1. Sleep: The Golden Chain That Ties Health and Our Bodies Together (A Review of Sleep Disorders)
Academy Of Medicine Clinical Day, February 24, 2012
Elliott K. Lee MD, FRCP(C), D. ABPN,
D. ABPN Addiction Psychiatry, D. ABSM
Assistant Professor, University of Ottawa Faculty of Medicine
Sleep Specialist, Royal Ottawa Mental Health Center Sleep Disorders Clinic

2. Objectives
Describe the importance of sleep and impact of sleep disorders in the community.
Understand common sleep disorders and how they can be assessed and treated. 

3. Outline Review sleep architecture, and how sleep is controlled.
Review insomnia and excessive daytime sleepiness, and their causes

4. SLEEP NREM Sleep REM Sleep
Stage N1, N2 (“Light sleep”) procedural memory (skills, motor learning)
Stage N3 Deep or “Slow Wave Sleep” (SWS)
CNS restoration Declarative memory
REM Sleep
Dreaming Mood Regulatory Role? Memory?

5. Sleep Hypnogram REM occurs more in the 2nd half of the night
Slow wave (stage 3-4, deep sleep) occurs in the 1st half

6. Insomnia Excessive Daytime Sleepiness

7. Insomnia
Affects 3.3 million Canadians (1/7) according to Statistics Canada (2002)
Especially: - Middle aged (45-64) - Widowed - Minimal education - Obese - Women > men

8. Treating Insomnia: Personal Sleep Hygiene
Maintain a regular wake/sleep schedule, possibly add mild sleep restriction.
Refrain from taking naps.
Exercise - but not within 3 hours of bedtime.
Establish a relaxing routine before bedtime.
Use the bedroom only for sleep activities.
Avoid clock watching
Set environment (light, noise, temperature) at comfortable levels.
Avoid caffeine after mid-afternoon.
Talk about adenosine – accumulates – helps us sleep – why exercise may be helpful for sleep

9. Medication options Zopiclone (Imovane) Trazodone (Desyrel)
Other options: - Melatonin - Tricyclic Antidepressants - Benzodiazepines - Mirtazapine (Remeron) - Atypical Antipsychotics

10. Eszopiclone Sleep Latency Sleep latency from ave = 70 min
Placebo = 45 min Eszopiclone = 27.3 min
Total Sleep Time
Total Sleep Time
Placebo = 330 min Eszopiclone = 390 min
Eszopiclone users had improved quality of life, and no reported incidence of tolerance or withdrawal
Walsh et al, Sleep, 2007

11. Obstructive Sleep Apnea (OSA)
Pauses in breathing > 10 seconds in length
Respiratory Disturbance Index (RDI): >5 hr = significant
Prevalence – up to 25% of men, and 9% of women
Key diagnostic questions: - Do you feel satisfied with the quality of your sleep? - Does your partner complain that you snore?

12. Obstructive Sleep Apnea Syndrome Symptoms
Snoring >80% *up to ½ of pts may sleep separately from partners
Apneic episodes (partner) 75%
AM Dry Mouth 74%
Restless Sleep/ AM H/A 50%
Sensation of choking %
Nighttime bathroom visits 28%
Kryger, Roth and Dement, Principles and Practice of Sleep Medicine, 2005 p. 1043

13. OBSTRUCTIVE SLEEP APNEA (OSA)
Causes
▪ Narrow Upper Airway
▪ Elevated BMI
▪ Family Hx
Exacerbated by:
▪ Medications – muscle relaxants, sedatives
▪ Alcohol Consumption
▪ Supine sleep
▪ REM sleep
▪ **Supine + REM sleep

15. Consequences of OSA

16. Odds Ratio – AHI to Hypertension
Peppard PE et al. N Eng J Med, 2000; 342(19):

17. Odds Ratio – AHI to Hypertension
Change in BP with use of CPAP (9 weeks)
Becker HF et al. Circulation, 2003; 107(1):68-73
Odds Ratio – AHI to Hypertension
Peppard PE et al. N Eng J Med, 2000; 342(19):

18. Cardiovascular Disease
Traditional View
Cardiovascular Disease
Obesity
Insulin Resistance
Hypertension
Low Grade Inflammation
Ischemic heart diseases
↑ Oxidative Stress
Arrhythmias
Endothelial Dysfunction
CV stroke/TIA

19. Atherosclerosis and Hypoxemia?
Savransky and colleagues studied mice – divided into 4 groups:
*Savransky V et al Am J Respir Crit Care Med, 2007
Intermittent Air (Control) 10
Chronic Intermittent Hypoxemia
Regular diet
High Cholesterol diet

20. Atherosclerosis and Hypoxemia?
Which ones developed atherosclerosis?
*Savransky V et al Am J Respir Crit Care Med, 2007
Intermittent Air (Control)
Chronic Intermittent Hypoxemia
Regular diet
High Cholesterol diet 9

21. Atherosclerosis and Hypoxemia?
Sections of aorta from the mice:
*Savransky V et al Am J Respir Crit Care Med, 2007
Intermittent Air (Control)
Chronic Intermittent Hypoxemia
Regular diet
High Cholesterol diet

22. Cardiovascular Disease
Modern View (?)
OSA
↑ Oxidative Stress
↑ Sympathetic Activity
Independent additive risk factor
Mechanical upper airway obstruction
Insulin Resistance
Intermittent Hypoxemia
Low grade Inflammation
Cardiovascular Disease
Obesity
Insulin Resistance
Hypertension
Low Grade Inflammation
Ischemic heart diseases
↑ Oxidative Stress
Arrhythmias
Endothelial Dysfunction
CV stroke/TIA

23. Fatal CV events and OSA
Months
Marin JM et al. Lancet, 2005

24. Nonfatal CV events and OSA
Marin JM et al. Lancet, 2005

25. Sleep and Mental Illness
OSA can exacerbate mental illness: - Aggression /cognition in schizophrenia - Depression - Nightmares in PTSD - Cognitive dysfunction in dementias - Relapse to substance abuse
Psychiatric illness
Sleep
Lee EK and Douglass AB. Can J Psychiatry, 2010; 55(7):

26. TREATMENTS FOR OSA **CPAP – Continuous Positive Airway Pressure
**Weight Loss - ↓ BMI = ↓ RDI
Avoid Alcohol Consumption
Avoid Sedative Medications
“Snoreball” Technique / Positional Therapy
Oral Appliance
Upper Airway Surgery
Tonsillectomy (pediatrics)
Uvulopalatopharyngoplasty (UPPP)
Maxillomandibular advancement
Tracheostomy

27. CPAP for OSA

29. Alcohol on Breathing 53 yr old male, “social drinker”
Snoring (baseline)
Snoring, 2nd night, drank EtOH 6-9 PM, about 8-10 drinks
Issa and Sullivan, J Neurol Neurosurg Psychiatr, 1982; 45:353-9

30. Oral Appliances Klearway- Silencer- Great Lakes Orthodontics
Johns Dental Labs

31. Surgery (UPPP)

32. Restless Legs Syndrome

33. Restless Legs Syndrome
NB- symptoms WHILE AWAKE
“URGE”
U – rge to move legs
R – est – symptoms worsened at rest
G – ets better with movement
E – vening – symptoms worse in evening
Often associated with periodic limb movements (PLMs), WHILE ASLEEP

34. Epidemiology – RLS Affects 5-15% of the population
Mean age – years old - prevalence increases with age - age of onset varies widely (children – elderly)
Up to 2.5X more common in women

35. Restless Leg Syndrome + PLMD
Thought to be related to same problem – dopamine deficiency in the brain
May be exacerbated by caffeine, nicotine, alcohol, or iron deficiency
Mainstay of treatment - Dopamine replacement therapy - levodopa, pramipexole, ropinirole - Other meds may also help - neurontin, benzodiazepines, opioids

36. Narcolepsy
A pathologic disorder of sleepiness during the day – key symptom – sleepiness
May have insomnia at nighttime
Affects about 1/2000 people
Very underdiagnosed; difficult to recognize
80% may have cataplexy, a REM sleep intrusion phenomenon on wakefulness
Related to cerebrospinal fluid deficiency of hypocretin (orexin)

37. Narcolepsy Treatment SLEEPINESS: CATAPLEXY:
Stimulants d-amphetamine (Dexedrine), methylphenidate (Ritalin) Novel - modafinil (Alertec / Provigil). - armodafinil
CATAPLEXY:
Antidepressants – e.g. venlafaxine
Sodium oxybate (Xyrem)

38. Summary
Sleep has a distinct architecture and is normally regulated by a complex set of environmental, biological and social influences
Insomnia and excessive daytime sleepiness are common issues among patients
If sleep is problematic, assessment for an underlying sleep disorder such as obstructive sleep apnea, restless legs syndrome, narcolepsy or others is important, as effective treatments are available for these conditions

39. Screening Questions For Symptoms Of Poor Sleep
Do you feel satisfied with the quality of your sleep?
Does you partner complain about your sleep?
Do you have difficulties falling or staying asleep?
Do you have problems with sleepiness during the day?