Non-Respiratory Sleep Disorder Pearls Canadian Respiratory Conference April 16, 2016
Gosia Eve Phillips, MD Diplomate, American Board of Psychiatry and Neurology, Cert. Sleep Medicine 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 sleep apnea 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
Insomnia
Circadian Rhythm Disorders
Sleep Related Movement Disorders
Hypersomnias 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 polysomnography
Multiple Sleep Latency Test
Ambulatory sleep study Insomnia
Insomnia
Sleep onset 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
Sleep hygiene 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 (bedroom) 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 naps 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 bedtime 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
Narcolepsy with Cataplexy Narcolepsy without Cataplexy Idiopathic Hypersomnia
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
Sleep Paralysis (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 sleep inertia 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!