Sleep Dysfunction in Multiple System Atrophy DR CALLUM DUPRE NEUROLOGY/SLEEP MEDICINE CAPITAL HEALTH SYSTEM
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1 Sleep Dysfunction in Multiple System Atrophy DR CALLUM DUPRE NEUROLOGY/SLEEP MEDICINE CAPITAL HEALTH SYSTEM
2 Categories of Disturbance Sleep Breathing Disorders Parasomnias Sleepiness Insomnia
3 Breathing? Sleep Apnea (Obstructive vs Central) Stridor Not just scary for the bed partner Hypoventilation
4 Sleep Apnea Obstructive vs Central Very common and very treatable Why does it matter? Increased Risk of Hypertension Heart Attack Stroke Worsens A.fib Diabetes High Cholesterol
5 Not only a disorder of the overweight
6 Signs and Symptoms Snoring! Snorts and Gasps Witnessed Apneas Multiple Awakenings (Nocturia) Nonrestorative Sleep Morning dry mouth, sore throat or headache Daytime Sleepiness
7 OSA: What do we do about it? CPAP vs BiPAP! Oral Appliances Positional Therapy Provent Surgery Weight Loss! Hypoventilation?
8 Stridor Wake vs sleep Treatment? PAP Suggests overactivity of the vocal cord musculature Tracheostomy Treating aggressively can have significant survival benefits
9 Parasomnias Usually REM-related Often the canary in the mine-shaft precedes the onset of symptoms by up to 10 years SSRI effect? DANGEROUS!!! Vigorous and violent at times with multiple episodes through the night 33-65% of patients with harm to themselves or their bed partner Aurora et al, JCSM, 2010
10 The numbers? RBD 70% of patients with MSA Older data: 38-65% risk of developing synucleinopathy Newer data? 33.1% at five years 75.7% at ten years 90.9% at 14 years The median conversion time was 7.5 years. Emerging diagnoses were dementia with Lewy bodies (DLB) in 29/65 subjects, Parkinson disease (PD) in 22, multiple system atrophy (MSA) in two, and mild cognitive impairment (MCI) in 12 Aurora et al, JCSM, 2010
11 REM Behavior Disorder Treatment? Clonazepam Melatonin Non-Benzodiazepine hypnotics?
12 REM Behavior Disorder Clonazepam Side Effects? Generally effective (>80%) Sedation But with side effects Gait Unsteadiness/Falls Confusion Worsening of sleep breathing disorders
13 REM Behavior Disorder Melatonin Conventionally used as a natural sleeping pill Often effective Safer but not perfect Doesn t just sedate the person through it Side Effects? (5/14) Sedation Confusion Morning headache Boeve et al, Sleep Medicine, 2003 Mcgrane et al, Sleep Medicine, 2014
14 REM Behavior Disorder Non-Benzodiazepines ( Z-drugs ) Side Effects? Not necessarily effective and with side effects Not well studied REM suppression vs sedate you through Sedation Gait Unsteadiness/Falls Confusion Worsening of sleep breathing disorders Other parasomnias
15 REM Behavior Disorder RBD IS DANGEROUS!!!!!!!!!!!!!! Specific Interventions Mattress on the floor Bedroom Safety? Padding corners/moving furniture Windows? Bed partner safety Guns/knives? Restraints??? recommend against
16 Fatigue vs Sleepiness 50% of MSA patients Underlying sleep disorders Medication induced Secondary Narcolepsy Often treatable!
17 Insomnia
18 Eliminate Bad Habits (Sleep Hygiene) Caffeine! Napping! Clock Watching! Alcohol or Nicotine! The bedroom environment
19 Maximize Good Habits (Sleep Hygiene) Worry Time Probably equally effective initially* Exercise Bedroom Temperature Mental Distraction Techniques Effects of drugs wears off if discontinued after 6-8 wks, effect of CBT persists for months
20 Medications? Older Supplements? Benzodiazepines Sedating Anti-depressants Newer Non-Benzodiazepine Hypnotics (Z-drugs) Melatonin Receptor Agonists
21 Medications vs Behavioral Strategies Each has their place Medications May be effective in the long run Risk of tolerance, dependence and side effects Behavioral Relaxation Training Cognitive Therapy Stimulus Control
22 Management of Insomnia: Take Home Messages New drugs safer, but not without side effects Minimal tolerance, minimal withdrawal effects Benefits still modest CBT as effective as drugs; still first line treatment for chronic primary insomnia Drugs are useful if CBT ineffective, unavailable or declined
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