SLEEP UPDATE 2008 SLEEP HYPNOGRAM. David Claman, MD UCSF Sleep Disorders Center

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1 SLEEP UPDATE 2008 SLEEP HYPNOGRAM David Claman, MD UCSF Sleep Disorders Center

2 Insomnia Case A 40 year old man c/o insomnia at sleep onset. He worries about sleep at night, and takes 2-3 hrs to fall asleep. He stays in bed while tossing & turning from 11 pm on. Once asleep, he sleeps well, but it is hard to get up for 6:30 am. He naps at lunch or after work to catch up. He sleeps late on the weekends. Occasional alcohol. Caffeine only in morning. PMH and exam negative. Differential Diagnosis of Insomnia Sleep onset or maintenance? Psychiatric / psychological Medical Drugs (especially caffeine and alcohol) Psychophysiological insomnia Poor sleep hygiene Circadian rhythm issues Jet lag or Shift work SLEEP HYGIENE Keep regular bedtime and wake-up time (Sleep Restriction?) Keep bedroom quiet, comfortable, & dark Relaxation technique for min before bed Get regular exercise Don t nap Don t lie in bed feeling worried, anxious, or frustrated Don t lie awake in bed for long periods of time Don t use alcohol, caffeine, or nicotine HYPNOTICS (no active metabolites) Zolpidem 5-10 mg Half-life 2-5 hrs Zaleplon 5-10 mg Half-life 1-2 hrs Triazolam mg Half-life 2-5 hrs Temazapam mg Half-life 7-14 hrs Eszopliclone (Lunesta) 1, 2 or 3 mg dose; Half-life 6 hrs Zolpidem CR (Ambien CR) 6.25 or 12.5 mg dose ; Half-life 3-4 hrs Ramelteon (Rozerem) 8 mg dose; half-life 2-5 hrs Takes 7-10 days to take effect Do not use with fluvoxamine (Luvox); hepatic metabolism; not a scheduled drug

3 OTHER SEDATIVES Benzodiazepines help with anxiety, but all have longer half-life Lorazepam hrs; Alprazolam hrs; Diazepam hrs Sedating anti-depressants Trazadone or Mirtazapine Benadryl (Tylenol PM) Consider non-sedating antidepressants to help anxiety Paroxetine mg or Citalopram mg (a.m. or p.m.) INSOMNIA SUMMARY Insomnia is common Is the insomnia a problem with sleep onset or sleep maintenance? Sleep hygiene interventions are essential and provide longer duration of benefit! Medications need to be individualized for the patient s specific needs LEG MOVEMENTS AT NIGHT Hypnic myoclonus (sleep starts) - normal! Restless Legs Syndrome (RLS) Most common symptom in insomnia Clinical Diagnosis Periodic Limb Movements of Sleep (PLMS) Legs most common (rhythmic contractions of anterior tibilias), but arms can occur Diagnosed by sleep study to document that kicking causes EEG arousals

4 TREATMENT OF RLS / PLMS Iron deficiency may worsen RLS If ferritin<50, replace iron to raise ferritin>100 May worsen on antidepressants Medications: Dopaminergic agents Pramipexole or Ropinirole Clonazapam Gabapentin Opiates DEFINITIONS Apnea: complete cessation of airflow for 10 or more seconds Hypopnea: decrease in airflow for 10 or more seconds, accompanied by 4% or greater oxygen desaturation Apnea-hypopnea index (AHI; aka RDI): the average number of respiratory events per hour of sleep; for Medicare: AHI > 15 qualifies for CPAP; mild AHI 5-15 qualifies for CPAP if pt is also sleepy, HTN, CHF or CVA

5 PREVALENCE OF SLEEP APNEA Wisconsin: 602 working subjects, age 30-60, studied by overnight polysomnography Obstructive sleep apnea defined as both AHI > 5 and hypersomnolence 9% of women had AHI >5; 22% c/o hypersomnolence; yields 2% prevalence 24% of men had AHI >5; 15% c/o hypersomnolence; yields 4% prevalence CLINICAL PREDICTORS OF OSA Sleep Heart Health: male, age, BMI, neck girth, snoring & apnea predict AHI>15 Young T et al. Arch Intern Med 2002 Apr 22;162(8): NEJM: snoring, daytime sleepiness, drowsiness while driving, obesity and HTN W Flemons; NEJM 2002;347(7): T Young; NEJM 1993;328: TREATMENT Weight loss 10% weight loss reduces AHI by 25% Avoid alcohol and sedatives Postural training Tennis balls effective in selected pts Nasal patency allergies may also reduce CPAP effectiveness CPAP Most consistently effective treatment CFLEX or BiLevel may help if high pressures are uncomfortable Oral (dental) appliances Surgery

6 LONGTERM USE OF CPAP Best compliance if AHI >30 & sleepy patient McArdle N et al. AJRCCM 1999;159: New Data on OSA & Cardiovascular Risk Spanish prospective observational study in 1387 men referred to sleep center; control group (n=264) recruited from a separate population-based study AHI < 5 simple snorer; if AHI >30, CPAP always recommended; AHI 5-30 mild-mod CPAP given if sleepy or heart failure At 3 & 6 month f/u, if CPAP use < 4 hrs per night, treatment stopped Severe OSA group (AHI> 30) had significantly higher rate of fatal (1.06 per 100 person-yrs) and non-fatal (2.13 per 100 person-yrs) cardiovascular events. CPAP treatment reduces risk to level comparable to other groups. JM Marin et al. Lancet Mar 16;365(9464): Cumulative Percentage of New Fatal (A) & non-fatal (B) Cardiovascular Events JM Marin et al. Lancet Mar 16;365(9464): KEY POINTS: 1. Increased mortality seen if AHI>30 2. CPAP reduced this risk

7 SURGICAL THERAPY Nasal Surgery Uvulopalatopharyngoplasty (UPPP) reduces AHI by 50% in 50-60% of patients For snoring only: Laser (LAUP); Radiofrequency (Somnoplasty); Pillar Tonsillectomy If 3-4+ hypertrophy, success rate as high as 80-90% Mandibular advancement Genioglossus advancement with hyoid Mandibular - maxillary osteotomy & advancement Tracheotomy remains gold standard SLEEP HISTORY!!! Question #1 What is the most common cause of sleepiness in the US? 1. Restless Legs Syndrome 2. Obstructive sleep apnea 3. Purposeful sleep deprivation 4. Nocturnal visits to Starbucks R e s t l e s s L e g s S y n d r o m e 13% 0% 2% O b s t r u c t i v e s l e e p a p n e a P u r p o s e f u l s l e e p d e p r i v... 85% N o c t u r n a l v i s i t s t o S t a r... Question #2 What is the most effective long-term treatment for insomnia? 1. Hypnotics 2. Sedatives 3. Sleep hygiene 4. Antidepressants H y p n o t i c s 2% 0% 2% S e d a t i v e s S l e e p h y g i e n e 97% A n t i d e p r e s s a n t s

8 Question #3 What is the prevalence of OSA? 1. Less than 1% 2. 2% in middle-age women and 4% in middle age-men 3. 9% in middle-age women and 25% in middle age-men 4. the same as snoring, which can be over 50% of men over the age of 50 L e s s t h a n 1 % 2% 2% 2 % i n m i d d l e - a g e w o m.. 72% 9 % i n m i d d l e - a g e w o m e... 25% t h e s a m e a s s n o r i n g, w h... GENERAL REFERENCES Behavioral and pharmacological therapies for late-life insomnia. CM Morin et al. JAMA 1999;281:991-9 Cognitive Behavioral Therapy and Pharmacotherapy for Insomnia Jacobs GD; Arch Intern Med 2004;164: No More Sleepless Nights: A Proven Program to Conquer Insomnia; Peter Hauri, PhD Principles and Practice of Sleep Medicine. 4th Edition. Kryger, Roth, & Dement Sleep Disorders. Clinic in Chest Medicine 2003 June; 24(2). Krahn LE, Black JL, Silber MH. Narcolepsy: New Understanding of Irresistible Sleep. Mayo Clin Proc 2001;76: Restless Legs Syndrome Foundation: also has good information about Periodic Limb Movements Restless Legs Syndrome. CJ Earley. NEJM 2003;348(21): The Journal SLEEP is devoted entirely to sleep medicine. OSA REFERENCES Principles and Practice of Sleep Medicine. 4th edition 2005 Clinics in Chest Medicine. Sleep Disorders. June 2003;24(2). Peppard PE, Young T, et al. Prospective Study of the Association Between Sleep- Disordered Breathing and Hypertension. NEJM 2000;342: Marin JM et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 2005 Mar 16;365(9464): Kanagala R, Murali NS et al. Obstructive Sleep Apnea and the Recurrence of Atrial Fibrillation. Circulation 2003;107: Yaggi HK, Concato J et al. Obstructive Sleep Apnea as a Risk Factor for Stroke and Death. NEJM 2005;353: Masa JF et al. Alternative Methods of Titrating Continuous Positive Airway Pressure. AJRCCM 2004;170: Ferguson KA, Ono T. Et al. A Randomized Crossover Study of an Oral Appliance vs Nasal-Continuous Airway Pressure in the Treatment of Mild-Moderate OSA. Chest 1996;109: