Non-Respiratory Disorder Pearls Canadian Respiratory Conference April 16, 2016

Gosia Eve Phillips, MD Diplomate, American Board of Psychiatry and Neurology, Cert. Assistant Professor of Medicine, Division of Respirology, Dalhousie University

Financial Interest Disclosure

 I have no conflict of interest.

“I’m interested in breathing disorders… Why would I want to know about non-respiratory sleep disorders?”

Why?

 Understand challenges in diagnosis and treatment of when comorbid sleep disorders are present

 Daytime symptoms may persist despite treatment of sleep apnea

 Identification and management of sleep disorders optimizes patient care Sleep Disorders

 Circadian Rhythm Disorders

 Sleep Related Movement Disorders

of Central Origin Objectives

 Evaluation of sleep disorders

 Diagnostic tests

 Management of sleep disorders

Evaluation

 Clinical History and Exam:

 Time course/ Precipitating factors

 Sleep-wake schedule

 Sleep-related phenomena, daytime symptoms

 Medical, psychiatric, substance history

 Sleep Studies

 Lab

 Multiple Sleep Latency Test

 Ambulatory Insomnia

Insomnia

or maintenance insomnia

 Waking earlier than desired

 Despite adequate opportunity & circumstances for sleep

Insomnia Symptoms

 fatigue or malaise  attention, concentration, or memory impairment  social or vocational dysfunction or poor school performance  mood disturbance or irritability  daytime sleepiness  motivation, energy, or initiative reduction  proneness for errors or accidents at work or while driving  tension, headache, GI upset  concerns about or dissatisfaction with sleep

Insomnia - Tx

 Cognitive Behavioural Therapy (CBT) (standard):

 Cognitive: change pt’s beliefs & attitudes about insomnia

 e.g. attention shifting, decatastrophizing, reappraisal

 Behavioural: may include stimulus control tx, sleep restriction, relaxation training

education: (insufficient evidence alone)

 health practices: diet, exercise, substance abuse

 environmental factors e.g. light, noise, T Insomnia - Tx

 Psychological & behavioural interventions effective:

 Stimulus control tx: break conditioned response to temporal (BT) & environmental () cues that pt. associates with sleeplessness

 Use bedroom only for sleep and intimacy

 Avoid eating or TV in bed

 Leave bedroom if unable to fall asleep after 20 min

 Establish consistent sleep-wake schedule & avoid Insomnia - Tx

 Relaxation training

 Methods to reduce somatic tension or intrusive thoughts at BT that interfere with sleep

 Guided imagery (focus on pleasant or neutral images to block out unwanted thoughts)

 Meditation

 Biofeedback e.g. muscle tension

 Progressive muscle relaxation

 Sleep restriction

 Time in Bed Restriction Pharmacologic Tx

 Can be considered short-term

 Tailor to patient’s comorbid conditions

 E.g.

 BZD/BZD r. agonists: Zopiclone, zolpidem

 Antidepressants: TCA’s, trazodone, mirtazapine

 AEDs: Gabapentin

 Atypical antipsychotics: quetiapine

 OTC anti-histamines, anti-histamine/analgesics & natural remedies not recommended d/t lack of efficacy and safety data Circadian Rhythm Disorders Circadian Rhythm Disorders

 Inability to set internal sleep-wake cycle to environmental time cues

Sequelae:

 Difficulty sleeping, EDS, or both

 Impairment of social, occupational, or other areas of functioning

Treatment - DSPS

 Bright Light Protocol

 10,000 lux phototherapy on awakening to “reset” the clock

 Advance wake time by ½ hour q2-3 days

 Melatonin ~12 hrs before desired wake-time

 Chronotherapy

 Delay in schedule of sleep time until desired sleep schedule reached

 Insufficient evidence to recommend hypnotics or stimulants Shift Work Disorder

 Insomnia or excessive sleepiness that is temporally associated with a recurring work schedule that overlaps the usual time for sleep

Shift Work Disorder-Tx

 To improve daytime sleep:

 Melatonin e.g. 2-3 mg prior to sleep

 Hypnotics prior to sleep Shift Work Disorder-Tx

 To improve alertness:

 Planned napping before or during shift

 Light exposure at work/restriction following shift

 Modafinil (Alertec)

 Caffeine Restless Legs Syndrome (RLS)/ Periodic Limb Movement Disorder (PLMD)

Restless Legs Syndrome (RLS)

 Urge to move legs, usually with or caused by uncomfortable & unpleasant sensations in legs

 Begins or worsens during rest or inactivity e.g. lying or sitting

 Partially or totally relieved by movement

 Worse, or only occurs in evening or night RLS

 Idiopathic

 Secondary

 Iron deficiency (ferritin <50 mcg/L)

 End-stage renal disease (25-50%)

 Peripheral neuropathy

Periodic Limb Movement Disorder

 Repetitive, highly stereotyped limb movements PSG

 PLMS index >15/hr (clinical correlation)

 Clinical sleep disturbance or EDF RLS/PLMD Treatment

RLS: 1/2-2 hrs before onset of RLS PLMD: at Low dose

 DA agonists

 e.g. pramipexole, ropinorole

 Carbidopa/Levodopa: prn use

 Anticonvulsants

 e.g. gabapentin, pregabalin

 Opioids

 e.g. oxycodone

 Benzodiazepines

 e.g. clonazepam

RLS/PLMS Treatment

 Avoidance of:

 Caffeine, EtOH, nicotine

 Antidepressants e.g. SSRI’s/SNRI’s, TCA’s

 Antihistamines

 DA antagonists

Central Disorders of Hypersomnolence

with Cataplexy  Narcolepsy without Cataplexy  Idiopathic

International Classification of Sleep Disorders 3 (ICSD-3) Narcolepsy/Sleep apnea

 Danish study, n=757 diagnosed with narcolepsy  One of the most common comorbid diagnoses in narcolepsy was sleep apnea  Odds ratio of sleep apnea = 19.2 prior to narcolepsy diagnosis

 Sleep. 2013 Jun 1; 36(6): 835–840. Comorbidity and Mortality of Narcolepsy: A Controlled Retro- and Prospective National Study; Jennum et al.

Narcolepsy

 Cardinal symptom: excessive daytime sleepiness  Irrepressible need to sleep or lapses into sleep  May have sleep attacks  Sleep refreshing  Sleepiness resumes after variable times

Other features of narcolepsy

 Hypnagogic hallucinations (40-80%)  Visual, tactile, kinetic, auditory  Associated w/ fear or dread

(40-80%)  Transient (sec.-minutes) inability to move or speak during transition between sleep & wakefulness  Often w/ hypnagogic hallucinations

 Nocturnal sleep disruption (50%) Narcolepsy with Cataplexy

 Cataplexy: sudden brief loss of muscle tone triggered by emotions  Usually positive e.g. laughter, joking, pride, elation, surprise > negative  Generally bilateral, duration=seconds, <2 min, can be localized  Head drop, facial sag, dysarthria, knee buckling to complete collapse  Consciousness preserved, at least initially, may fall asleep  Loss of DTR’s

Cataplexy

Chloe

https://www.youtube.com/watch?v=iva_CPA-Qbw&feature=player_detailpage Treatment of Narcolepsy

 Scheduled naps

 Hypersomnia:

 Modafinil, stimulants

 Sodium oxybate (GHB)

 Cataplexy:

 Sodium oxybate, TCA’s, SSRI’s, venlafaxine

Idiopathic Hypersomnia

 Constant & severe excessive sleepiness

 Prolonged unrefreshing naps >1hr

 Few or no awakenings

 “Sleep drunkenness”: severe and prolonged with great difficulty waking

 Irritability, automatic behavior, psychomotor retardation, poor coordination, confusion

 Lasts minutes to >1hr

 Repeated returns to sleep

Idiopatic Hypersomnia Therapy

 Wake-promoting agents/stimulants e.g. modafinil, methylphenidate, dextoamphetamine with variable effect

 May need high doses or combination of drugs

 Lack of efficacy, tolerance, and side effects common Conclusion

 Consider full spectrum of sleep disorders

 Insomnia, Hypersomnias, RLS/PLMD, Circadian Rhythm Disorders

 History +/- sleep studies key for evaluation

 Treatment goal

 Improve health

 Improve social/occupational function

 Better QOL

Thank you for your attention!