CURRENT 0 CLINICAL 0 PRACTICE

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1 SLEEP DISORDERS

2 CURRENT 0 CLINICAL 0 PRACTICE Bone Densitometry in Clinical Practice: Application and Interpretation, by SYDNEY Lou BONNICK, 1998 Sleep Disorders: Diagnosis and Treatment, edited by J. STEVEN POCETA AND MERRILL M MITLER, 1998 Diseases of the Liver and Bile Ducts, edited by GEORGE Y. Wu and JONATHAN ISRAEL, 1998 The Pain Management Handbook: A Concise Guide to Diagnosis and Treatment, edited by M ERIC GERSHWIN and MAURICE E. HAMILTON, 1998 Allergic Diseases: Diagnosis and Treatment, edited by PHIL LIEBERMAN and JOHN A. ANDERSON, 1997 Osteoporosis: Diagnostic and Therapeutic Principles, edited by CLIFFORD J. ROSEN, 1996

3 SlEEP DISORDERS DIAGNOSIS AND TREATMENT Edited by ]. STEVEN POCETA, MD and MERRILL M. MITLER, PhD Scripps Clinic and The Scripps Institute, La Jolla, CA Foreword by SHIRLEY OTIS, MD ~ SPRINGER SCIENCE+BUSINESS ~MEDIA,LLC

4 ISBN ISBN (ebook) DOI / Springer Science+Business Media New York Originally published by Humana Press Inc. in 1998 Softcover reprint of the hardcover 1 st edition 1998 For additional copies, pricing for bulk purchases, andlor information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel: ; Fax: ; humana@humanapr.com All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher. All articles, comments, opinions, conclusions, or recommendations are those of the author(s), and do not necessarily reflect the views of the publisher. Cover design by Patricia F. Cleary This publication is printed on acid-free paper.em:> ANSI Z (American National Standards Institute) Permanence of Paper for Printed Library Materials). Photocopy Authorization Policy: Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Springer Science+Business Media, LLC. provided that the base fee of US $8.00 per copy, plus US $00.25 per page, is paid directly to the Copyright Clearance Center at 222 Rosewood Drive, Danvers, MA For those organizations that have been granted a photocopy license from the CCC, a separate system of payment has been arranged and is acceptable to Springer Science+Busin Media,LLC. The fee code for users of the Transactional Reporting Service is: [ /98 $ $00.25]

5 FOREWORD Everyone sleeps! Sleep is that familiar to us all, yet still remains a medical mystery. The Britannica definition "the normal periodic suspension of consciousness during which the powers of the body are restored" takes into account the essential nature of sleep for optimal human well-being. This has been known since time immemorial. The fear and problems of inadequate sleep are expressed in a quote from Henry IV: o Sleep, 0 gentle Sleep! Nature's soft nurse, how have I frightened thee, That thou no more wilt weigh mine eyelids down and steep my senses in forgetfulness? Shakespeare: Henry IV III.i. Despite many remarkable advances in the study of disorders of sleep, including a new appreciation of the physiologic, endocrinologic, and biologic processes involved, this knowledge has not been welldisseminated to the public nor to the physicians caring for them. Thus, although our knowledge base has increased exponentially, sleep disorders remain a significant and under-treated public health problem. At a time when cost consciousness is pervasive in medicine, the total costs to the public resulting from sleep disorders is almost impossible to estimate. The costs include the risks from the association of sleep apnea with stroke, headache, and hypertension, as well as the costs associated with accidents because of sleep deprivation. Even with the wealth of information regarding sleep disorders available to us, their importance and treatment have not been emphasized in our medical training or clinical practices. Most of the knowledge of the diagnosis and treatment of sleep disorders has existed in small laboratory and specialty-based centers. Many victims of sleep disorders go unaided because of this ignorance. As American medicine has trended toward the primary care physician as director of medical care (versus specialist-directed care), it becomes increasingly important for our primary care physicians to be knowledgeable about disorders of sleep. Nowhere has the trend toward primary-driven health care been more revolutionary than here at the Scripps Clinic. Over the last six years, Scripps has transitioned from v

6 vi Foreword a primarily multispecialty clinic to a greater than 50% primary care physician facility. This trend may be welcomed by some and scorned by others, but for conditions as common as insomnia and snoring, no physician is better positioned for intervention than the primary care physician. Here at Scripps Clinic, we have emphasized the cooperation of specialist and generalist in those areas where the greatest impact can be made. We therefore welcome this informative, clear, and concise book aimed at the education of primary care providers for improvement in patient care delivery. The authors ofthese chapters have been carefully selected to present current expert opinion in a reader-friendly way, emphasizing a practical approach to the disorders. The primary care physician will find that these chapters elucidate sleep complaints and their relationship to common clinical syndromes. The book is clearly and logically organized, easily readable, and should stand as an authoritative work for primary physicians for many years to come. Shirley Otis, MD

7 PREFACE The field of sleep disorders medicine has expanded rapidly in the United States and around the world. Before the 1970s, the study of sleep was an area populated by a few neurologists, psychiatrists, and physiologists. With the recognition that obstructive sleep apnea is a common clinical condition and that many common drugs produce undesirable sedation during the day, the field has grown rapidly. Individual membership in the American Sleep Disorders Association has increased from fewer than 400 members in 1984 to more than 2400 members in Most hospitals and medical groups now have routine access to sleep disorders consultations and laboratories. Physicians in virtually any type of practice will encounter patients with some form of sleep disorder, be it obstructive sleep apnea after extubation, or insomnia in a patient with depression. Primary care physicians routinely see patients in whom the chief complaint suggests a specific sleep disorder, or in whom a sleep disorder indirectly influences their medical condition. Sleep Disorders' major goal is to educate general practitioners in several areas of the clinical practice of sleep disorders medicine. The authors have striven to provide timely and experience-based advice that would be of daily, practical use to any physician. The emphasis is firmly on practice: History-taking, physical examination, differential diagnosis, utilization oflaboratory tests, appropriate use of consultation, and treatments. Certain chapters repeat elements found in others-these points are usually important aspects of a common problem, such as determining the cause of insomnia. We hope that after reading Sleep Disorders: Diagnosis and Treatment, the reader will have a working knowledge of sleep-related conditions, and thus will be able to approach patients suffering disorders of sleep in full confidence. Dr. Patrick Strollo is an active clinician and researcher as well as a member of the American Sleep Disorders Association committee on primary care education. He offers a broad perspective on the evaluation of patients with sleep disorders in a general practice, and elaborates on the details of history-taking and physical examination. As in any field, there are a series of questions whose answers are instrumental to the proper assessment of sleep disorder complaints, and many aspects ofthe sleep disorders history are not appreciated by those outside the field. Thus, the chapter presents a method to develop and expand upon any vii

8 viii Preface sleep related complaint, including sleepiness in the day, fatigue, snoring, or insomnia. Five chapters are devoted to specific conditions that are common in the field of sleep disorders. Dr. Kingman Strohl reviews the many aspects of obstructive sleep apnea. His chapter discusses pathophysiology in sufficient depth for one to understand the typical presentations, symptoms, and therapeutic approach. There is an emphasis on screening procedures, as well as on risk stratification. Dr. J. Steven Poceta, a neurologist and sleep specialist at Scripps Clinic, discusses the restless legs syndrome, which is a condition increasingly recognized by both patients and physicians. A practical approach to diagnosis and treatment is given. Drs. Rafael Pellayo and Christian Guilleminault have worldrenowned expertise in the diagnosis and treatment of central nervous system conditions such as narcolepsy. They review diagnostic criteria, typical presentations, "red flags" in the history, as well as treatment options. Dr. Milton Erman, our colleague at the Scripps Clinic, has a busy practice in sleep disorders as well as research interest in insomnia. He has written numerous papers and chapters on insomnia and its treatment, and is active in several trials of behavioral, medical, and other treatments. He approach is both intellectually stimulating and practical. His description of insomnia and his approach to differential diagnosis will remove the frustration and puzzlement that occur in many practitioners facing such patients. Dr. Daniel Kripke is a recognized expert in circadian rhythms, affective disorder, and bright light therapy. He is also a practicing sleep disorders specialist whose chapter on circadian rhythm disturbances and seasonal affective disorder will be useful in assessing patients with almost any sleep or emotional complaint. Practical aspects of the use of bright light therapy are included for the treatment of jet lag. Drs. Wallace Mendelson and Cosmo Caruso discuss the pharmacology ofbenzodiazepines, other hypnotic-sedatives, tricyclic antidepressants, serotonin reuptake inhibitors, and stimulants. Dr. Ronald Dahl provides a detailed overview of sleep disorders in children, emphasizing common sleep complaints and common sleep disorders in various age groups. Dr. Stephen Johnson is the Director ofthe Western Montana Medical Clinic, holds an MBA, and started his clinic's sleep center in In his chapter, considerations are given to the cost-benefit analysis of diagnosing and treating sleep disorders, as well as the approach to sleep disorders from a managed-care perspective. An emphasis on evolving technologies and protocols should help the reader understand the multitude off actors involved in clinical decision making in this area.

9 Preface ix Drs. Richard Simon, Eric Ball, and Jennings Falcon present their experience when the Walla Walla Clinic set out to train a clinician and set up a sleep lab. Their chapter clarifies the fact that patients with sleep disorders are often overlooked in primary care, but that with education and training, recognition of these disorders is beneficial to patients. We wish to thank all our authors for their fine efforts. It was a pleasure working with such knowledgable and hard-working professionals. We hope that Sleep Disorders will be found as helpful to primary care physicians worldwide as we intended. J. Steven Poceta, MD Merrill M. Mitler, PhD

10 CONTENTS Foreword by Shirley Otis... v Preface vii Contributors... xiii 1 Sleep Disorders in Primary Care... 1 Patrick J Strollo, Jr. 2 Insomnia Milton K. Erman 3 The Uses of Bright Light in an Office Practice Daniel F. Kripke 4 Restless Legs Syndrome and Nocturnal Myoclonus J. Steven Poceta 5 Narcolepsy and Excessive Daytime Sleepiness Rafael Pelayo and Christian Guilleminault 6 Obstructive Sleep Apnea Syndrome Kingman P. Strohl 7 Pharmacology in Sleep Medicine Wallace B. Mendelson and Cosmo Caruso 8 Common Sleep Problems in Children Ronald Dahl 9 Sleep Disorders in Primary Care Practice Richard D. Simon, Jr., Eric M. Ball, and Jennings C. Falcon 10 Sleep Medicine as Preventive Medicine Stephen F. Johnson Index xi

11 CONTRIBUTORS ERIC M. BALL, MD, FACp Kathryn Severyns Dement Sleep Disorders Center, Department of Medicine, St. Mary Medical Center, Walla Walla Clinic, Walla Walla, WA COSMO CARUSO, MD Pulmonary Physicians of Kansas City, Inc., Kansas City, MO RONALD DAHL, MD Child and Adolescent Sleep Laboratory, Departments of Psychiatry and Pediatrics, Western Psychiatric Institute and Clinic, Pittsburgh, PA MILTON K. ERMAN, MD Department of Psychiatry, University of California, San Diego, CA; The Scripps Research Institute, La Jolla, CA; California Sleep Monitoring, Inc., La Jolla, CA; Division of Neurology, Scripps Clinic, La Jolla, CA JENNINGS C. FALCON II, MD Kathryn Severyns Dement Sleep Disorders Center, Department of Neurology, St. Mary Medical Center, Walla Walla Clinic, Walla Walla, WA CHRISTIAN GUILLEMINAULT, MD Sleep Disorder Clinic, Department of Psychiatry, Stanford University Medical Center, Palo Alto, CA STEPHEN F. JOHNSON, MD, MBA St. Patrick Hospital Sleep Center, Missoula, MT; Western Montana Clinic, Missoula, MT; VRIIManaged Care Montana, Missoula, MT DANIEL F. KRIPKE, MD Department of Psychiatry, University of California, San Diego, CA WALLACE B. MENDELSON, MD Sleep Research Laboratory, University of Chicago, Chicago, IL RAFAEL PELAYO, MD Sleep Disorder Clinic, Department of Psychiatry, Stanford University Medical Center, Palo Alto, CA J. STEVEN POCETA, MD Division of Neurology, Scripps Clinic, La Jolla, CA; Department of Neuropharmacology, The Scripps Research Institute, La Jolla, CA RICHARD D. SIMON, JR., MD Kathryn Severyns Dement Sleep Disorders Center, Department of Medicine, St. Mary Medical Center, Walla Walla Clinic, Walla Walla, WA xiii

12 xiv Contributors KINGMAN P. STROHL, MD Center for Sleep Disorders Research, Department of Medicine, Case Western Reserve University and Veterans Affairs Medical Center, Cleveland, OH PATRICK J. STROLLO, JR., MD, FCCP, FABSM Pulmonary Sleep Disorders Laboratory, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, P A

C URRENT C LINICAL P RACTICE

Thyroid Disease C URRENT C LINICAL P RACTICE SERIES EDITOR: NEIL S. SKOLNIK, MD Dermatology Skills for Primary Care: An Illustrated Guide, DANIEL J. TROZAK, DAN J. TENNENHOUSE, AND JOHN J. RUSSELL, 2006