Managing Sleep and Its We are such stuff Disorders: Beyond Sleep - PowerPoint PPT Presentation

Managing Sleep and Its We are such stuff Disorders: Beyond Sleep As dreams Hygiene are made on, and our little life Is rounded Descartes Li, MD with a sleep UCSF Professor of Psychiatry William Shakespeare, The Tempest Case Vignette Outline Jeff is a 54-year-old physician who reports that he awakens every morning at 4am no • Introduction matter what time he goes to sleep. • Epidemiology Extremely tired/sleepy mid-afternoon which • Foundational concepts makes it difficult to work productively. • Diagnosis and assessment of sleep What is the next best step in management? • Treatment 1

Outline Why do we sleep? • Introduction: Why do we sleep? 1. restoration • Epidemiology 2. energy conservation, • Foundational concepts 3. processing and memory consolidation. • Diagnosis and assessment of sleep • Treatment processing and memory Outline consolidation 1. Even slugs need to sleep • Introduction 2. If humans don’t sleep, learning is • Epidemiology: impaired Are we getting enough? • Foundational concepts • Diagnosis and assessment of sleep • Treatment Krishnan, H. C., Gandour, C. E., Ramos, J. L., Wrinkle, M. C., Sanchez-Pacheco, J. J. and Lyons, L. C. (2016a). Acute sleep deprivation blocks short- and long-term operant memory in Aplysia. Sleep 39, 2161-2171. Krishnan, H. C., Noakes, E. J. and Lyons, L. C. (2016b). Chronic sleep deprivation differentially affects short and long-term operant memory in Aplysia. Neurobiol. Learn. Mem. 134, 349-359. doi:10.1016/j.nlm.2016.08.013 2

Industrialization and Hours of Sleep • Society sleeps 1.5 hours less per hour per night compared to 100 years ago Sleep, those little 1942: average 7.9 hours per night 2001: 6.7 hours per night slices of death — • The increase in work performance how I loathe demanded by our 24 hour economy them. has effectively added a 13th month of ― Edgar Allan Poe work compared to the last century This Photo by Unknown Author is licensed under CC BY-SA Effect of technology on sleep “microsleeps” Thirty-one percent (31%) of drivers will fall asleep while driving at least once in their lifetime.  100,000 accidents a year happen because of tiredness. Gradisar M, Wolfson AR, Harvey AG, Hale L, Rosenberg R, Czeisler CA. The Sleep and Technology Use of Americans: Findings from the National Sleep Foundation’s 2011 Sleep in America Poll. J Clin Sleep Med. 2013;9(12):1291-1299. doi:10.5664/jcsm.3272 3

Blue Light blocking glasses https://www.ncbi.nlm.nih.go v/pmc/articles/PMC383634 0/ Doctors, after a 24 hour shift Outline o Experience a 1.5 to 2 SD deterioration in performance • Introduction relative to baseline • Epidemiology o Make 300% more fatigue-related medical errors that lead to a patient’s death (5X as many serious diagnostic • Foundational concepts errors overall) • Diagnosis and assessment of sleep o Suffer 61% more needlestick and other sharp injuries • Treatment o Double their risk of an MVA o Perform as if they have a BAC of 0.05 to 0.10% Lockley SW, Barger LK, Ayas NT, Rothschild JM, Czeisler CA, Landrigan CP. Effects of Health Care Provider Work Hours and Sleep Deprivation on Safety and Performance. The Joint Commission Journal on Quality and Patient Safety. 2007;33(11):7-18. doi:10.1016/S1553-7250(07)33109-7 4

What is Sleep Debt? Opponent Process (or Two Process) Model of Sleep (aka homeostatic drive or pressure) • Sleep Debt and • Alerting Force work at the same time • But they fluctuate independently At any given time, the sum is called sleep propensity What is the Alerting Force? Brain centers (aka Circadian rhythm) 5

Melatonin What happens when you are “post-call” Sleep tip: Raise body temperature S = Sleep Debt C = 1/Alerting Force (early in the day) Which leads to a compensatory decrease in core body temperature that night see also www.Tuck.com However, raising skin temperature may also be helpful Raymann RJEM, Swaab DF, Van Someren EJW. Skin deep: enhanced sleep depth by cutaneous temperature manipulation. Brain. 2008;131(Pt 2):500- 513. doi:10.1093/brain/awm315 6

Summary: Opponent Process Outline Model of Sleep • Introduction • Sleep Debt and • Epidemiology • Foundational concepts • Alerting Force work at the • Diagnosis and assessment of same time sleep • Treatment • But they fluctuate independently Test Question Test Question 62yo woman with sleep maintenance 62yo woman with sleep maintenance insomnia for the past six months. Self- insomnia for the past six months. Self- prescribed trial of Unisom not helpful. What prescribed trial of Unisom not helpful. What is the next best step in the management of is the next best step in the management of this patient? this patient? A. Assess for mood disorders and other A. Assess for mood disorders and other comorbidities comorbidities B. Schedule for polysomnography B. Schedule for polysomnography C. Require 2-week sleep diary C. Require 2-week sleep diary D. Give industry provided samples D. Give industry provided samples E. Refer to a sleep medicine specialist E. Refer to a sleep medicine specialist 7

Evaluation of Four questions Insomnia or Hypersomnia Question comment 1) How long does it usually take Normal sleep latency is about 10 you to fall asleep? minutes; Be aware of patients with • Duration and natural history of symptoms short latencies, such as 2 minutes • Past and present medical & psychiatric 2) How many times a night do Ask this of the patient's sleep partner history you wake up? as well. • Medications & substances: prescription, non-prescription, “alternative” therapies 3) After each awakening, how Combined with question #2 gives how • Habits – alcohol, caffeine, nicotine long does it take to fall back much sleep is being lost asleep? • Family history • Lifestyle and stressors 4) Do you feel refreshed upon Most important question awakening in the morning? • Rule out sleep apnea or periodic limb movements of sleep How much coffee do you drink? Case Vignette Key Rule outs 54-year-old physician reports that he awakens every morning at 4am no matter • Obstructive sleep apnea what time he goes to sleep. Extremely • Narcolepsy tired/sleepy mid-afternoon which makes it • Restless leg syndrome difficult to work productively. Drinks about five cups of coffee throughout • Nocturnal myoclonus the day to stay awake, but this seems to • Caffeinism interfere with going to bed at a reasonable time How much caffeine is there in a cup of coffee? What is the half-life of caffeine? 8

How much caffeine in the Caffeine following products? Can you drink coffee and then sleep? Overuse can lead to restlessness, anxiety, cardiac arrhythmias, gi distress, irritability, etc What about Non-caffeine stimulants? 227mg Eg, modafanil (Provigil), methylphenidate 133mg 80mg (per ounce, about 20) How Much Caffeine? (Starbucks Featured Dark Roast) Vivarin 200mg/pill 340mg 195mg 260mg 9

What is the half-life of Assume ½ life = 5hours caffeine? Time amount Question: If you take 240mg of 12noon 240mg caffeine at 12noon, how much is still 5pm 120mg in your body at 10pm? 10pm 60mg Half-life of caffeine = 3 to 7 hours (in healthy active individuals) What about another cup of coffee (133mg) at 3pm?  using formula above, that gives another 50mg at 10pm Answer: 60mg (which is the equivalent of 16oz of Diet Coke) Total = 60mg+50mg = 110mg Summary and Key Rule outs Outline • Obstructive sleep apnea • Introduction • Narcolepsy • Epidemiology • Restless leg syndrome • Foundational concepts • Nocturnal myoclonus • Diagnosis and assessment of sleep • Caffeinism • Treatment – CBT-I – Pharmacotherapy 10