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Sleep Apnea, Insomnia and other Sleep Disorders

 

One-third of the population will complain about a sleep difficulty, if asked, during the past year and of those individuals, about one-half think that it’s fairly serious – so about one-sixth. Finally, of those, about 10% were prescribed medication and some 5% used some over-the-counter medication. Sleep problems really are quite prevalent and that, for the most part, I think physicians tend not to make the diagnosis or uncover these until a patient comes to us and sleep disorders, insomnia, apnea, narcolepsy, nocturnal myoclonus, restless leggs syndrome

What I’m going to do is talk a little bit about the history of sleep disorders and how we got to today’s understanding and discuss a little bit about sleep physiology. Just enough so that we can understand some of the derangements that occur in sleep physiology that present clinically, talk about the normal changes in aging, "Do you sleep longer or shorter?" and so on and so forth. We’ll talk about evaluation and hopefully make this a practical way to evaluate people and

Why do we sleep? It turns out no one really knows. We’ve got a lot of good explanations here – tissue growth and repair, problems with energy metabolism, the immune system and so on. We know what some of the consequences of going without sleep are and we will discuss some of these a little further on but things like increased accidents; and decreased performance, particularly in those types of tasks which are repetitive. So we have a resident who is out there on the wards, generally they do

We know that sleep is divided up basically into sections and we will talk about how these follow each other. We start out being awake and have alpha waves on the EEG and this is how we classify our sleep patterns. We go into non REM or non rapid eye

Nocturnal penile tumescence. So we often will do the snap gauge or the postage stamp test to see if a gentleman can obtain an erection during sleep. This occurs during REM or dream sleep. Finally, control of respirations, I’ve already alluded to, is very

If it’s exclusively a sleep onset problem, think about, especially in the younger patient, psychophysiologic insomnia. So the person who may have anxiety, work stress, etc.

Delayed sleep phase. We will talk about some of the sleep cycle problems, poor sleep habits or difficulties with psychiatric disorders or some of the leg movement disorders that we will allude to. If it is more sleep maintenance, particularly now in our older individuals, that the person is able to go to sleep but then has trouble maintaining sleep, look at alcohol and medications.

Advanced sleep phase. So this would be that lark who is getting up early in the morning, maybe waking up at 4:30 but is actually getting their seven hours of sleep but says, "My God, I can’t get up at 4:30 in the morning" even though they’ve gone to bed at 8:30, and wondering what they heck they can do. Poor sleep hygiene, nocturnal worrying, covert psychiatric disorders such as depression and finally some of the primary sleep disorders that we are going to

It says, "So there he was, this big gorilla just lying there and Jim here says, "Do you suppose it’s dead or just asleep?" Well, what are we going to get when we take the history? We want to know about difficulty falling asleep. So is this a sleep onset or sleep maintenance problem. How long has it been going on. Is it associated with multiple awakenings. How about daytime sleepiness and fatigue. What’s been the functional impact. Excessive movements. Snoring.

Date and day of the week. Maybe this is just something that happens on the weekend when someone is really binging on alcohol. What are the habits prior to sleep. Maybe this person really has a big meal and that is causing further reflux. What are their activities prior to bedtime.

Some of the things we are going to talk about with sleep hygiene is to try to get people to ease into sleep and use the bedroom for sleeping and not for all sorts of other activities which might actually program them or get them in a behavioral chain so they

Jet lag. If you look at our body’s natural sleep cycle, it tends to be about 25-26 hours and people generally accommodate much, much better going from East to West than West to East because we can lengthen our day and do pretty well but trying to go the

So what have you all done here? First of all, you’ve come here to a review course to learn something. Maybe you were plied with drinks on the plane. You sit here in this dark room where you have none of the normal cues that help entrain us into a 

How about the treatment? What could these people, who are flying off from Turkey, be able to do? First of all, you can 

Sunlight is probably the number one thing you can do short of medication. If you can get yourself into the sun instead of this dark room in the morning at your location at the appropriate time, you will take an adjustment period of about two weeks and

Finally, the short acting benzodiazepines such as Triazolam have been used and have been clearly shown to be effective in adapting. So taking it at bedtime at the location bedtime. There are some drawbacks, though. Short term memory loss and some people who get depersonalization syndrome. Occasionally, withdrawal from these, rebound. So you’ve got to be careful

The eight hour became standard in 1914 – Henry Ford. Of course, Edison in 1882 with his invention of the electric light bulb really changed the industrial face of America. These two events all of a sudden made it possible to work throughout the night and to do so in a way where industrial productivity was the key. It affects about 15-25% of workers so this is a big issue for

Identify the poor adjusters. So people who aren’t able to key in and get with the program. Permanent shifts if possible. I know that is hard for many people to swallow but frankly if you are going to have to change all the time, you are really better off to have permanent shifts and if not, at least allow two weeks, preferably four to six weeks, between shift adjustments so 

Let’s talk now a little bit about advanced sleep phase. Advanced sleep phase would be characterized by early morning arousal, daytime fatigue and a tendency to go to sleep earlier in the evening. So this would be those elders. Those would be those larks 

Sleep apnea. Central sleep apnea may sound like a real rare bird to you. I know it did to me before I really was interested in this area. No history of snoring. There is nocturnal breathing sensation and presents as excessive daytime sleepiness or insomnia. We’ve all heard of Undines curse and things like that but how many times have you seen that? But I bet you every one of you has a person in their practice who has this and the people who are going to have this, beyond those who have multiple massive 

Contrast that to obstructive sleep apnea which is sort of more of what I think most of us think about, in family medicine at least, where there is an obstruction to nasal oral airflow but there is still this drive to breathe. Characteristically there would be snoring, maybe some unusual sounds. There can be increasing problems with breathing the spouse may report. "Gee, my husband, he 

The problem here is if we look at men and women as they age and we look at the prevalence of habitual snoring, about age 65, you’ll see probably half the population plus are habitual snorers. So if we use snoring as a marker for people with sleep apnea, 

The problems with diagnosis therefore are increased incidence of snoring with aging and increased incidence of brief apneic spells. There’s been a lot of good work that has taken what appear to be normal elders, put them in sleep labs and what happens? Well, they have periods of apnea. They have hypopnea where they’re not breathing as deeply. They have disordered 

Treatment for obstructive sleep apnea. Weight loss is very effective and it doesn’t have to be actually a large amount of weight. Many of these individuals lose 10 or 15 pounds and you think what good does that do? Actually, it can have a real significant impact. Probably the most common thing we do is nasal continuous positive airway pressure or nasal CPAP. We have a lot more small setups now that are very easily tolerated for most individuals although the discontinuation rate still approaches 50%. Uveal palatal pharyngoplasty or the surgery. Again, it’s about a toss of the coin, about 50/50. The take home message 

So if you’ve got somebody who’s got just a little bit of snoring, you can laser them, you can do a UVP and you can stop their snoring but that isn’t what we’re trying to do with sleep apnea surgery. We’re trying to decrease those hypopneas, we’re trying to decrease those apneas, we’re trying to decrease the oxygen desaturation and the very people who have the worst problems 

Help for snorers. Exercise. Avoiding anything that is going to increase flaccidity like alcohol, tranquilizers, antihistamines. Raising the head of the bed. A soft collar. Drinking caffeine or something like Dexatrim that will not allow someone to get into those deeper stages. Again, it has to be used very cautiously. Sleeping sideways or having a tennis ball on the pajama back so if they roll over to lay on their back they’ll go back over.

A Second Wind from Snore Stopper and you can see here he’s got the Breathe Right nasal strip there or here’s the Breath Eze septum stimulator which relieves snoring. None of these things have been shown to do one iota of benefit for sleep apnea. None of them have been shown to do anything for snoring. So if you have a drugstore, recommend these. Otherwise, I’d say, if someone asks you, there is no evidence that they are effective.

Narcolepsy is a characteristic disorder that basically is the intrusion of REM sleep into daily activity. So just think about what happens with REM sleep and you’ve got narcolepsy down. Sleep attacks, so you fall asleep. Cataplexy or this weakness because remember there is skeletal muscle atonia. Accidents. Well, of course, you’re driving along and you have an attack, that is going to be bad news. Amnesia because you’re asleep in these bizarre hypnagogic hallucinations which are dreams.

Now, why am I spending a moment to talk about this? Well, that young 35-year-old male (there is a male predilection) who comes in and they’ve had a car accident and you’ve done the evaluation with the EEG and they don’t have a seizure disorder, you’ve done the evaluation for cardiac problems and you’ve done your EP studies and so on and so forth, think about this. The average time to diagnose this is between 10 and 20 years because no one thinks about the diagnosis. While these aren’t going to walk into your office very often, the one time it does you can tremendously help this individual by making the diagnosis earlier 

I’m not going to talk a lot about treatment because I think we’ll probably most times want to have someone else helping who is an expert in this therapy but diagnosis is where it is at for primary care there, in

Sleep related myoclonus. Nocturnal myoclonus is repetitive stereotypic leg movements. They are non REM so non rapid eye movement sleep. They interfere with falling and staying asleep. So these occur early on in the sleep cycle generally. A person might complain of fatigue or muscle aches and the treatment is generally benzodiazepines, clonazepam.

Restless leg syndrome. Restless legs is this disagreeable crawling, awful sensation in the legs. You’ve just got to move them. It can be idiopathic which is probably the most common cause but also can be associated with things like pregnancy, renal failure. Periodic leg movements in sleep is sort of this whole catchall of people that have funky movements while they are sleeping. While the benzodiazepines may be useful, and you know them probably as well as anyone, the real treatment that is best is Sinemet in this individuals – a levodopa/carbidopa. So if you’ve get somebody with restless leg syndrome, you may not remember it but come back to the notes because you know that there’s a good drug and that’s Sinemet. Remember don’t give it with MAOIs, with a history of glaucoma, melanoma

In adults, if you have an elder or someone who is older who begins sleep walking think about a neurologic problem until proven otherwise. In kids you see it all the time and don’t worry about it. You know how to probably treat this already but adults who come in with a new onset of sleep walking, there is something going on in their noggin until we find out otherwise.

I’m going to skip a few of these just so we can move on to treatment. It says, "Sir, the following paradigm shifts occurred while you were out." So this is our cue to turn to treatment in a new carousel.

Treatment of sleep disorders is very gratifying. People really like you but it all is based on history and physical. It is based on making the diagnosis, instituting some sleep hygiene – which are the sleep habits – and what are some sleep habits that one can institute? A light snack if it is not contraindicated. If the person doesn’t have GRD or something. Limiting alcohol, caffeine, nicotine, other stimulants. Using hypnotics on a short term basis and we will turn to that in just a few moments.

Winding down prior to bedtime and scheduling worry time prior to bedtime. Even having people take a set of index cards and writing down all their worries on those beforehand. Regular rising time so that we try to get people into a good habit. You go to bed at the same time, you get up at the same time. If you can’t go to sleep within 15 minutes, get up and do something that is not particularly activating. It may be a little handwork, doing some reading, maybe watching some TV and when you feel sleepy

We’ve heard about the eosinophilia-myalgia syndrome associated with L-tryptophan. Have people drink a class of warm milk and they can get their L-tryptophan now in that way. I won’t go into this since it’s off the market now. Over-the-counter sleeping pills are predominantly antihistamines and may be effective over a very short term but remember there is a significan

Sleeping on the job again. Well, what else is over at that health food store today? Melatonin. Ultrasnooze melatonin. Hey, this is good stuff. Or how about Arise. We can use it for jet lag. Melatonin has permeated the health food stores and unfortunately while there is some tantalizing research evidence that melatonin may be effective, the best data is really, really lousy when you

Unless, you are a rat they probably don’t particularly pertain to you and secondly, where do they get this melatonin? Cow brains. What have we been hearing about cow brains? I mean, mad cows’ disease. Who knows what’s in this stuff? How is it standardized? When I buy melatonin in Ultrasnooze and I buy melatonin solution and I buy melatonin this, I have no idea what I’m getting. There is no standardization at all. So my take on this is, "Gees, if you want to try it, okay. But I 

So that leaves us with a number of prescription medications and sometimes I think these have gotten rather bad raps. The oldest one is this Chloral hydrate, at least that I recommend. I don’t recommend we use barbiturates or any of the older medications. Clearly, there are a number of medications now that have a much better safety profile. Chloral hydrate is

Benzodiazepines. What are their actions? About one month for sleep problems. Now, I’m not talking about someone who’s got GAD or social phobia or any of the other indications for benzodiazepines. I’m talking about for sedative hypnosis. Less withdrawal and dependence than many of the other drugs that proceeded them. Decreased suicide risk. 

We’re headed into the home stretch but I still have some important things to cover and probably one of the biggest things here now is zolpidem. Zolpidem is really, I think, an addition to our armamentarium that is worthwhile to consider and provides perhaps the most effective alternative with little habituation, probably little disturbance in the sleep architecture and is an effective alternative to the benzodiazepines.

How about guidelines for hypnotic therapy overall, whichever drug you use. I think the biggest thing here is to warn the patient and talk about the education. Talk to them. Tell them what to expect. "Gees, if you are having problem functioning during the day, if you’re sleepy in the morning, I need to know about this. You will tend to get a little better over 

Sleep center referral. Obviously someone who has got a possibility of a sleep apnea and you’re thinking about that. I’d say a word about home apnea monitoring. There is no good evidence that the typical home monitoring units are good for diagnosis. They may be useful to follow somebody but I would be very reluctant to entrust someone to a life long therapy or potentially quite aggressive therapy to a home diagnosis. I want them in a sleep center where I’ve got a real hard and fast diagnosis on someone who I’m thinking about committing to a nasal CPAP or a UVP or