View Written Summary: Family Practice, 57:28

Volume 57, Issue 28

July 28, 2009

The following is an abstracted summary, not a verbatim transcript, of the lectures/discussions on this audio program. If, after reviewing the summary, you would like to hear the contents and earn CME/CE credit, simply use your browser's back button to return to the order page and add this program to your cart.

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Sleep Disorders: Diagnosis and Management

From the University of California, Los Angeles’s 3rd Annual Advances in Sleep Medicine

Educational Objectives

The goal of this program is to improve management of insomnia and obstructive sleep apnea (OSA). After hearing and assimilating this program, the clinician will be better able to:

1. Describe predisposing, precipitating, and perpetuating factors leading to insomnia.

2. Discuss medical, psychiatric, and circadian rhythm problems associated with insomnia.

3. Choose appropriate drugs and sleep hygiene methods for treating individuals with insomnia.

4. Distinguish patients with OSA from those with central sleep apnea.

5. Identify patients who might benefit from surgical vs nonsurgical treatment of OSA.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and planning committee members to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. For this program, the following has been disclosed: Dr. Ancoli-Israel serves as a consultant and/or scientific board member for Arena, Cephalon, Ferring Pharmaceuticals, Orphagen Pharmaceuticals, Pfizer, Philips Respironics, sanofi-aventis, Sepracor, Schering-Plough, Somaxon Pharmaceuticals, and Takeda Pharmaceuticals. Dr. Avidan is on the Speaker’s Bureaus for Cephalon, Pfizer, Sepracor, and Takeda. In thier lectures, both speakers present information related to off-label use of a therapy, product, or device. The planning committee reported nothing to disclose.

Acknowledgments

Drs. Ancoli-Israel and Avidan were recorded at 3rd Annual Advances in Sleep Medicine, sponsored by the David Geffen School of Medicine at the University of California, Los Angeles, and held February 21, 2009, in Marina del Rey, CA. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Update on Management of Insomnia

Sonia Ancoli-Israel, PhD, Professor of Psychiatry, University of California, San Diego, School of Medicine, and Director, Gillin Sleep and Chronomedicine Research Center, University of California, San Diego, La Jolla, CA

Definition of insomnia: difficulty initiating or sustaining sleep, or nonrestorative sleep; insufficient sleep must result in daytime consequence, eg, irritability or difficulty concentrating; many patients unaware of deficits in function; ask others who know patient well about effects of sleep loss

Predisposing, precipitating, and perpetuating factors (3Ps): predisposing factors — innate; eg, depressive or anxious personality; does not necessarily lead to insomnia; precipitating factors — include medications, sudden stress; may lead to acute insomnia; once removed, sleep returns to normal; perpetuating factors —habits nonconducive to sleep; serve as treatment targets

Prevalence: according to surveys, 10% to 20% of patients meet diagnostic criteria; 30% to 50% complain of difficulty sleeping (at some point); primary care practices — 1 in 2 patients have insomnia; ask patients about sleep; »5% of chronic insomniacs make appointment for sleep problems; »25% might mention it, if seeing physician for different chief complaint (»66% never mention insomnia)

Impact of insufficient sleep: impaired cognitive function (memory and concentration); poor general health (eg, increased risk for viral illnesses, falls, and mortality), particularly in older adults; psychiatric disorders; poor job performance; reduced quality of life; decreased safety (from vehicular accidents); effects on family and coworkers; increased health care costs — due to secondary effects of insufficient sleep; generalized malaise leads to repeated physician visits

Comorbidities

Overview: formerly, distinction made between primary and secondary insomnia; National Institutes of Health (NIH)’s 2005 State-of-the-Science Conference statement — insomnia comorbid with other conditions (not secondary); difficult to know which condition arose first (eg, depression vs insomnia)

Psychiatric disorders: untreated insomnia increases risk (particularly for depression); patient survey and 1-yr follow-up —in those whose insomnia resolved, fewer had psychiatric disorders, including depression, anxiety disorders, and alcohol abuse; 7 to 8 studies show untreated insomnia increases risk for depression; study — fluoxetine plus placebo vs fluoxetine plus eszopiclone for insomnia and depression; fluoxetine plus eszopiclone treatment improved depression more than fluoxetine alone; similar studies in other psychiatric disorders

Medical conditions and treatments: wide range of conditions disturb sleep — eg, dementias, Parkinson’s disease, headaches, cardiovascular (CV) disease, pulmonary disorders, gastrointestinal disorders; medications — anticholinergics, activating antidepressants, antihypertensives, and bronchodilators, central nervous system stimulants, statins, corticosteroids, decongestants, b-agonists, diuretics, histamine₂ blockers, and smoking cessation aids; to improve sleep, adjust dose or time of day medication taken; over-the-counter drugs; caffeine, alcohol, and nicotine —disrupt sleep; ask patients about timing and quantity; alcohol consumption in evening helps in falling asleep but leads to wakefulness later in night; any drug that affects neurotransmitter systems likely associated with insomnia

Circadian rhythm disorders: common in patients with insomnia; circadian rhythms — 24 hr; standard phase — sleepiness begins at 10 to 11 pm (core body temperature drops); sleep duration, 7 to 8 hr (adults); adolescents — sleepiness delay (1-2 AM) and delay in normal awakening (11 am to noon); drop in core body temperature occurs later; need 9 to 10 hr of sleep; adults —most outgrow delayed sleep pattern, but some become “night owls”; take detailed sleep history to distinguish between sleep deprivation and phase delay; standard question — “What time would you take a test?”; answer of afternoon or early evening — likely phase delayed; older adults — advanced sleep phase (ie, sleepiness occurs at 6-7 pm, wakefulness 3-5 am); commonly complain of awakening during night; first scenario — forced wakefulness until 10:30 pm; person still waking up at 3 to 5 am; daytime napping becomes part of pattern to stay awake at night; second scenario —evening naps (30 min to 1 hr) result in sleep-onset problems; not insomnia; advanced sleep phase plus bad habits (napping in evening); conclusion — treatment available for shifting sleep phase; no morbidity or mortality associated with advanced sleep phase

Treatment of Insomnia

Behavioral therapy: most effective (according to NIH conference); more effective than pharmacologic therapy; sleep hygiene — promotes good habits; by itself not as effective as when combined with stimulus-control therapy or sleep restriction; relaxation training — effective

Cognitive behavioral therapy (CBT)

Overview: cognitive — aimed at maladaptive thoughts one has about sleep; behavioral (sleep hygiene) — exercise; increase exposure to bright light (melatonin secreted in darkness); darkness in bedroom; avoid naps (to increase sleep drive); sleep environment — dark and quiet; comfortable temperature; “worry time” — 10 to 15 min/day each day at same time; effective for those patients who worry at night; other tips — avoid heavy meals and drinking within 3 hr of bedtime; when awakened during night, avoid looking at clock; for better chance of returning to sleep, do not open eyes; use night light if going to bathroom

Efficacy: treatment study — CBT plus temazepam, CBT alone, temazepam alone, or placebo; end point — amount of time patient awake at night; CBT — immediate improvement after treatment (maintained for 2 yr); temazepam — initial improvement, then worse over time; combination —improvement, then slightly worse (not as effective as either treatment alone); conclusions — CBT effective; consider integrating into practice or referring patients

Pharmacologic Therapy

Self-treatments: include alcohol and herbal remedies; melatonin — no data to show efficacy; useful for circadian rhythm changes but not effective for sleep-onset problems

Antihistamines: diphenhydramine used more often than any other drug for sleep; advantages — inexpensive and easy to obtain; disadvantages — efficacy not consistent; tolerance develops; residual effects; no well-defined effective dose; poorly defined half-life; adverse effects — dry mouth, blurred vision, urinary retention, constipation, and diminished cognitive function; study — diphenhydramine (25-50 mg) causes symptoms of delirium (eg, confusion, agitated behavior, poor sleep) in older cognitively intact patients; take-home message — drugs not benign, particularly in older adults; consistent use increases risk for side effects; similar conclusion reached by NIH panel

Sedating antidepressants: include trazodone, doxepin, and amitriptyline; used at low doses; little evidence to support efficacy or safety in nondepressed individuals; some potential adverse events (not seen often); no well-defined dose; NIH —short-term trazodone use improves most sleep, but effect may not last >2 wk; doxepin — effective for »4 wk; no data on other antidepressants; all antidepressants have potentially significant adverse effects; monitor patients and choose treatment carefully

Drugs approved by Food and Drug Administration (FDA): older benzodiazepines — long half-lives; many (eg, flurazepam, triazolam) have severe side effects; temazepam effective and commonly used; newer drugs — shorter half-lives (eg, zolpidem 2 hr, zaleplon 1 hr, eszopiclone 6 hr); zolpidem extended-release — longer half-life than regular zolpidem; ramelteon — shorter half-life; long-term use — only 3 approved; eszopiclone (eg, Lunesta); ramelteon (eg, Rozerem), and Zolpidem extended-release (eg, Ambien CR); others — approved for short-term use; use clinical judgment on continuing use; efficacy and safety — all newer drugs safe and effective for short-term management; longer studies (>1 yr; available for some) show continued efficacy and safety without rebound; NIH statement — frequency and severity of adverse effects for newer drugs much lower than in older benzodiazepines; ramelteon — works on melatonin receptors (not g-aminobutyric acid [GABA] receptors); alters circadian rhythms more than sleep; not sedating, but helps with sleep onset; nonaddictive

Determining drug choices: 1) chief complaint — falling asleep or staying asleep; newer drugs for difficulty falling asleep; eszopiclone and zolpidem extended-release maintain sleep; can take zaleplon during night (as long as ³4 hr before awakening time); use complaint to decide on drug; 2) amount of time available for being in bed — 8 hr ideal; read label for required inactivity (7-8 hr for most drugs, except zaleplon [4 hr] and ramelteon [none]); advise patients to stay in bed for sufficient time (ie, avoid getting up while still sedated; 3) sleep history — diaries and questionnaires; bottom line — talk to patient about sleep hygiene (eg, alcohol and caffeine ingestion), medical and psychiatric problems, and stress

Sample questions: difficulty falling or staying asleep; ability to function; falling asleep at inappropriate times (insomniacs have difficulty sleeping during the day, but feel fatigued); ideal choice of sleep/wake times; time in bed vs time asleep (many insomnia patients spend too much time in bed); other symptoms (eg, restless legs syndrome, sleep apnea [SA]);

Last resort: consider referral to sleep clinic

Obstructive Sleep Apnea

Alon Y. Avidan, MD, MPH, Associate Professor, Department of Neurology, David Geffen School of Medicine at University of California, Los Angeles, Director, Neurology Clinic, Director, Neurology Residency Program, and Associate Director, UCLA Sleep Disorders Center,

Background and epidemiology: obstructive sleep apnea (OSA) likely in »30% of patients who snore; likelihood increases with — male sex, overweight (body mass index [BMI] >35), age ³40 yr, and family history; other factors — large neck size in males >17 yr of age; high blood pressure (BP)

Clinical signs and symptoms: lesion — at level of velopharynx, where posterior pharynx contacts soft palate; velopharyngeal space — critical area where breathing stops; parapharyngeal fat pads also occlude velopharyngeal air space; sleep-disordered breathing spectrum — normal breathing and snoring on one end; apnea on opposite end; middle of spectrum — respiratory effort-related arousals (snoring in crescendo pattern), daytime sleepiness, and hypopneas (incomplete apneas; do not always result in complete airway occlusions but pathophysiology and treatment similar to that of OSA); polysomnography (PSG) — absence of air flow ³10 sec; usually increased respiratory effort, some paradoxic breathing (chest and abdomen working in opposition), oxygen desaturation <4%, compared to oxygen level before event, electroencephalographic (EEG) evidence for arousal; in OSA, 50 to 60 events per hour of sleep

Distinction between obstructive and central apnea

Obstructive: cessation of nasal and oral airflow; patient trying to overcome resistance to airflow and generating breathing effort; paradoxic breathing; EEG shows arousal and delayed oxygen desaturation (response to obstruction); daytime sleepiness; effects on CV system — most patients develop physiologic response (eg, bradycardia) during event; some develop sinus arrest; ventricular fibrillation most pathologic

Central: no airflow or breathing effort; pathophysiology —due to CV disease, brainstem lesions, stroke, or congestive heart failure; treatment — similar to that for OSA (but better addressed with bilevel positive pressure [biPAP] ventilation)

Upper airway resistance syndrome: crescendo snoring; laborious breathing; EEG arousal; explains fatigue and sleepiness in patients with narrow air space but without obesity

Snoring: independent risk factor for hypertension or stroke; associated with high BP and daytime sleepiness; treated with weight loss and positional therapy

Effects of OSA: unrefreshing sleep, poor memory, irritability, and impotence; physical examination (PE) — height-to-weight ratio, BMI, neck circumference, oral air space, and size of uvula and soft palate

Mallampati system: classification system (I-IV) to document ease of intubation; ask patient to extend tongue; higher score means increased risk for OSA; positive correlation with apnea/hypopnea index (AHI; indication of severity of OSA)

Neck circumference and intranasal examination: neck — in men, >17 in; in women, >16 in; intranasal examination —check for nasal polyps or other obstructions that would preclude nasal CPAP; document tonsil size (tonsillectomy curative in children) and size of soft palate and uvula (resection option)

Facial morphology: certain syndromes (eg, Pierre Robin sequence) can push soft palate closer to velopharyngeal air space; physical features (children) — tonsillar hypertrophy, adenoidal hypertrophy, obesity, and impaired growth and development; often present with hyperactivity

Diagnosing OSA: PSG (common) — EEG, eye electrodes (to track rapid eye movement [REM] sleep), snoring, airflow, respiratory effort, and oxygen saturation; add leads if parasomnia suspected; recommend 2 electromyographic (EMG) electrodes on chin and leg; hypnogram — illustration of sleep stages, oxygen saturation, and other physiologic parameters over time; pronounced hypoxemia during REM sleep

Nonsurgical Treatment

Self-treatments: weight loss; positional therapy; avoiding substances that worsen apnea (eg, alcohol, long-acting sedative hypnotics); positional therapy — tennis balls to make sleeping on back uncomfortable (causes low back pain); wedge pillow

CPAP therapy: pneumonic splint (as pressure increased from 0 to 15 cm H₂O, dimensions of upper airway improve); adherence — challenging (patients complain about claustrophobia and appearance of equipment); involve family or bed partner; improvement takes months (need motivated patient)