1
Q
What is sleep (non-disordered sleep)?
A
Reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment
2
Q
What is insomnia?
A
Disorder (symptom) of sleep initiation and/or sleep maintenance associated with daytime impairment(s)
3
Q
What is obstructive sleep apnea?
A
- Sleep related breathing disorder
- Abnormalities of respiration during sleep
- Repetitive apnea or hypoponeas recurring w/ sleep
4
Q
What are the two types of functions of normal sleep?
A
- Restorative function
- Homeostatic function
5
Q
What systems are affected by sleep/sleep deprivation?
A
- Every system is dependent on sleep
- Endocrine: metabolism/fat distribution/cellular energy, obesity and insulin resistance
- Cardiovascular: sympathetic/ANS, blood pressure regulation
6
Q
What are the two processes that regulate normal sleep?
A
Homeostatic process (S) Circadian process (C)
7
Q
How does the homeostatic process affect sleep?
A
- Depends on the amount of sleep and wakefulness
- Balance between the need for sleep (sleep pressure) with increasing duration of wakefulness
8
Q
How does the circadian process affect sleep?
A
- Depends on endogenous circadian peace maker generating near 24 hour cycles of behavior
- Regulated by the SCN (suprachiasmatic nucleus) in the hypothalamus to “consolidate” sleep and wakefulness
9
Q
How does normal sleep change with aging?
A
- Decrease in N3 (women preserve with aging)
- Decrease in REM
- Sleep efficiency decreases 80 to 85%
- Ability to sleep in consolidated, longer sleeping bouts decreases (homeostatic dysfunction rather than circadian)
- Need for sleep does not decrease
- Daytime sleepiness increases
- Napping may increase
- And apparent shift is prevalent with earlier fall asleep an earlier awakening (Melatonin related, SCN aging)
- Difficulty tolerating phase shifts
10
Q
When should we assess sleep?
A
Every clinical interface
11
Q
What are some clinically valuable sleep symptom and pattern assessment instruments?
A
- Epworth sleepiness scale
- Stanford sleepiness scale
- Functional outcomes of sleep questionnaire
- Sleep diary (Consensus diary - recommended)
12
Q
What are some OSA screening tools?
A
- STOP-BANG (Snore, Tired, Observed apnea, High blood pressure, BMI, Age, Neck circumference, Gender)
- Berlin questionnaire
13
Q
How do we determine OSA response to treatment tools?
A
- Epworth sleepiness scale (ESS)
- Functional outcomes of sleep questionnaire (FOSQ)
14
Q
What are some insomnia screening and response to treatment tools?
A
- Insomnia severity instrument (ISI)
- Pittsburgh sleep quality index (PSQI)
- Consensus sleep diary
15
Q
What are some general diagnostic criteria for diagnosing chronic insomnia?
A
One or more reported:
- Difficulty initiating sleep
- Difficulty maintaining sleep
- Waling up earlier than desired
- Resistance to going to bed on appropriate schedule
- Difficulty sleeping w/o intervention
16
Q
What are some diagnostic criteria for diagnosing chronic insomnia related to nighttime difficulty?
A
One or more reported:
- Fatigue/malaise
- Attention, concentration, or memory impairment
- Impaired social, family, occupational, or academic performance
- Mood disturbance/irritability
- Daytime sleepiness
- Behavioral problems
- Reduced motivation/energy/initiative
- Proneness for errors/accidents
- Concerns about or dissatisfaction with sleep
17
Q
What are some other factors to consider when diagnosing chronic insomnia?
A
- Sleep/wake complaints can’t be explained purely by inadequate opportunity or circumstances for sleep
- Sleep disturbance and associated daytime sx occur at least 3x/wk
- Sleep disturbance and associated sx present for at least 3mo
- Sleep/wake difficulty is not better explained by another sleep disorder
18
Q
How is criteria for diagnosing chronic insomnia different from diagnosing acute insomnia?
A
- Disturbance and associated sx present for LESS THAN 3mo
19
Q
When would we diagnose someone with Other Insomnia Disorder?
A
- Complain of difficulty initiating and maintaining sleep but DO NOT meet full criteria for either chronic or short-term insomnia
- May be applied when gathering more sleep information
- Use this diagnosis sparingly
20
Q
What are some relevant factors in the patient history related to insomnia?
A
- Circumstances surrounding onset
- Type of insomnia relative to diagnostic criteria (sleep/wake sx)
- Severity, frequency, course
- Daytime consequences
- Past tx
- Factors that ameliorate/exacerbate
- Medical factors
- Pharmacological considerations
- Psychiatric factors
- Work, family, and social factors
- Comorbid sleep disorders
- Behavioral factors including routines, sleep practices, cognitive factors (i.e. worry)
- Environmental factors
21
Q
How do we diagnose insomnia?
A
- Clinical assessment
- Sleep diary records
+/- Polysomnography (PSG) to r/o other sleep disorders w/ high clinical suspicion or no tx response
+/- Actigraphy to obtain objectively measured sleep/ wake patterns
22
Q
What are some psychological and behavioral tx for insomnia?
A
- Sleep Restriction Therapy
- Stimulus Control Therapy
- Relaxation Therapy
- Cognitive Therapy
- Sleep Hygiene Education
- Cognitive Behavioral Therapy
23
Q
What is Sleep Restriction Therapy?
A
- Restrict time in bed as close as possible to actual sleep time, strengthening the homeostatic sleep drive
- Sleep “window” is then gradually increased over days/weeks
24
Q
In what populations is Sleep Restriction Therapy contraindicated?
A
- Seizures
- Parasomnias like sleepwalking
- Bipolar
- Occupational drivers
25
What is Stimulus Control Therapy?
Standard set of instructions designed for reinforce the association btwn bed and bedroom with sleep and to establish consistent sleep/wake schedule:
- Go to bed only when sleepy
- Get out of bed when unable to sleep (may be contraindicated in older adults d/t falls)
- Use bed/bedroom for sleep only
- Arise at same time every morning
- No napping
26
What is Relaxation Therapy?
- Progressive muscle relaxation, meditation
| - Requires some professional guidance at outset and daily practice for weeks-months
27
What is Cognitive Therapy?
- Approach using questioning and behavioral experiments to reduce excessive worrying about sleep and reframe faulty beliefs about insomnia and daytime consequences
- Trained interventionist required
28
What is Sleep Hygiene Education?
General guidelines about practices and environmental factors that promote or interfere with sleep
29
What is Cognitive Behavioral Therapy?
Multimodal intervention combining some of cognitive and behavioral procedures, selection based on expert evaluation of insomnia
30
What is 1st line pharmacological tx for insomnia?
Short-intermediate acting benzodiazepine receptor agonists (BZD or newer BzRAs) or ramelteon
31
What are some examples of benzodiazepine receptor agonists (BZD or newer BzRAs)?
- Zolpidem
- Eszopiclone
- Zaleplon
- Temazepam
32
What is the next step if the initial agent is unsuccessful?
Alternate short-intermediate acting BzRAs or ramelteon
33
What are good pharmacological agents when treating comorbid depression/anxiety?
Sedating antidepressants
34
What are some examples of sedating antidepressants used for insomnia tx?
- Trazodone
- Amitriptyline
- Doxepin
- Mirtazapine
35
What are some alternative insomnia tx?
- Combined BzRA or ramelteon and sedating antidepressant
- Anti-epilepsy
medications (gabapentin, tiagabine)
- Atypical antipsychotics
(quetiapine and olanzapine)
* These medications may only be suitable for patients
with comorbid insomnia who may benefit
from the primary action of these drugs as well as
from the sedating effect*
36
What medications are NOT recommended for pharmacological tx of insomnia?
- OTC antihistamine or antihistamine/analgesic type drugs (OTC "sleep aids")
- Herbal/nutritional substances (valerian, melatonin)
- Barbituates and barbituate-types drugs
- Chloral hydrate
37
Define obstructive sleep apnea (OSA)
- Repetitive hypopneas (partial airway collapse) and apneas (complete airway collapse) during sleep
- Results in intermittent hypoxia and sleep fragmentation
38
How do we classify OSA by severity?
- Mild: Apnea Hypopnea Index (AHI) 5-15 events/hr
- Moderate: AHI 15-30 events/hr
- Severe: AHI >30 events/hr
39
How do we diagnose OSA?
Requires (A & B) or C
A: Presence of one or more:
- Complaints of sleepiness, nonrestorative sleep, fatigue or insomnia sx
- Wakes with breath holding, gasping, or choking
- Observed habitual snoring, breath interruptions, or both during sleep
- Diagnosed w/ HTN, mood disorder, congitive disfunction, CAD, CVA, HF, AF, of T2DM
B: Polysomnography (PSG) or Out of Center Sleep Test (OCST): >5/hr predominantly obstructive events
C: PSG or OCST: >15/hr predominantly obstructive events
40
What is the pathophysiology of OSA?
- Airway narrowing (velopharyngeal space, retropalatal space, retroglossal space)
- Phasic inspiratory muscle "dullness" during sleep
- Other factors: anatomically small airway, excess soft tissue
All result in airway partial of complete collapse
41
What do cortical arousals on EEG indicate?
- Protective mechanism
| - Fragmentation of sleep
42
Risk factors for OSA
- Obesity
- Age 65+
- Male (2:1 or 3:1 M:F ratio in community based examples)
- FH of SDB (2-4 fold increase)
- ETOH exacerbates OSA
- Ethnicity (AA, Mexican Americans, Pacific Islanders, East Asians)
- Disorders of craniofacial abnormalities (i.e. Marfan Syndrome, Down syndrome)
43
Where can you get the most reliable information about a person's sleeping patterns?
The bed partner!
44
What does the clinical presentation look like for a person with OSA?
- Bed partner witnesses snoring, nocturnal snorting, gasping, and apneas
- Excessive daytime sleepiness (EDS)
- Fatigue
- Drowsiness as opposed to EDS
45
What are some other nighttime s/sx of OSA?
- Choking or dyspnea that resolves quickly (as opposed to PND) in sleep
- Unexplained awakenings and unrefreshing sleep (older adults)
- Restlessness during sleep
- Nocturia
- GER
- Dry mouth
46
What are some other daytime s/sx of OSA?
- MVA (single)
- Concentration, attention, memory, and/or judgement difficulties (F)
- Personality changes (i.e. aggression, irritability, anxiety, depression
- Reduced libido or impotence
- Morning or nocturnal headaches (dull, generalized; resolve 1-2 hrs after sleep)
47
What physical exam components should you include when assessing someone with OSA?
• Height/Weight…BMI
• Neck Circumference (>40cm, 61% sensitivity, 93% specificity for OSA, regardless of sex)
• Retrognathia, dental overjet (forward extrusion upper incisors beyond lower incisors)
• Evidence of bruxism, dental clenching/grinding, TMJ on oral/dental exam
• Oropharyngeal exam may reveal macroglossia, narrow posterior pharynx,
edematous/erythematous uvula, low-lying soft palate
48
What does the Mallampati scale assess and how is it scored?
- Visually evaluate position of soft palate, tip of uvula,
lateral tonsillar pillars, and tongue in seated, mouth wide open and tongue protrusion
- Scored as class 1-4
Class I: Can see bottom of uvula
Class 2: Can't see bottom of uvula but can still see large portion of posterior pharynx
Class 3: Can barely see top of uvual
Class 4: Cannot see uvula or posterior pharynx
49
What are 2 clinically valuable SCREENING tools for assessing OSA?
- Berlin Questionnaire
| - STOP-BANG
50
How is the Berlin Questionnaire scored?
Scored as low or high risk based on sum of points w/in 3 categories:
- High risk: 2 positive categories
- Low risk: only 1 positive category
51
How is the STOP-BANG scored?
Scored as sum score of 8 YES(1)/NO(0) items:
- High risk: 5-8
- Intermediate risk: 3-4
- Low risk: 0-2
52
What are 2 clinically valuable SYMPTOM EVAL tools for assessing OSA?
- Epworth Sleepiness Scale
| - Fatigue Severity Scale
53
How is the Epworth Sleepiness Scale Scored?
- Sum score of 8 items
| - >10 suggests excessive daytime sleepiness
54
How is the Fatigue Severity Scale scored?
- 7pt Likert Scale
- Sum score from 9 item responses
- Score >36 indicates fatigue
55
For OSA diagnosis, when woukd you use Home Sleep Study/Test (HSS/HST) vs PSG?
- HSS/HST unattended, portable monitoring
- For pts w/ high likelihood of OSA and no significant comorbidities
- Includes monitoring of oximetry, airflow, respiratory effort, snoring, position, heart rate
56
How do we tx OSA?
- Medical therapies
- Positive Pressure Therapy
- Oral appliance
- Surgery (UA)
57
What are some medical therapy strategies for OSA?
- Weight loss: 10% reduction in weight = 50% reduction in AHI
- Position therapy: avoid sleeping supine
- Eliminate ETOH and/or sedative use
- Medications
58
What are some medications that are NOT efficacious options for tx OSA?
- O2
- Methylxantines
- Progestational agents
- SSRIs
- Mixed serotonin receptor agonists
59
What are some wake promoting agents/stimulants that can be considered when EDS is present and consequential?
- Amphetamines and methylphenidate (efficacious, SE include dependence)
- Modafinil (Provigil) or Armodafinil (Buvigil) safer wake promoting agents (indirect dopamine receptor agonists)
- THESE DO NOT TX OSA, ONLY ASSOCIATED EDS
- FDA approved indication: persistent sleepiness ON PAP TX (and adherent)
60
What is positive airway pressure (PAP)?
- Continuous (CPAP), bi-level (inspiratory/expiratory; BPAP), or auto-adjusting (APAP)
- Delivers positive pressure to pneumatically splint upper airway open
61
What are some important factors to management of the patient on PAP?
- Can add O2 (not indicated in OSA without underlying CVD, HF, COPD, restrictive pulmonary disease)
- Mask selection important to users
- Heated humidification reduces dry mouth, nasal congestions, excessive salivation during daytime
- Nasal saline sprays, nasal corticosteroid sprays may be needed
- If using nasal only mask interface, must have patent nasal airway
62
When is surgical/laser tx indicated in OSA?
- Most effective in mild-moderate OSA
- F/u polysomnogram 12-15 weeks post-procedure
- May reduce success with CPAP if needed
63
What are the steps necessary for getting oral appliances for patients with OSA?
- Dentist referral
- Recurrent dental f/u to "advance" device
- F/u polysomnogram when final advancement determined by dentist
- Adherence
Primary Care Exam 3
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