Use of Technology in the Assessment of Type 2 Diabetes and Sleep Apnea

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1 Use of Technology in the Assessment of Type 2 Diabetes and Sleep Apnea Eileen R. Chasens, PhD Associate Professor University of Pittsburgh September 3, 2014

2 Disclosure I do not own a Smart Phone, I have never used Twitter, I don t have cable television. I don t feel deprived because of this. Forget about me paying for satellite radio, I do go on Facebook but just to view baby pictures. However, I love how technology can help improve health care delivery and research!

4 Treatment with Insulin

5 Early Monitoring of Glucose Benedict s Test Urine Glucose Dipstick *Unable to detect hypoglycemia. unable to obtain tight control

6 Improvement in Monitoring of Diabetes with Technology * Technology allowed paradigm change to recognize monitoring and self-management resulted in better glucose control and decreased complications

7 Problem with Sliding Scale Insulin The sole use of sliding scale insulin is strongly discouraged in hospitalized patients. A more physiological insulin regimen including basal, prandial, and correctional insulin is recommended. ADA, (2014). Standards of Medical Care

8 Technology and Diabetes We live at a time with amazing technology to help with the management of diabetes. We live at a time of epidemic increase in the prevalence of diseases based in the over consumption of food and persons with a sedentary lifestyle.

9 Origins of Sleep Medicine

10 To tell a story

11 How important is sleep to good health and life.ask a rat. Total sleep deprivation resulted in the death of all rats (10) within 2 to 3 weeks (Everson, Bergmann, and Rechtschaffen, 1989).

12 Discovery of electrical activity of the brain with Electroencephalogram Late 19 th centuryrecording of brain activity in animals 1929 EEG in humans

13 Sleep Stages REM not discovered until 1951

14 Obstructive Sleep Apnea Sleep apnea first described in 1965 Repetitive episodes of upper airway obstruction during sleep Apnea- complete cessation of breathing for 10+ seconds Hypopnea decreased breathing by > 50% with oxygen saturation for 10+ seconds Severity of Sleep Apnea Mild = AHI = 5-14 Moderate = AHI =15-29 Severe AHI = 30+ Will my grant pay for one of these sweeties?

15 Evaluate for Symptoms of Sleep Apnea Symptoms Loud snoring & breathing pauses Memory problems, depression, impaired concentration Daytime sleepiness **DX. with Sleep Study (Polysomnography) Could I keep him in my project office?

16 Joe: Depiction Distorted Diagnosis of Sleep Disorders OSA was felt to be a rather uncommon condition affecting only severely over-weight men. This lead to under diagnosis in women, children, and persons who are not sleepy.

17 Evaluate for Risk Factors for OSA Risk Factors for OSA Male gender 2:1 Increased age Obesity OSA Risk for: Heart disease Metabolic Syndrome Psychological (cognition & mood) The relationship between OSA and type 2 diabetes first recognized IDF in 2003

18 Sleep Apnea By 1978, relationship between intraluminal airway pressure and EMG activity of the genioglossus muscle in the pathophysiology of upperairway collapse in the pharyngeal segment of the airway Tracheostomy was recognized as an effective treatment Just trach em.

19 CPAP Treatment (1981) Application of CPAP via nose was demonstrated to prevent upper-airway collapse Revolutionized the treatment of OSA

20 Are you still awake?

21 ~ when my work on examining sleep in persons with diabetes began, as a doctoral student

22 Dissertation Work Examined nocturnal urine production in persons with type 2 diabetes Glucose control measured with A1C Pooled urine specimens to check for glycosuria Sleep study -portable Suzanne PSG Results- OSA very prevalent, nocturnal minute volume was higher at daytime

23 Presence and Severity of OSA in Patients with T2DM Severe 23% Moderate 31% None 13% Mild 33% None Mild Moderate Severe Foster, G. D., et al. (2009). Diabetes Care, 32(6),

24 Problem 1-did they have OSA? AreUSleeping Device for screening Single Channel Device Many false positives Excessive $$$ Especially poor device for premenopausal women ApneaLink device for screening 4 Channel Device, Medicare approved In-laboratory sleep studies (N-CTRC) Resources in N-CTRC for sleep evaluation

25 Home Sleep Study Ecologically valid Sensitive Not good for persons with complex sleep disorders Must be checked by a trained PSG tech Diagnosis by board certified sleep physician

26 Problem 2- What measure does one want to measure metabolic glucose control? Fasting blood glucose Fasting insulin HOMA R Finger stick BG readings A1C Fructosamine Glucose Variability

38 This is where technology has really helped! Problem 3: Adherence to CPAP American Academy of Sleep Medicine suggest early and routine assessment of CPAP use and treatment response Early studies of CPAP relied on self report Hour meter readings (device powered on, more accurate)(kribbs et al, 1993; Engleman et al., 1996; Rauscher et al, 1987) CPAP mask-on at pressure 10% < then machine time (Kribbs et al, 1993) Use of Smartcard improvement but still has problems! Web based use of modem

39 Treatment of OSA with CPAP Clinical expectation is that patients/ participants use CPAP for sleep duration Patient use CPAP averages 4.7 hrs/night (Kribbs et al., 1993; Engleman et al, 1994; Reeves-Hoche, 1994) Clinical benchmark 4 hrs/night for 70% of all nights Dose response ESS 4 hrs/night MSLT > 6 hrs/night Functional outcomes 7.5 hrs/night (Weaver, 2007)

40 Factors that Influence CPAP Adherence Disease characteristics Nasal complaints Depression/mood Intervention to promote CPAP adherence General CPAP education & anticipation of common problems Early and often follow-up during first weeks of treatment

41 Encore AnyWhere Real-time Data Access wireless modem module enables compliance data to be automatically uploaded on a daily basis. Prescription changes -can be automatically communicated back to the patient's device. Management by Exception - can be set to automatically identify problem patients

42 Graphic Display

43 Summary Data

46 Thank you for inviting me to speak. Eileen R. Chasens, PhD

Polysomnography (PSG) (Sleep Studies), Sleep Center

Polysomnography (PSG) (Sleep Studies), Sleep Center Policy Number: 1036 Policy History Approve Date: 07/09/2015 Effective Date: 07/09/2015 Preauthorization All Plans Benefit plans vary in coverage and some plans may not provide coverage for certain service(s)