SLEEP MEDICINE Erve Sõõru North Estonia Medical Centre, pulmonologist-somnologist Estonian Sleep Medicine Association 2016

IMPORTANCE OF SLEEP Is a constitutive component of human life. Both sleep quality and duration are factors that influence health and wellbeing. Quantitative and qualitative sleep deficits lead to deterioration of health and impaired cognitive function. Is a dynamic process involving complex neural activation. Disordered brathing (SDB) is a term used to describe a spectrum of respiratory disturbances that occur during sleep.

SLEEP HYPNOGRAM

SLEEP AND DIFFERENT AGES

„BIOLOGICAL CLOCK“

HOMEOSTATIC REGULATION DURING SLEEP Sleep onset is associated with changes in the autonomic nervous system that reduce heart rate, systolic blood pressure and cardiac output. Obstructive sleep apnoea (OSA) causes hypertension with elevated sympathetic outflow to the vasculature. Circadian rhythms regulate the release of many hormones during sleep, such as cortisol, growth hormone, and leptin and ghrelin. Sleep deprivation influences metabolic regulation and associated with glucose intolerance and dysregulation of appetite hormones.

IMPORTANCE OF SLEEP The ideal duration of sleep would be approx. 7 hours. 7-hours sleepers experience the lowest risks all-cause mortality, whereas those with shorter or longer sleep duration have significantly higher mortality risk. Reported that 20 % of the population suffer from sleep disorders in Europe: - 6-15 % insomnia; - 5% obstructive sleep apnoea (OSA); - 4% restless legs syndrome.

SLEEP DISORDERS (1) Daytime somnolence. Bad sleep hygiene or insufficient sleep; shift work; sleep apnoea; depression; narcolepsy. Narcolepsy. Cataplexy: sudden and transient episode of loss of muscle tone triggered by emotions. Restless legs syndrome. Need to move the legs to stop uncomfortable leg sensations that improve with moving. Disturbs sleep and can induce insomnia and somnolence. Depression. Lask of interest and pleasure in daily activities, insomnia or excessive sleeping, lack of energy or inability to concentrate. Negative thoughts of death or even suicide.

SLEEP DISORDERS (2) Insomnia. Difficulty initiating (20 min) off maintaining sleep with the perception of poor-quality sleep. Can produce tiredness or somnolence during the day or be symptom of depression. Somnolence induced by drugs. Antianxiety drugs, some antidepressants or antihistamines or narcotics. Neurological diseases. Infectons, tumours, Steiner myopathy, stroke etc. Other sleep disorders: - REM behaviour disorders. Singular behaviours during sleep. - classical parasomnias. Somnambulism, nocturnal terrors, nightmares and the basic chronobiological entities.

CIRCADIAN RHYTHM DISORDERS Circadian rhythmicity has been demonstarted in all human cells and regulates integral physiological processes as core body temperature and hormone secretion, including cortisol, prolactin and growth hormone. There are significant inter-individual variation as a result of age, sex and morningness/eveningness preference. The latter reflects an individual`s preferences for timing activity and correlates with timing of individual`s circadian pacemaker. For example: - CRD is common in blind individuals. - In irregular sleep/wake syndrome, there is an absence of well-defined sleep/wake cycle and there is no major sleep period. - Shift work disorder is common in 24 –h societies and can lead to significant morbidity.

SLEEP DISORDERED BREATHING (SDB) Obstructive sleep apnoea syndrome (OSAS) is characterised by recurrent episodes of partial or complete upper airway collapse during sleep. Minimal diagnostic criteria exist for OSAS and central sleep apnoea syndrome (CSAS). Obesity hypoventilation syndrome (OHS) is also part of the spectrum of sleep disordered breathing. Hypoventilation syndromes can occur independent of obesity.

OBSTRUCTIVE SLEEP APNOEA SYNDROME Normal

OBSTRUCTIVE SLEEP APNOEA SYNDROME OSAS is now recognised as one of the most common chronic respiratory disorders in adults. Physicians are seeing an increasing number of patients with OSAS. Untreated OSA has dangerous health consequences. Upper airway collapse is multifactorial. There are substantial sex differences and important ageing effects. OSAS is highly prevalent with an estimated prevalence of at least 4% in males and 2% of females. Obesity has very close relationship with apnoea-hypopnoea index (AHI). The influence of male sex and body mass index (BMI) on OSAS tends to wane with age.

PREDISPOSING FACTORS OF SDB General: ageing, males, Asian or African-American race. Anatomical abnormalities: nasal obstruction, microghnatia, hyoid bone displacement, hypertrophy of uvula, soft palate and tonsils, macroglossia, upper airway shape and lenght Functional factors: factors affecting upper airway collapsibility (drugs and alcohol), airway inflammation, instability of respiratory drive. Associated diseases: obesity, congenital syndromes (Pierre Robin, Down etc.), endocrine disorders, heart failure, stroke, chronic kidney disease, gastro-oesophageal reflux disease.

PATHOPHYSIOLOGY OF OSA OSA patients are characterised by a compromised upper airway anatomy, involving more than one specific site in most patients, with abnormal collapsibility, leading to a passive narrowing at the end of expiration. OSA patients have a sleep-induced loss of compensatory mechanisms (high upper airway muscle activity, negative pressure upper airway reflex). Ventilatory control (loop gain) and sleep instability (arousal treshold) contribute to upper airway instability. OSA has detrimental effects on cerebral function; has multiple negative effects on the cardiovascular system; affects the metabolic syndrome.

DAYTIME SYMPTOMS OF OSA Excessive daytime sleepiness Fatigue Morning dry mouth Morning headache Difficulty concentrating Irritability, mood changes

NIGHT-TIME SYMPTOMS OF OSA Witnessed apnoeas Snoring Nocturnal choking Disturbed unrefreshing sleep Thirst during the night Nocturnal diuresis, enuresis Nocturnal sweating Impotence Excessive salivation Gastro-oesophageal reflux

QUESTIONNAIRES ON SLEEP The EPWORTH SLEEPINESS SCALE is used to subjectively quantify sleepiness across a range of everyday situations, with a cumulative score of > 10 suggesting EDS. The BERLIN QUESTIONNAIRE has high specificity for identifying subjects with moderate-severe OSAS, but relatively low sensitivity. The STOP –BANG QUESTIONNAIRES have high sensitivity for identifying subjects with SDB, but relatively low specificity. Sleep quality can be subjectively assessed by the PITTSBURGH SLEEP QUALITY INDEX.

EPWORTH SLEEPINESS SCALE Situations: Sitting and reading Watching television Sitting inactive in a public place As a passenger in a car for an hour without 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 minutes in traffic Each situation is scored from 0 to 3, with 0 representing no chance of dozing and 3 a high likelihood of dozing. The upper limit of normal of the sum of the scores is generally considered to be 10.

STOP-BANG QUESTIONNAIRE Do you snore loudly? Do you often feel tired, fatigued or sleepy during the daytime? Has anyone observed you stop bretahing while you sleep? Do you have or are you being treated for high blood pressure? BMI ≥ 35 kg/m²? Age ≥ 50 years? Neck circumference ≥ 40 cm? Male? High risk of OSAS: answering yes to three or more items. Low risk of OSAS: answering yes to fewer than three items.

European Directory of Health Apps 2012-2013; http://www. patient-view

POLYSOMNOGRAPHY The term polysomnography (PSG) was first introduced by Holland at al. In 1974. It comparises the recording, analysis and interpretation of multiple, simultaneous physiological parameters that are used in diagnosis of sleep disorders. PSG is essential to the understand of normal and abnormal sleep. The polysomnogram is a summary output of electrophysiological signals integrating sleep signals, respiratory signals, cardiovascular signals and movement. The recording of sleep states requires acquisition of three main measures: the EEG, EOG and EMG.

SLEEP INVESTIGATIONS

DIAGNOSTIC ALGORITHMS The gold standard for the diagnosis of OSAH is attended PSG, but this is time-consuming and expensive. There has been a shift from laboratory PSG to home portable monitoring in patients with high pre-test probability of OSAS. Two groups of patients need to be evaluated: - those with symptoms, - those with risk factors for OSAS. A network approach is likely to be the best care model for managing the growing sleep medicine caseload.

DAYTIME SLEEPINESS The causes of excessive daytime somnolence (EDS) are many and varied and not all will be attributable to sleep disorders. Few very specific sleep disorders that can be diagnosed with the aid of daytime tests of sleepiness, such as narcolepsy and idiopathic hypersomnolence.

COST OF SLEEP DISORDERS The deleterious effects of sleep disorders on health have ben well demonstrated in OSA, it promotes: - hypertension, - weight gain, - type 2 diabetes mellitus, - cardiovascular complications, - an increased risk of motor vehicle accidents (MVAs). Like any chronic disease, may carry a significant economic cost. Costs can be: - direct costs are defined as hospital care, cost of drugs, cost of medical care and cost of care at other institutions, - indirect costs are defined as the value of lost production, including sick leave, short– or long-term disability and early mortality.

ECONOMIC ASPECTS OF SLEEP DISORDERS It is generally assumed that when the cost-effectiveness ratio of medical intervention is below a given treshold, the intervention is below a given treshold, the intervention is worth paying for. In international terms, the threshold is assumed to be between two and three times per capita gross domestic product of given country. To evaluate the cost-benefit, cost-utility and cost-effectiveness of insomnia therapies, and even to compare them to each other, we need a common tool of measure: the quality-adjusted life-year (QALY). - OSA is associated with an increased risk of MVAs; driver licensing laws vary greatly within the EU with regard to OSA. - pharmacological intervention for RLS has favorable cost-utility balances, - insomnia is cause of workplace disability.

SLEEP HYGIENE INSTRUCTIONS (1) Increase drive for sleep at night (sleep homeostatic factors): - avoid naps, except for a brief (30 minutes) during the day; but check with your physician first, because in some sleep disorders, naps can be beneficial. - avoid spending too much time awake in bed. - get regular exercise eash day, preferably 40 minutes each day. It is best to complete exercise at least 3 to 4 hours before bedtime. - take a hot bath within 2 hours before bedtime.

SLEEP HYGIENE INSTRUCTIONS (2) Increase regularity of sleep/wake schedule (circadian factors): - keep a regular bedtime and wake time 7 days a week (do not deviate more than 1 hour). - do not expose yourself to bright light if you have to get up at night. - increase exposure to bright light during the day. - exercise at a regular time each day.

SLEEP HYGIENE INSTRUCTIONS (3) Medication and drug effects: - do not smoke after 19.00. Give up smoking entirely, if possible. - avoid caffeine after 22.00. Limit intake of caffeinated beverages and food. - restrict alcocholic beverage consumption. Alcochol can fragmented sleep over second half of sleep. - review medications that could be stimulating or sedating with your doctor.

SLEEP HYGIENE INSRUCTIONS (4a) Arousal in sleep setting: - keep the clock face turned away, and do not find out what time it is when you wake up at night. - avoid streneuos exercise after 18.00. - do not eat and drink heavily for 3 hours before bedtime. A light bedtime snack my help. - if you have trouble with heartburn, be specially careful to avoid heavy meals and spices in the evening. - do not retire too hungry or too full. - keep your room dark, quiet, well ventilated, and at a comfortable temperature throughout the night.

SLEEP HYGIENE INSTRUCTIONS (4b) - Use a bedtime ritual. Reading before lights-out may be helpful if it relaxing. -Set aside worry time; make a list of problems for the following day. Learn simple relaxations skills to use if you wake up at night. Use stress management in the daytime. Avoid unfamiliar sleep environments. Be sure the mattress is not too soft or too firm, and that pillow is of proper height and firmness. Use bedroom for sleep and sex only; do not work or do other activities that lead to prolonged arousal.