The Art of Good Sleep June 9, 2019 Texas Family Medicine - PowerPoint PPT Presentation

The Art of Good Sleep June 9, 2019 Texas Family Medicine Symposium W. David Brown, PhD, FAASM, DBSM

Speaker Disclosure • Dr. Brown has disclosed that he has no actual or potential conflict of interest in relation to this topic.

Learning Objectives By the end of this educational activity, the learner should be better able to: 1. Evaluate various sleep‐related conditions utilizing evidence‐based recommendations and guidelines, including ordering appropriate diagnostic testing based on patient history and physical examination. 2. Develop a treatment plan utilizing nonpharmaceutical management of insomnia such as lifestyle modification, cognitive behavioral therapy and alternative therapies. 3. Review basic theories of insomnia in adults and pediatric patients.

Brief Review • Sleep is controlled by two main factors • Homeostasis • Circadian Rhythms • Sleep is also a behavior • There are over 70 diagnosable sleep disorders • Sleep is critically important for all aspects of human health and well‐being

Two Process Model

Two-Process Model of Sleep Regulation

Core Temperature and Sleep From Duffy JF, et al. 1998. Core (rectal) body temperatures for young and older subjects. Solid circles = Older subjects (n =43); open circles = young subjects (n = 97); solid bar, usual sleep episode of older subjects; open bar, usual sleep episode of young subjects. Data are plotted with respect to actual time of day.

Childhoods E nd • Strong Phase Delay during Adolescence • Trend reverses in early 20’s • Earlier in women

Sleep Myths • Insomnia patients are very accurate in estimating how long it takes them to fall to sleep and how long they slept • Most people sleep through the night without waking • The older you get, the fewer hours of sleep you need • Drinking alcohol will help you sleep • You can catch up on your sleep over the weekend • Watching TV helps you sleep • Never wake up a sleepwalker • Eating Turkey will put you to sleep • Counting Sheep helps you fall to sleep Frankel BL, et al. Recorded and reported sleep in primary insomnia. Arch Gen Psychiatry , 1976, 33: 615‐623

Insomnia patients are very accurate in estimating how long it takes them to fall to sleep and how long they slept • Very few “Universals in psychology or medicine but this seems to one of them • Insomnia patients tend to grossly overestimate how long it takes them to fall to sleep and how long they actually slept • This has clinical implications • If you hold someone to their reported time in bed, you will end up sleep depriving them • Controlled sleep deprivation will increase Stage N3 sleep, decrease SOSL, and Decrease number and duration of awakenings • Most Severe Example is Sleep State Misperception Frankel BL, Coursey RD, Buchbinder R, Snyder F. Recorded and reported sleep in chronic primary insomnia. Arch Gen Psychiatry, 1976;33:615‐23.

Sleep State Misperception • Complaint is “I don’t sleep • May go days with no sleep at all • Not manic, not abusing amphetamines • Go to bed at the same time • Stay in bed all night • Get up at the same time • Are not sleepy during the day • Often report dreams • Ask bedpartner if they appear to be asleep

ou Fall to Sleep Counting Sheep Helps Y

Insomnia

Significance of Insomnia • Among the most common health complaints in medical practice • 9‐15% of adult population reports chronic insomnia • 27% report occasional insomnia • 50% of Primary Care patients report Intermittent insomnia and 19% have chronic insomnia • Reduced Quality of Life • Increased absenteeism • Reduced productivity • Higher health care costs • Increased risk of depression • Increased risk of chronic medication use • Cognitive Impairments • Placement in nursing home Ancoli‐Israel S and Roth T. Sleep, 1999; 22(Supplement 2), S347‐S353. Ohayon M. Epidemiology of insomnia: what we know and what we still need to learn . Sleep Medicine Reviews, Volume 6, Issue 2, May 2002, Pages 97‐111.

Behavioral Treatment of Insomnia • 70‐80% of patients with insomnia benefit from treatment • Only 20‐30% become good sleepers • Total Sleep Time is increased by a modest 30‐45 minutes • Increased sleep satisfaction • Five studies met criteria for analysis. Low to moderate grade evidence suggests CBT‐I has superior effectiveness to benzodiazepine and non‐benzodiazepine drugs in the long‐term, while very low‐grade evidence suggests benzodiazepines are more effective in the short‐term. Mitchell M, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Family Practice, 2012, 13:40 http://www.biomedcentral.com/1471‐2296/13/40 Trauer JM, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta‐analysis. 2015 Aug ;163(3):191‐204.

Initial Assessment • What is the complaint – “I can’t sleep” (trouble falling or staying asleep or both) • Get sleep phase • Differentiate diagnosis – Primary Sleep Disorder, RLS, PLMS, Circadian Rhythm Disturbance, OSA • Daytime functioning – Sleepy, tired, hyperactive, fatigued • Substance Use – Prescription and OTC medications, Medications for sleep, Caffeine, recreational drugs • Medical History – Anemia, thyroid, Flu, Chronic pain, Cardiac, Pulmonary, Obesity, Tonsillar Hypertrophy • Psychological History – Depression, Anxiety, Trauma, Bullying, Divorce, Stress • Environment – Share room, how dark, electronics, temperature, sound, music, safe • Family History – Depression, sleep disorders

Determining Circadian Phase • Ask about bedtime on school/work days and weekends • Ask about wake time on School/Workdays and weekends • If they have no constraints when will they awaken spontaneously • More difficult in adults but in children, when do they awaken spontaneously in summer

E xample • 16‐year‐old male • CC: “I have a hard time falling to sleep” School Days Weekends Summer Bedtime 10:00 PM 2:00 AM 2‐3:00 AM SOSL 2+ hours < 30 minutes < 30 minutes Wake time 6:30 AM 2:00 PM 11:00 AM TST 6 hours 12 hours 8 – 9 hours Estimated Sleep Phase is 2 AM until 11 AM

Two-Process Model of Sleep Regulation

Sleep Diary

Circadian Rhythm Disturbance Dangerous Driver

Actigraphy • Motion and light recorder • Step better than the sleep diary • Less data than a sleep study but you get two weeks of data not just a single night

No melatonin With Melatonin 1 mg • 4‐year‐old male • Mother states “He never sleeps.” • She does not watch him only hears him at night • Melatonin has no effect

Polysomnographic E valuation • 8‐year‐old male • Difficulty falling to sleep • Difficulty staying asleep • Bed 8 PM, Asleep 10 PM • Sleepwalking 2‐3 AM • Restless Sleeper • Snoring • Dry Mouth • Tonsils size: +4 on the right (impinging on the uvula), +3‐4 on the left • Mallampatti Grade: 1‐open • 121 episodes of impaired breathing • AHI = 19.3 episodes/hr. • REM AHI = 92.7 episodes/hr. • Low O2 = 74% • CO2 >50 mm hg = 1.4% of TST • SOSL 21 minutes • SE = 71%

Sleep Hygiene Model • Specific kinds of behaviors are conducive to or incompatible with sleep and by modifying behavior insomnia may be alleviated • Sleep hygiene is not necessary or sufficient for the occurrence of insomnia • Patients with insomnia do not engage in more poor sleep hygiene practices than good sleepers • Monotherapy with good sleep hygiene does not reliably produce benefit Stepanski EJ an Wyatt JK. Use of sleep hygiene in the treatment of insomnia. Sleep Med Rev . 7 (2003), 215‐225

Sleep Hygiene • Clock in room • No Electronics – RHT and Blue Light • Less time in bed is better than more • Clinician knows sleep hygiene rules and finds violations • If you give a list to patient and say see me in 2 weeks, you will not see them again.

Physiologic Model of Insomnia • Insomnia is considered a disorder of hyperarousal • Physiologic arousal and sleep are mutually exclusive • Early studies found clear evidence of increased physiological arousal (Increased heart rate, respiration rate, skin conductance, etc.) • Methodological flaws limited value (mixed types of insomnia, control of sleep and wake states) • Some features such as core temperature are higher 24 hours whereas heart rate was only increased during sleep. • Whole body metabolic rate is higher but could be related to physical fitness (Based on oxygen consumption) • Heart Rate Variability shows increased sympathetic activity • 400 mg of caffeine 3 times/day for a week mimics insomnia • Evidence of physiologic arousal but does not rise to the level of a test. Riemann D, et al. The hyperarousal model of insomnia: A review of the concept and its evidence. Sleep Medicine Reviews, Volume 14, Issue 1, February 2010, Pgs 19‐31