Sleep: The Golden Chain That Ties Health and Our Bodies Together (A Review of Sleep Disorders)

1. Sleep:The Golden Chain That Ties Health and Our Bodies Together(A Review of Sleep Disorders) Academy Of Medicine Clinical Day, February 24, 2012 Elliott K. Lee MD, FRCP(C), D. ABPN, D. ABPN Addiction Psychiatry, D. ABSM Assistant Professor, University of Ottawa Faculty of Medicine Sleep Specialist, Royal Ottawa Mental Health Center Sleep Disorders Clinic

2. Objectives • Describe the importance of sleep and impact of sleep disorders in the community. • Understand common sleep disorders and how they can be assessed and treated. 

3. Outline • Review sleep architecture, and how sleep is controlled. • Review insomnia and excessive daytime sleepiness, and their causes

5. Sleep Hypnogram

6. Insomnia Excessive Daytime Sleepiness

7. Insomnia • Affects 3.3 million Canadians (1/7) according to Statistics Canada (2002) • Especially:- Middle aged (45-64)- Widowed- Minimal education- Obese- Women > men

8. Treating Insomnia:Personal Sleep Hygiene • Maintain a regular wake/sleep schedule, possibly add mild sleep restriction. • Refrain from taking naps. • Exercise - but not within 3 hours of bedtime. • Establish a relaxing routine before bedtime. • Use the bedroom only for sleep activities. • Avoid clock watching • Set environment (light, noise, temperature)at comfortable levels. • Avoid caffeine after mid-afternoon.

9. Medication options • Zopiclone (Imovane) • Trazodone (Desyrel) • Other options:- Melatonin- Tricyclic Antidepressants- Benzodiazepines- Mirtazapine (Remeron)- Atypical Antipsychotics

10. Sleep Latency Eszopiclone Sleep latency from ave = 70 min Placebo = 45 minEszopiclone = 27.3 min Total Sleep Time Total Sleep Time Placebo = 330 minEszopiclone = 390 min Eszopiclone users had improved quality of life, and no reported incidence of tolerance or withdrawal Walsh et al, Sleep, 2007

11. Obstructive Sleep Apnea (OSA) • Pauses in breathing > 10 seconds in length • Respiratory Disturbance Index (RDI): >5 hr = significant • Prevalence – up to 25% of men, and 9% of women • Key diagnostic questions:- Do you feel satisfied with the quality of your sleep?- Does your partner complain that you snore?

12. Obstructive Sleep Apnea Syndrome Symptoms • Snoring >80%*up to ½ of pts may sleep separately from partners • Apneic episodes (partner) 75% • AM Dry Mouth 74% • Restless Sleep/ AM H/A 50% • Sensation of choking 18-31% • Nighttime bathroom visits 28% Kryger, Roth and Dement, Principles and Practice of Sleep Medicine, 2005 p. 1043

13. OBSTRUCTIVE SLEEP APNEA (OSA) • Causes ▪ Narrow Upper Airway ▪ Elevated BMI ▪ Family Hx • Exacerbated by: ▪ Medications – muscle relaxants, sedatives ▪ Alcohol Consumption ▪ Supine sleep ▪ REM sleep ▪ **Supine + REM sleep

15. Consequences of OSA

16. Odds Ratio – AHI to Hypertension Peppard PE et al. N Eng J Med, 2000; 342(19): 1378-84

17. Change in BP with use of CPAP (9 weeks) Becker HF et al. Circulation, 2003; 107(1):68-73 Odds Ratio – AHI to Hypertension Peppard PE et al. N Eng J Med, 2000; 342(19): 1378-84

18. Traditional View CardiovascularDisease Obesity Insulin Resistance Hypertension Low Grade Inflammation Ischemic heart diseases ↑ Oxidative Stress Arrhythmias CV stroke/TIA Endothelial Dysfunction

19. Atherosclerosis and Hypoxemia? • Savransky and colleagues studied mice – divided into 4 groups: *Savransky V et al Am J Respir Crit Care Med, 2007 Regular diet High Cholesterol diet

20. Atherosclerosis and Hypoxemia? • Which ones developed atherosclerosis? *Savransky V et al Am J Respir Crit Care Med, 2007 0 0 Regular diet High Cholesterol diet 0 9

21. Atherosclerosis and Hypoxemia? • Sections of aorta from the mice: *Savransky V et al Am J Respir Crit Care Med, 2007 Regular diet High Cholesterol diet

22. Modern View (?) OSA ↑ Oxidative Stress ↑ Sympathetic Activity Independent additive risk factor Mechanical upper airway obstruction Insulin Resistance Intermittent Hypoxemia Low grade Inflammation CardiovascularDisease Obesity Insulin Resistance Hypertension Low Grade Inflammation Ischemic heart diseases ↑ Oxidative Stress Arrhythmias CV stroke/TIA Endothelial Dysfunction

23. Fatal CV events and OSA Months Marin JM et al. Lancet, 2005

24. Nonfatal CV events and OSA Marin JM et al. Lancet, 2005

25. Sleep and Mental Illness • OSA can exacerbate mental illness:-Aggression /cognition in schizophrenia- Depression- Nightmares in PTSD- Cognitive dysfunction in dementias- Relapse to substance abuse Psychiatricillness Sleep Lee EK and Douglass AB. Can J Psychiatry, 2010; 55(7): 403-12

26. TREATMENTS FOR OSA • **CPAP – Continuous Positive Airway Pressure • **Weight Loss - ↓ BMI = ↓ RDI • Avoid Alcohol Consumption • Avoid Sedative Medications • “Snoreball” Technique / Positional Therapy • Oral Appliance • Upper Airway Surgery • Tonsillectomy (pediatrics) • Uvulopalatopharyngoplasty (UPPP) • Maxillomandibular advancement • Tracheostomy

27. CPAP for OSA

29. Alcohol on Breathing Snoring (baseline) 53 yr old male, “social drinker” Snoring, 2nd night, drank EtOH 6-9 PM, about 8-10 drinks Issa and Sullivan, J Neurol Neurosurg Psychiatr, 1982; 45:353-9

30. Oral Appliances Klearway- Great Lakes Orthodontics Silencer- Johns Dental Labs

31. Surgery (UPPP)

32. Restless Legs Syndrome

33. Restless Legs Syndrome • NB- symptoms WHILE AWAKE • “URGE” U – rge to move legs R – est – symptoms worsened at rest G – ets better with movement E – vening – symptoms worse in evening • Often associated with periodic limb movements (PLMs), WHILE ASLEEP

34. Epidemiology – RLS • Affects 5-15% of the population • Mean age – 27- 41 years old- prevalence increases with age- age of onset varies widely (children – elderly) • Up to 2.5X more common in women

35. Restless Leg Syndrome + PLMD • Thought to be related to same problem – dopamine deficiency in the brain • May be exacerbated by caffeine, nicotine, alcohol, or iron deficiency • Mainstay of treatment- Dopamine replacement therapy - levodopa, pramipexole, ropinirole- Other meds may also help - neurontin, benzodiazepines, opioids

36. Narcolepsy • A pathologic disorder of sleepiness during the day – key symptom – sleepiness • May have insomnia at nighttime • Affects about 1/2000 people • Very underdiagnosed; difficult to recognize • 80% may have cataplexy, a REM sleep intrusion phenomenon on wakefulness • Related to cerebrospinal fluid deficiency of hypocretin (orexin)

37. Narcolepsy Treatment • SLEEPINESS: • Stimulantsd-amphetamine (Dexedrine), methylphenidate (Ritalin)Novel - modafinil (Alertec / Provigil). - armodafinil • CATAPLEXY: • Antidepressants – e.g. venlafaxine • Sodium oxybate (Xyrem)

38. Summary • Sleep has a distinct architecture and is normally regulated by a complex set of environmental, biological and social influences • Insomnia and excessive daytime sleepiness are common issues among patients • If sleep is problematic, assessment for an underlying sleep disorder such as obstructive sleep apnea, restless legs syndrome, narcolepsy or others is important, as effective treatments are available for these conditions

39. Screening Questions For Symptoms Of Poor Sleep • Do you feel satisfied with the quality of your sleep? • Does you partner complain about your sleep? • Do you have difficulties falling or staying asleep? • Do you have problems with sleepiness during the day?