1. Nitun Verma MD MBA Medical Director Washington Center for Sleep Disorders http://www.washingtonsleep.com

2. Presenter Background Tufts University MD MBA Georgetown University Residency Stanford University Fellowship Board Certified in adult / pediatric sleep medicine

3. Washington Center for Sleep Disorders There are only 2 accredited sleep centers in the East Bay Established relationships with surgeons, dentists, equipment providers for a multidisciplinary treatment approach

4. Washington Center for Sleep Disorders Conditions Treated Changes in sleep associated with adolescence, menopause, retirement Obstructive Sleep Apnea (OSA) Insomnia Restless Legs Syndrome (RLS) Delayed/Advanced Sleep Phase Syndrome Narcolepsy

5. Drowsy Driving

6. QUIZ: How many US drivers fall asleep at the wheel every day?

7. 80,000

8. Drowsy Driving Who is at risk? Young people, particularly males Work requires long or odd hours Commercial drivers Persons with undiagnosed or untreated sleep disorders Those who have consumed alcohol People taking prescription medication that contain sedatives http://www.aasmnet.org/Resources/FactSheets/DrowsyDriving.pdf

9. QUIZ: How many sleep-related motor vehicle accidents are there each year ?

10. 250,000

11. Drowsy Driving Who is at risk? Get enough sleep Take breaks while driving Short nap, preferably 15 to 20 minutes in length. Do not drink alcohol Do not drive late at night http://www.aasmnet.org/Resources/FactSheets/DrowsyDriving.pdf

12. QUIZ: How many people in the US have a sleep disorder?

13. 30,000,000

14. Obstructive Sleep Apnea

15. Only 1 out of 10 people with OSA are diagnosed by their doctor.

16. Is obstructive sleep apnea and snoring the same thing?

17. Obstructive Sleep Apnea What is it? Airway narrowing Crisis and shocks Shallow sleep Can’t remember it

18. Obstructive Sleep Apnea What is it?

20. Airway narrowing Crisis and shocks Shallow sleep Can’t remember it

21. Is obstructive sleep apnea and snoring the same thing?

22. Obstructive Sleep Apnea What happens if you have it? Heart and blood vessels

23. Obstructive Sleep Apnea What happens if you have it? Heart and blood vessels

24. Neurocognitive Effects of OSA Hyperactivity, rebelliousness, aggression more common in SDB children Inattention Difficulty regulating emotions Lower grades than unaffected children Decreased performance on IQ tests

25. Insomnia

26. 30% of adults have symptoms of insomnia 10% of adults have insomnia that is severe enough to cause daytime consequences Almost 10% of adults are likely to have chronic insomnia http://www.aasmnet.org/Resources/FactSheets/Insomnia.pdf

27. Insomnia Effects Fatigue Moodiness Irritability or anger Anxiety about sleep Lack of concentration Poor Memory Poor quality performance at school or work Lack of motivation or energy Headaches or tension Upset stomach Mistakes/accidents at work or while driving http://www.aasmnet.org/Resources/FactSheets/Insomnia.pdf

28. Insomnia Types Adjustment Sleep Disorder Psychophysiologic Insomnia Paradoxical Insomnia Insomnia due to a mental disorder Idiopathic Insomnia Inadequate Sleep Hygiene Behavioral Insomnia of Childhood Insomnia due to a drug or substance Insomnia due to a medical condition

29. Sleep Hygiene Good sleep habits = good sleep without meds Regular sleep schedule Prevent heart burn at night Avoid stimulants in afternoon / evening Avoid naps after 3pm

30. Cognitive Behavioral Therapy Stimulus Control Therapy Stimulus Control Therapy Go to bed only when sleepy-not just fatigued, but sleepy. Get out of bed when unable to sleep (e.g., after 20 min), go to another room, and return to bed only when sleep is imminent. Curtailing all sleep-incompatible activities (overt and covert); no eating, TV watching, radio listening, planning or problem solving in bed. Arise at a regular time every morning regardless of the amount of sleep the night before. Avoid daytime napping.

31. Restless Legs Syndrome

32. “Creepy crawling” sensations in legs at night (rarely arms and rarely pain) Sensations decrease with movement or massage Delay sleep time 10% of people have symptoms of RLS Women have 1.5 – 2x increased risk Most people are treated after many years of symptoms

33. Restless Legs Syndrome Factors that make it worse Medical conditions: iron deficiency, kidney disease Medications: antihistamine, antidepressant, tranquilizer Also: obesity, sleepiness, pregnancy, smoking Risk increased if other sleep disorders also present

34. Restless Legs Syndrome Treatments Massage, compresses, movement Medications: some for intermittent use, others for daily use Specific to iron deficiency: Iron replacement

35. Narcolepsy

36. Common Vignette: 19 year old male presents with symptoms of sleepiness for over 3 months. When telling a joke or surprised, his jaw becomes slack, but consciousness is maintained. A few times he has had to hold on to the wall or railing for support. These episodes last between 30 seconds to 2 minutes. Also when waking up from sleep, he occasionally feels paralyzed, unable to move. This is very frightening to him, but resolves spontaneously. Because of sleepiness, his school performance has deteriorated.

37. Narcolepsy Summary EDS / Cataplexy / Sleep Hallucinations Etiology unclear but genetics / environment / autoimmune possible Treat both EDS and Cataplexy

38. Prevalence 0.05% general population (1 out of 2,000) 55% of narcoleptics are ever diagnosed (some sources 1 out of 4) 10 years is the time to diagnosis 2 nd decade of life is peak onset Symptoms are rare before 5 years of age EDS before cataplexy Japan 0.16% Israel <0.01%

39. Signs and Symptoms EDS (excessive day time sleepiness) Cataplexy Sleep Paralysis Sleep Hallucinations

40. Signs and Symptoms EDS Can also occur while active Can occur as a sleep attack Can occur several times a day Naps are refreshing (important to distinguish from idiopathic hypersomnia) Can result in poor work / school performance Need to monitor driving safety

42. Signs and Symptoms Cataplexy (60% of patients with narcolepsy have it) Abrupt / reversible loss of voluntary muscle tone Tendon reflexes inhibited 30 seconds – 2 minutes Usually bilateral Consciousness usually maintained Severity and frequency vary Common= muscle tone decreases, slurred speech Severe= total body collapse Important to identify triggers

43. Signs and Symptoms Sleep Paralysis Upon awakening or falling asleep Frightening to patient (affects 3-5% of non-narcoleptic population as well)

44. Signs and Symptoms Hallucinations Sleep onset (hypnagogic) Upon waking (hypnopompic)

45. Mignot E. Narcolepsy: A Guide for Understanding, Diagnosing, and Treating Narcolepsy.

46. Obstructive Sleep Apnea Quizzes Sleep Apnea Quiz Sleepiness Quiz Insomnia Quiz Online quizzes at www. washingtonsleep. com that do the scoring for you

47. Nitun Verma MD MBA Medical Director