1. Introduction to Sleep & Common Sleep Disorders Jason Marx, MD, FCCP, DABSM Assistant Professor, University of Maryland SOM Medical Director, St Joseph Sleep Disorders Center May, 2015

2. Outline & Goals Science of sleep Sleeping Better Obstructive Sleep Apnea & RLS Conclusions/Questions

3. What is Sleep? Sleep is a regulated, reversible, and recurring loss of consciousness Typical features:  Recumbent position  Inability to perceive and respond to environment  Closed eyes  Minimal movement

4. Basic Overview of Sleep/Wake Regulation Sleep and wakefulness are highly regulated states governed by a balance of simultaneous factors: homeostatic sleep drive circadian rhythm individual vulnerability environmental factors (caffeine; activity; noise) performance factors (stress; urgency; posture)

5. Normal Sleep Sleep is divided into 2 states: Non-rapid eye movement (NREM) Rapid-eye movement (REM) NREM is subdivided into 3 states: N1 N2 N3

6. Sleep Stages NREM – 75% - 80% NREM Sleep – Stage N1 – 3% - 8% – Stage N2 – 45%- 55% – Stage N3 – 15% - 20% REM – 20% - 25%, atonia of all muscles, except respiratory and eye muscles

7. NREM vs REM Sleep Physiologic Variable Heart rate Respiratory rate Blood pressure Skeletal muscle tone Brain O 2 consumption Response to CO 2 Response to O 2 Body temperature Dreams NREM REM Regular Irregular Regular Variable Preserved Absent Reduced Increased Same as W Depressed Same as W Homeothermic Poikilothermic Minimal Complex http://www.aasmnet.org/Resources/MedSleep/(RosenG)intro.ppt#279,16,NREM vs. REM Sleep

8. Normal Sleep A typical night’s sleep consists of 4-6 cycles of a NREM sleep period followed by REM sleep period BedtimeAwake time http://www.aasmnet.org/Resources/MedSleep/(RosenG)intro.ppt#277,14,Normal Sleep Histogram

9. Function of Sleep Functions of sleep remain unclear It is likely sleep serves multiple functions Proposed functions: Repair of body Organization of memory Maintenance of immune function Energy conservation Protective behavior

10. Why do we sleep? If we don’t sleep, …? Short Sleepers & Long Sleepers have higher mortality

11. Consequences of Too Little Sleep Unstable mood Poor motor skills Learning and recall problems

12. Sleep Need Individual differences exist, but the majority of people require 8 hours of time in bed per 24 hour period for optimal performance. Insufficient sleep results in a “sleep debt” which continues to accumulate until adequate recovery sleep is obtained. This debt must be repaid! We do not adapt to getting less sleep than we need. The need to sleep must be satisfied, just like hunger and thirst.

13. How much sleep? Adults need about 7-8 hours of sleep a night Teenagers need about 9-10 hours of sleep at night Children need 10-13 hours of sleep at night and younger children may need a nap during the day

14. Factors that Modify Sleep Amount and time of last sleep Time of the day Individual variations in sleep need Environment Sleep disorders Medical and psychiatric conditions

15. What happens to sleep with aging? Ohayon, MM. Sleep 2004;27:1255-73 Stage R Stage N3 Stage N2 Stage N1

16. Menopause 25-50 % of woman complain of poor sleep Vasomotor Symptoms Insomnia ---- depression Fibromyalgia Obstructive Sleep Apnea

17. Recognizing Sleep Deprivation Falling asleep at work Troubles focusing Slow reaction time Need to continually re-check work Irritability with co-workers and family Apathy

18. Sleep Hygiene How to Sleep B.E.T.T.E.R. B edroom E xercise T ime in bed Comfortable and safe Dark and cool and Quiet Active during the day, not too close to bedtime Restrict to 8 hrs or less; Establish amount necessary to stay alert during the day Get out of bed after final morning awaken Go to bed when sleepy in the evening, do not skip “sleep window” of opportunity to stay up past bedtime http://www.aasmnet.org/Resources/MedSleep/(Guilleminault)SleepLossinHealthIllness.ppt#465,44,Sleep Hygiene How to Sleep B.E.T.T.E.R.

19. Sleep Hygiene How to Sleep B.E.T.T.E.R. T ension E ating habits R hythm Relax before bed Avoid caffeine Avoid alcohol Avoid Tobacco Eat healthy Sleep during the dark of night Be active during the light of day Keep a consistent sleep schedule

20. Timing is Everything! Best bedtime is: When pressure to sleep is greatest and The ability to stay awake is least. Low point in circadian drive for wakefulness High point in drive to sleep Greater sleep debt will make this happen sooner Poor sleep hygiene habits will make this happen later Use good sleep hygiene to take advantage of your tendency to fall asleep and stay awake.

21. Obstructive Sleep Apnea What is Obstructive Sleep Apnea? What are the symptoms? How is it diagnosed? How is treated? Why treat it?

22. OSA Symptoms Snoring Witnessed pauses, gasping, choking Sudden awakenings with gasping, choking Unrefreshing sleep with AM headache, dry mouth Daytime Sleepiness Poorly controlled high blood pressure

23. PHARYNX

24. OSA Risk Factors Men (until women post menopausal) Obese (BMI > 30) Thick Neck ( > 40 cm) Age > 50 Family History Small Airway/Jaw/Large Tonsils

25. Definition & Diagnosis of OSA The Apnea-Hyponea Index (AHI) or The Respiratory Disturbance Index (RDI) – AHI < 5: normal – AHI 5 -15: mild – AHI 15 - 30: moderate – AHI > 30: severe – O 2 nadir >85%: mild – O 2 nadir 80 - 85%: moderate – O 2 nadir < 80%: severe

26. OSA Treatments Weight Loss Snore Ball Oral Appliances Surgery CPAP

27. Why Treat OSA? Heart Disease Insulin Resistance/Diabetes Motor Vehicle Accidents Daytime Sleepiness Neurocognitive Deficits Fatty Liver Post-operative complications Pulmonary Hypertension

28. Restless Leg Syndrome Urge to move legs, usually uncomfortable sensation Begins or worsens with inactivity Partially or totally relieved with movement Worse in evening and night

29. RLS Epidemiology 5-15% prevalence 2:1 women:men Iron deficiency Pregnancy End-Stage Renal Disease Family History (early onset, 45 yrs) Nicotine, Caffeine, SSRIs, Diphenhydramine, Alcohol

30. Treatment of RLS Nonpharmacologic Avoid Caffeine and Nicotine Light stretching Distraction CPAP

31. Treatment of RLS Pharmacologic Iron Dopaminergic Drugs Anticonvulsants Benzodiazepines Opiates

32. Outline & Goals Science of sleep Sleeping Better Obstructive Sleep Apnea & RLS Conclusions/Questions