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Modern Management of Sleep Disorders

Modern Management of Sleep Disorders. Douglas C. Bauer, MD University of California, San Francisco. No Disclosures. Introduction. 40 million Americans suffer from sleep disorders 95% are undiagnosed and untreated Prevalence of sleep disorders increases with age.

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Modern Management of Sleep Disorders

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  1. Modern Management of Sleep Disorders Douglas C. Bauer, MD University of California, San Francisco No Disclosures

  2. Introduction • 40 million Americans suffer from sleep disorders • 95% are undiagnosed and untreated • Prevalence of sleep disorders increases with age

  3. Percent Reporting Symptoms of Insomnia 2002 ‘Sleep in America’ poll, National Sleep Foundation

  4. Trends in Sleep Duration 1 Webb WB et al. Bull Psychom Soc 1975; 6: 47-48 2 National Sleep Foundation. 2000 Sleep in America poll

  5. Consequences of Sleep Disorders • Research has focused on daytime sleepiness, resulting in: •  Performance & productivity in the workplace •  Accidents and injuries •  Mood disorders & cognitive performance •  Quality of life • Until very recently, sleep loss was not believed to have any impact on human health

  6. Van Cauter Laboratories:Sleep Debt Study* • 11 healthy college-aged men • Sleep restriction (4 hours per night) for 6 consecutive 24-hour periods • Measured endocrine function before and after sleep restriction * Spiegel et al, Lancet, 1999

  7. Sleep Debt Study Results & Conclusions Sleep restriction results in: •  Glucose tolerance, thyrotropin •  Evening cortisol levels •  Activity of sympathetic nervous system Conclusions: • Sleep debt has a harmful impact on endocrine function and carbohydrate metabolism. • These effects are similar to those seen in normal aging. • Sleep debt may increase the severity of age-related chronic diseases including obesity, diabetes, CVD… and osteoporosis?

  8. Definitions • Insomnia (insufficient or poor quality sleep) • Hypersomnia (excessive daytime sleepiness)- Sleep disordered breathing/sleep apnea- Narcolepsy • Parasomnia (coordinated motor activity)-Restless leg syndrome

  9. Normal Sleep • REM (Rapid Eye Movement)- Characteristic eye movement- EEG resembles wakefulness • Non REM- 75% of sleep- Four stages: correlate with depth of sleep- Progressive cortical inactivity • Sleep architecture changes with aging

  10. ‘Normal’ Age-Related Changes in Sleep • Decreased total sleep time • Alterations in sleep architecture •  slow wave (stages 3 & 4) sleep •  sleep latency •  sleep efficiency • Alterations in circadian rhythms • phase advance •  amplitude of rhythm • Increased fatigue and daytime napping

  11. High prevalence (> 50%) More common in women than men Often secondary to a primary sleep disorder Commonly associated with psychiatric disorders or depression Insomnia in the Elderly

  12. Symptoms of Insomnia • Difficulty initiating or maintaining sleep • Wake after sleep onset • Early morning awakening • Awakening not rested

  13. Primary sleep disorder Hyperthyroidism Arthritis Chronic renal failure Chronic lung disease Heart failure Neurological disorders Dementia/AD Parkinson’s disease Medical Conditions That Cause Insomnia Note: sleep disordered breathing is not a common cause of insomnia

  14. Alcohol CNS stimulants Beta-blockers Bronchodilators Calcium channel blockers Corticosteroids Decongestants Stimulating antidepressants Thyroid hormones Nicotine Drugs That Cause Insomnia

  15. Sleep-Disordered Breathing (Sleep Apnea) • Symptoms include loud snoring, choking, gasping during sleep • Usually associated with daytime sleepiness • Risk factors include: • Older age • Male sex • CVD risk factors such as obesity • Craniofacial structure

  16. Definition of Sleep Apnea/SDB • Apnea = cessation of respiration • Hypopnea = partial decrease (>50%) of respiration • Duration 10 seconds  Respiratory Disturbance Index (RDI): • # apneas + hypopneas / hour slept • typical cutpoint is RDI  15

  17. Prevalence of Sleep Disordered Breathing • Heavily dependent on definition used • 2-4% in younger adults (20-60 yrs) • > 10% in elderly

  18. Consequences of Sleep Disordered Breathing • Excessive daytime sleepiness • Increased risk of accidents & injuries • Cognitive impairments • Increased risk of hypertension and cardiovascular events? • Via hypoxemia, sympathetic activation, acute hypertension and decreased stroke volume

  19. Sleep Heart Health Study • 6000+ participants from existing cohort studies: CHS, Framingham, ARIC • Men & women, mean age 63y (min 40y) • In-home polysomnography & ongoing ascertainment of CVD events • Aim: to test whether SDB/apnea increases risk for incident CVD events Shahar, Am J Respir Crit Care Med. 2001 163(1):19-25

  20. Prevalent HTN by Quartiles of RDI, Age < 65 P(trend)<.001 in both men and women Shahar, Am J Respir Crit Care Med. 2001 163(1):19-25

  21. Prevalent HTN by Quartiles of RDI, Age  65 p(trend)=.004 in women, NS in men Shahar, Am J Respir Crit Care Med. 2001 163(1):19-25

  22. Odds for Prevalent CVD by Quartiles of RDI* P<.0003 *Both sexes, all ages

  23. Other Causes of Hypersomnia: Narcolepsy - Extreme daytime sleepiness, frequent brief naps, cataplexy- Rare, familial, presents in 20s and 30s- Requires sleep study and daytime Multiple Sleep Latency Test (MSLT)- Treatment: stimulants, anticholinergics

  24. Parasomnias:Restless Leg Syndrome • Intense dysesthesias, repetitive jerking- Worse at bedtime- Often awakens patient - Often familial, progresses with age • Etiology unknown • Treatment- Sinemet 25/100 qhs (70% respond)- Clonazepam 0.5-2 mg qhs

  25. Evaluation of Sleep Disorders: History • Sleep pattern (patient and bedroom partner)- Insufficient sleep time- Delayed onset- Frequent or early awakening • Daytime correlates • Medications and habits • Associated nocturnal symptoms

  26. Evaluation of Sleep Disorders: Physical Exam and Routine Lab • Less helpful than historical features • Thorough exam of head and neck, and cardiorespiratory system • Signs of coexisting disease or complications • Consider thyroid function, Hct, UA, and glucose

  27. Evaluation of Sleep Disorders:Sleep Studies • Polysomnography (oximetry, EEG, EKG, EMG, observation) • Indications- Unexplained hypersomnia (esp. with snoring) - Unexplained sleep-related CV findings (e.g. pulmonary hypertension)- Abnormal complex sleep behavior - Unremitting chronic insomnia that does not respond to therapy

  28. Insomnia Therapies • Which of following is superior to benzodiazepine receptor agonists for primary insomnia?1) sleep hygiene2) cognitive behavioral therapy 3) anti-histamines 4) anti-depressants (TCA, SSRI, and trazadone)

  29. Treatment of Insomnia: Non-Pharmacologic • Treat underlying disorders • Begin with non-pharmacologic treatment- Sleep education (changes with aging)- Sleep hygiene (diet, exercise, habits, environment)- Establish optimal sleep pattern

  30. Non-Pharmacologic Therapy: Cognitive Behavioral Therapy • Cognitive therapy • Change maladaptive thought processes • Behavioral therapy (stimulus control, sleep restriction, relaxation, good sleep hygiene) • RCT of 46 adults with chronic insomnia • Superior short and long-term (6 mo) outcomes with CBT compared to zopiclone or placebo Sivertsen et al, Jama 2006, 295(25): 2851

  31. Treatment of Insomnia: Pharmacologic • Depression - TCA, trazadone, SSRI, combinations (suppress REM)- Not recommended if not depressed • Anxiety, panic - Benzodiazepines (suppress REM and non REM stage 3 and 4) • - Not recommended if not anxious • Idiopathic?

  32. Treatment of Insomnia: Pharmacologic • Problems with anti-histamines: anti-cholinergic, sedation, cognitive dysfunction • Problems with benzodiazepines: habit forming, tachyphylaxis, suppression of REM sleep, cognitive dysfunction, falls • Short-term benzodiazepine use (<2 wk) may be helpful in some patients • Alternatives to benzodiazepines?

  33. Benzodiazepine Receptor Agonists • Zolpidem (Ambien), Zaleplon (Sonata), Eszopiclone (Lunesta) - Activate 1 of 3 benzodiazepine receptors- No anxiolytic or muscle relaxing effects- No tolerance (studies up to one year) - Preserves REM sleep, less withdrawal, little abuse potential - Rapid onset, half life 2-3 hours

  34. An unexpected side effect…

  35. Other Drugs • Melatonin (OTC)- Secreted by pineal gland, receptors in hypothalamus- Low serum levels associated with poor sleep- Not FDA approved; safety? • Ramelteon (Rozerem) • Melatonin receptor agonist. FDA approved but no long-term safety data

  36. Conclusions • Sleep disorders are common • Associated with significant morbidity • Drugs treatment over utilized, non-pharmacologic treatment often successful • Primary care providers can diagnose and treat most patients with insomnia • Speciality referral (sleep study) for selected patients with unexplained hypersomnia or severe insomnia

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