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Overview Of Sleep Disorders Sleep Medicine……60 years of progress

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1 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, FABSM Medical Director, Cleveland Sleep & Research Center Assistant Professor of Medicine Case Western Reserve University Fellow American Academy of Sleep Medicine

2 History of Sleep Medicine…1953 to Present From 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 : 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 specialty European 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

3 Sleep……. A Vital Sign of Human Health: Bi-Directional relationship
Diabetes, Weight Gain, Hypothyroid Insomnia and Hypersomnolence PTSD, Anxiety Mood Disorders , ADHD OSA and ….. Hypertension, A Fib MI, Stroke, CHF PTSPD H Opioids & CSA Pain Threshold CFM –Pain & Sleep Alzheimer's Disease, Stroke Parkinson Disease

4 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

5 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

6 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

7 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.

8 Normal Sleep 1 2 3 5 6 7 8 4 REM Awake 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 time Stages 3 and 4 Slow-wave sleep 10% to 20% of total sleep time Growth Hormone Age and delta sleep Historical Perspective Greeks: Hypnos &Thanatos 1929: 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)

9 Magnitude of the Sleep Disorders
Underserved & Under-recognized Discipline 50-60 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 pathology Neurological Conditions Sleep disturbance& fatigue are hallmark of MS, Parkinson disease, Alzheimer's Disease, Narcolepsy, Sleep Waking Disorders Sleep Deprivation Challenger Tragedy, >100,000 road accidents annually Circadian Rhythm Shift Work, Delayed Phase Syndrome

10 Sleep Public Health Challenges : Sleep Deprivation, Shift Work, Under Diagnosis of Sleep Disorders :

11 Federal Crash Statistics
The National Highway Traffic Safety Administration estimates 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)

12 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“

13 Sleep Disorders………Its Not all about sleep apnea
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 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 scales Investigations: Sleep Diary, PSG-MSLT Sleep Diagnosis: OSA, Restless Legs Syndrome, Chronic Insomnia Bruxism, Narcolepsy:

14 Obstructive Sleep Apnea
Choking Choking

15 Stage 2 Sleep with Alpha Intrusions

16 Rapid Eye Movement Sleep
Increased REM frequency

17 Periodic Limb Movement Syndrome (PLMS)

18 Bruxism (Teeth Clenching)
Central PLMS

19 Stage 2 Sleep with Alpha Intrusions

20 Snoring & OSA……A Trojan Horse of Sleep Medicine

21 AHI >5 with Hypersomnolence AHI> 5 alone Snorer and
Prevalence of Sleep Apnea No sound epidemiological survey in general population using true random sample and had PSG Wisconsin: Survey  625 Accepted with 25% non snorers participants, age underwent overnight PSG; OSAS definition: AHI>5 with hyper somnolence Ages 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%

22 Sleep Disordered Breathing Disease Mechanism
Narrow oropharynx but similar narrowing seen in normal Mechanism different in different patients due to factors related to control of breathing OSA worsens over the time Upper Airway Anatomy Plus Control of Breathing Anatomy: Bony Structure, Soft Tissue, Obesity 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

23 Obstructive Sleep Apnea
Choking Choking

24 EKG Airflow Thoracic effort Abd. effort SAO2 Exhale Airway obstructs Airway opens Effort gradually increases Inhale Paradoxing Paradoxing Ends Night Symptoms: Loud Snoring, Choking, Frequent awakening, Restless Sleep Daytime tiredness/Sleepiness, Mood-Memory, Concentration Consequences: Increased BP, Stroke, Diabetes,

25 Sleep-Disordered Breathing…. Disease Mechanism
Mechanism of Sleep-Apnea and Sleep Hpoventilation 1) Narrow Upper Airway: Obesity, E.N.T problems, Dysmorphism 2) Control of Breathing: Hormones, Cardiac Dysfunction Apnea Hypopnea Hypoventilation PO PCO Negative Intra-Thoracic Pressure Arousal, Sympathetic Activation , Systemic-Pulmonary Vasoconst Signs & Symptoms: Sleepiness, Hypertension- LV dysfunction , Corpulmonale

26 STOP-BANG A simple screening tool for Sleep Apnea
Snoring BMI Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? BMI more than 35 kg/m2 Age Age over 50 yr old? Tired Neck circumference Do you often feel tired, fatigued, or sleepy during daytime? Neck circumference greater than 40 cm , 15.7 inches? Observed Gender Has anyone observed you stop breathing during your sleep? Gender male? Pressure High Risk STOP: Yes to 2 or More Do you have or are you being treated for high blood pressure? STOP 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 situation 0 = would never dose; 1 = slight chance of dozing 2 = moderate chance of dozing; 3 = high chance of dozing Situation Chance of Dozing ( 0-3) Sitting and reading Watching TV Sitting, inactive in a public place (eg, a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic The Epworth Sleepiness Scale (ESS) is a self-administered questionnaire used to determine excessive daytime sleepiness. Respondents are asked to use a numeric scale from 0 to 3 corresponding to the likelihood (never, slight, moderate and high) that they may fall asleep in 8 given situations. An ESS score can range from 0 to 24. A score greater than 10 indicates a high level of sleepiness Mitler and Miller. Behav Med. 1996;21:171. Mitler MM, Miller JC. Methods of testing for sleepiness. Behav Med. 1996;21:

28 Consequences of OSA Longitudinal 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

29 Evaluation & Diagnosis
Clinical Questions and Epworth Home Sleep Study PSG

30 Types of Sleep Studies Home 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

31 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

32 Circadian Sleep Disorders
1/Lavie/p293/¶3. 2/Monk/p458/col 1/¶3. 3/Edgar/p 1065/Abstract Wake During the day, SCN activity promotes arousal Maintains state of wakefulness Sleep At night, SCN arousal is attenuated Allows normal sleep to occur 3/Kilduff/p144/col1/¶2. It is believed that the 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.1-3 1. Lavie P. Sleep-wake as a biological rhythm. Annu Rev Psychol. 2001;52: 2. Monk TH, Welsh DK. The role of chronobiology in sleep disorders medicine. Sleep Med Rev. 2003;7: 3. Edgar DM, Dement WC, Fuller CA. Effect of SCN lesions on sleep in squirrel monkeys: evidence for opponent processes in sleep-wake regulation. J Neurosci. 1993;13: 1/Lavie/p293¶3. 2/Monk/p458/col1/¶3 3/Edgar/p 1065/Abstract 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

33 Sleep Homeostasis and Models of Sleep Regulation
Borbély, A., & Achermann, P. (1999). Sleep Homeostasis and Models of Sleep Regulation Journal of Biological Rhythms, 14 (6), DOI:

34 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)

35 Treatment- CRSD Planned napping Timed light exposure
Administration of melatonin Enhance Alertness Hypnotic medications

36 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

37 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 pain 30% 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

38 Prevalence of Insomnia* in the General Adult Population
Percent Some prevalence estimates of insomnia are based on the Diagnostic Interview Schedule (DIS) criteria, which require a report of at least 2 weeks of disrupted sleep.1 These epidemiological studies and others that applied similar or more stringent criteria have yielded fairly consistent results in prevalence rates for insomnia, ranging from 9% up to 17.7%.1-6 KEY POINT Significant insomnia, lasting 2 weeks or more, appears to occur at a fairly consistent rate, ranging between about 10 and 18%. 1. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention? JAMA. 1989;262: 2. Ohayon MM, Caulet M, Lemoine P. Comorbidity of mental and insomnia disorders in the general population. Compr Psychiatry. 1998;39: 3. Ohayon MM, Roth T. What are the contributing factors for insomnia in the general population? J Psychosom Res. 2001;51: 4. Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the National Sleep Foundation Survey. I. Sleep. 1999;22(suppl 2):S347-S353. 5. Ishigooka J, Suzuki M, Isawa S, Muraoka H, Murasaki M, Okawa M. Epidemiological study of sleep habits and insomnia of new outpatients visiting general hospitals in Japan. Psychiatry Clin Neurosci. 1999;53: 6. Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry. 1997;154: Ford 1989 Ohayon 1998 Ohayon 2001 Ancoli- Israel 1999 Ishigooka 1999 Simon 1997 *Insomnia = sleep disturbance every night for two weeks or more, or similarly stringent criteria. Ford DE, Kamerow DB. JAMA. 1989;262: Ohayon MM, et al. Compr Psychiatry. 1998;39: Ohayon MM, Roth T. J Psychosom Res. 2001;51: Ancoli-Israel S, Roth T. Sleep. 1999;22(suppl 2):S347-S353. Ishigooka J, et al. Psychiatry Clin Neurosci. 1999;53: Simon GE, VonKorff M. Am J Psychiatry. 1997;154:

39 Insomnia in Patients With Chronic Medical Conditions
Severe Insomnia† Percentage of Patients With Insomnia A 1998 report described insomnia prevalence data derived from the Medical Outcomes Study, a 4-year observational study of patients with chronic medical and psychiatric conditions.1 Using a sleep questionnaire completed by 3,445 patients, Katz and McHorney attempted to quantify the associations between insomnia and a number of chronic medical illnesses. They found that even in the absence of depression, large numbers of patients with specific medical conditions reported having insomnia (defined on the basis of initiation and maintenance of sleep, respiratory problems during sleep, quantity of sleep, perceived adequacy of sleep, and daytime somnolence).1 In significant proportions of these patients, the insomnia was considered severe.1 Such results highlight the importance of screening for insomnia among patients with a variety of chronic conditions. KEY POINTS Insomnia is present in large numbers of patients with a variety of medical conditions; in significant proportions of these patients, the insomnia may be severe. Clinicians should be alert to sleep problems in patients with chronic conditions because sizable numbers of these patients may have concurrent insomnia. 1. Katz DA, McHorney CA. Clinical correlates of insomnia in patients with chronic illness. Arch Intern Med. 1998;158: Diabetes CHF Hip Impairment Obstructive Airway MI Angina BPH *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:

40 Insomnia…the most common sleep disorder

41 Insomnia Treatment Sleep Hygiene Cognitive Behavior Therapy

42 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 Insomnia Exercise, CBT, Sleep Hygiene

43 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

44 What to do and not to Do Recognize that there is a sleep problem & bring it to the attention What is the nature of Sleep Problem: Insomnia, Sleep Apnea, Restless Legs, Shift Work 3. Determine Circadian Phase Diet/light snack , exercise, hot bath, relaxing techniques, Bed timing and sleep timing, prescription medications What Not to do Clock watching, thinking about next day issues, worrying about sleep, Coffee/Smoking/Alcohol Catching-up over the week-ends

45 Excessive Sleepiness Disorders
Mechanistic Approach Narcolepsy Idiopathic Hypersomnia Post-Traumatic Hypersomnia Mood Disorders Sleep Apnea PLMS/Leg Movements Sleep Walking Sleep-Wake Dysregulation Sleep Disruption Circadian Misalignment Delayed Phase Syndrome Advanced Phase Syndrome Shift Work Disorder Non-24 hour Rhythm

46 Narcolepsy Characterized by excessive sleepiness + cataplexy and other REM phenomena Sleep paralysis Hypnagogic hallucinations Etiology unknown Pathology: Genetic predisposition Hypocretin/orexin deficiency Autoimmune disease Neurochemical abnormalities Environmental triggers Head trauma

47 Assessment of Sleepiness
Behavioral Facial expression, posture, yawning, myosis Subjective 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.

48 Sleepiness and REM Sleep Assessed by Multiple Sleep Latency Test (MSLT)
Number of REM Periods Recorded in All 5 Naps Sleep Latency 20 5 16 4 Control 13.4 ± 4 12 3 REM periods/5 naps (mean) Minutes 8 2 Narcolepsy 4 1 3.0 ± 2.7 1 2 3 4 5 Narcolepsy Control Naps Control N=17 Narcolepsy N=57 Adapted from Mitler et al. Psychiatr Clin North Am. 1987;10:593.

49 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 ;15:836; Bassetti and Aldrich. Neurol Clin. 1996;14:545; Mamelak et al. Sleep. 1986;9:285.

50 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

51 Uncomfortable Leg Sensations

52 Types of RLS Primary RLS Genetic or Familial Secondary RLS
Iron deficiency Pregnancy End-stage renal disease Various polyneuropathies

53 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

54 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

55 Cleveland Sleep Center a comprehensive approach
Patient Care Clinic Diagnostic Sleep Laboratory Dental Sleep Medicine Respiratory Therapy Education Public Education Preceptorship Physician Education Research In-House Pharmaceutical

56 Acknowledgments Fruit Fly Narcoleptic Dog Rat

57 Acknowledgments Nazima and Shazeena 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

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