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OVERVIEW OF SLEEP DISORDERS
SLEEP MEDICINE……60 YEARS OF PROGRESS
More has been learned about sleep in the last 60 years than in the past 6000 years
Mansoor Ahmed. MD, FACCP, FABSMMedical Director, Cleveland Sleep & Research CenterAssistant Professor of MedicineCase Western Reserve UniversityFellow American Academy of Sleep Medicine
History of Sleep Medicine…1953 to PresentFrom Basement To Congress to Wall Street
Until 1975, Sleep Medicine was deemed experimental ,1995 Canada followed
4 Mile Stones : 1: REM Sleep 2: PSG 3 : Circadian Biology 4: OSA
1964: Stanford Narcolepsy Center (C Dement Ad in SF Chronicle for Narcolepsy ..100 responded and 50 were diagnosed to have narcolepsy)1964 Association of Professional Sleep Societies (APSS) 1968: R & K Manual of Sleep Scoring 1970: Stanford Sleep Center 1975: 5 Sleep Centers (Montefiore, OH State, Baylor, U-Pittsburg, and U-Cincinnati 1975-1977: American Sleep Disorders Association, Accreditation 1978: Certification Exam and Journal of SLEEP 1990: US Congress Created National Commission on Sleep Disorders 1991: ICSD-1 , ICSD 2: 2005 1996 – At last…The AMA recognized sleep medicine as a specialtyEuropean Development: First Sleep Text Book, Human EEG, Sleep Apnea.
1963: Paris Symposium: ( Prof Fischgold) Sleep Epilepsy, Sleep Walking, Night
Terrors. 1965: Discovery Of Sleep Apnea by Gestualt ,Tassinar and Jung & Khulo
Sleep……. A Vital Sign of Human Health: Bi-Directional relationship
PTSPDInsomnia and HypersomnolencePTSD, Anxiety Mood Disorders , ADHD
Diabetes, Weight Gain, Hypothyroid
HOSA and …..Hypertension, A FibMI, Stroke, CHF
Opioids & CSAPain Threshold
Alzheimer's Disease, StrokeParkinson Disease
CFM –Pain & Sleep
Presentation Summary
General Introduction Normal sleep and why we sleep Magnitude of Sleep Disorders , Sleep Deprivation and
Public Health Relationship between sleep and other medical
specialties: Sleep Disorders : Case Presentation: PTSD
Snoring & Obstructive Sleep Apnea Circadian Rhythm Sleep Problems: Shift Work, Night Owl Syndrome,: ADD-ADHD, Jet Lag Insomnia Narcolepsy
and other Hypersomnolence Disorders Restless Leg Syndrome
Normal Sleep
Put your thoughts to sleep,do not let them cast a shadow
over the moon of your heart. Let go of thinking. ……...Rumi
Sleep is essential for physical, emotional and mental health
Functions of Sleep
We learned more about sleep functions when we don’t sleep Emotional Integration, Memory Consolidation & REM sleep Link between REM sleep and PTSD and other psychiatric
disorders ……………..From Sigmund Freud to current status
Glymphatics Glial channels carrying CSF expand by 60% during sleep Clean-up of any unwanted substances/ by products 2X more
efficient Implications in Alzheimer’s disease, stroke and dementia Shift-workers pre-disposition to neurological disorders
Medication and Sleep• Hypnotics and sedatives (benzo and non-
benzo • OCD insomnia medications
• Stimulants: Caffeine, Ritalin, Modafinil)
• Adverse effects of commonly used medicine on sleep & Breathing :
• Opioids: Center Sleep Apnea, Respiratory arrest
• beta blockers: Melatonin and Insomnia• Alcohol: Most commonly used hypnotic ,
adverse effect on sleep• Caffeine: The most commonly used stimulant, effect on sleep and alertness.
Normal Sleep
1 2 3 5 6 7 84
1REM
Awake
234
Hours
Rapid eye movement (REM) sleep• 20% to 25% of total sleep time• Active mind and Motor Paralysis• Intellectual Function• Sexual Functionality
Non–rapid eye movement (NREM)
Stage I Transition to sleep5% of total sleep Stage 2 50% of total sleep timeStages 3 and 4 Slow-wave sleep 10% to 20% of total sleep time
• Growth Hormone• Age and delta sleep
Historical PerspectiveGreeks: Hypnos &Thanatos1929: Human EEG Alpha Waves (Hansberger)1953: REM Sleep (Asrenski, Klietman and Dement)1968: Sleep Stages Scoring Rules ( R&K) 1965: OSA Clinical Studies (Gastaut)1970: Stanford First Sleep Clinic ( Dement)1982: CPAP (John Remmer ,Sullivan)
Magnitude of the Sleep Disorders
Underserved & Under-recognized Discipline50-60 million American suffer from 80 identified sleep disorders
Sleep and Cardio-Vascular Disorders 51% of CHF patients has underlying sleep-breathing disorder OSA is an independent risk factor for hypertension. 30-40% patients with hypertension has OSA
Mood Disorders and Sleep, PTSD, ADHD 70% of Patients with mood disorders has sleep pathologyNeurological Conditions Sleep disturbance& fatigue are hallmark of MS, Parkinson disease,
Alzheimer's Disease, Narcolepsy, Sleep Waking DisordersSleep Deprivation Challenger Tragedy, >100,000 road accidents annuallyCircadian Rhythm Shift Work, Delayed Phase Syndrome
Sleep Public Health Challenges : Sleep Deprivation, Shift Work, Under Diagnosis of Sleep Disorders
:
Federal Crash Statistics
100,000 police-report crashes annually 1,550 fatalities (4%) 71,000 injuries $12.5 billion in monetary losses (Knipling 1995) Another 1 million crashes are linked to inattention, which increases
with fatigue (Wang 1996)
The National Highway Traffic Safety Administration estimates
Sleep Disorders
Case Presentation:
A: Snoring & Obstructive Sleep Apnea B: Circadian Rhythm Sleep Problems: Shift Work, Night Owl Syndrome Jet Lag C: Insomnia D: Narcolepsy and other Hypersomnolence Disorders E: Restless Leg Syndrome
What we are dealing with here, are two gigantic problems for our society – An epidemic of undiagnosed and untreated sleep
disorders; and pervasive sleep deprivation with all its consequences for errors, accidents, disability, damages and death“
SLEEP DISORDERS………ITS NOT ALL ABOUT SLEEP APNEA
47 Year female, history of depression, anxiety, history noted for childhood trauma, subsequent spousal abuse, alcohol abuse; History of Chronic Fibromyalgia referred by pain specialist for snoring and OSA evaluation :
History of Sleep initiation and Sleep Maintenance Insomnia, uncomfortable sensation in legs, night mares, teetth Clenching frequent nocturnal awakening, non-restorative sleep., Wake up tired, severe day-time sleepiness, cataplexy-sleep paralysis
Clinical Evaluations: Sleep Wakefulness history, ENT, PTSD scalesInvestigations: Sleep Diary, PSG-MSLT
Sleep Diagnosis: OSA, Restless Legs Syndrome, Chronic Insomnia
Bruxism, Narcolepsy:
Sleep and Psychiatry are inherently linked together at every level.. From disease mechanism to clinical Symptoms to outcomes
Multiple Psychiatric Pathologies with Multiple Sleep Pathologies
Obstructive Sleep Apnea
ChokingChoking
Stage 2 Sleep with Alpha Intrusions
α intrusions
Rapid Eye Movement SleepIncreased REM frequency
Periodic Limb Movement Syndrome (PLMS)
Limb Movements
Bruxism (Teeth Clenching)
Bruxism
PLMS
Central
Stage 2 Sleep with Alpha Intrusions
α intrusions
Snoring & OSA……A Trojan Horse of Sleep Medicine
Prevalence of Sleep ApneaNo sound epidemiological survey in general population using true random sample and had PSG
Wisconsin: Survey 3513-- 625 Accepted with 25% non snorers participants, age 30-60 underwent overnight PSG;
OSAS definition: AHI>5 with hyper somnolence
Ages 50-60 with RDI >15: 4% Women, 9.1% men Peak Prevalence: 4.7%, Age: 45-64 Neck Size is more correlated to severity of apnea than BMI 10% increase//Decrease in weight: 32% increase in AHI, 24% decrease Age: SHHS: 20% Men, 10% women develop SA in 5 years, 48% CHF patients have sleep Apnea, Sleep Apnea incidence is far higher in patients with resistant hypertension, A -Fib,
Diabetes
T Young, NEJM 1993; 328:1230-5
AHI >5 with Hypersomnolence
AHI> 5 alone Snorer and
non snorer
Women 2% 18.9 & 5% Men 4% 34% & 16.1%
Sleep Disordered BreathingDisease Mechanism
Narrow oropharynx but similar narrowing seen in normal Mechanism different in different patients due to factors related to control of breathingOSA worsens over the time Upper Airway Anatomy Plus Control of Breathing
1. Anatomy: Bony Structure, Soft Tissue, Obesity2. Control of Breathing : Chemo responsiveness, Negative pressure Upper Airway Muscles: Tongue, Palate, Hyoid Bone
•Control Of Breathing : Magdy Younes, John Remmer, Jerry Dempsey, Safwan Badr, Neil Cherniack, • Atul Malhotra, David White , S Javaheri
Obstructive Sleep Apnea
ChokingChoking
Night Symptoms: Loud Snoring, Choking, Frequent awakening, Restless SleepDaytime tiredness/Sleepiness, Mood-Memory, ConcentrationConsequences: Increased BP, Stroke, Diabetes,
Inhale
Exhale
Airway obstructs Airway opens
Paradoxing
Paradoxing Ends
EKG
Airflow
Thoracic effort
Abd. effort
SAO2
Effort gradually increases
Sleep-Disordered Breathing…. Disease Mechanism
Mechanism of Sleep-Apnea and Sleep Hpoventilation1) Narrow Upper Airway: Obesity, E.N.T problems, Dysmorphism2) Control of Breathing: Hormones, Cardiac Dysfunction
Apnea Hypopnea Hypoventilation
PO2 PCO2 Negative Intra-Thoracic Pressure
Arousal, Sympathetic Activation , Systemic-Pulmonary Vasoconst
Signs & Symptoms: Sleepiness, Hypertension- LV dysfunction , Corpulmonale
STOP-BANGA simple screening tool for Sleep Apnea
Snoring Do you snore loudly (louder than
talking or loud enough to be heard through closed doors)?
Tired Do you often feel tired, fatigued,
or sleepy during daytime?
Observed Has anyone observed you stop
breathing during your sleep?
Pressure Do you have or are you being
treated for high blood pressure?
BMI BMI more than 35 kg/m2
Age Age over 50 yr old?
Neck circumference Neck circumference greater than
40 cm , 15.7 inches?
Gender Gender male? High RiskSTOP: Yes to 2 or MoreSTOP BANG: Yes to 3 or more
27
Epworth Sleepiness Scale (ESS)
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation0 = would never dose; 1 = slight chance of dozing2 = moderate chance of dozing; 3 = high chance of dozing
Situation Chance of Dozing ( 0-3)
Sitting and readingWatching TVSitting, inactive in a public place (eg, a theater or a meeting)As a passenger in a car for an hour without a breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic Mitler and Miller. Behav Med.
1996;21:171.
Consequences of OSALongitudinal Findings- Sleep Health Heart Study
6441 Patients
Direct Cardiovascular Outcomes between 5 and 8.7 years Hyperextension, Stroke, CHF . Increased risk of Hypertension if higher BMI in men With cardiovascular disease larger increases in AHI
Long Term Outcomes Positive association between severity of SDB at PSG 1 and
subsequent increase in BMI Men more likely to have an increase in RDI with increase in weight
than women Both men and women had a greater increase in RDI with weight
gain than a decrease in RDI with weight loss Severe SDB showed increased risk of all-cause mortality in the 8.7
years following PSG
Evaluation & Diagnosis
1. Clinical Questions and Epworth2. Home Sleep Study3. PSG
Types of Sleep StudiesHome Sleep Testing ( HST)
Type 1 – Attended in-lab polysomnography
Type 2 – Comprehensive portable polysomnography – Minimum of 7 channels including EEG, EOG, chin EMG, ECG/HR, airflow,
respiratory effort and O2 saturation
HST: Type 3 – Modified portable sleep apnea testing – Minimum of 4 channels including ECG/HR, O2 saturation and at least 2
channels of respiratory movement or respiratory movement and airflow
Type 4 – Continuous single or dual bioparameters – For example, airflow and/or O2 saturation
Emergent OSA Therapy
Weight Loss CPAP New PAP Modalities Correction of enlarged tonsils,
Sinuses, UA surgery Oral Advancement Therapy Implantable Neuro-stimulator Provent: PEEP Mechanisms
CPAP is the most effective but compliance is the key issue
Circadian Sleep Disorders
Wake• During the day, SCN activity
promotes arousal• Maintains state of wakefulness
Sleep• At night, SCN arousal is
attenuated• Allows normal sleep to occur
SCN plays a pivotal role in maintaining wakefulness by generating an “alerting signal” that opposes the homeostatic sleep drive.
During the evening, the alerting signal is thought to be attenuated, in part via elevation in melatonin concentration during the night, allowing sleep to occur
Borbély, A., & Achermann, P. (1999). Sleep Homeostasis and Models of Sleep Regulation Journal of Biological Rhythms, 14 (6), 559-570 DOI:
Sleep Homeostasis and Models of Sleep Regulation
Circadian Rhythm Sleep Disorders (CRSD)
“The essential feature of CRSDs is a persistent or recurrent pattern of sleep disturbance due primarily to alterations in the circadian timekeeping system or a misalignment between the endogenous circadian rhythm and exogenous factors that affect the timing or duration of sleep.” – ICSD-2.
6 Distinct CRSDs are recognized in the ICSD-2: Delayed Sleep Phase Type (DSPD) Advanced Sleep Phase Type (ASPD) Irregular Sleep-Wake Phase Type (ISWR) Free-Running Type (FRD) Jet Lag Type (JLD) Shift Work Type (SWD)
Treatment- CRSD
Planned napping Timed light exposure Administration of melatonin Enhance Alertness Hypnotic medications
Insomnia
Insomnia is common and can have serious consequences, such as increased risk of depression and hypertension
Acute and chronic insomnia require different management approaches
Chronic insomnia is unlikely to spontaneously remit, and over time will be characterized by cycles of relapse and remission or persistent symptoms
Chronic insomnia is best managed using non-drug strategies and adjunctive use of medications
Insomnia
A symptom of either difficulty in falling asleep maintaining sleep or just sense of having insufficient sleep, causing an uncomfortable subjective experience, in some ways analogous to chronic pain30% general population experience insomnia Most of the patients patients with mood disorders has sleep pathology
Psychiatric disorders are the single largest cause of chronic insomnia in sleep-clinic population
Ancoli-Israel1999
Prevalence of Insomnia* in the General Adult Population
10.2
17.716.8
9
11.710
0
5
10
15
20P
erce
nt
Ford1989
Ohayon1998
Ohayon2001
Ishigooka1999
Simon1997
*Insomnia = sleep disturbance every night for two weeks or more, or similarly stringent criteria.1. Ford DE, Kamerow DB. JAMA. 1989;262:1479-1484.2. Ohayon MM, et al. Compr Psychiatry. 1998;39:185-197.3. Ohayon MM, Roth T. J Psychosom Res. 2001;51:745-755.4. Ancoli-Israel S, Roth T. Sleep. 1999;22(suppl 2):S347-S353. 5. Ishigooka J, et al. Psychiatry Clin Neurosci. 1999;53:515-522.6. Simon GE, VonKorff M. Am J Psychiatry. 1997;154:1417-1423.
Insomnia in Patients WithChronic Medical Conditions
0
10
20
30
40
50
60
Per
cent
age
of P
atie
nts
With
Inso
mni
a
Diabetes
MI
CHF
Angina
HipImpairment
BPH
ObstructiveAirway
Severe Insomnia†
Insomnia*
*Sleep disturbance “some” or “a good bit” of the time for four weeks.†Sleep disturbance “most” or “all” of the time for four weeks.MI = myocardial infarction; CHF = congestive heart failure; BPH = benign prostatic hypertrophy.Katz DA, McHorney CA. Arch Intern Med. 1998;158:1099-1107.
Insomnia…the most common sleep disorder
Insomnia Treatment
Sleep Hygiene Cognitive Behavior Therapy Pharmacotherapy
Therapeutic Agents
Sedative-hypnotics Sedating antidepressants Selective melatonin agonist and Melatonin Antihistamines Anxiolytics
Alternative and herbal medications- Valerian Root Extract
Hypnotics can be used on long term basis in Primary InsomniaExercise, CBT, Sleep Hygiene
Components of Cognitive Behavior Therapy
Stimulus control (daytime and sleeping environments) Sleep restriction Relaxation techniques (progressive relaxation, imagery training, biofeedback,
meditation, hypnosis and autogenic training) to reduce physical and mental arousal
Reduce negative perceptions about battle ground of sleep Write about worries in the evening Stopping thoughts (repeating word “the” every three sec.) Sleep hygiene education
What to do and not to Do
1. Recognize that there is a sleep problem & bring it to the attention
2. What is the nature of Sleep Problem: Insomnia, Sleep Apnea, Restless Legs, Shift Work3. Determine Circadian Phase
Diet/light snack , exercise, hot bath, relaxing techniques, Bed timing and sleep timing, prescription medications
What Not to doClock watching, thinking about next day issues, worrying
about sleep, Coffee/Smoking/Alcohol Catching-up over the week-ends
EXCESSIVE SLEEPINESS DISORDERS
Mechanistic Approach
Sleep-Wake Dysregulation
Circadian Misalignment
Sleep Disruption
•Delayed Phase Syndrome •Advanced Phase Syndrome•Shift Work Disorder•Non-24 hour Rhythm
•Narcolepsy•Idiopathic Hypersomnia•Post-Traumatic Hypersomnia•Mood Disorders
•Sleep Apnea•PLMS/Leg Movements•Sleep Walking
Narcolepsy• Characterized by excessive sleepiness + cataplexy and
other REM phenomena1. Sleep paralysis2. Hypnagogic hallucinations
• Etiology unknown
Pathology:• Genetic predisposition • Hypocretin/orexin deficiency • Autoimmune disease• Neurochemical abnormalities• Environmental triggers• Head trauma
Assessment of SleepinessBehavioral
• Facial expression, posture, yawning, myosisSubjective
• Epworth Sleepiness Scale (ESS)• Stanford Sleepiness Scale (SSS)
Objective• Multiple Sleep Latency Test (MSLT) • Polysomnography (PSG)• Actigraphy• Maintenance of Wakefulness Test (MWT)
Mitler and Miller. Behav Med. 1996;21:171.
Control N=17Narcolepsy N=57
Adapted from Mitler et al. Psychiatr Clin North Am. 1987;10:593.
Sleepiness and REM Sleep Assessed by Multiple Sleep Latency Test (MSLT)
Sleep Latency
Naps
0
Min
utes
4
8
12
16
20
13.4 ± 4
3.0 ± 2.7
1 2 3 4 5
Number of REM PeriodsRecorded in All 5 Naps
REM
per
iods
/5 n
aps
(mea
n)
0
1
2
3
4
5
0
Narcolepsy
Control
Narcolepsy Control
Narcolepsy: Traditional Management Approaches
Excessive daytime sleepiness• Structured nocturnal sleep• Naps: scheduled and PRN• Stimulants or wake promoting agents
Cataplexy• Antidepressants (TCA or SSRI)
Sleep fragmentation • Sleep hygiene• Hypnotics (limited utility)
General• Personal and family counseling• Support
Parkes. Sleep. 1994;17:S93; Mitler M et al. Sleep. 1994;17:352; Daly and Yoss. Narcolepsy. In: Handbook of clinical Neurology. Vol.15.1994;15:836; Bassetti and Aldrich. Neurol Clin. 1996;14:545; Mamelak et al. Sleep. 1986;9:285.
Restless Legs Syndrome
Key RLS Diagnostic Criteria Urge to move legs-usually accompanied by uncomfortable
sensations Temporary relief with movement Onset or worsening of symptoms at rest or inactivity, such as
lying or sitting Worsening of symptoms in the evening or at night
Other Diagnostic Considerations Positive family history of Restless Legs Syndrome Periodic limb movements during wakefulness or sleep
(PLMW or PLMS) Sleep disturbance
Uncomfortable Leg Sensations
Types of RLS
Primary RLS Genetic or Familial
Secondary RLS Iron deficiency Pregnancy End-stage renal
disease Various
polyneuropathies
Treatment: What to Expect
Treatment of underlying causes of RLS
Several prescription medications very effective
Effectiveness of medication varies for each person
Worsening of symptoms
Key Messages Sleep is critical for physical and mental health, and emotional restoration Sleep loss / inadequate or disturbed sleep compromises all treatments and therapies Sleep Function: Emotional Integration, Memory Consolidation, Clean-up of unwanted
substances in the brain 50-60 million Americans suffer from chronic sleep disorders, with most common ones
being: chronic insomnia; obstructive sleep apnea; restless legs syndrome, and disorders of severe sleepiness including shift work syndrome and narcolepsy
despite the fact that sleep disorders are not difficult to diagnose, a majority of sleep disorder sufferers remain undiagnosed
A greater need for implementing screening tools: STOP-BANG for sleep apnea; Epworth Sleepiness Scale for excessive sleepiness
Sleep and Sleep disturbances play a central role in the mechanism of psychiatric disorders such as PTSD, depression and anxiety. Evaluation of sleep and correction of disturbed sleep should be CRTICAL part of any treatment
Sleep disorders are predictive of Parkinson's and Alzheimer's disease Sleep disorders can be effectively managed and treated, with significant improvement in
quality of life Importance of Public Health Awareness…….Sleep Education
Cleveland Sleep Centera comprehensive approachPatient Care• Clinic• Diagnostic Sleep Laboratory• Dental Sleep Medicine• Respiratory Therapy
Education• Public Education• Preceptorship• Physician Education
Research• In-House • Pharmaceutical
Acknowledgments
Fruit Fly Narcoleptic Dog
Rat
Acknowledgments
Parents Mentors: Magdy Younes, J Remmers, Nick Anthonison, M
Kryger Patients Colleagues: Rozina Aamir, Zahra Jishi, Martin Scharf Maryam Ahmed , Abdulrazzak Dardari Staff, Alithea, Sandy, Noel Cyrill, Nancy, Eden
Nazima and Shazeena