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BEHAVIORAL HEALTH ECHO MODULE 4: SLEEP DISORDERS April 11, 2019 Jeremy Stoddart MD Assistant Professor (Clinical) Department of Psychiatry Sleep|Wake Center

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BEHAVIORAL HEALTH ECHO MODULE 4: SLEEP DISORDERS April 11, 2019 Jeremy Stoddart MD Assistant Professor (Clinical) Department of Psychiatry Sleep|Wake Center BEHAVIORAL HEALTH ECHO MODULE 4: SLEEP DISORDERS April 11, 2019 Jeremy Stoddart MD Assistant Professor (Clinical) Department of Psychiatry Sleep|Wake Center © UNIVERSITY OF UTAH HEALTH Addressing Sleep In Primary Care © UNIVERSITY OF UTAH HEALTH I have no pertinent financial or commercial conflicts to disclose. © UNIVERSITY OF UTAH HEALTH OBJECTIVES • Define sleep and hypothesized purposes of sleep • Describe key features of major sleep disorders • Demonstrate evaluation tools for assessing sleep health & pathology © UNIVERSITY OF UTAH HEALTH WHY CARE ABOUT SLEEP? • 46% of Americans report inadequate sleep • 54% of drivers have driven drowsy within the last year • 28% of drivers drive drowsy at least monthly1 • Abnormalities in sleep are linked to cardiovascular, neurologic, immune, endocrine, psychiatric, occupational and 2 relationship dysfunction. 1. http://www.sleepfoundation.org 2. https://imgur.com/gallery/8Ff96 © UNIVERSITY OF UTAH HEALTH DEFINITIONS OF SLEEP Behavioral Physiologic • Decreased mobility (polysomnographic) • Species-specific sleeping • EEG: synchronized or posture theta/sawtooth • Decreased • EMG: reduced to absent responsiveness • EOG: slow rolling or rapid • Quiescence eye movements • increased reaction time • Elevated arousal threshold • Attenuated cognitive function © UNIVERSITY OF UTAH HEALTH BIOLOGICAL FUNCTIONS OF SLEEP • Body and brain tissue restoration • Facilitation of waste clearance of the CNS via glymphatic system • Energy conservation • Adaptation • Memory reinforcement and consolidation • Synaptic neuronal network integrity • Thermoregulation © UNIVERSITY OF UTAH HEALTH SLEEP DURATION CONSENSUS • 2015:AASM, Sleep Research Newborns (0-3 mos): 14-17 h Society, National Healthy Sleep Awareness Project, Infants (4-11 mos): 12-15 h Sleep Health Objective of Toddlers (1-2 years): 11-14 h Healthy People. Preschoolers (3-5): 10-13 h • n=2391, 20-39 y – Sleep <7 hours associated with School-age (6-13): 9-11 h low physical and mental HRQOL Teenagers (14-17): 8-10 h – Sleep <6 hours associated with Young adults (18-25): 7-9 h higher risk for cardiovascular disease Adults (26-64): 7-8 h • In the last half of the 20th Older adults (65+): 7-8 h century, average sleep duration has decreased by 1.5-2 hours per night. © UNIVERSITY OF UTAH HEALTH BORBÉLY’S TWO PROCESS MODEL Process S Process C • Sleep/wake homeostasis or • Circadian Rhythm “sleep drive” • Genetic variations: (night • As wakefulness progresses, owls/morning larks) adenosine builds in CNS and • Suprachiasmatic nucleus inhibits DA firing and promotes (SCN): pacemaker slow wave sleep (SWS) and – Produces melatonin drowsiness – Regulates changes in • Caffeine is an adenosine biorhythms: • Core body temperature receptor antagonist • Appetite • Sleep • Hormones • 24.15 hours • Stabilized by zeitgeibers (time givers): 450 nm light (blue) suppresses melatonin production in pineal gland Daroff RB, Jakovic J, Mazziota JC, Pomeroy SL, eds. Bradley’s Neurology in Clinical Practice. 7th ed. Vol 1. London: Elsevier, 2016:1615-1685. © UNIVERSITY OF UTAH HEALTH PROCESS C Daroff RB, Jakovic J, Mazziota JC, Pomeroy SL, eds. Bradley’s Neurology in Clinical Practice. 7th ed. Vol 1. London: Elsevier, 2016:1615-1685. © UNIVERSITY OF UTAH HEALTH PRIMARY SLEEP COMPLAINTS • Excessive daytime sleepiness • Insomnia • Abnormal sleep behaviors © UNIVERSITY OF UTAH HEALTH EXCESSIVE DAYTIME SLEEPINESS • Yawning, sagging of eyelids, nodding, increased reaction time. • Differs from fatigue: a state of sustained lack of energy as might be seen in MS coupled with lack of motivation or drive. © UNIVERSITY OF UTAH HEALTH TAKING A HISTORY Sleep hygiene: Breathing events: • Evening routine • Snoring • Bedtime vs sleep-onset • Nasal congestion • Wake time vs out-of-bed • Tonsils Movements • Weight change • Urge to move • Gasping • Leg discomfort • Witnessed apneas • PLMS • Sleep position • Dream enactment Daytime symptoms: Nocturnal event • Naps • Sleepwalking • Drowsy driving/near miss • Night terror • School/job performance • Rhythmic movement • Cataplexy • Timing, duration, recall? • Sleep attacks • Hallucinations/paralysis © UNIVERSITY OF UTAH HEALTH EXCESSIVE DAYTIME SLEEPINESS 0-5 Lower Normal Daytime Sleepiness 6-10 Higher Normal 11-12 Mild Excessive Daytime Sleepiness 13-15 Moderate EDS 16-24 Severe EDS 1. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14:540-5. © UNIVERSITY OF UTAH HEALTH SPECIALTY ASSESSMENT OF EDS Mean Sleep Latency Test Maintenance of (MSLT) Wakefulness Test (MWT) • Measures tendency to fall • Similar to MSLT but asleep by measuring time to instead patients are fall asleep using PSG seated and ability to stay • Assuming adequate sleep (>7 hours/night for 2 weeks), awake without subjects are given 4-5 nap stimulation is assessed opportunities spaced by 2 Psychomotor Vigilance hours and limited to 20 minutes. Test (PVT) • Need to be free of sleep • Direct measure of motor disrupting medication (aka: and visual attention psychotropics) . © UNIVERSITY OF UTAH HEALTH FLOWCHART OF EXCESSIVE DAYTIME SLEEPINESS Principles and Practice of Sleep Medicine, Chapter 58, 576-586.e3. 2017 © UNIVERSITY OF UTAH HEALTH CIRCADIAN RHYTHM DISORDERS A. A persistent or recurrent pattern of sleep disruption that is primarily due to an alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep–wake schedule required by an individual’s physical environment or social or professional schedule. B. The sleep disruption leads to excessive sleepiness or insomnia, or both. C. The sleep disturbance causes clinically significant distress or impairment in social, occupational, and other important areas of functioning. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 390-391. 2013 © UNIVERSITY OF UTAH HEALTH CRD PRESENTATION • Difficulty falling asleep at their desired time* • Difficulty waking at desired time • When allowed to set their own schedule, patients exhibit normal quality and amounts of sleep for their age. *allowing for adequate amounts of sleep © UNIVERSITY OF UTAH HEALTH http://sleepeducation.org/docs/default-document-library/sleep-diary.pdf © UNIVERSITY OF UTAH HEALTH © UNIVERSITY OF UTAH HEALTH ACTIGRAPHY © UNIVERSITY OF UTAH HEALTH CIRCADIAN RHYTHM DISORDERS Insomnia during the major sleep period and/or excessive sleepiness (including inadvertent sleep) during the major awake period • Shift Work Type Circadian Rhythm Disorder – associated with a shift work schedule (work hours outside 7 am to 7 pm) • Social Jet Lag – Mismatch between workday and non-workday sleep times • Delayed Sleep Phase Circadian Rhythm Disorder – Sleep onset insomnia, difficulty awakening and excessive morning sleepiness • Advanced Sleep Phase Circadian Rhythm Disorder – Early morning sleep maintenance insomnia, excessive afternoon/evening sleepiness • Non-24 Hour Sleep-Wake Disorder (Free-Running Disorder) – 18-73% of totally blind individuals; extremely rare in sighted individuals – Typically delay sleep-wake phase successively each day • Irregular Sleep-Wake Rhythm Disorder – No regular sleep-wake pattern – No major sleep phase © UNIVERSITY OF UTAH HEALTH FLOWCHART OF EXCESSIVE DAYTIME SLEEPINESS Principles and Practice of Sleep Medicine, Chapter 58, 576-586.e3, 2017. © UNIVERSITY OF UTAH HEALTH SLEEP DISTURBANCES • Sleep disordered breathing (OSA/OHS) • Restless Legs Syndrome • Periodic Limb Movement Disorder • GERD • Pain • BPH • CHF © UNIVERSITY OF UTAH HEALTH SLEEP DISORDERED BREATHING Obstructive Sleep Apnea (Can’t Breathe) • Upper airway collapse with sleep disruption or intermittent hypoxemia • Continued respiratory effort without airflow Central Sleep Apnea (Won’t Breathe) • Pause of central ventilatory drive • No respiratory effort or airflow Periodic Breathing • Cheyne-Stokes Respirations • Alternating hyperventilation and central apneas due to unstable ventilatory control Sleep-related Hypoventilation • Non-obstructive decreases in minute ventilation © UNIVERSITY OF UTAH HEALTH SDB QUESTIONNAIRES • STOP BANG • Berlin • Sn=0.84; Sp=0.56 • Sn=0.69; Sp=0.83 • Low risk for OSA: yes to 0 to 2 questions. High • High Risk: > 2 categories with score 2+ risk for OSA: yes to 3 or more questions.1 • Low Risk: ≤ 1 category with score 2+ 1. From Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008;108[5]:812−21, with permission. 2. Kang K, Park KS, Kim JE, et al: Usefulness of the Berlin Questionnaire to identify patients at high risk for obstructive sleep apnea: a population-based door-to-door study. Sleep Breath 2013; 17: pp. 803-810 © UNIVERSITY OF UTAH HEALTH WILLIS-EKBOM DISEASE/ RESTLESS LEGS SYNDROME 1. Urge to move the legs accompanied by/due to discomfort 2. Urge or discomfort more prevalent when at rest 3. Urge or discomfort is relieved by movement 4. Urge or discomfort occurs only or worse in the evening 5. The above do not occur only in context of another medical or psychiatric condition (eg arthritis, habitual tapping, myalgias, sciatica, etc.) Modified from Allen RP, Picchietti DL, Garcia-Borreguero D, et al. Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria—history, rationale, description, and significance. Sleep Med 2014;15(8):860−73. • Assessment © UNIVERSITY OF UTAH HEALTH FLOWCHART OF EXCESSIVE
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