Surgery for and Snoring and Considerations for Managing Insomnia in Older Adults: Safe and Effective Treatment Eric J. Kezirian, MD, MPH Professor and Vice Chair, Otolaryngology – Head & Neck Surgery Past President, International Surgical Sleep Society Board-Certified in Otolaryngology and Sleep Medicine

Sleep-Doctor.com [email protected]

http://sleep-doctor.com/blog Disclosures

Medical Advisory Board ReVENT Medical Medical Advisory Board Pillar Palatal Medical Advisory Board Cognition Life Science Medical Advisory Board CryOSA Research Funding Inspire Medical Systems Consultant Nyxoah Consultant Split Rock Scientific Intellectual Property Rights Magnap, Endoscope Consultant, IP Rights Berendo Scientific Consultant Gerard Scientific

http://sleep-doctor.com/blog Snoring No good measures of quantification Smartphone apps: SnoreLab ($10)

Behavioral: sleep disruption

Association with carotid intima-media thickening and atherosclerosis No association with femoral IMT, atherosclerosis ? Clinical relevance (low levels)

http://sleep-doctor.com/blog (OSA) Symptomatic, repeated upper airway obstruction during sleep Severity quantified: apnea-hypopnea index (AHI) Mild (>5-15), Moderate (>15-30), Severe (>30)

Behavioral: sleep disruption Health-related: cardiovascular, endocrine

National Institutes of Health – OSA affects 18-20 million American adults http://sleep-doctor.com/blog Marin Lancet 2005

Prospective cohort study

CV events only in untreated severe OSA Odds of CV death increased (adjusted OR 2.87; 95% CI 1.17- 7.51)

http://sleep-doctor.com/blog OSA Risk Factors

Male Age—children, older adults Overweight / Obese Neck circumference >16 inches W, >17 inches M Structural abnormalities Large tonsils or adenoids Large Craniofacial abnormalities Disruptive snoring Daytime sleepiness

http://sleep-doctor.com/blog Sleep Studies Necessary for diagnosis of OSA In-laboratory polysomnogram Home sleep apnea test

Payors prefer home tests In-lab needed for concerns about central sleep apnea; insomnia; or cardiac, pulmonary, or neurologic disease

http://sleep-doctor.com/blog Snoring and OSA Treatment Behavioral measures Weight loss Avoid supine body position Avoid alcohol and sedatives PAP Surgery Oral appliances

http://sleep-doctor.com/blog OSA Treatment

Positive airway pressure CPAP BPAP APAP

http://sleep-doctor.com/blog Common Role of OSA Surgery Adults unable to tolerate PAP therapy (30-50%) In addition to behavioral measures, options: No treatment Surgery Oral appliances

Goal is resolution of OSA, although may accept improvement, based on belief that partial treatment better than none

http://sleep-doctor.com/blog Uvulopalatopharyngoplasty (UPPP)

http://sleep-doctor.com/blog Surgery Does Not Work?

137/337 = 40.7%

Table 8 Level 4 Sher, Sleep 1996;19:156-177 http://sleep-doctor.com/blog OSA Surgical Procedures and Outcomes

Surgery = Anatomy

Effective surgery directed at site(s) of obstruction Nasal Region Region Tongue Region

http://sleep-doctor.com/blog Palate Procedures Uvulopalatopharyngoplasty Expansion Sphincter Pharyngoplasty Lateral Pharyngoplasty Uvulopalatal Flap Relocation Pharyngoplasty Transpalatal Advancement Pharyngoplasty Z-

Pillar Procedure Palate Radiofrequency Laser-assisted Palatoplasty Injection Snoreplasty Others (CAPSO, variations) http://sleep-doctor.com/blog Pillar Procedure PTFE (Dacron) implants placed into soft palate Office procedure Stiffen palate by: • implant stiffness • natural healing process (muscle growing into spaces in implants)

http://sleep-doctor.com/blog Modified Expansion Sphincter Pharyngoplasty, aka Functional Expansion Pharyngoplasty

http://sleep-doctor.com/blog OSA ≠ OSA ≠ OSA: Patients Are Different

http://sleep-doctor.com/blog Drug-Induced Sleep Endoscopy (DISE) Developed in Europe (1991) Used in several centers around the world but less commonly in U.S.

Fiberoptic endoscopy of sedated patient Goal: reproduce SDB seen on sleep study

VOTE Classification Kezirian Eur Arch ORL 2011 DISE associated with surgical outcomes Green Laryngoscope 2019

http://sleep-doctor.com/blog Velum (Palate)

http://sleep-doctor.com/blog Oropharyngeal Lateral Walls

http://sleep-doctor.com/blog Tongue

http://sleep-doctor.com/blog Epiglottis

http://sleep-doctor.com/blog Hypopharyngeal Procedures

Tongue radiofrequency Tongue stabilization Hyoid suspension Midline

Maxillomandibular advancement

http://sleep-doctor.com/blog Tongue Radiofrequency

Many areas of the body Heart, prostate, oncology

Energy delivered to create injury, then fibrosis

http://sleep-doctor.com/blog Midline Glossectomy

http://sleep-doctor.com/blog Maxillomandibular Advancement

http://sleep-doctor.com/blog Hypoglossal Nerve Stimulation Inspire Upper Airway Stimulation • Inspire therapy: Stimulation – Fully implanted lead – Senses breathing – Mild stimulation to key airway muscles via hypoglossal nerve Generator – Turns on with a sleep remote

Sensing lead

http://sleep-doctor.com/blog What Do I Do?: Structure-Based Approach Velum/Palate UPPP ± Other palate procedures (ESP and LP) Oro LW ? Hyoid suspension, ESP, LP, MAD/MMA Tongue Genioglossus advancement Tongue RF Tongue stabilization Tongue resection (BMI >30/32) Upper Airway Stimulation (BMI<32; multi) Epiglottis Hyoid suspension vs. Partial epiglott

Maxillofacial MMA Counseling patients key: BMI, AHI, mandible (SNB), ?age http://sleep-doctor.com/blog Conclusions Evaluation of the pattern of upper airway obstruction may enable: Targeted, more effective treatment of OSA Development of new devices or procedures

Poor outcomes have always been considered a failure of surgical technique/skill Selection of appropriate procedures may be just as important

http://sleep-doctor.com/blog Insomnia ≥3 months of difficulty with sleep initiation, maintenance, duration, or quality despite adequate opportunity Prevalence 15-24% High-risk: older adults, woman, shift workers, medical or psychiatric disorders Causes: caffeine (lasts 8-12 hours), corticosteroids, beta-agonists, antidepressants

http://sleep-doctor.com/blog Melatonin Important in Older Adults (Karasek Exp Gerontol 2004)

http://sleep-doctor.com/blog Treatments Sleep aids (alcohol, antihistamines – not good) Cognitive-behavioral therapy (CBT-I) • Sleep hygiene • Stimulus control • Relaxation training – breathing, meditation • Cognitive therapy – education to correct dysfunctional beliefs • Sleep restriction – 5-6 hours, increase slowly Specific training – MD/DO, Psychologist, NP/PA Internet-based CBT-I (not available): Sleepio, SHUTi

http://sleep-doctor.com/blog Medications (Winkelman NEJM 2015)

http://sleep-doctor.com/blog Medications

Benzodiazepines: bad for anyone Sedative-hypnotics (Z drugs): bad for older adults --independent association with risk of falls (Kolla 2013) Adjusted OR 4.37 (3.34-5.76)

Melatonin – dose? timing? 10 mg x 1 month? Ramelteon ( Cannabinoids – research in infancy Herbal medications – research favors placebo Mind-body (meditation, acupuncture, Tai chi, yoga) – small studies http://sleep-doctor.com/blog Prolonged Release Melatonin 2 mg: self-reported sleep (WADE BMC Medicine 2010)

http://sleep-doctor.com/blog Conclusions Insomnia is common Different types of insomnia Options include sleep hygiene alone, medications (not ideal for long-term use, except for melatonin which seems safe), and CBT-I Melatonin may be good place to start for older adults

http://sleep-doctor.com/blog