Learning Objectives Communicate risk factors associated with not - PDF document

Managing Sleep Health in Primary Care Managing Sleep Health in Primary Care Paul P. Doghramji, MD, FAAFP Family Practice Physician Collegeville Family Practice & Pottstown Medical Specialists, Inc. Medical Director of Health Services, Ursinus College – Collegeville, PA Attending Family Practice Physician, Pottstown Memorial Medical Center – Pottstown, PA Learning Objectives ▪ Communicate risk factors associated with not getting enough sleep ▪ Explain the sleep/wake cycle and circadian rhythms ▪ Identify common sleep disorders in primary care ▪ Use appropriate diagnostic tools to assess patients’ sleep health 1

Managing Sleep Health in Primary Care Agenda ▪ What is sleep? ▪ Sleep stages ▪ Sleep physiology ▪ Dreaming ▪ Sleepiness ▪ Sleep disorders ▪ Insomnia and comorbidities Sleep Perspectives ▪ Behavioral ▪ Reversible ▪ Perceptual disengagement from, and unresponsiveness to, the environment ▪ Neurophysiological ▪ Two distinct states: REM sleep and NREM ▪ Actively produced, not a result of passive inactivity ▪ Highly regulated by homeostatic and circadian processes ▪ Produces changes in the entire organism, not just the CNS ▪ Teleological ▪ Necessary for survival; deprivation leads to functional impairments and eventual death ▪ Important for clearance of neurotoxic waste products (e.g., beta amyloid) that accumulate in the brain during wakefulness NREM = non-rapid eye movement Carskadon MA, Dement WC (2005), Normal human sleep: an overview. In: Principles and Practice of Sleep Medicine, 4th ed., Kryger MH et al., eds. Philadelphia: Elsevier/Saunders, pp13-23. Science vol 342, 18 Oct 2013. 2

Managing Sleep Health in Primary Care What does sleep do? The 4R’s of Sleep: ▪ Rest ▪ Restore ▪ Repair ▪ Rejuvenate 3 PROPER-ties of Sleep ▪ Proper duration ▪ Proper timing ▪ Proper quality ▪ Improper duration and/or timing and/or quality can lead to insufficient rest/restore/rejuvenate/repair -> poor health and decreased longevity 3

Managing Sleep Health in Primary Care Why is sleep important? ▪ Cognition and performance ▪ Mood regulation ▪ Mental health ▪ Physical health ▪ Safety 4

Managing Sleep Health in Primary Care Sleep Stages SLEEP  REST Two States of Sleep Rapid eye movement (REM) sleep Non-REM sleep ▪ When dreaming occurs ▪ 3 stages ▪ “Active brain in a paralyzed body” ▪ Based primarily on EEG Typical Sleep Architectural Pattern of a Young Human Adult N 1 & REM N 2 N3 Hours 1 2 3 4 5 6 7 8 Stage I & REM sleep (red) are graphed on the same level because their EEG patterns are very similar Adapted from Hauri P. The Sleep Disorders. Kalamazoo, Mich: Upjohn ; 1982:8. 5

Managing Sleep Health in Primary Care Sleep Architecture ▪ Sleep is entered through stage N1 ▪ Orderly progression from stage N1 to N3 and, typically within 90 minutes of sleep onset, to the 1st REM period ▪ 90-minute cycle of REM-NREM repeats throughout sleep ▪ As the night progresses ▪ REM periods increase in duration and density of eye movements ▪ N3 sleep becomes less prominent in the 2 nd half of the night Sleep Stage Characteristics NREM REM Heart rate Steady Variable Blood pressure Steady Labile Respirations Regular Irregular Skeletal muscle tone Normal Decreased Thermoregulation Waking modes Decreased Penile tumescence Infrequent Frequent Mental activity Limited Dreaming Brain O 2 consumption Decreased Waking level Lee-Chiong T, ed. Sleep: A Comprehensive Handbook . Hoboken, NJ: Wiley & Sons; 2006. 6

Managing Sleep Health in Primary Care Sleep Across the Life Span 700 600 Total Sleep Time (min) Total Time in Bed 500 Awake in Bed 400 NREM N 1 REM 300 200 NREM N 2 100 NREM N 3 0 0 5 10 20 30 40 50 60 70 80 Age (years) Adapted from Williams RL, et al. Electroencephalography of Human Sleep: Clinical Applications. New York, NY: John Wiley & Sons; 1974. 7

Managing Sleep Health in Primary Care Sleep Physiology Brainstem Mechanisms Underlying Sleep and Arousal 8

Managing Sleep Health in Primary Care Orexin = Hypocretin ▪ Hypothalamic peptides (OX1 and OX2) ▪ Localized in the dorsolateral hypothalamus ▪ Wide projections throughout brain and spinal column ▪ Peptide neurotransmitters involved in ▪ Arousal ▪ Locomotion ▪ Metabolism (energy and appetite control) ▪ Increase blood pressure & heart rate Peyron et al. J Neurosci . 1998;18:9996. Moore et al. Arch Ital Biol . 2001;139:195. Silber & Rye. Neurology . 2001;56:1616. Flip Flop Switch Model of Arousal and Sleep Awake Sleep Modified from Saper CB, et al. Nature . 2005;437(7063):1257-1263. 9

Managing Sleep Health in Primary Care Dreaming When do we dream? ▪ Dreaming occurs in all stages of sleep ▪ 80% of persons who are awakened during REM sleep and sleep onset (N1 & N2) ▪ 40% of persons who are awakened from a deep sleep 10

Managing Sleep Health in Primary Care REM and Non-REM Dreams N1 & N2 N3 REM Simpler, shorter More diffuse Tend to be and have fewer (e.g., about a bizarre and D associations color or an detailed, with R than REM sleep emotion) storyline plot E dreams associations A M Highest recall during sleep stages with EEG patterns S most like those in the waking state Foulkes D. Dreaming: a cognitive-psychological analysis. Hillsdale, N.J.: Erlbaum, 1985. Frightening Dreams TYPE OF ASSOCIATED INCIDENCE SYMPTOMS SLEEP STAGE DREAM FACTORS Frequent REM sleep, usually 20% to 30%, Frightening, detailed plots nightmares in late in sleep (4 - 6 Usually no pathology declines with age Difficult return to sleep children a.m.) “Thin - boundary” / creative Frequent Increased awakenings personality nightmares in 5% to 8% Daytime memory REM sleep May have associated adults impairment and anxiety psychopathology 8% - 68% of Stereotypic dreams of the Significant trauma veterans REM sleep and sleep PTSD trauma Daytime hyper- >25% of trauma onset Intense rage, fear, grief arousability & anxiety victims REM sleep Most common in Acting out of dreams REM sleep Degenerative neurologic behavior late middle age and  REM EMG tone Nocturnal injuries illness in 50% disorder in men 1% to 4% of Deep sleep, early Blood-curdling screams No pathology in children children (1- 3 a.m.) Night terrors Autonomic discharge Psychiatric & neurologic Declines with age Stages 3 & 4 Limited recall disorders in adults Rare in adults arousals on PSG REM = rapid eye movement; EMG = electromyography PAGEL JF, Nightmares and Disorders of Dreaming. Am Fam Physician. 2000 Apr 1;61(7):2037-2042. 11

Managing Sleep Health in Primary Care Sleepiness Sleepiness: How do patients describe it? ▪ “I’m tired all the time” ▪ “I have no energy” ▪ “I feel fatigued” ▪ “I feel depressed” ▪ “I don’t feel rested” ▪ “I don’t sleep well” The International Classification of Sleep Disorders: Diagnostic and Coding Manual. 2nd ed. Westchester, IL: American Academy of Sleep Medicine; 2005. Chervin RD. Chest 2000;118:372-379. Shen J, et al. Sleep Med Rev 2006;10:63-76. 12

Managing Sleep Health in Primary Care Patients Also Mean Other Things “TIRED” Lack of Sleepiness Fatigue motivation “I don’t feel like Tendency to fall Sensation of doing anything…” asleep or inability weariness, to stay awake tiredness, exhaustion, loss of energy; the desire to rest Improved by sleep Improved by rest, exertion makes it worse Sleepiness in America % of US Adults Reporting that They Are So Sleepy it Interferes with Their Daily Activities 37% 40% 30% 20% 16% 10% 0% At least a few days per month At least a few days per week National Sleep Foundation. “Sleep in America” Poll. March 2002. 13

Managing Sleep Health in Primary Care Assessment Options: Sleep Parameters ▪ Subjective: based on self-report ▪ Epworth ▪ Insomnia Severity Scale ▪ Diaries ▪ Often do not reflect objective sleep measures ▪ Objective: Sleep lab or home sleep monitor ▪ Wearable technology (eg, Fitbit) increasingly capable of more objective sleep assessment: eg, total sleep time, slow wave sleep, REM sleep ▪ Not reimbursable, not validated in clinical practice Epworth Sleepiness Scale Rate the chances of dozing in sedentary situations Never Slight Moderate High Sitting and reading 0 1 2 3 Watching television 0 1 2 3 Sitting, inactive in a public place 0 1 2 3 (eg, a movie theater or a meeting) As a passenger in a car for an hour 0 1 2 3 without a break Lying down to rest in the afternoon 0 1 2 3 when circumstances permit Sitting and talking to someone 0 1 2 3 Sitting quietly after lunch 0 1 2 3 without alcohol In a car, while stopped for a few 0 1 2 3 minutes in the traffic Score >=10 Prompts Further Evaluation Johns MW. Sleep . 1991;14:540-545. 14