1. Thank You !!! Dr. Constance Kay, MS Support Group Dr. Constance Kay, MS Support Group AWAKE Group of the Villages AWAKE Group of the Villages Phillip Ratliff & Lois Brach, Coordinators Phillip Ratliff & Lois Brach, Coordinators Heather Ellington, Office Manager, VSL Heather Ellington, Office Manager, VSL John Crawford, Technical Director, VSL John Crawford, Technical Director, VSL Thomas Chaput, Sleep Technologist, VSL Thomas Chaput, Sleep Technologist, VSL Miyoshi Scott, Nurse, VSL Miyoshi Scott, Nurse, VSL

2. Sleep & Multiple Sclerosis Juan A. Albino, MD, FCCP Board Certified in Sleep Medicine Village Sleep Lab 751-4955 Accredited by the AASM, 1/08 Accredited by the AASM, 1/08

3. Common Sleep Disorders Insomnia: wants to sleep but cannot Insomnia: wants to sleep but cannot Sleep Deprivation: does not want to sleep but can; problem of sleep quantity Sleep Deprivation: does not want to sleep but can; problem of sleep quantity Sleep Apnea: sleepy during day, snores (throat obstruction) problem of sleep quality Sleep Apnea: sleepy during day, snores (throat obstruction) problem of sleep quality Restless Legs Sydrome: leg discomfort, relieved by movement, symptoms day and night Restless Legs Sydrome: leg discomfort, relieved by movement, symptoms day and night Parasomnias: abnormal sleep behaviors Parasomnias: abnormal sleep behaviors Circadian Rhythm Disorders: sleep clock not in harmony with the environment Circadian Rhythm Disorders: sleep clock not in harmony with the environment

4. Restless Legs Syndrome (RLS) Urge to move legs, discomfort at rest, worse at night, relieved by movement Urge to move legs, discomfort at rest, worse at night, relieved by movement Affects 10% of population, women more Affects 10% of population, women more Severity: mild, 7%, to incapacitating, 3% Severity: mild, 7%, to incapacitating, 3% Familial or Primary, often begins in childhood; 2ary: other disorders present Familial or Primary, often begins in childhood; 2ary: other disorders present Disruptive of social activities and sleep Disruptive of social activities and sleep Common, easily diagnosed, and treatable Common, easily diagnosed, and treatable

5. RLS and PLMD Periodic Leg Movement Disorder, PLMD Periodic Leg Movement Disorder, PLMD Involuntary leg movements while asleep Involuntary leg movements while asleep RLS occurs while awake, but 80% PLMD RLS occurs while awake, but 80% PLMD Both PLMD and RLS can disrupt sleep Both PLMD and RLS can disrupt sleep Leg movements are common during sleep Leg movements are common during sleep Need sleep study to diagnose PLMD but not RLS Need sleep study to diagnose PLMD but not RLS Same treatment for PLMD and RLS Same treatment for PLMD and RLS

6. Good Sleep Hygiene: Basics Regular times for sleeping and awakening Regular times for sleeping and awakening Maintain bedroom dark, quiet, cool Maintain bedroom dark, quiet, cool Use bed only for sleep and sex Use bed only for sleep and sex Avoid late daytime naps Avoid late daytime naps Avoid at night: alcohol, caffeine, nicotine Avoid at night: alcohol, caffeine, nicotine Sleep around 7 to 8 hours every night Sleep around 7 to 8 hours every night Prudent exercise and eating Prudent exercise and eating Avoid stressful situations at bedtime Avoid stressful situations at bedtime Test: spontaneous bedtime and rise time Test: spontaneous bedtime and rise time

7. Multiple Sclerosis & Sleep Problems Sleep Problems present before MS: can worsen Sleep Problems present before MS: can worsen Sleep Problems caused by MS: can be managed Sleep Problems caused by MS: can be managed Sleep Problems develop independent of MS: often complicated by MS Sleep Problems develop independent of MS: often complicated by MS

8. Multiple Sclerosis & Sleep Problems Insomnia & Sleep Apnea Insomnia & Sleep Apnea Daytime Sleepiness & Fatigue Daytime Sleepiness & Fatigue Disruptions during Sleep Disruptions during Sleep Anxiety and Depression Anxiety and Depression Neurological complications of MS Neurological complications of MS

9. MS & Insomnia Primary Insomnia: present before MS Primary Insomnia: present before MS Insomnia due to MS: improves with better treatment of MS symptoms at night Insomnia due to MS: improves with better treatment of MS symptoms at night Depression / insomnia: before or after MS Depression / insomnia: before or after MS Urge to urinate: bladder, prostate, etc. Urge to urinate: bladder, prostate, etc. Sleep apnea sometimes causes insomnia Sleep apnea sometimes causes insomnia Medications: some antidepressants, stimulants Medications: some antidepressants, stimulants

10. Insomnia due to MS: Causes Leg and bladder spasticity Leg and bladder spasticity Pain syndromes Pain syndromes Respiratory muscle weakness: upper airway (throat): aspiration, sleep apnea Respiratory muscle weakness: upper airway (throat): aspiration, sleep apnea Respiratory muscle weakness: lower airway (lungs): ventilation (hypoxemia) Respiratory muscle weakness: lower airway (lungs): ventilation (hypoxemia) Environmental: temperature & humidity Environmental: temperature & humidity

11. Frequent Urination Causes: light sleep, bladder problem, prostate problem, drugs, infections Causes: light sleep, bladder problem, prostate problem, drugs, infections Light sleep: insomnia, Sleep Apnea, PLMD Light sleep: insomnia, Sleep Apnea, PLMD Consider urological evaluation Consider urological evaluation Avoid too much fluids, salt, diuretics, alcohol, caffeine Avoid too much fluids, salt, diuretics, alcohol, caffeine Consider sleep study (polysomnogram) Consider sleep study (polysomnogram) Medicines for bladder (Detrol, Ditropan) or prostate Medicines for bladder (Detrol, Ditropan) or prostate

12. Depression and Anxiety Anxiety: difficulty going to sleep, worries Anxiety: difficulty going to sleep, worries Depression: difficulty going or staying asleep, or waking up early; hopeless, helpless, no fun, sad Depression: difficulty going or staying asleep, or waking up early; hopeless, helpless, no fun, sad Depression: before or after MS; problem recognizing, admitting to illness Depression: before or after MS; problem recognizing, admitting to illness Drugs are effective in treating both Drugs are effective in treating both Treat chronic insomnia: behavioral therapy Treat chronic insomnia: behavioral therapy Beware: anti-anxiety drugs & sleepiness; anti- depressants & insomnia Beware: anti-anxiety drugs & sleepiness; anti- depressants & insomnia

13. Drugs and Insomnia Anti-depressants: Prozac, Celexa, Zoloft, Paxil, take in the morning or add sedating one at night: trazodone Anti-depressants: Prozac, Celexa, Zoloft, Paxil, take in the morning or add sedating one at night: trazodone Stimulants for fatigue: methylphenidate, though modafinil better Stimulants for fatigue: methylphenidate, though modafinil better Coffee, alcohol, tobacco: avoid Coffee, alcohol, tobacco: avoid

14. Primary Insomnia: Before MS Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime impairment Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime impairment Acute Insomnia (<4 weeks): stress, illness Acute Insomnia (<4 weeks): stress, illness Sleep medicines work well in acute stage Sleep medicines work well in acute stage Chronic Insomnia: >4 weeks, often years Chronic Insomnia: >4 weeks, often years Treat basic problem: >60% psychological Treat basic problem: >60% psychological Psychotherapy and behavioral therapy better than medicines, not easy to treat Psychotherapy and behavioral therapy better than medicines, not easy to treat Psychologists, Psychiatrists, PCP Psychologists, Psychiatrists, PCP

15. Treatment of Chronic Insomnia Sleep Hygiene: avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before bed Sleep Hygiene: avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before bed regular sleep hours, avoid day naps, exercise regular sleep hours, avoid day naps, exercise Restriction: only go to bed when ready to sleep, if in bed sleep 90% of the time; out of bed and bedroom if awake over 20 min Restriction: only go to bed when ready to sleep, if in bed sleep 90% of the time; out of bed and bedroom if awake over 20 min Stimulus control: simple bedroom furniture and bedroom strictly for sleep Stimulus control: simple bedroom furniture and bedroom strictly for sleep Proper perspective: good if adequate sleep over 75% of the time, don’t exaggerate the problem Proper perspective: good if adequate sleep over 75% of the time, don’t exaggerate the problem

16. Treatment of Chronic Insomnia: Sleeping Pills Anti-histamines: available over the counter Benadryl (diphenhydramine) Anti-histamines: available over the counter Benadryl (diphenhydramine) Sedating anti-depressants: trazodone Sedating anti-depressants: trazodone Sedatives: temazepam (Restoril), triazolam (Halcion), flurazepam (Dalmane) Sedatives: temazepam (Restoril), triazolam (Halcion), flurazepam (Dalmane) Specific drugs: Ambien (generic), Ambien CR (not generic), Lunesta, short acting but expensive; Rozerem (not habit forming) Specific drugs: Ambien (generic), Ambien CR (not generic), Lunesta, short acting but expensive; Rozerem (not habit forming) Natural Substances: melatonin, valerian root, chamomile tea, lavender, kava, jazmine scent, little to no proof that they help, side effects Natural Substances: melatonin, valerian root, chamomile tea, lavender, kava, jazmine scent, little to no proof that they help, side effects

17. Day Time Sleepiness Insomnia due to MS: leg spasticity, urination, pain, neuromuscular weakness Insomnia due to MS: leg spasticity, urination, pain, neuromuscular weakness Drugs: anti-anxiety & antispasmodics for legs or for bladder dysfunction Drugs: anti-anxiety & antispasmodics for legs or for bladder dysfunction Sleep Apnea: poor sleep quality Sleep Apnea: poor sleep quality Restless Legs Syndrome / Periodic Leg Movement Disorder Restless Legs Syndrome / Periodic Leg Movement Disorder Primary Insomnia: hyperarousal, little daytime sleepiness Primary Insomnia: hyperarousal, little daytime sleepiness

18. Drugs and Daytime Sleepiness Muscle Relaxants: baclofen (Lioresal), tizanidine (Zanaflex), dantrolene (Dantrium) Muscle Relaxants: baclofen (Lioresal), tizanidine (Zanaflex), dantrolene (Dantrium) Anti-anxiety: alprazolam (Xanax), clonazepam (Klonopin), lorazapam (Ativan) Anti-anxiety: alprazolam (Xanax), clonazepam (Klonopin), lorazapam (Ativan) Drugs for bladder dyfunction: oxybutynin (Ditropan), tolterodine (Detrol) Drugs for bladder dyfunction: oxybutynin (Ditropan), tolterodine (Detrol) Manage: change drug, lower dose Manage: change drug, lower dose

19. Sleep Apnea: Risk Factors Affects: 4 to 5% of population: common Affects: 4 to 5% of population: common Family history, Sleep maintenance insomnia Family history, Sleep maintenance insomnia Obesity: 80 % of sleep apnea patients; central (visceral, apples) obesity Obesity: 80 % of sleep apnea patients; central (visceral, apples) obesity Increasing age, Male gender Increasing age, Male gender Large tonsils / adenoids in children Large tonsils / adenoids in children Small mandible, large neck Small mandible, large neck Smoking, alcohol, sedatives, nasal allergies Smoking, alcohol, sedatives, nasal allergies

20. Sleep Apnea: Consequences During night: snoring, snorting, gasping, difficult or stops breathing, wife worries During night: snoring, snorting, gasping, difficult or stops breathing, wife worries During day: sleepy, tired, depressed, irritable, impotent, forgets, sometimes few complaints During day: sleepy, tired, depressed, irritable, impotent, forgets, sometimes few complaints More accidents: work, home, motor vehicle More accidents: work, home, motor vehicle Higher death rates with severe sleep apnea Higher death rates with severe sleep apnea Hypertension, Congestive Heart Failure Hypertension, Congestive Heart Failure Heart Attacks, Strokes, Atrial Fibrillation Heart Attacks, Strokes, Atrial Fibrillation Promotes Obesity and Diabetes Promotes Obesity and Diabetes Problems: at night, during day, risk factor Problems: at night, during day, risk factor

21. What is OSA? Cessation of airflow with ongoing respiratory effort NORMALSNORINGSLEEP APNEA Obstructive Sleep Apnea

22. Sleep Apnea: Treatment Behavioral: Weight Loss, Sleep Position (Sleep on side, head raised), Oxygen, Avoid sedatives Behavioral: Weight Loss, Sleep Position (Sleep on side, head raised), Oxygen, Avoid sedatives CPAP: proven therapy, needs motivation: widely available, 70%: patients adapt well CPAP: proven therapy, needs motivation: widely available, 70%: patients adapt well Surgery: tracheostomy, tonsillectomy, pull forth mandible or tongue Surgery: tracheostomy, tonsillectomy, pull forth mandible or tongue Bariatric Surgery: banding, bypass (Bob Eisenhauer, 259-1485) Bariatric Surgery: banding, bypass (Bob Eisenhauer, 259-1485) Dental appliances: also pull forth mandible or tongue; expertise necessary Dental appliances: also pull forth mandible or tongue; expertise necessary

23. Treatment -CPAP treatment –Positive pressure keeps airway open –100% effective CPAP therapy Treatment Options: CPAP

24. Summary: Sleep Apnea Very common and dangerous Very common and dangerous Easily diagnosed and treated Easily diagnosed and treated Benefits of treatment: sleep better at night, also Benefits of treatment: sleep better at night, also Feel better during the day: less sleepiness and fatigue, more energy, less accidents Feel better during the day: less sleepiness and fatigue, more energy, less accidents Reduce risk factor for heart disease and strokes Reduce risk factor for heart disease and strokes Control better: obesity, diabetes, hypertension Control better: obesity, diabetes, hypertension Bed partner sleeps better: less noise and less worry (but dog is scared of CPAP) Bed partner sleeps better: less noise and less worry (but dog is scared of CPAP)

25. Neuromuscular Weakness: Breathing & Sleep in MS Weakens throat and/or lungs (diaphragm) Weakens throat and/or lungs (diaphragm) Advanced disease, night problem, not day Advanced disease, night problem, not day Sleep apnea, aspiration, speech & eating problems, shortness of breath Sleep apnea, aspiration, speech & eating problems, shortness of breath Infections: aspiration, weak cough Infections: aspiration, weak cough Night: low oxygen, high carbon dioxide: sleep disruptions, insomnia Night: low oxygen, high carbon dioxide: sleep disruptions, insomnia Management: head elevation 35 angle, avoid bedtime eating, BIPAP, Oxygen Management: head elevation 35 angle, avoid bedtime eating, BIPAP, Oxygen

26. Summary: Sleep Disorders & MS Majority of MS Patients have sleep disorders, but the majority are easily diagnosed and treated Majority of MS Patients have sleep disorders, but the majority are easily diagnosed and treated Most common disorders: depression, pain, sleep apnea, leg & bladder spasticity, restless legs, anxiety, poor sleep hygiene, drug side effects Most common disorders: depression, pain, sleep apnea, leg & bladder spasticity, restless legs, anxiety, poor sleep hygiene, drug side effects Fatigue and daytime sleepiness are hard to distinguish Fatigue and daytime sleepiness are hard to distinguish Neuromuscular weakness at night easily missed Neuromuscular weakness at night easily missed

27. Websites American Sleep Apnea Association: www.sleepapnea.org American Sleep Apnea Association: www.sleepapnea.orgwww.sleepapnea.org National Multiple Sclerosis Society: www.nationalmssociety.org National Multiple Sclerosis Society: www.nationalmssociety.org Restless Legs Syndrome Foundation: www.rls.org Restless Legs Syndrome Foundation: www.rls.org National Sleep Foundation: www.sleepfoundation.org National Sleep Foundation: www.sleepfoundation.orgwww.sleepfoundation.org American Insomnia Association: www.americaninsomniaassociation.org American Insomnia Association: www.americaninsomniaassociation.org www.americaninsomniaassociation.org National Institute on Neurological Disorders and Stroke: www.ninds.nih.gov National Institute on Neurological Disorders and Stroke: www.ninds.nih.gov Village Sleep Lab www.villagesleeplab.com (Dr. Albino, coming in February, 2008) Village Sleep Lab www.villagesleeplab.com (Dr. Albino, coming in February, 2008)

28. Books Multiple Sclerosis: A Guide for the Newly Diagnosed by Nancy J Hollard et. al. Multiple Sclerosis: A Guide for the Newly Diagnosed by Nancy J Hollard et. al. The Promise of Sleep by William Dement The Promise of Sleep by William Dement Sleeping Well by Michael Thorpy Sleeping Well by Michael Thorpy The MS Workbook: Living Fully with Multiple Sclerosis by George H. Kraft et. al. The MS Workbook: Living Fully with Multiple Sclerosis by George H. Kraft et. al. A Woman’s Guide to Sleep Disorders by Meir H. Kryger A Woman’s Guide to Sleep Disorders by Meir H. Kryger Say Good Night to Insomnia by Gregg D. Jacobs Say Good Night to Insomnia by Gregg D. Jacobs