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

2. 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!

3. 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

4. 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

6. 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

7. Sleep Duration

8. 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%

9. 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

10. 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

11. 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

12. 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: % inc’d risk over 22 years
Nissan et al Diabetes Care 2004

13. Penn State Adult Sleep Cohort

14. 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

15. 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

16. Restless Legs Syndrome

17. 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

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

19. 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

20. 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

21. Periodic limb movement syndrome

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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. 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

29. 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

30. 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

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

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

33. 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

34. Questions