Sleep Medicine in Primary Care Ann M Romaker, MD Medical Director UCMC Sleep Center di

MC Sleep Disorders Insomnia - up to 40% of pts in primary care practices Restless Legs/Periodic Limb Movement Disorder: 3-11% Substance Use/Abuse Obstructive Sleep Apnea—everybody!

78yoF reports “I just can’t sleep at night. I can’t turn my mind off 78yoF reports “I just can’t sleep at night. I can’t turn my mind off. I worry about my husband’s health, and what I have to do the next day.” What is the next step? Treat her underlying anxiety with an SSRI Refer for Cognitive Behavioral Therapy for insomnia Obtain more information Recommend PRN diphendyramine C – more info

More Information Timing: bedtime, sleep latency, number and duration of awakenings, wake time Duration of the problem. Precipitating factors, if any Caffeine and alcohol--amount and timing of ingestion Medications, prescribed and OTC Illicit substances

Insufficient Sleep Time chronic sleep deprivation from too little time for sleep overscheduling activities work, child care responsibilities computers, gaming, exercise close to bed time

Sleep Duration

Definitions of Insomnia Dissatisfaction with the amount and quality of sleep association with daytime consequences sleep onset, sleep maintenance, early am awakening irritability, fatigue, cognitive impairment Duration acute <3weeks chronic >3 months >3x/wk Primary 20% Comorbid 80%

Risk factors Female, particularly post menopausal Middle aged and older adults Shift Workers Lower socioeconomic status Living alone (single, separated, divorced, widowed) Medical Conditions Mental Illness Family History

34yoM c/o insomnia “forever”. He wants medication to help him sleep 34yoM c/o insomnia “forever”. He wants medication to help him sleep. You reply: “I don’t prescribe sleeping pills. Insomnia isn’t going to kill you. Eat right, exercise and cut back on caffeine. You’ll be fine” “You should see a psychiatrist about your anxiety and depression” “Stop using the electronics an hour before bedtime” “Insomnia that is longstanding can be managed but not cured. The best therapy is cognitive behavioral therapy. You can get it online” ?C

Consequences Short term: fatigue, hypersensitivity to light and noise, decreased self esteem, negativity, decreased attention, concentration and memory Long term: doubles the risk of future anxiety disorders 2 to 6X risk of future depression Increased accidents, both personal and work related Increased risk of falls without hypnotics Less likely to be promoted Rely on emotional-oriented coping strategies rather than problem solving

Long Term Consequences HTN: inc’d nocturnal systolic pressure and nondipping status Lanfranchi, et al Sleep 2009 CARDIAC DISEASE: inc’d risk of CAD and MI Laugsand et al Circulation 2011 DIABETES: 57-84% inc’d risk over 22 years Nissan et al Diabetes Care 2004

Penn State Adult Sleep Cohort

Insomnia treatment CBT has the best long term outcomes Education Sleep Hygiene Stimulus Control Sleep Restriction Online programs 75% efficacy—Shuti Hypnotics: 2% of patients escalate the prescribed dose Risk of falls in the elderly related to insomnia>>use of hypnotics Diphenhydramine not a good or safe alternative

Restless Legs Syndrome Diabetic Neuropathy Radicular Nerve irritation 45yoF PMHx DM2, HTN and chronic back pain reports that she can’t sleep. Her legs are uncomfortable and she bounces them nonstop, day and night, R >>L She has: Restless Legs Syndrome Diabetic Neuropathy Radicular Nerve irritation Nervous Leg Bouncing A - RLS

Restless Legs Syndrome

Diagnostic Features of RLS An urge to move the limbs associated with paresthesias or dysesthesias Symptoms that start or worsen with rest Relieved/improved with physical activity Symptoms are worse at night/evening May be associated with ferritin levels <50

Causes of RLS Idiopathic Anemia/low ferritin even with NML Hb Pregnancy HRT Medications: antihistamines, antipsychotics, SSRIs, TCAs, metoclopramide, caffeine

Association with PLMD Periodic Limb Movements of sleep (PLMs) occur in up to 45% of individuals >65yo 80-90% of pts with RLS demonstrate PLMs. Their presence on a sleep study supports the Dx of RLS

RLS Assoc with both systolic and diastolic HTN – risk inc’s with the frequency of the RLS symptoms Women with RLS appear to have inc’d risk of CAD Inc’d risk of depression Dec’d quality of life on a par with CHF

Periodic limb movement syndrome

Which Drugs for RLS are associated with punding? Gabapentin Benzodiazepines Dopaminergic Agents Opioids Dopaminergic agents

Treatment Dopaminergic agents: ropinirole*, pramipexole * Gabapentin* and gabepentin encacarbil Rotigotine Pregabalin Iron replacement—goal is ferritin >50 Opiates * take 2 hours before bedtime due to slow onset of action

Dopaminergic Drugs Impulse control disorders in 20% of pts Most common is punding (urge to take things apart, repetitive hand movements), but also compulsive gambling, shopping and hypersexuality Augmentation: RLS symptoms developing earlier in the day occurs at a rate of 8% per year. More common with shorter acting agents Dopamine Agonist Withdrawal Syndrome occurs in about 20% No longer the drug of choice forinitial therapy

Substance Use/Abuse Caffeine affects sleep for up to 8 hours following ingestion Nicotine is a stimulant Drugs of abuse Medications: many drugs can cause both insomnia and hypersomnia depending on the dose and the individual Take a careful history

True or False Average nighty CPAP use is 6 hours CPAP use is correlated with better CV outcomes OSA has been shown to be an independent risk factor for cancer Nonsnorers do not develop OSA F; mixed; T; F

Average nightly use around the world varies from 3.7 to 5.3 hours Outcome studies results are mixed The Sleep Heart Health Study at year 22 of follow up reported an independent association between OSA and Cancer Nonsnorers have OSA.

OSA Highly associated with CV disease 82% of pts with AFib have OSA WHO recommends a sleep study before adding a 3rd antiHTN agent 60% of men presenting with ACS or CVA/TIA have underlying OSA Independent risk factor for HTN, AFib, CHF, CVA, MVA, DM, dementia, impotence, and CA

CPAP CPAP is the gold standard Highly effective in lowering BP and other CV risk factors, as well as improving sleepiness, improving attention and mood, as well as QOL 50% of pts use it all night, every night Those who skip nights have been shown to wear it an average of 3 hours on the nights they use it

CPAP How much PAP is enough? Campos-Rodriquez et al demonstrated that 1 hr of nightly use improved mortality Several studies have demonstrated improvement in CV outcomes only in those who used it 6 hours a night, 7 nights a week Some use is better than none; more use appears to be better up to 6 hours

Factors that Affect PAP Use Nasal Resistance Marital and socioeconomic status OSA severity Type of Mask Age Claustrophobia Culture Body Image Coping Skills

Non PAP Options Weight Loss Exercise Oxygen Drugs Positional Therapy Oral Appliance Therapies nPEEP Surgery--Inspire

None of these works as well as CPAP in improving CV outcomes, mood, sleepiness and quality of life The first 3 weeks of use are critical in helping pts be successful PAP therapy. If you are managing your own OSA pts, current recommendations from the ACCP and the AASM are that they be seen within 1 to 2 weeks of starting PAP therapy. Formal PAP compliance programs appear to improve adherence

Questions