1. Sleep case #1

2. Case 64 yo male smoker with hyperlipidemia BMI 28 Prev diagnosis of OSA Referred for daytime sleepiness

3. Prev results 12/2006 sleep study: AHI 15.8 5/2007 PAP titration – good response to CPAP 6cm, 54 mins of sleep including REM-supine seen Did not get home CPAP at that time Summer 2012: Another provider started him on CPAP based on 2006/2007 study results and ordered PSG which was performed in 10/2012

4. Visit Jan 2013 Started on CPAP over the summer 2012 Using it nightly and has met compliance with 4.5h ave use Feels he is sleeping better No improvement in daytime sleepiness (ESS 18/24) Irregular schedule Difficulty falling and staying asleep Estimates he gets 3-6 hours sleep/night Works as a school bus driver

5. Assessment? Next steps? Any special considerations in this patient?

6. 10/2012 sleep study

7. Sleep study results 10/2012 TIB 424 min TST 344 min WASO 67 min Sleep efficiency 81% Sleep latency 11 mins, REM latency 17.5 mins Sleep stages: 4.1% N1, 70.5% N2, 0% N3, 25.4% REM Position: 65 min supine, 278 min on left AHI 5.2 overall, supine 10.9, REM 16.5, supine REM 57 Sat >90% entire study

8. Impression? Next steps?

9. PSG on CPAP/MSLT performed

13. PSG/MSLT results PSG: TST 382 mins, efficiency 83%, CPAP titrated from 6cm to 8cm. AHI 0. MSLT – Nap 1: SL 1 min, REM latency 11 min – Nap 2: SL 1 min, no REM periods – Nap 3, SL 1 min, no REM periods – Nap 4: SL 4 min, no REM periods – Nap 5: SL 1 min, REM latency 5 min Mean SL: 1.8 min, 2 SOREMs

14. Diagnosis? Treatment?

15. Narcolepsy #2 cause of daytime sleepiness (#1 = OSA) Onset typically teens and early 20’s, but can be after age 40 NL with and without cataplexy Pathology of NL + cataplexy (~70%): loss of neurons that produce orexin (a.k.a. hypocretin) – Wake-promoting – Stabilize wake/sleep – Inhibit REM NL without cataplexy less well-understood – Possibly less extensive loss of orexin

16. Symptoms of narcolepsy EDS Fragmented sleep REM-related phenomena intrude into wakefulness – (Cataplexy) – Hypnagogic hallucinations – Sleep paralysis

17. Multiple Sleep Latency Test PSG the night before 5 opportunities to nap, every 2 hours – 20 minutes to fall asleep – If fall asleep, allow 15 minutes of sleep Data obtained: – Number of naps in which sleep is obtained – Mean sleep latency If no sleep, 20 minutes for that nap – Number of SOREMs

18. Diagnosis of Narcolepsy EDS + cataplexy Narcolepsy without cataplexy – definitive diagnosis – Mean SL < 8 mins – ≥ 2 SOREMs

19. Treatment of Narcolepsy Wake-promoting agents – Modafinil/armodafinil (provigil/nuvigil) Likely increase dopa signaling – Amphetamines e.g Methylphenidate REM-suppressing drugs – Increase norepi and serotonin Venlafaxine Fluoxetine Tricyclics – Sodium oxybate at bedtime (analog of GHB, GABA analog)