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Intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep disorders emerson m. wickwire, phd, abpp, cbsm co-director,

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Presentation on theme: "Intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep disorders emerson m. wickwire, phd, abpp, cbsm co-director,"— Presentation transcript:

1 intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep disorders emerson m. wickwire, phd, abpp, cbsm co-director, center for sleep disorders pulmonary disease and critical care associates

2 disclosures: The Sleep Apnea Success Guidebook HealthMedia- scientific consultant (2009)

3 what you’ll learn… I.almost everything you’ll ever need to know about the two most common sleep disorders II.a whole is greater than the sum of its parts III.multi-system problems require multi-prong treatment approaches

4 essential facts: insomnia I.definition: what disorder looks like II.consequences: what disorder does III.clinical aspects: how to evaluate and treat

5 sleep onset insomnia trouble falling asleep

6 trouble staying asleep sleep maintenance insomnia

7 waking too early early morning awakening

8 non-restorative sleep

9 DAYTIME CONSEQUENCE insomnia symptoms frequently overlap & complaints may change over time

10 fatigue/malaise attention, concentration, or memory impairment social/vocational dysfunction or poor school performance mood disturbance/irritability daytime sleepiness motivation/energy/initiative reduction proneness for errors/accident at work or while driving tension headaches/GI symptoms concerns or worries about sleep daytime consequences

11 epidemiology of the most common sleep disorder 30-40% transient 10-15% chronic clinical practice: >50%

12 Foley et al, Number of Medical Conditions Percent of Respondents Reporting any Insomnia or 3 4 insomnia increases with medical problems n=1506 age 55-84

13 Taylor et al, 2007 p values are for Odds Ratios adjusted for depression, anxiety, and sleep disorder symptoms. Heart Disease Cancer HTN NeuroPulmUrinaryDiabetes Chronic Pain GI Any medical problem % p<.05 p<.01 p<.001 medical problems in insomnia n=772 age = 20 to 98

14 INSOMNIA Decreased TST Increased SOL/WASO Impaired sleep efficiency Decreased SWS PSYCHIATRIC ISSUES Anxiety Depression Insomnogenic drugs Substance abuse Altered ACTH and cortisol Concerns or worries re: sleep

15 insomnia as a disease of physiologic hyperarousal Bonnet, 1998; Bonnet & Arand, 1995; Lushington et al., 2000; McClure et al., 2001; Perlis, 2001; Stepanski, 1988 increased metabolic rate increased body temperature increased heart rate increased catecholamines increased high-frequency eeg

16 hyperarousal: beta eeg Perlis et al, 2001

17 hyperarousal: hpa axis Vgontzas et al, 2001 ACTH elevated from 1400 to 1730 and 2100 to 0030cortisol elevated from only p=.07 p=.04

18 increased brain metabolism Nofzinger et al., 2004

19 hyperarousal: neuroimaging

20 attentional systems are active ARAS: activates/deactivates cortex; alertness Hypothalamus: sleep & wake Thalamus: sensory processing; activates/deactivates cortex Mesial Temporal Cortex: memory; novelty detection Cingulate: excitatory role in emotions & motivated behavior Insular cortex: perceptions of disgust & pain

21 attentional systems are active ARAS: activates/deactivates cortex; alertness Hypothalamus: sleep & wake Thalamus: sensory processing; activates/deactivates cortex Mesial Temporal Cortex: memory; novelty detection Cingulate: excitatory role in emotions Insular cortex: perceptions of disgust & pain

22 Harvey model sleep beliefs & worry insomnophobia battlemind sufferers: cognitive not somatic arousal cognitive factors in insomnia Harvey, 2002; Morin et al., 2007; Lichstein & Rosenthal, 1980

23 how insomnia develops: biobehavioral pathway

24 Predisposing Risk Factors Biology/ Hard-wiring Personality Temperament Insomnia No Insomnia Spielman, 1987

25 Predisposing Risk Factors Biology/ Hard-wiring Personality Temperament Insomnia No Insomnia Spielman, 1987

26 Compensatory Behaviors Spend more time in bed “Try harder” to sleep Sleep in on weekends Take naps Sleep outside bedroom Overuse caffeine/stimulants Various OTC sleep aids Obsess/ overfocus on sleep Insomnia No Insomnia Environmental Stressor Medical illness Loss of loved one Job transition Cumulative effect Predisposing Risk Factors Spielman, 1987

27 Insomnia No Insomnia “Compensatory” Behaviors Spend more time in bed “Try harder” to sleep Go to bed earlier Sleep in on weekends Take naps Sleep outside bedroom Overuse caffeine/stimulants Decrease daytime activity Various OTC sleep aids Obsess/ overfocus on sleep Predisposing Risk Factors Environmental Stressor Spielman, 1987

28 Insomnia No Insomnia Predisposing Risk Factors Environmental Stressor “Compensatory” Behaviors Spielman, 1987

29

30 ACUTE CHRONIC (> 1 mo)

31 CBT-i

32 insomnia causes problems n=1741

33 insomnia, CVD & mortality n=1741 n=3430

34 insomnia worsens quality of life Leger et al., 2001 n=1053

35 insomnia precedes depression n=1053 men Chang et al., 1997

36 insomnia post-deployment: #1 symptom & may predict ptsd n=2249

37 assessment

38 ask! (doctors don’t ask & patients don’t tell) frequency (>3x/ week) intensity (>30m sol/waso, quality) duration (>1 mo) daytime sequelae do you snore?

39 1. Please rate the SEVERITY of your sleep problem(s). NoneMildModerate SevereVery Severe Difficulty falling asleep: Difficulty staying asleep: Problem waking up too early: 2. How SATISFIED/dissatisfied are you with your current sleep pattern? Very UnsatisfiedVery Satisfied 3. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.)? Not at all InterfereInterfere Very Much 4. How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life? Not at all NoticeableVery much Noticeable 5. How WORRIED/distressed are you about your current sleep problem? Not at all WorriedVery much Worried clinical screening: insomnia severity index Bastien et al., 2001 <7 none >7 subthreshold >14 mod severe >21 severe

40 use CBT-I: recommended 1 st line treatment primary & comorbid insomnias adults of all ages & hypnotic users* combined therapies: no benefit over cbt-i alone cbt-i aids hypnotic taper

41 essential facts: insomnia

42 essential facts: srbd I.definition: what disorder looks like II.consequences: what disorder does III.clinical aspects: how to evaluate and treat

43 snoring and sleep apnea

44

45 no obstruction hypopneasnoring apnea Obstructive Sleep Apnea (OSA) Upper Airway Resistance Syndrome (UARS)

46 no obstruction hypopneasnoring apnea AHI (OSA only) <5 none 5-14 mild mod 30+ severe UARS flow-limited breaths *subtle detection

47 ↓O 2  EEG arousal ↓ total sleep mechanisms of srbd

48 anatomical abnormalities genetic factors collapsibility of upper airway weight gain behavioral factors causes of srbd

49 EDS, mood disturbance, performance deficits quality of life, libido obesity, dm, htn, stroke, cardiovascular death, overall mortality enormous societal costs consequences of srbd

50 assessment of srbd out of lab (“at home”) in lab (gold standard)

51 treatments for srbd digeridoooral appliance

52 surgery: not first-line treatment

53 gold standard: positive airway pressure slide from D Kirsch, MD

54 36 RCTs, N=1718 vs control ↓objective & subjective sleepiness  quality of life  neurocognitive function vs oral appliance (OA) ↓ AHI  sleep efficiency  minimum O 2 Giles, Lasserson, Smith, White, Wright & Cates, 2006 pap works

55 LESS BAD eliminates OSA (95+%) ↓ sleepiness ↓ hospitalizations ↓ car accidents ↓ HTN (esp nocturnal) ↓ pulmonary artery pressures ↓ GERD MORE GOOD ↑ qol ↑ cognition ↑ glucose control ↑ gas exchange ↑ heart function in heart failure pts ↓ reduces cardiac arrhythmias during sleep

56 srbd in ptsd evidence of increased srbd in ptsd especially uars hypothesis: massive sympathetic burst alters pharyngeal muscle tone ↑ increased respiratory effort =  EEG sleep: 37% of variance in symptoms

57 a whole is greater than the sum of its parts: insomnia, srbd, or both? I.secondary insomnia: a myth dismissed II.frequent co-occurrence III.hypothesized mechanisms

58 a myth… NIH 1983 (that was then) insomnia is a symptom (only) treat the primary disorder NIH 2005 (this is now) insomnia is a disorder, typically coexisting with other disorders treat both conditions improvements insomnia can improve other outcomes

59 a myth… dismissed NIH 1983 (that was then) insomnia is a symptom (only) treat the primary disorder NIH 2005 (this is now) insomnia is a disorder, typically coexisting with other disorders treat both conditions improvements in insomnia can improve other outcomes

60 impacts quality of life worsens clinical outcomes frequently does not remit with treatment of “primary” condition comorbid insomnia is a disorder

61 not just a symptom consistency of complaints independent course of disorder responds to different treatment than comorbid disorder responds to same type of treatment across different disorders Harvey, 2001; Lichstein et al., 2004

62 insomnia & srbd: research boom

63 insomnia is common in srbd

64 insomnia is there (and not just a symptom) n=105 70% men M age=53.9±14 insomnia criteria: ISI>15 duration>6 months PSG SOL or WASO>30m w/daytime impairment Smith et al., % moderate-severe insomnia (insomnia unrelated to SRBD)

65 (n=100, 43 men, M age=49±14) Hagen, Patel, & McCall, 2009; Nguyen et al., 2010; Lichstein et al., 2010 half or more of patients… 61% moderate-severe insomnia (ISI) (n=166, 138 men, M age=54.8±11.8) 49.3% moderate-severe insomnia (ISI) 84% of OSA patients also meet DSM-IV/ ICSD-2 criteria for chronic insomnia

66 29-43% % 92.7% (15.7 UARS) 90.9% (40.9 UARS) Wickwire & Collop, 2010 and it works both ways: occult srbd in insomnia

67 Krakow et al., 2001; Krakow et al., 2002; Krakow et al., 2004 insomnia & srbd in ptsd (n=44, 37 women, M age=40.9±12.4) 90.9% srbd (50% OSA; 40.9% UARS) (n=78, 50 women, M age=51.5±13) 95% srbd (41% OSA; 54% UARS) 99% insomnia (n=187 women, M age=37±11) 89.8% rdc symptoms srbd ( confm’d in 21 tested )

68 ↓ sleep (self-report and psg) ↓ neurocognitive function ↓ psychomotor reaction times ↑ sleepiness (self-report and mslt) ↑ psychiatric distress & pain consequences are additive (1+1=3)

69 subtle, atypical presentations no loud snoring/ normal weight older patients postmenopausal women patients with chronic pain ptsd/mTBI?

70 onset insomnia & srbd severity: inverse relationship Gold et al., 2007 %

71 osa patients not always sleepy N=4653 Luyster, Buysse, & Strollo, 2010

72 Complex insomnia hypothesis. Chung K Chest 2003;123: ©2003 by American College of Chest Physicians

73 Complex insomnia hypothesis. Chung K Chest 2003;123: ©2003 by American College of Chest Physicians

74 Complex insomnia hypothesis. Chung K Chest 2003;123: ©2003 by American College of Chest Physicians

75 Complex insomnia hypothesis. Chung K Chest 2003;123: ©2003 by American College of Chest Physicians

76 Benetó et al., 2009

77

78

79

80 multi-system problems require multi-prong treatment approaches I.treatment interactions & combined therapies II.case study & clinical recommendations III.a comprehensive practice model

81 insomnia medications can worsen breathing older benzodiazepines bad 1.negatively impact breathing 2.raise arousal threshold newer hypnotics minimal impact AHI off-label meds may pose risk

82 untreated insomnia can compromise OSA treatment only insomnia predicted negative outcome in oral appliance for osa Machado et al., 2006 N=188

83 sleep maintenance insomnia predicts poor cpap adherence N=232 Wickwire, Smith, Birnbaum, & Collop, 2010

84 cbt-i #1 surgery #1 surgery #2 cbt-I #2 Guilleminault et al., 2009 combined treatments provide additive benefit

85 treating both disorders improves outcomes Krakow et al., 2004, 2006 in patients with symptoms of insomnia and srbd, nasal strips improved sleep treatment of srbd improved outcomes following cbt-i (8/17 remit  15/17 remit)

86 requires additional evaluation srbd may be common in patients with treatment-resistant insomnia refractory insomnia Guilleminault et al., 2002; Krakow et al., 2006, 2010

87 screen –insomnia and srbd –poor subjective sleep quality –nonrestorative sleep/ daytime fatigue antennae up –older adults –postmenopausal women –trauma survivors treat both conditions, concurrently if possible clinical recommendations

88 insomnia –be very careful w/ benzodiazepines and off- label medications –sleep hygiene not effective in isolation, not effective in handout –refer to insomnia specialist if available srbd –appreciate frequent co-morbidity of insomnia –intervene early for cpap adherence –refer to sleep specialist: snoring, obesity, htn, dm, refractory insomnia clinical cautions

89 self-referred for insomnia study ineligible per phone screen (osa) discussed treatment options initial evaluation scheduled Wickwire, Schumacher, Baran, Richert, & Roffwarg, 2007 the real-world: case study

90 61 y.o. Caucasian male lifelong Mississippi resident normal weight college degree US Army veteran PT VA employee w/shift work “happily” married 31 years 2 adult daughters & 2 grandchildren patient characteristics

91 recently diagnosed w/ OSA (AHI=31) GERD chronic knee pain denies past psychiatric treatment denies history substance abuse current daily meds: high blood pressure, GERD, baby aspirin, otc sleep aid prn medical history

92 father had trouble falling asleep –blamed sciatic nerve –slept on sofa brother suffers PTSD –experiences sleep problems –takes sleep medication wife snores and suffers EDS relevant family history

93 ↑ SOL –I can’t fall asleep at night (25-year Hx) –I don’t like to take pills (drug stupor) OSA –I never dreamed I had apnea… I only started snoring two years ago… they made a mistake –apnea is obstruction… obese people… –PAP is frustrating, loud, straps too tight, hard to get adjusted right what’s on his mind?

94 can’t concentrate or read can’t stay alert deer hunting tired & eyes irritated wants to nod off during work irritable* assessing daytime sleepiness

95 rumination: grandson’s health, nephew’s safety, involved with family (softball) thinking about “tomorrow” previous day: “what someone said, what family goes through” physical discomfort: pressure on feet, sensitive to physical, blankets, spouse bedroom environment: tempur Pedic bed TV in bedroom (wife falls asleep with TV) wife snores; he hears her “rustling” around assessing sleep onset insomnia

96 Primary insomnia Obstructive sleep apnea Plan: 1.CBT for PAP acceptance and adherence  what, how, why 2.CBT for insomnia diagnoses & treatment plan

97 OSA #2: cbt insomnia #1: cpap the plan: a systematic approach

98 OSA mood insomnia #2: cbt #1: cpap

99 2 45-minute sessions principles of behavioral change elicit personalized risks & benefits incorporate guided imagery motivational enhancement Aloia et al., 2004

100 develop a pre-sleep routine typical activity/ arousal level: Wickwire, Schumacher, & Clarke, 2008

101 marker ritual (“greased shoot” to sleep) sacred sleeping environment develop a pre-sleep routine

102 Last meal or snack of day END DAY ACTIVITIES- Leave work Change pajamas/ T-shirt Read 30- minutes (paper, magazine, book) Relaxation CD Breathing exercises Bathroom routine EARPLUGS Lights out/ Bed pre-sleep routine

103 self-report: m/day, falling asleep with mask on, waking and removing it CPAP 30m-300m (mean = 108.5m/ night over 2 week pd) improved pap adherence

104 sleep latency total sleep time wake after sleep onset sleep efficiency

105 beforeafter BDI-21(0) STAI-T49th %31st % ISI2216 ESS105 DBAS knowledge4/55/5 acceptability quantitative improvement

106 definitely not as tired much less nodding less drowsy in deer stand no sleep aid in past 3 months no TV in bedroom, no late eating following pre-sleep routine & using deep breathing exercises qualitative improvement

107 silos & 3-month waits pulmonary (psg) psychology (cbt) neurology psychiatry (meds) surgery

108 patient hassle & system burden

109 a better alternative: our model

110 MD MOD-10 in-lab psg at home test MTF/PCP or specialist MD PAP oral appliance medication PhD insomnia actigraphy PTSD/mTBI PhD CBT PAP success IRT Follow-up Care pap adherence data HIPAA secure website AHLTA friendly data Treatment Evaluation prompt scheduling coordination w/ referring providers

111 in conclusion: insomnia & srbd I. common, bad, & highly treatable II. frequently co-occur additive negative effects III.combined treatments are best demand comprehensive care

112 (410) x13


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