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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.

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Presentation on theme: "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."— Presentation transcript:

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. 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. Understand common sleep disorders and how they can be assessed and treated.

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

4 SLEEP NREM Sleep Stage N1, N2 (“Light sleep”) procedural memory (skills, motor learning) Stage N3 Deep or “Slow Wave Sleep” (SWS) CNS restoration Declarative memory REM Sleep Dreaming Mood Regulatory Role? Memory?

5 Sleep Hypnogram

6 Insomnia Excessive Daytime Sleepiness

7 Insomnia Affects 3.3 million Canadians (1/7) according to Statistics Canada (2002) Affects 3.3 million Canadians (1/7) according to Statistics Canada (2002) Especially: - Middle aged (45-64) - Widowed - Minimal education - Obese - Women > men 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. Maintain a regular wake/sleep schedule, possibly add mild sleep restriction. Refrain from taking naps. Refrain from taking naps. Exercise - but not within 3 hours of bedtime. Exercise - but not within 3 hours of bedtime. Establish a relaxing routine before bedtime. Establish a relaxing routine before bedtime. Use the bedroom only for sleep activities. Use the bedroom only for sleep activities. Avoid clock watching Avoid clock watching Set environment (light, noise, temperature) at comfortable levels. Set environment (light, noise, temperature) at comfortable levels. Avoid caffeine after mid-afternoon. Avoid caffeine after mid-afternoon.

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

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

11 Obstructive Sleep Apnea (OSA) Pauses in breathing > 10 seconds in length Pauses in breathing > 10 seconds in length Respiratory Disturbance Index (RDI): >5 hr = significant Respiratory Disturbance Index (RDI): >5 hr = significant Prevalence – up to 25% of men, and 9% of women 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? 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 Snoring>80% *up to ½ of pts may sleep separately from partners Apneic episodes (partner)75% Apneic episodes (partner)75% AM Dry Mouth74% AM Dry Mouth74% Restless Sleep/ AM H/A50% Restless Sleep/ AM H/A50% Sensation of choking18-31% Sensation of choking18-31% Nighttime bathroom visits28% Nighttime bathroom visits28% Kryger, Roth and Dement, Principles and Practice of Sleep Medicine, 2005 p. 1043

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

14

15 Consequences of OSA

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

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

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

19 Atherosclerosis and Hypoxemia? Savransky and colleagues studied mice – divided into 4 groups: Savransky and colleagues studied mice – divided into 4 groups: Intermittent Air (Control) 10 Chronic Intermittent Hypoxemia 10 Regular diet High Cholesterol diet *Savransky V et al Am J Respir Crit Care Med, 2007

20 Atherosclerosis and Hypoxemia? Which ones developed atherosclerosis? Which ones developed atherosclerosis? Intermittent Air (Control) Chronic Intermittent Hypoxemia Regular diet High Cholesterol diet 0 0 0 9 *Savransky V et al Am J Respir Crit Care Med, 2007

21 Atherosclerosis and Hypoxemia? Sections of aorta from the mice: Sections of aorta from the mice: Intermittent Air (Control) Chronic Intermittent Hypoxemia Regular diet High Cholesterol diet *Savransky V et al Am J Respir Crit Care Med, 2007

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

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

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

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

27 CPAP for OSA

28

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

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

31 Surgery (UPPP)

32 Restless Legs Syndrome

33 NB- symptoms WHILE AWAKE NB- symptoms WHILE AWAKE “URGE” “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 Affects 5-15% of the population Mean age – 27- 41 years old - prevalence increases with age - age of onset varies widely (children – elderly) 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 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 Thought to be related to same problem – dopamine deficiency in the brain May be exacerbated by caffeine, nicotine, alcohol, or iron deficiency 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 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 A pathologic disorder of sleepiness during the day – key symptom – sleepiness May have insomnia at nighttime May have insomnia at nighttime Affects about 1/2000 people Affects about 1/2000 people Very underdiagnosed; difficult to recognize Very underdiagnosed; difficult to recognize 80% may have cataplexy, a REM sleep intrusion phenomenon on wakefulness 80% may have cataplexy, a REM sleep intrusion phenomenon on wakefulness Related to cerebrospinal fluid deficiency of hypocretin (orexin) Related to cerebrospinal fluid deficiency of hypocretin (orexin)

37 Narcolepsy Treatment SLEEPINESS: –Stimulants d-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 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 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 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? Do you feel satisfied with the quality of your sleep? Does you partner complain about your sleep? Does you partner complain about your sleep? Do you have difficulties falling or staying asleep? Do you have difficulties falling or staying asleep? Do you have problems with sleepiness during the day? Do you have problems with sleepiness during the day?


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