May 27, 2015 Gosia Eve Phillips, MD Diplomate, American Board of Psychiatry and Neurology Assistant Professor of Medicine, Dalhousie University Medical Director, MedSleep Atlantic
>50% of MS patients suffer from poor sleep Fatigue is a very common symptom in MS Sleep disorders Often go unrecognized May affect quality of life May exacerbate other MS symptoms May be associated with health risks
Insomnia Sleep-related breathing disorders Circadian Rhythm Disorders Sleep-related movement disorders Hypersomnias of central origin Parasomnias
Most common sleep disorder Persistent difficulty with sleep initiation, duration, consolidation, or quality Despite adequate opportunity & circumstances for sleep Result in some daytime impairment
1 of: fatigue or malaise attention, concentration, or memory impairment impaired social, family, occupational or academic performance mood disturbance or irritability daytime sleepiness behavioural problems e.g. hyperactivity, impulsivity aggression reduced motivation, energy, or initiative proneness for errors or accidents concerns about or dissatisfaction with sleep
Chronic Insomnia 3 times/week; 3 months duration Inadequate Sleep Hygiene Psychophysiologic Insomnia Due to Mental Disorder Due to Drug or Substance Due to Medical Condition Paradoxical Insomnia Idiopathic Insomnia Short-Term Insomnia <3 months duration
1 of: Improper sleep schedule e.g. daytime napping, highly variable BT or WT, excessive time in bed Routine use of products with alcohol, nicotine, caffeine, especially close to BT Engaging in mentally or physically stimulating or emotionally upsetting activities close to BT Frequent use of bed for activities other than sleep e.g. TV, reading, studying, snacking, thinking Uncomfortable sleeping environment
Sleep difficulty &/or increased arousal in bed with 1 of: Excessive focus on & heightened anxiety about sleep Difficulty falling asleep when planned; no difficulty falling asleep when not intending to sleep Sleep better away from home than at home Mental arousal in bed Body tension with inability to relax
Temporally associated with mental disorder Common in mood and anxiety disorders Treatment may improve outcome of sleep disturbance and mental disorder Insomnia often persists even if mental disorder treated Thus warrants separate treatment attention
Caused by use or withdrawal of a drug or substance Stimulants e.g. caffeine, amphetamines, cocaine Medications e.g. steroids, nasal decongestants Discontinuation of sedating meds Alcohol: fragmented & restless sleep Sedative hypnotics & anxiolytics: tolerance & rebound insomnia
Coexisting medical or physiologic condition known to disrupt sleep E.g. pulmonary disorder with shortness of breath, cough, wheezing; neurologic disorder; pain disorder; pregnancy; menopause Waxes & wanes with severity of condition
Sleep state misperception Patient underestimates the amount of sleep achieved Mismatch with objective findings Daytime impairment is less severe than expected
Onset in infancy or childhood No identifiable precipitant or cause Persistent course with no sustained remission
Temporal association with identifiable stressor that is psychosocial, interpersonal, environmental, or physical Sleep disturbance resolves when stressor resolves or adaptation occurs Sleep disturbance lasts <3 months
Cognitive Behavioural Therapy (CBT) +/- sedative/hypnotics Long-term use of sedative/hypnotics not recommended due to potential for tolerance and addiction
Cognitive: change patient s beliefs & attitudes about insomnia e.g. attention shifting, decatastrophizing, reappraisal Behavioural: may include stimulus control treatment, sleep restriction, relaxation training Sleep hygiene education: (insufficient alone) health practices: diet, exercise, substance abuse environmental factors e.g. light, noise, temperature
Behavioural interventions: Stimulus control treatment: break conditioned response to temporal (bedtime) & environmental (bedroom) cues that patient associates with sleeplessness Use bedroom only for sleep and intimacy Avoid eating or TV in bed Leave bedroom if unable to fall asleep after 20 min Establish consistent sleep-wake schedule & avoid naps
Sleep restriction Time in Bed Restriction Relaxation training Methods to reduce tension or intrusive thoughts at bedtime that interfere with sleep Guided imagery (focus on pleasant or neutral images to block out unwanted thoughts) Meditation Biofeedback e.g. muscle tension Progressive muscle relaxation
Can be considered short-term Tailor to patient s comorbid conditions E.g. Antidepressants: TCA s, trazodone, mirtazapine Antiepileptic medications: gabapentin Atypical antipsychotics: quetiapine Benzodiazepines/BZD receptor agonists: zopiclone, zolpidem Over the counter anti-histamines, anti-histamine/analgesics & natural remedies not recommended due to lack of efficacy and safety data
Obstructive (OSA) Central (CSA) Mixed Sleep Related Hypoventilation/Hypoxemia
Obstructive Sleep Apnea Increased frequency may be related to weight gain from inactivity due to disability medications which relax tone in throat Central Sleep Apneas/Hypoventilation Brainstem lesions affecting respiratory control centers (consider MRI brain & C-spine)
Nocturnal: Snoring, witnessed apneas, gasping and choking Nocturia Insomnia e.g. restless sleep, frequent arousals Daytime: Nonrestorative sleep, excessive daytime fatigue Excessive daytime sleepiness Morning headache Cognitive deficits Personality and mood changes Sexual dysfunction
Sleep Studies Lab polysomnography Home sleep study
Monitors sleep stages, provides data regarding electrical & muscular states during sleep Parameters: EEG EOG EMG, submentalis muscle EMG, bilateral ant tibialis Nasal/ oral airflow Breathing effort (chest & abdomen) EKG Oximetry
Nasal airflow Respiratory effort Arterial oxygen levels Heart rate Decibels of snoring Sleep position Limitations: No EEG/EMG monitoring false negatives
While asleep, upper airway obstructs Leads to sleep disruption, oxygen desaturations
Increased BMI (major) ~60% of moderate to severe OSA attributable to obesity increased neck circumference predicts higher AHI Anatomic abnormalities e.g. macroglossia, long soft palate, enlarged uvula, enlarged tonsils & adenoids, micro/retrognathia Aging Menopause Alcohol, sedatives Nasal congestion
Apnea Hypopnea Index (AHI): A + H/hour <5: normal 5-15: mild OSA 15-30: moderate OSA 30: severe OSA Severity of sleep apnea does not correlate with severity of symptoms
Rates as high as 24% in men and 9% in women Increases with age, although appears to plateau in the elderly Ratio of OSA in men compared to women ~2:1
Excessive daytime fatigue and sleepiness Cognitive impairment Mood changes Hypertension Coronary Artery Disease Arrhythmias Stroke Diabetes Mellitus
~1/2 of patients with OSA had anxiety and depression ~1/4 of patients with severe OSA had excessive daytime sleepiness Rezaeitalab et al. J Res Med Science 2014
40% of OSA patients have HTN 30-40% of HTN patients have OSA Linear relation between severity of OSA and odds of having HTN Absence of normal BP decrease during sleep may be earliest sign of HTN Wisconsin Sleep Cohort Study
Risk of CAD increases with OSA severity CPAP decreases occurrence in cardiovascular events and cardiovascular death Sorajja et al. Chest 2008
More frequent in OSA Increase with OSA severity Reduced with treatment Atrial fibrillation Resistance against antiarrhythmic drugs, ablation, cardioversion strongly related to OSA Vizzard et al. 2014
Independent of other risk factors Correlation of increased severity of OSA with increased stroke and death Sleep Heart Health Study Artz et al. Am J Respir Crit Care Med 2005 Yaggi et al. N Eng J Med 2005
Majority of patients with DMII have OSA OSA is independently associated with abnormal glucose metabolism, increased risk for DMII Chest 2008
Positive Airway Pressure (PAP) Dental device Surgical correction of upper airway obstruction Provent Conservative measures
During inspiration valve opens to allow for nearly unobstructed airflow. During expiration valve closes, restricting airflow to create EPAP and maintain pressure in the airway through the start of the next inspiration.
Weight reduction Non-supine sleep position Avoidance of alcohol and sedatives close to BT
Fatigue in MS is not always due to MS Sleep disorders common in MS patients Institute treatment to improve quality of life and reduce potential health risks