Sleep:The Golden Chain That Ties

Health and Our Bodies Together(A Review of Sleep Disorders)

Academy Of Medicine Clinical Day, February 24, 2012Elliott K. Lee MD, FRCP(C), D. ABPN, D. ABPN Addiction Psychiatry, D. ABSM

Assistant Professor, University of Ottawa Faculty of MedicineSleep Specialist, Royal Ottawa Mental Health Center Sleep

Disorders Clinic

Objectives

Describe the importance of sleep and impact of sleep disorders in the community.

Understand common sleep disorders and how they can be assessed and treated. 

Outline

Review sleep architecture, and how sleep is controlled.

Review insomnia and excessive daytime sleepiness, and their causes

SLEEP

NREM Sleep

Stage N1, N2 (“Light sleep”)

procedural memory (skills, motor learning)

Stage N3 Deep or “Slow Wave

Sleep” (SWS)

CNS restorationDeclarative memory

REM Sleep

DreamingMood Regulatory Role?

Memory?

Sleep Hypnogram

Insomnia Excessive Daytime Sleepiness

Insomnia

Affects 3.3 million Canadians (1/7) according to Statistics Canada (2002)

Especially:- Middle aged (45-64)- Widowed- Minimal education- Obese- Women > men

Treating Insomnia:Personal Sleep Hygiene

Maintain a regular wake/sleep schedule, possibly add mild sleep restriction.

Refrain from taking naps. Exercise - but not within 3 hours of bedtime. Establish a relaxing routine before bedtime. Use the bedroom only for sleep activities. Avoid clock watching Set environment (light, noise, temperature)

at comfortable levels. Avoid caffeine after mid-afternoon.

Medication options

Zopiclone (Imovane)Trazodone (Desyrel)Other options:

- Melatonin- Tricyclic Antidepressants- Benzodiazepines- Mirtazapine (Remeron)- Atypical Antipsychotics

Eszopiclone

Sleep latency from ave = 70 minPlacebo = 45 minEszopiclone = 27.3 min

Total Sleep TimePlacebo = 330 minEszopiclone = 390 min

Eszopiclone users had improved quality of life, and no reported incidence of tolerance or withdrawal

Sleep Latency

Total Sleep Time

Walsh et al, Sleep, 2007

Obstructive Sleep Apnea (OSA) Pauses in breathing > 10 seconds in length Respiratory Disturbance Index (RDI): >5 hr =

significant Prevalence – up to 25% of men, and 9% of women Key diagnostic questions:

- Do you feel satisfied with the quality of your sleep?- Does your partner complain that you snore?

Obstructive Sleep Apnea Syndrome Symptoms

Snoring >80%*up to ½ of pts may sleep separately from partners

Apneic episodes (partner) 75%AM Dry Mouth 74%Restless Sleep/ AM H/A 50%Sensation of choking 18-

31%Nighttime bathroom visits 28%Kryger, Roth and Dement, Principles and

Practice of Sleep Medicine, 2005 p. 1043

OBSTRUCTIVE SLEEP APNEA (OSA)

Causes ▪ Narrow Upper Airway ▪ Elevated BMI ▪ Family Hx

Exacerbated by: ▪ Medications – muscle relaxants,

sedatives ▪ Alcohol Consumption

▪ Supine sleep ▪ REM sleep ▪ **Supine + REM sleep

Consequences of OSA

Odds Ratio – AHI to Hypertension

Peppard PE et al. N Eng J Med, 2000; 342(19): 1378-84

Odds Ratio – AHI to Hypertension

Peppard PE et al. N Eng J Med, 2000; 342(19): 1378-84

Change in BP with use of CPAP (9 weeks)

Becker HF et al. Circulation, 2003; 107(1):68-73

Traditional View

Obesity

Insulin Resistance

Low Grade Inflammation

↑ Oxidative Stress

Endothelial Dysfunction

Hypertension

Ischemic heart diseases

Arrhythmias

CV stroke/TIA

CardiovascularDisease

Atherosclerosis and Hypoxemia?Savransky and colleagues studied mice

– divided into 4 groups:

Intermittent Air (Control)

10

10

Chronic Intermittent Hypoxemia

10

10

Regular diet

High Cholesterol

diet

*Savransky V et al Am J Respir Crit Care Med, 2007

Atherosclerosis and Hypoxemia?Which ones developed atherosclerosis?

Intermittent Air (Control)

Chronic Intermittent Hypoxemia

Regular diet

High Cholesterol

diet

0

0

0

9

*Savransky V et al Am J Respir Crit Care Med, 2007

Atherosclerosis and Hypoxemia?Sections of aorta from the mice:

Intermittent Air (Control)

Chronic Intermittent Hypoxemia

Regular diet

High Cholesterol

diet

*Savransky V et al Am J Respir Crit Care Med, 2007

Modern View (?)

Obesity

Insulin Resistance

Low Grade Inflammation

↑ Oxidative Stress

Endothelial Dysfunction

Hypertension

Ischemic heart diseases

Arrhythmias

CV stroke/TIA

CardiovascularDisease

Mechanical upper airway obstruction

↑ Oxidative Stress

↑ Sympathetic Activity

Insulin Resistance

Intermittent Hypoxemia

Low grade Inflammation

Independent additive risk factor

OSA

MonthsMarin JM et al. Lancet, 2005

Fatal CV events and OSA

Nonfatal CV events and OSAMarin JM et al. Lancet, 2005

Sleep and Mental Illness

OSA can exacerbate mental illness:- Aggression /cognition in schizophrenia- Depression- Nightmares in PTSD- Cognitive dysfunction in dementias- Relapse to substance abuse

Sleep Psychiatricillness

Lee EK and Douglass AB. Can J Psychiatry, 2010; 55(7): 403-12

TREATMENTS FOR OSA

**CPAP – Continuous Positive Airway Pressure **Weight Loss - ↓ BMI = ↓ RDI Avoid Alcohol Consumption Avoid Sedative Medications “Snoreball” Technique / Positional Therapy Oral Appliance Upper Airway Surgery

Tonsillectomy (pediatrics) Uvulopalatopharyngoplasty (UPPP) Maxillomandibular advancement Tracheostomy

CPAP for OSA

Stage 4Stage 3Stage 2Stage 1

REMWake

Movement

23:00 00:00 01:00 02:00 03:00 04:00 05:00 06:00

STAG

ING

60

80

100

23:00 00:00 01:00 02:00 03:00 04:00 05:00 06:00

OXI

MET

RY

0

10

20

23:00 00:00 01:00 02:00 03:00 04:00 05:00 06:00

CPAP

Alcohol on Breathing

Issa and Sullivan, J Neurol Neurosurg Psychiatr, 1982; 45:353-9

Snoring (baseline)

Snoring, 2nd night, drank EtOH 6-9 PM, about 8-10 drinks

53 yr old male, “social drinker”

Oral Appliances

Silencer-

Johns Dental Labs

Klearway-

Great Lakes Orthodontics

Surgery (UPPP)

Restless Legs Syndrome

Restless Legs Syndrome

NB- symptoms WHILE AWAKE“URGE”

U – rge to move legs

R – est – symptoms worsened at rest

G – ets better with movement

E – vening – symptoms worse in evening

Often associated with periodic limb movements (PLMs), WHILE ASLEEP

Epidemiology – RLS

Affects 5-15% of the population Mean age – 27- 41 years old

- prevalence increases with age- age of onset varies widely

(children – elderly)Up to 2.5X more common in women

Restless Leg Syndrome + PLMD

Thought to be related to same problem – dopamine deficiency in the brain

May be exacerbated by caffeine, nicotine, alcohol, or iron deficiency

Mainstay of treatment- Dopamine replacement therapy

- levodopa, pramipexole, ropinirole- Other meds may also help

- neurontin, benzodiazepines, opioids

Narcolepsy

A pathologic disorder of sleepiness during the day – key symptom – sleepiness

May have insomnia at nighttimeAffects about 1/2000 peopleVery underdiagnosed; difficult to recognize80% may have cataplexy, a REM sleep

intrusion phenomenon on wakefulnessRelated to cerebrospinal fluid deficiency of

hypocretin (orexin)

Narcolepsy Treatment

SLEEPINESS: – Stimulants

d-amphetamine (Dexedrine), methylphenidate (Ritalin)

Novel - modafinil (Alertec / Provigil).- armodafinil

CATAPLEXY:– Antidepressants – e.g. venlafaxine– Sodium oxybate (Xyrem)

Summary

Sleep has a distinct architecture and is normally regulated by a complex set of environmental, biological and social influences

Insomnia and excessive daytime sleepiness are common issues among patients

If sleep is problematic, assessment for an underlying sleep disorder such as obstructive sleep apnea, restless legs syndrome, narcolepsy or others is important, as effective treatments are available for these conditions

Screening Questions For Symptoms Of Poor Sleep

Do you feel satisfied with the quality of your sleep?

Does you partner complain about your sleep?

Do you have difficulties falling or staying asleep?

Do you have problems with sleepiness during the day?