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Sleep Disorders?” 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! .
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