The Tired Student: Fatigue and Sleep Disorders in College Students

1. The Tired Student…Fatigue and Sleep Disorders in college students. David S. Reitman, MD, MBA George Washington University Washington, DC

2. Objectives • Define “fatigue” and “sleep disorder.” • Understand Sleep Physiology as an active biological process • Review the clinical workup of a fatigued/sleep disordered student • Use cases to discuss major diagnoses and treatment modalities

3. What is “Fatigue” Three Main types: • Weakness • Inability to initiate activity • Decreased ability to maintain activity • Mental Fatigue • Problems with concentration, memory, emotions

4. Epidemiology of Fatigue • Prevalence: ~7% of Adults • 7 million office visits annually • Chronic Fatigue (not CFS): • Medical or Psych Dx cause fatigue in 67% • Of patients with fatigue 60-80% have psych diagnosis.

5. Infection Inflammatory Sleep disorders Neoplasm Nutritional Endocrine Cardiovascular Neurologic Psychiatric Disorders Stress Substance abuse Medications Caffeine Causes of Fatigue and sleep problems in college students (broad categories)

6. Role of the College Health Professional Physiologic / Psychologic Disorder vs Environmental Disorder Vs Sleep Disorder

7. Sleep in College Students • Recommendations (National Sleep Foundation): 8hr 30m – 9hr 15min • The reality (Lund et al, 2009): 7.02 hrs mean sleep time (25% of students: <6.5 hrs) (only 29% get 8+ hrs)

8. Sleep times and Rise times National Sleep Foundation 2006

9. Sleep Bedtimes in College Students • Vela-Bueno et al 2008

10. How does this affect College Students? Perceived sleep debt= (Desired sleep) – (Actual Sleep obtained) Vela-Bueno, 2007

11. Back to the basics…… Sleep Physiology 101

12. 3 Principle Sleep Regulators • Circadian Rhythms • Homeostatic Drive • Ultradian Rhythms

13. Circadian Rhythm

14. Circadian Rhythms • Allow organisms to anticipate a 24 hour light-dark cycle. • Human Circadian rhythm is 24.2 hrs. • Requires adjustment • Accounts for sleep differences • Infants/Toddlers • Children • Adolescents • Balanced by Homeostatic Drive

15. Homeostatic Sleep Drive • Sleep drive reflects time period of wakefulness

16. Ultradian Rhythms • Occur within the context of sleep. • Common Sleep Myths • “It’s a time for the brain to rest” NO!!!!! • Very active process • Brain extremely involved • “Sleep is a static process once you fall asleep” NO!!!! • Sleep is a dynamic process • REM vs NREM

17. Sleep Architecture • Sleep Cycles 90 min-2 hrs • Normal Sleep must follow these cycles

18. NREM Sleep • Stage 1: • Transition to sleep from wakefulness • 2-5% of sleep time in young adults • Stage 2: • Slowing frequency on EEG • 40-50% of sleep time in young adults

19. NREM Sleep • Stage 3 / Stage 4 • Deepest sleep. Hardest to wake. • May serve a restorative function • Eg. Energy levels, wakefulness • 20% sleep time in young adults

20. REM Sleep Probably functions for Memory Consolidation Key Features: • Rapid Eye movements 2. Active, fast frequency EEG • (similar to wakefulness) 3. Virtual Paralysis of voluntary muscles (except EOMs)

21. REM Sleep Characteristics (ANS) • Predominantly Vagal • Sympathetic Bursts • Associated with body-wide sympathetic events •  BP •  HR •  RR • Can be accompanied by long asystoles

22. Putting it all together

23. Question… • Overnight “working?”

24. Back to the clinic….

25. Diagnosing the problem: History • Define “fatigue” • Frequency of Fatigue? • Onset? • Abrupt • Gradual • Related to illness • Daily Pattern • Factors that alleviate or worsen • Impact on Daily life • History of Medical issues • History of Psych • Depression • Anxiety • Bipolar • Somatoform d/o’s • Recent stresses or changes • Medications • Drug/EtOH use • Exercise

26. Diagnosis- Physical Examination • General appearance • Agitation? • Body Habitus • Eye Exopthalmos • Thyroid exam • Oropharyngeal exam • Cardio-respiratory examination • Neurologic evaluation • Cognitive abilities • Tremors

27. Lab Studies Tailor Studies to your suspicions…. CBC ESR Comprehensive Metabolic Panel TSH CK (if muscle weakness suspected) Other ID workup if indicated

28. Case #1: Greg • 19 y.o. College Sophomore. • Complains about “Insomnia.” • Falls asleep at 3 a.m. • Gets up at 8 a.m. for a 9 a.m. class • Drinks coffee to stay awake • 2-3 hour nap after lunch • Weekends- out with friends until 3 a.m., then sleeps until 1 p.m. Diagonosis????

29. Circadian Rhythm Disorders • Delayed sleep phase syndrome (DSPS) • Disconnect between sleep times and societal demands • Seen in 17% College Students • Mean age 20 yrs • Different from “Motivated Sleep Phase Delay” (non-volitional) • Sleep Architecture? Maintained

30. Delayed Sleep Phase Syndrome (DSPS)

31. Delayed Sleep Phase Syndrome –Treatment • Treatments • Chronotherapy • Gradual (2 hour increments) • Dramatic (24 hour) • Bright Light therapy • Melatonin • ? Long term safety • Give 0.3mg-3 mg 5-7 hours prior to desired sleep onset

32. Sleep Hygiene • Caffeine Intake • Pre-bedtime activity • Studying • Computer / TV • Exercise (early) • Weekend Sleep patterns • Eating before bed • EtOH • Stress Management • Naps…

33. Napping…The good, the bad, and the sleepy

34. Case #2: Peter “My girlfriend won’t sleep with me…because I snore!” 20 yo. Average build (not overweight) No significant health problems in past States that he tries to get 8-9 hours of sleep/night. Rarely naps. But, complains about “feeling tired”

35. <8: Normal • 8-11 mild sleepiness • 12-15 moderate sleepiness • 15-18 severe sleepiness

36. Case#2 : What data do you want to know? Polysomnography

37. Obstructive Sleep Apnea Syndrome - Anatomy Compromised upper airway patency REM sleep Atonia!

38. Obstructive Sleep Apnea Syndrome • Risks: • Age 18+ • African Americans • Obesity • Craniofacial abnormalities • Current smokers (3X) • Nasal Congestion (2X) • Snorers (7X)

39. Obstructive sleep Apnea Manifestations • Short Term • Daytime Sleepiness • Poor Concentration • Increased errors and accidents • Headaches and somatic complaints • Long Term • Hypertension • Pulmonary Htn. • Cor Pulmonale • Sudden Cardiac arrythmia

40. OSA Treatments • Behavioral • Weight Loss • Sleep Position • EtOH Avoidance • Continuous Positive Airway Pressure (CPAP)

41. OSA Treatments • Oral Appliance • Surgical Repair

42. Case #3: Marsha

43. Case #3: Marsha • 19 y.o….“Tired all the time.” • Needs a note to take two incompletes. • Fatigue for the last 5 months • Sleep doesn’t help • Tried to exerciseslept 18 hours! • Started last fall when she had H1N1. • No fever, but “still feels like she has the flu.” • Myalgias intermittently • Sore throat

44. Case #3: Marsha • Physical Exam • Tired appearing, otherwise unremarkable • Labs: • CBC 8.6>42/13<210 • Comp Met Panel – all WNL • ESR 8 • TSH/T4 all WNL • EBV IgG/IgM – non-reactive • CMV IgG/IgM – non-reactive

45. Case #3: Marsha • Other notes: • Always a Straight-A student. • Supportive parents. • No history of depression or other mental health issues • But, very frustrated that she can’t stay awake to succeed in classes. • Starts to cry… “I need to get at least an A-minus in my classes or I will be a “failure!”

46. Thoughts? Diagnoses???

47. Chronic Fatigue Syndrome (CFS) • CDC Definition: • Unexplained, persistent fatigue that is not due to ongoing exertion, is not substantially relieved by rest, is of new onset (not lifelong) and results in a significant reduction in previous levels of activity. • Four or more of the following symptoms are present for six months or more: • Impaired memory or concentration • Postexertional malaise (extreme, prolonged exhaustion and exacerbation of symptoms following physical or mental exertion) • Unrefreshing sleep • Muscle pain • Multi-joint pain without swelling or redness adults • Headaches of a new type or severity • Sore throat that’s frequent or recurring • Tender cervical or axillary lymph nodes

48. Is CFS a real diagnosis? • No Lab Tests or markers • Similar symptoms to other illnesses • Patient’s frequently do not look sick • Symptoms vary by type, number and severity • Symptoms vary within a given individual

49. Infectious? Immune dysfunction? Lower levels of NK cells, immune complexes, autoantibodies. (May indicate inflammatory process) Elevated titers of antiviral antibodies against measles, HHV-6, EBV, CMV Endocrine? Non-specific cortisol depressions. Neurally-mediated hypotension? Tilt table testing abnormal in 1 series Resolution with fludrocortisone, atenolol Depression? Sleep Dysruption? Lower sleep times, efficiency and REM sleep Proposed Etiologies for CFS

50. Treatment of CFS- What has (not) been shown to work? • Medications • Antidepressants • small studies, conflicting • Methylphenidate • Small studies, ?improved concentration/fatigue • Steroids • Conflicting studies • IVIG • Small, conflicting studies • Galantamine (ACTase inhibitor) • No benefits • Acyclovir • No benefits • Others • Amantadine, doxycycline, Mg, exclusion diets • No benefits noted