Sleep & Women: Sex Specific Factors, Considerations and Management Strategies

1. Sleep & Women: Sex Specific Factors, Considerations and Management Strategies

2. Charlene E. Gamaldo, MD, FAASM Associate Professor Johns Hopkins University

3. Rachel Marie E. Salas, MD Assistant Professor Johns Hopkins University

4. Identify basic Sleep Physiology concepts • Describe common sleep disorders for women • Understand treatment approaches to common sleep disorders • Review “Take Home Tips” to improve sleep health Objectives

5. Basic Sleep Physiology Concepts

6. Drive for sleep >drive for food, water, and freedom from pain • Microsleeps • Sleep deprivation causes death in experimental animals • Sleep debt must eventually be repaid Basic Sleep Concepts

7. 8 60 18 36 50 80 Who has time for sleep?

8. Homeostatic Drive • Desire to sleep which increases with prolonged wakefulness • Homeostatic drive decreases with napping • Circadian Rhythm • Natural sleep-wake cycle controlled by “biological clock” • Heavily influenced by light/dark Sleep-Wake Cycle

9. 100% Siesta  SleepPropensity Sleep-Wake Cycle Regulation 0% 12:00PM 6:00PM 12:00AM 6:00AM 6:00 AM 24-hourPeriod

10. Women and Sleep

11. Methodology • 25 minute telephone survey, 9/12/06 and 10/28/06 • 1,003 American women • 18 – 64 years old • Unique element: Oversampled pregnant and post partum women

12. Poor health is linked to sleep problems • Of women who are in fair to poor health: 66% 26% 46% 54% Sleep in America Poll 2007:Sleep, Health and Women……key findings 40%

13. Factors Related to Our Understanding of an Individual’s Sleep Experience Biological Factors Hormones Genetic Factors Psychological Factors Expectations Stress Responses Mood Socio-cultural Factors Reporting to Health Care Providers Child Rearing Work

14. Women & Sleep Disorders:Treatments

15. Daytime Symptoms • Fatigue/ malaise • Attention, concentration, or memory impairment • Impaired social, family, vocational, or academic performance • Mood disturbance/irritability • Behavioral problems (hyperactivity, impulsivity, aggression) • Reduced motivation/energy/initiative • Concerns about or dissatisfaction with sleep • Proneness for errors/accidents • Daytime sleepiness • Sleep Complaints • Difficulty initiating sleep • Difficulty maintaining sleep • Waking up earlier than desired • Resistance to going to bed on appropriate schedule • Difficulty sleeping without parent or caregiver intervention Insomnia Diagnosis: ICSD-3

16. Three diagnostic categories of insomnia: • Chronic insomnia • Criteria A and B > 3 months • Short-term insomnia • Criteria A and B < 3 months • Other insomnia disorders (as transition diagnosis will be used sparingly) Insomnia Disorder: ICSD-3

17. No distinction between primary and secondary • No distinction between adult and peds subclassification type • No inclusion of “non restorative sleep” as insomnia symptom criteria Key Changes to ICSD-3

18. OSA 39% to 55% RLS 68.6% They can also have other primary sleep disorders, such as sleep apnea, RLS, CRD, and narcolepsy Factors that Impact on Sleep:Primary Sleep Disorder (Chronic vs. Acute Insomnia) DSPD 5-10% of insomnia patients 7-16% of adolescents Shift Work Disorder  20.1% Narcolepsy  33% to 81% 10 % of general population  Insomnia

19. Health Sequalae of Chronic Insomnia In the short term, • A slower metabolism and resulting gain weight • Depression and anxiety • Decreased short term memory • Poor performance in new or complex tasks • Decreased immune function • Increased skin problems

20. In the long term, Health Sequalae of Chronic Insomnia Higher chance of developing diseases Highermortality rate

21. Increased Prevalence of Medical Disorders in those with Insomnia p values are for Odds Ratios adjusted for depression, anxiety, and sleep disorder symptoms. From a community-based population of 772 men and women, aged 20 to 98 years old.

22. 95% CI: 1.42-2.70 95% CI: 1.45-2.45 42.3 40.1 30.6 30.7 Insomnia may be a Predictor of Hypertension n=4602 n=4157 n=192 N=286

23. Insomnia with Objective Short Sleep Duration is Associated with a Risk for Hypertension Vgontzas 2009

24. Insomnia with Objective Short Sleep Duration is Associated with a High Risk for Type 2 Diabetes Vgontzas 2009

25. Autonomic & Central Dysregulation of Arousal Networks…… Insomnia Patients Asleep Healthy Subjects Awake Nofzinger 2004

26. Behavioral Techniques on the Horizon…….

27. Expanding CBT-I Provider Net • Primary care NPs with specialized CBT-I training and ongoing supervision sustained 6 month objective & subjective improvement (Espie 2007) • Master’s-level CBT-I trained practitioners improved outcomes of insomniacs with chronic pain (Jungquist 2010)

28. Alternative modes of delivering CBT-I • Telephone • Self-help method • Online programs

30. RLS/WED: Essential Criteria Met 1. U= urge to move the legs, usually associate with unpleasant leg sensations 2. R = rest induces symptoms 3. G = getting active (physically and mentally) brings relief 4. E = evening and night make symptoms worse 5. R = Rule out mimics

31. About 20% of pregnant women experience RLS • Parity increases the risk: 1 child OR 1.98; 3 children OR 3.57 (Berger) • Iron loss through menstruation may be a factor RLS is a “woman’s” disease, and increases in prevalence with age • RLS Consequences: • Sleep disturbance • Daytime sleepiness • Poor memory and concentration • Increased irritability • Decreased motivation • Depression Women and RLS (WED): Consequences

32. HOW……do you address insomnia complaints?

33. Antihypertensives: B-blockers, diuretics,clonidine, methyldopa Central nervous system stimulants: Sympathomimetics, caffeine, nicotine, amphetamines, ephedrine Anticholinergics Decongestants: pseudoephedrine Corticosteroids Stimulant laxative • Herbal remedies Antidepressants: Bupropion, SSRIs, venlafaxine Alcohol Factors that Impact Sleep: Medications and Other Substances Histamines, H2 blockers: Cimetidine Bronchodilators: Theophylline Anti-Parkinsonian agents: Levodopa

34. Neurotransmitters Involved in Sleep and Arousal Pharmacological Targets for Insomnia Treatments Gulyani 2012

35. FDA-Approved Drugs for Insomnia

36. FDA-Approved Drugs for Insomnia

37. Zolpidem Various Formulations: Sublingual Short & Long acting pills Nasal sprays Controversies….. Use in Elderly New FDA Warnings January, 2013 FDA requires lowering the starting dosage of Zolpidem drugs (Brand-named Ambien, Edluar and Zolpimist) due to lower metabolic clearance in women Zolpimist Oral Spray Approved Borden 2011 CBS News 2013

38. New Drugs Under Clinical Trials

39. Cognitive Behavioral Therapy for Insomnia (CBT-I)

40. Good Sleep Practices

41. During the day 1. Get exposure to bright light and participate in activity 2. Socialize 3. Optimize the timing of medications to optimize sleep and wakefulness drugs at night, alerting agents in the day 4. Avoid caffeine and alcohol 5. Establish a bedtime wind-down regimen Good Sleep Practices

42. 19 (4 males) primary insomnia (DSM-IV): average age 45 years • 6 month moderate exercise protocol: 3 days/week for 50 minutes on lab treadmill • Results: Significant improvements in sleep quality (PSG, sleep diary) and mood • (POMS questionnaire) • No time of day effect for morning vs. late-afternoon exercise “The Skinny” on Exercise and Sleep Passos 2011

43. During the night 1. Make the bedroom for 3 S’s ONLY (Sleep, Sick, or Sex) 2. Keep the bedroom relatively dark and quiet (a low level night light may help) 3. A low level constant white noise can help mask outside noise 4. Allow the body temperature to drop (take a hot shower at night; keep a cool environment in the bedroom) 5. Make sure the bed is comfortable 6. Change or clean pillows, sheets, and comforters on a regular basis Good Sleep Practices

45. Women DO Have Unique Characteristics that put US at risk for sleep complaints • Provide 7-9 hours of opportunity • Sleep needs to be accepted as Essential • POOR Sleep should not be ACCEPTED as a “The WAY IT GOES” • In many cases these ARE TREATABLE with Changes in Behaviors or Treatment by Specialist Final 5 Take Home Tips