep hours, avoid day naps, exercise regular sleep hours, avoid day naps, exercise Restriction: only go to bed when ready to Restriction: only go to bed when ready to

sleep, if in bed sleep 90% of the time; out of sleep, if in bed sleep 90% of the time; out of bed and bedroom if awake over 20 minbed and bedroom if awake over 20 min

Stimulus control: simple bedroom furniture Stimulus control: simple bedroom furniture and bedroom strictly for sleepand bedroom strictly for sleep

Proper perspective: good if adequate sleep Proper perspective: good if adequate sleep over 75% of the time, don’t exaggerate the over 75% of the time, don’t exaggerate the problemproblem

Treatment of Chronic Insomnia: Treatment of Chronic Insomnia: Sleeping PillsSleeping Pills

Anti-histamines: available over the counter Anti-histamines: available over the counter Benadryl (diphenhydramine)Benadryl (diphenhydramine)

Sedating anti-depressants: trazodoneSedating anti-depressants: trazodone Sedatives: temazepam (Restoril), Sedatives: temazepam (Restoril),

triazolam (Halcion), flurazepam (Dalmane)triazolam (Halcion), flurazepam (Dalmane) Specific drugs: Ambien (generic), Ambien Specific drugs: Ambien (generic), Ambien

CR (not generic), Lunesta, short acting but CR (not generic), Lunesta, short acting but expensive; Rozerem (not habit forming)expensive; Rozerem (not habit forming)

Natural Substances: melatonin, valerian Natural Substances: melatonin, valerian root, chamomile tea, lavender, kava, root, chamomile tea, lavender, kava, jazmine scent, little to no proof that they jazmine scent, little to no proof that they help, side effectshelp, side effects

Day Time SleepinessDay Time Sleepiness

Insomnia due to MS: leg spasticity, Insomnia due to MS: leg spasticity, urination, pain, neuromuscular urination, pain, neuromuscular weaknessweakness

Drugs: anti-anxiety & antispasmodics Drugs: anti-anxiety & antispasmodics for legs or for bladder dysfunctionfor legs or for bladder dysfunction

Sleep Apnea: poor sleep qualitySleep Apnea: poor sleep qualityRestless Legs Syndrome / Periodic Leg Restless Legs Syndrome / Periodic Leg

Movement DisorderMovement DisorderPrimary Insomnia: hyperarousal, little Primary Insomnia: hyperarousal, little

daytime sleepinessdaytime sleepiness

Drugs and Daytime Drugs and Daytime SleepinessSleepiness

Muscle Relaxants: baclofen (Lioresal), Muscle Relaxants: baclofen (Lioresal), tizanidine (Zanaflex), dantrolene tizanidine (Zanaflex), dantrolene (Dantrium) (Dantrium)

Anti-anxiety: alprazolam (Xanax), Anti-anxiety: alprazolam (Xanax), clonazepam (Klonopin), lorazapam clonazepam (Klonopin), lorazapam (Ativan)(Ativan)

Drugs for bladder dyfunction: Drugs for bladder dyfunction: oxybutynin (Ditropan), tolterodine oxybutynin (Ditropan), tolterodine (Detrol)(Detrol)

Manage: change drug, lower doseManage: change drug, lower dose

Sleep Apnea: Risk FactorsSleep Apnea: Risk Factors

Affects: 4 to 5% of population: commonAffects: 4 to 5% of population: common Family history, Sleep maintenance insomniaFamily history, Sleep maintenance insomnia Obesity: 80 % of sleep apnea patients; Obesity: 80 % of sleep apnea patients;

central (visceral, apples) obesitycentral (visceral, apples) obesity Increasing age, Male genderIncreasing age, Male gender Large tonsils / adenoids in childrenLarge tonsils / adenoids in children Small mandible, large neckSmall mandible, large neck Smoking, alcohol, sedatives, nasal allergiesSmoking, alcohol, sedatives, nasal allergies

Sleep Apnea: ConsequencesSleep Apnea: Consequences During During nightnight: snoring, snorting, gasping, : snoring, snorting, gasping,

difficult or stops breathing, wife worriesdifficult or stops breathing, wife worries During During dayday: sleepy, tired, depressed, : sleepy, tired, depressed,

irritable, impotent, forgets, sometimes few irritable, impotent, forgets, sometimes few complaintscomplaints

More More accidentsaccidents: work, home, motor vehicle: work, home, motor vehicle Higher death rates with severe sleep apneaHigher death rates with severe sleep apnea Hypertension, Congestive Heart FailureHypertension, Congestive Heart Failure Heart Attacks, Strokes, Atrial FibrillationHeart Attacks, Strokes, Atrial Fibrillation Promotes Promotes ObesityObesity and and DiabetesDiabetes Problems: at night, during day, risk factorProblems: at night, during day, risk factor

What is OSA?•Cessation of airflow with ongoing respiratory effort•NORMAL SNORING SLEEP APNEA

Obstructive Sleep Apnea

Sleep Apnea: Treatment Sleep Apnea: Treatment

Behavioral: Weight Loss, Sleep Position Behavioral: Weight Loss, Sleep Position (Sleep on side, head raised), Oxygen, (Sleep on side, head raised), Oxygen, Avoid sedatives Avoid sedatives

CPAPCPAP: proven therapy, needs motivation: : proven therapy, needs motivation: widely available, 70%: patients adapt wellwidely available, 70%: patients adapt well

Surgery: tracheostomy, tonsillectomy, pull Surgery: tracheostomy, tonsillectomy, pull forth mandible or tongueforth mandible or tongue

Bariatric Surgery: banding, bypass (Bob Bariatric Surgery: banding, bypass (Bob Eisenhauer, 259-1485)Eisenhauer, 259-1485)

Dental appliances: also pull forth mandible Dental appliances: also pull forth mandible or tongue; expertise necessaryor tongue; expertise necessary

Treatment -CPAP treatment–Positive pressure keeps airway open–100% effective

CPAP therapy

Treatment Options: CPAP

Summary: Sleep ApneaSummary: Sleep Apnea Very common and dangerousVery common and dangerous Easily diagnosed and treatedEasily diagnosed and treated Benefits of treatment:Benefits of treatment: sleep better at sleep better at

nightnight, also, also Feel better during the dayFeel better during the day: less sleepiness : less sleepiness

and fatigue, more energy, less accidentsand fatigue, more energy, less accidents Reduce risk factorReduce risk factor for heart disease and for heart disease and

strokesstrokes Control betterControl better: obesity, diabetes, : obesity, diabetes,

hypertensionhypertension Bed partner sleeps betterBed partner sleeps better: less noise and : less noise and

less worry (but dog is scared of CPAP)less worry (but dog is scared of CPAP)

Neuromuscular Weakness: Neuromuscular Weakness: Breathing & Sleep in MSBreathing & Sleep in MS

Weakens throat and/or lungs (diaphragm)Weakens throat and/or lungs (diaphragm)Advanced disease, night problem, not dayAdvanced disease, night problem, not daySleep apnea, aspiration, speech & eating Sleep apnea, aspiration, speech & eating

problems, shortness of breathproblems, shortness of breath Infections: aspiration, weak coughInfections: aspiration, weak coughNight: low oxygen, high carbon dioxide: Night: low oxygen, high carbon dioxide:

sleep disruptions, insomniasleep disruptions, insomniaManagement: Management: head elevationhead elevation 35 angle, 35 angle,

avoid bedtime eating , avoid bedtime eating , BIPAP, OxygenBIPAP, Oxygen

Summary: Sleep Disorders & Summary: Sleep Disorders & MSMS

Majority of MS Patients have sleep disorders, Majority of MS Patients have sleep disorders, but the majority are easily diagnosed and but the majority are easily diagnosed and treatedtreated

Most common disorders: depression, pain, Most common disorders: depression, pain, sleep apnea, leg & bladder spasticity, restless sleep apnea, leg & bladder spasticity, restless legs, anxiety, poor sleep hygiene, drug side legs, anxiety, poor sleep hygiene, drug side effectseffects

Fatigue and daytime sleepiness are hard to Fatigue and daytime sleepiness are hard to distinguish distinguish

Neuromuscular weakness at night easily Neuromuscular weakness at night easily missedmissed

WebsitesWebsites

American Sleep Apnea Association: American Sleep Apnea Association: www.sleepapnea.orgwww.sleepapnea.org

National Multiple Sclerosis Society: National Multiple Sclerosis Society: www.nationalmssociety.orgwww.nationalmssociety.org

Restless Legs Syndrome Foundation: www.rls.orgRestless Legs Syndrome Foundation: www.rls.org National Sleep Foundation: National Sleep Foundation:

www.sleepfoundation.orgwww.sleepfoundation.org American Insomnia Association: American Insomnia Association:

www.americaninsomniaassociation.orgwww.americaninsomniaassociation.org National Institute on Neurological Disorders and National Institute on Neurological Disorders and

Stroke: www.ninds.nih.govStroke: www.ninds.nih.gov Village Sleep Lab www.villagesleeplab.com (Dr. Village Sleep Lab www.villagesleeplab.com (Dr.

Albino, coming in February, 2008)Albino, coming in February, 2008)

BooksBooks

Multiple Sclerosis: A Guide for the Newly Multiple Sclerosis: A Guide for the Newly Diagnosed Diagnosed by Nancy J Hollard et. al.by Nancy J Hollard et. al.

The Promise of SleepThe Promise of Sleep by William Dement by William Dement Sleeping WellSleeping Well by Michael Thorpy by Michael Thorpy The MS Workbook: Living Fully with Multiple The MS Workbook: Living Fully with Multiple

Sclerosis Sclerosis by George H. Kraft et. al.by George H. Kraft et. al. A Woman’s Guide to Sleep DisordersA Woman’s Guide to Sleep Disorders by by

Meir H. KrygerMeir H. Kryger Say Good Night to InsomniaSay Good Night to Insomnia by Gregg D. by Gregg D.

JacobsJacobs