Sleep and Circadian Rhythm Disorders diagnosis and management

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1 Sleep and Circadian Rhythm Disorders diagnosis and management Dr Kirstie Anderson Consultant Neurologist Regional Sleep Service Newcastle

Bedtime stories how to take a sleep history Do you snore heavily obstructive sleep apnoea, STOPBANG Do you need to move your legs in bed at night restless legs What drugs are taken and when

2 Bedtime stories how to take a sleep history Do you snore heavily obstructive sleep apnoea, STOPBANG Do you need to move your legs in bed at night restless legs What drugs are taken and when (caffeine/nicotine/alcohol) Take me through your typical 24 hours shift work, sleep restriction, insomnia Can you get through the day without napping fatigue versus sleepiness If you could sleep when you want to, do you sleep well? Parasomnia witness,? childhood,? time of night?out of bed/bedroom Epworth sleepiness score >10 sleepy, >17 very sleepy, 0-1 insomnia. BMI BP

3 A snapping of the tendons 24 year old man referral chronic insomnia with a broken night. He is frustrated and sleepy during the day as a result Epworth sleepiness score 18 (normal < 10, insomnia typically 0-2). Well, no medication. BMI 21 "Do you get an uncomfortable feeling in your legs that makes you need to move in the last hour before bed or when you first get into bed?"

4 Treatment of Restless legs KISS first Lifestyle nicotine/caffeine/alcohol RLS-UK (Replace ferritin if below 75) Stop contributory meds if possible metoclopramide, SNRI Screen for comorbid obstructive sleep apnoea

Pharmacotherapies for RLS Gabapentin - 5-7 hour half life, take 1 hour before bedtime, 100mg - 600mg Pregabilin - 6 hour half life, 1 hour before bedtime. Good for anxiety.

5 Pharmacotherapies for RLS Gabapentin hour half life, take 1 hour before bedtime, 100mg - 600mg Pregabilin - 6 hour half life, 1 hour before bedtime. Good for anxiety. Dose range up to 150mg Side effects of sedation, weight gain Opiates and clonazepam helpful for some, but potential for dependency and worsening snoring and sleep apnoea Iron - oral or intravenous, not if ferritin >100 Ropinirole 0.5mg-4mg 90mins before Sx onset 4-6 hour half life, may need bd at mid afternoon and late evening Rotigotine patch OD 1-4mg good for the nauseated or day/night symptoms. 5-10% get rash Pramipexole 125mcg - 500mcg 5-7 hour half life, more potent but more peripheral oedema % relief in RCTs but...

6 Case history 61 yr lady 20 yrs in remission with bipolar on a stable dose of lithium. history of typical, severe restless legs GP had tried pregabilin, amitriptyline and temazepam without success. Careful discussion and pramipexole issued. Review at 6 weeks, had spent 5000 online shopping Augmentation earlier and higher 60% at 5 years, worst with madopar Impulse control disorder 13% in most recent case series

7 The cause of sleepiness? 42 year old lawyer with 2 year history of daytime sleepiness and fatigue, epworth sleepiness score 14 Concerns about concentration and work performance Slim (BMI 24) without history of snoring or restless legs. No sedative medications Some dream recall

8 The cause of sleepiness? 42 year old lawyer with 2 year history of daytime sleepiness, epworth sleepiness score 14 Slim (BMI 24) without history of snoring or restless legs. No sedative medications Some dream recall take me through your 24 hours? typically week days bed after midnight, up between 5 and 6 for gym Sleep diaries average total sleep time 4.8 hours weekdays with most daytime naps fridays and weekends SLEEP RESTRICTION

9 The cause of sleepiness? 41 yr old female Very sleepy since age 14 (ESS 21) and several near misses driving Fragmented night sleep, vivid dream recall, occasionally had dream enactment, sleep paralysis For 5 years odd episodes of knees buckling or face feeling loose with head and jaw drop when laughing with friends. Could fall judder

seized by somnolence first described 1880 by Gelineau A sleep

1% population Brief, refreshing naps for many and a broken night

sleep paralysis is common Narcolepsy 1/3 don't have cataplexy

10 seized by somnolence first described 1880 by Gelineau A sleep switch disorder Young onset for most (mean age onset 14). 0.1% population Brief, refreshing naps for many and a broken night Hypnagogic hallucinations can lead to referral to psychiatry, sleep paralysis is common Narcolepsy 1/3 don't have cataplexy They are VERY sleepy Tell me when you last fell asleep Tell me your last dream

11 Narcolepsy - treatment Lifestyle explain as a sleep switch problem and timed power naps. Need to inform DVLA. Garden centres> call centres Cataplexy TCAs and SNRI/SSRI work venlafaxine most commonly used Uppers Modafinil first line, at least a third need second line agent. Teratogenic, 25% get dose initiation nausea and headache. Dose range 100mg 400mg, escalate weekly. Review 4-6 weeks Methylphenidate useful in paediatric group given once daily dosing Dexamphetamine flexible with dose range 5mg - 40mg, used bd or tds Sodium oxybate now funded by NHS England for those under 19 Pitolisant histamine reverse agonist, hospital issued at present

and/or obstructive sleep apnoea Opioids Aware no-one

12 Hard to avoid opioids in a sleep talk from the North East 30-50% of the pain clinic have severe central and/or obstructive sleep apnoea Opioids Aware no-one should be on >120mg morphine from chronic, non-cancer pain

13 Seen in first fit clinic Bus driver age 62 seen in first fit clinic Blackout Crashed bus (no injury to anyone) Routine bloods, ECG normal CT head normal BMI 31 BP146/89 Next test?

severe mental health problems 50% of the pain clinic 30% of CFS/ME Clues for those who sleep alone Neck

14 Obstructive sleep apnoea 10% of men and 5% of women over 40 Home respiratory sleep study for diagnosis High risk populations Alcohol, opiates Metabolic syndrome, arrthymia Treatment resistant hypertension 20% with severe mental health problems 50% of the pain clinic 30% of CFS/ME Clues for those who sleep alone Neck cirumference > 17inches but 20% are thin Nocturia, insomnia (25%) dry mouth, sore throat, choking unrefreshing night sleep

15 All a psychiatrist needs to know about CPAP You can t cheat the machine Need > 4hrs use for DVLA AHI apnoea hypopnoea index Mild 5-15 Moderate Severe >30 Symptomatic sleepiness - we stop them driving as do DVLA but restart with compliance data with use >4 hours a night Sleepy despite CPAP Check notes compliance data, do they snore through it? If so need pressure increase in sleep clinic Compliance below 4 hrs/night (6) If sleepy despite good use and no residual snore then another sleep disorder or depression based on the research. Back to respiratory please if they have a machine 90% will have long term OSA unless weight drops Done properly better compliance than just about anything else in the NHS

16 Causes of hypersomnia 1. Too little sleep count the hours - 30% adults in the western world have some sleep restriction. social jet lag 2. Poor quality sleep obstructive sleep apnoea, restless legs syndrome 3. A sleepy brain sedating medication, (narcolepsy, idiopathic hypersomnia) 4. Circadian rhythm disorder shift work >40yrs, delayed sleep phase syndrome <25 years

17 To sleep, perchance to scream 59 yr old male shouting out at night 8 year history of occasional vocalisations +/- limb movement. Getting worse. 2 months ago punched the headborad and one month ago tried to strangle his wife. Otherwise well with refreshing sleep. Recurrent violent dreams including escape from prison, being chased by guards

18 Acting out dreams 59 yr old male shouting out at night 8 year history of occasional vocalisations +/- limb movement. Getting worse. 2 months ago punched the headboard and one month ago tried to strangle his wife. Otherwise well with refreshing sleep REM sleep behaviour disorder loss of the normal REM atonia seen on polysomnography 80-90% will develop a parkinsonian neurodegeneration at 15years Melatonin 2-10mg first line average effective dose 6mg Clonazepam 0.5mg to 2mg but often dose limiting sedation Recurrent violent dreams including escape from prison, being chased by guards

Diagnosis and treatment of bumps in the night NREM Parasomnia first hour, first half of the night, complex motor actions, little or no recall, out of bedroom. Hard to wake, last several minutes.

19 Diagnosis and treatment of bumps in the night NREM Parasomnia first hour, first half of the night, complex motor actions, little or no recall, out of bedroom. Hard to wake, last several minutes. Most have childhood or young adult onset. Rx regular schedule If late onset review prescription and screen for OSA/RLS or neurodegenerative REM Parasomnia rare first hour, usually second half of night, violent brief movements, dream recall. Easy to wake. Older. Polysomnography part of diagnostic criteria. Melatonin but need for review Nocturnal seizures Younger groups, can have recall, brief, hypermotor but stereotyped dystonic posturing, often sleepy, multiple times per night. Sore muscles, blood on pillow, enuresis. MRI often normal. Carbamazepine / other anticonvulsant

20 Another insomniac? 36 yr old. Always a bad sleeper Never asleep before 2-3am Mornings a nightmare, always late for school/work Son the same Delayed sleep phase syndrome Well treated with low dose melatonin 1mg at 9pm

21 A broken clock Circadian Rhythm Disorder Diagnosis made by history, sleep diaries +/- actigraphy Key features in the history Quality of sleep often remains good if you could sleep when you want to would you sleep well? Take me through your 24 hours 6 Distinct circadian rhythm disorders Delayed sleep phase syndrome <25yrs Advanced sleep phase syndrome Shift work disorder >40yrs Jet lag syndrome Irregular sleep wake disorder Non 24 hour pattern

22 Bits and pieces quick fixes As patient is drifting off to sleep a sound loud noise and flash of light that causes a physical jolt distressing, sits up, heart racing. Then 3 further times before consultation Occasional events bolt upright in bed, throat closing over and choking feeling, can t speak, stridor and panic ++ Bruxism Isolated sleep paralysis if ESS normal, no features for narcolepsy direct to NHS choices and keep sleep/wake regular. Low dose SNRI can help but rarely needed for this Sx alone

23 Summary Take a sleep history in all your patients (and bring light and exercise into their lives!) The commonest cause of significant sleepiness in those > 40 is sleep apnoea 30% of all neurology / psychiatry long term conditions Ask everyone about restless legs (and their bedpartners) Review the prescription sedatives / stimulants, timing and dose of caffeine/nicotine/alcohol. Stop / reduce regular opioids Simple sleep questionnaires and sleep diaries the only test for diagnosis of insomnia and circadian rhythm disorder Parasomnia in the young look for triggers (and wear pyjamas!), in the elderly consider associated neurodegeneration CBTi should be first line for insomnia with or without comorbidities

24 Come and learn more about sleep

Index. sleep.theclinics.com. Note: Page numbers of article titles are in boldface type.

Index. sleep.theclinics.com. Note: Page numbers of article titles are in boldface type. Note: Page numbers of article titles are in boldface type. A Actigraphy, 475, 485, 496 Adolescents, sleep disorders in, 576 578 Adults, sleep disorders in, 578 580 Advanced sleep phase disorder, 482 Age,