Sleep Disorders Beth A. Malow, M.D., M.S. Associate Professor of Neurology Director, Vanderbilt Sleep Disorders Program

NIH Research on Sleep and Sleep Disorders Program Announcement (2-9-05)  Estimated 70 million people in the US suffer from sleep problems (50% have chronic sleep disorder)  30 million American adults have insomnia  18 million Americans have sleep apnea  250,000 Americans have narcolepsy  10-20% of adults have restless legs syndrome  Each year, 100,000 accidents and 1500 traffic fatalities are related to drowsy driving  Each year, sleep disorders, sleep deprivation, and excessive daytime sleepiness add approximately $16 billion annually to the cost of health care in the US and result in $50 billion annually in lost productivity

Presentation Objectives  To discuss the differential diagnosis of common sleep concerns and the essentials of the sleep history  To describe polysomnography (sleep studies) and what is measured  To highlight obstructive sleep apnea and insomnia as examples of treatable sleep disorders

Sleep disorders– Common concerns  “I can’t fall asleep or stay asleep”  “I’m too sleepy during the day”  “I’m told I do unusual things in my sleep”

Sleep disorders– Common concerns  “I can’t fall asleep or stay asleep” –Psychophysiological Insomnia (often stress-related) –Inadequate Sleep Hygiene (poor sleep habits) –Medications (corticosteroids) –Medical Disorder (arthritis, back pain) –Neurologic Disorder (epilepsy, Parkinson’s disease) –Psychiatric Disorder (anxiety, depression) –Obstructive Sleep Apnea –Restless Legs Syndrome

Sleep disorders- Common concerns  “I’m too sleepy during the day” –Not enough sleep (sleep deprivation) –Sleep is disrupted (sleep apnea, periodic limb movements of sleep, frequent awakenings from medical or neurological disorder) –CNS pathology (narcolepsy, with REM intrusions into wakefulness– cataplexy, sleep paralysis, hypnic hallucinations) –Medications (antiepileptic drugs) –Depression

Sleep disorders- Common concerns  “I’m told I do unusual things in my sleep”  Parasomnias: disorders in which undesirable physical or mental phenomena occur during sleep – NREM arousal disorders (sleepwalking, night terrors) – REM sleep behavior disorder (dream-enacting behavior) – Rhythmic movement disorder (head banging) – Sleep Starts (hypnic jerks) – Nocturnal seizures may mimic parasomnias

Case example  A house officer complained of difficulty staying awake on afternoon rounds. Her call schedule varied depending on the rotation, but was usually once every three nights, with her getting at most 2 hours sleep on a call night. When not on call, she had difficulty falling asleep and tossed and turned worrying that she would not be able to sleep well that night. Her bedtime when not on call varied between 10 PM and 2 AM depending on her work assignments and whether her twin 2-year-old sons awakened from sleep. She would frequently awaken about 2 hours after falling asleep.

Case example  During the day, she drank coffee and caffeinated soda in the afternoons and early evenings to stay awake. She often missed her exit on the expressway while driving home from work. Her husband said that she snored heavily when she slept on her back and described her sleep as restless. She has had difficulty losing weight since the birth of her twins and is about 30 pounds overweight. She occasionally took Benadryl to sleep.

Sleep disorders- Common concerns  “I’m too sleepy during the day” –Not enough sleep: med student with erratic schedule and twins, stress and caffeine-related insomnia –Sleep is disrupted: ? Obstructive sleep apnea –CNS pathology: narcolepsy? –Medications: Benadryl? –Depression: maybe?

Sleep disorders-- Referral for Study  Polysomnography: Overnight sleep study to evaluate and quantify overall sleep architecture, breathing, leg movements, abnormal behaviors –Sleep apnea –Periodic limb movements –Parasomnias (includes video-EEG) –Narcolepsy (along with daytime multiple sleep latency test) –Not usually indicated for insomnia

Young, JAMA, 2004 Risk Factors, Symptoms, Outcomes, and Comorbid Conditions of Obstructive Sleep Apnea (OSA) in Adults

How is OSA treated?  Continuous positive airway pressure (CPAP)  Weight loss  Positional therapy (to get person off back)  Oral appliances: for mild to moderate OSA  Surgery: Uvulopalatopharyngoplasty (UPPP), maxillofacial surgery, nasal somnoplasty, adenotonsillectomy (in children and young adults)

Continuous positive airway pressure (CPAP) works by using pressurized air to splint open the upper airway, preventing collapse during sleep A titration study in the sleep lab is followed by prescribing CPAP for home use

Treatment of OSA with CPAP

Psychophysiological Insomnia n People with this disorder have a few nights of insomnia, perhaps due to some major stressor (death in family, new job, divorce) and then learn behaviors to prevent sleep. These behaviors include: –Marked overconcern with the inability to sleep with focused absorption on sleep problem: vicious cycle develops! –Associating bedroom with not sleeping (conditioned arousal) n Psychophysiological insomnia may also lead to: – Inadequate sleep hygiene – Inappropriate use of stimulants or alcohol to promote sleep

Psychophys. Insomnia- Treatment n Stimulus control (learning not to associate bedroom with not sleeping):  Go to bed only when sleepy  Use bed and bedroom only for sleep (no reading, TV watching, eating, etc.)  Get out of bed and go into another room when you are unable to sleep for minutes

Psychophys. Insomnia- Treatment n Sleep restriction: curtailing the amount of time spent in bed to the actual amount of sleep  Many people are so worried about how long it takes them to fall asleep that they go to bed extra early (9 PM bedtime but don’t fall asleep until 1 AM!)  Using sleep restriction, these people would go to bed at 11 PM or midnight and fall asleep immediately, thereby breaking the cycle of lying awake in bed worrying about going to sleep.

Psychophys. Insomnia- Treatment n Sleep hygiene education:  Exercising, but avoiding exercise too close to bedtime  Regular bedtime and waketime  Avoiding daytime naps  Avoiding alcohol, caffeine, cigarettes  Appropriate room temperature and noise level  Light snack, rather than heavy meal at bedtime  Avoid taking problems to bed

Taking a Sleep History  Chief complaint –Sleepiness, insomnia, abnormal sleep behavior –How long symptoms going on? What brought patient or parent to seek medical attention?  Nighttime sleep (from bedpartner or parent) –Snoring, kicking, abnormal behaviors  Sleep/wake schedule –Bedtime and wake time on weekdays and days off –Time to fall asleep, wakings, any naps during day

Taking a Sleep History  Other daytime symptoms –Cataplexy, hallucinations, sleep paralysis –Creeping/crawling feelings in legs while falling asleep –Work performance, School performance  Daytime Sleepiness (or hyperactivity)  Medical, Neurological, and Psychiatric History  Medications  Remember to ask about alcohol, caffeine, cigarettes, herbals, illicit drugs, and over-the-counter products

Vanderbilt Sleep Disorders Center