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

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

5 sleep onset insomnia trouble falling asleep 5

6 sleep maintenance insomnia
trouble staying asleep 6

7 early morning awakening
waking too early 7

8 non-restorative sleep
8

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

10 daytime consequences 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 10

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

12 insomnia increases with medical problems
80 Number of Medical Conditions 10 20 30 40 50 60 70 Percent of Respondents Reporting any Insomnia 1 2 or 3 4 n=1506 age 55-84 Sleep Problems and Multiple Medical Conditions The objective of the study undertaken by Foley and colleagues was to assess the association between sleep problems and chronic disease in older adults. A majority of the participants (83%) reported 1 or more of 11 medical conditions and nearly 1 in 4 elderly respondents (age 65–84 years) had major comorbidity (ie, ³4 conditions). As shown on the slide, there was a correlation between reports of insomnia and the number of medical conditions reported. Depression, heart disease, bodily pain, and memory problems were associated with more prevalent symptoms of insomnia (not shown). The authors concluded that the sleep complaints common in older adults are often secondary to their comorbidities and not to the aging process itself. Furthermore, the authors suggest that these types of studies may be useful in promoting sleep awareness among health professionals and among older adults, especially those with heart disease, depression, chronic bodily pain, or major comorbidity. Foley D, et al. J Psychosomatic Res. 2004;56: Foley et al, 2004

13 medical problems in insomnia
age = 20 to 98 Heart Disease Cancer HTN Neuro Pulm Urinary Diabetes Chronic Pain GI Any medical problem % p<.05 p<.01 p<.001 Taylor DJ; Mallory LJ; Lichstein KL et al. Comorbidity of chronic insomnia with medical problems. SLEEP 2007;30(2): p values are for Odds Ratios adjusted for depression, anxiety, and sleep disorder symptoms. Taylor et al, 2007

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

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

16 hyperarousal: beta eeg
Perlis et al, 2001 16

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

18 increased brain metabolism
Nofzinger et al., 2004 18

19 hyperarousal: neuroimaging
Nofzinger et al., 2004

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

23 how insomnia develops: biobehavioral pathway
23

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

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

26 Overuse caffeine/stimulants Various OTC sleep aids
Environmental Stressor Medical illness Loss of loved one Job transition Cumulative effect 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 Predisposing Risk Factors Spielman, 1987

27 Overuse caffeine/stimulants Decrease daytime activity
“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 Environmental Stressor Insomnia No Insomnia Predisposing Risk Factors Spielman, 1987

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

29 Spielman, 1987

30 CHRONIC (> 1 mo) ACUTE

31 CBT-i

32 insomnia causes problems

33 insomnia, CVD & mortality

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

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

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

37 assessment

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

39 insomnia severity index
clinical screening: insomnia severity index 1. Please rate the SEVERITY of your sleep problem(s). None Mild Moderate Severe Very Severe Difficulty falling asleep: Difficulty staying asleep: Problem waking up too early: 2. How SATISFIED/dissatisfied are you with your current sleep pattern? Very Unsatisfied Very 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 Interfere Interfere 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 Noticeable Very much Noticeable 5. How WORRIED/distressed are you about your current sleep problem? Not at all Worried Very much Worried <7 none >7 subthreshold >14 mod severe >21 severe Bastien et al., 2001

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

41 essential facts: insomnia

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

43 snoring and sleep apnea

44 snoring and sleep apnea

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

46 AHI (OSA only) <5 none 5-14 mild 15-29 mod 30+ severe UARS flow-limited breaths *subtle detection no obstruction snoring hypopnea apnea

47 mechanisms of srbd ↓O2  EEG arousal ↓ total sleep

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

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

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

51 treatments for srbd digeridoo oral appliance

52 surgery: not first-line treatment

53 positive airway pressure
gold standard: positive airway pressure slide from D Kirsch, MD 69. Sullivan CE, Issa FG, Berthon-Jones M, Eves L. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981;1(8225):

54 pap works 36 RCTs, N=1718 vs control vs oral appliance (OA)
↓objective & subjective sleepiness  quality of life neurocognitive function vs oral appliance (OA) ↓ AHI  sleep efficiency  minimum O2 Giles, Lasserson, Smith, White, Wright & Cates, 2006

55 LESS BAD MORE GOOD eliminates OSA (95+%) ↑ qol ↓ 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?
secondary insomnia: a myth dismissed frequent co-occurrence 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 58

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 59 59

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

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 61

62 insomnia & srbd: research boom

63 insomnia is common in srbd

64 39% moderate-severe insomnia
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 39% moderate-severe insomnia (insomnia unrelated to SRBD) Smith et al., 2004

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

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

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

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

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
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 Benetó et al., 2009

78 Benetó et al., 2009

79 Benetó et al., 2009

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

81 insomnia medications can worsen breathing
older benzodiazepines bad negatively impact breathing 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

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

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

85 treating both disorders improves outcomes
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) Krakow et al., 2004, 2006

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

87 clinical recommendations
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

88 clinical cautions insomnia srbd
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

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

90 patient characteristics
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

91 medical history 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

92 relevant family history
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

93 what’s on his mind? ↑ SOL OSA
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

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

95 assessing sleep onset insomnia
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

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

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

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

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

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

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

102 pre-sleep routine 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

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

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

105 quantitative improvement
before after BDI-2 1 (0) STAI-T 49th % 31st % ISI 22 16 ESS 10 5 DBAS-10 59.7 51.4 knowledge 4/5 5/5 acceptability 65.7 75.4

106 qualitative improvement
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

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

108 patient hassle & system burden

109 a better alternative: our model

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

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 111

112 ewickwire@pulmdocs.com (410) 997-5944 x13


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