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

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Managing Sleep and Its Disorders: Beyond Sleep Hygiene

Descartes Li, MD UCSF Professor of Psychiatry

We are such stuff As dreams are made

n, and our

little life Is rounded with a sleep

William Shakespeare, The Tempest

Outline

Introduction
Epidemiology
Foundational concepts
Diagnosis and assessment of sleep
Treatment

Case Vignette

Jeff is a 54-year-old physician who reports that he awakens every morning at 4am no matter what time he goes to sleep. Extremely tired/sleepy mid-afternoon which makes it difficult to work productively. What is the next best step in management?

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Outline

Introduction: Why do we sleep?
Epidemiology
Foundational concepts
Diagnosis and assessment of sleep
Treatment

Why do we sleep?

1. restoration
2. energy conservation,
3. processing and memory

consolidation.

processing and memory consolidation

1. Even slugs need to sleep
2. If humans don’t sleep, learning is

impaired

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

Outline

Introduction
Epidemiology:

Are we getting enough?

Foundational concepts
Diagnosis and assessment of sleep
Treatment

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Sleep, those little slices of death — how I loathe them.

― Edgar Allan Poe

This Photo by Unknown Author is licensed under CC BY-SA

Industrialization and Hours of Sleep

Society sleeps 1.5 hours less per hour

per night compared to 100 years ago

1942: average 7.9 hours per night 2001: 6.7 hours per night

The increase in work performance

demanded by our 24 hour economy has effectively added a 13th month of work compared to the last century

“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.

Effect of technology on sleep

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

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https://www.ncbi.nlm.nih.go v/pmc/articles/PMC383634 0/

Blue Light blocking glasses Doctors, after a 24 hour shift

Experience a 1.5 to 2 SD deterioration in performance

relative to baseline

Make 300% more fatigue-related medical errors that

lead to a patient’s death (5X as many serious diagnostic errors overall)

Suffer 61% more needlestick and other sharp injuries
Double their risk of an MVA
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

Outline

Introduction
Epidemiology
Foundational concepts
Diagnosis and assessment of sleep
Treatment

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5 Opponent Process (or Two Process) Model of Sleep

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 Sleep Debt?

(aka homeostatic drive or pressure)

What is the Alerting Force?

(aka Circadian rhythm)

Brain centers

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Melatonin Raise body temperature (early in the day)

Which leads to a compensatory decrease in core body temperature that night

Sleep tip:

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

However, raising skin temperature may also be helpful

What happens when you are “post-call”

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Summary: Opponent Process Model of Sleep

Sleep Debt and
Alerting Force

work at the same time

But they

fluctuate independently

Outline

Introduction
Epidemiology
Foundational concepts
Diagnosis and assessment of

sleep

Treatment

Test Question

62yo woman with sleep maintenance insomnia for the past six months. Self- prescribed trial of Unisom not helpful. What is the next best step in the management of this patient?

A. Assess for mood disorders and other

comorbidities

B. Schedule for polysomnography
C. Require 2-week sleep diary
D. Give industry provided samples
E. Refer to a sleep medicine specialist

Test Question

62yo woman with sleep maintenance insomnia for the past six months. Self- prescribed trial of Unisom not helpful. What is the next best step in the management of this patient?

A. Assess for mood disorders and other

comorbidities

B. Schedule for polysomnography
C. Require 2-week sleep diary
D. Give industry provided samples
E. Refer to a sleep medicine specialist

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Evaluation of Insomnia or Hypersomnia

Duration and natural history of symptoms
Past and present medical & psychiatric

history

Medications & substances: prescription,

non-prescription, “alternative” therapies

Habits – alcohol, caffeine, nicotine
Family history
Lifestyle and stressors
Rule out sleep apnea or periodic limb

movements of sleep

Four questions

Question comment 1) How long does it usually take you to fall asleep? Normal sleep latency is about 10 minutes; Be aware of patients with short latencies, such as 2 minutes 2) How many times a night do you wake up? Ask this of the patient's sleep partner as well. 3) After each awakening, how long does it take to fall back asleep? Combined with question #2 gives how much sleep is being lost 4) Do you feel refreshed upon awakening in the morning? Most important question

How much coffee do you drink?

Key Rule outs

Obstructive sleep apnea
Narcolepsy
Restless leg syndrome
Nocturnal myoclonus
Caffeinism

Case Vignette

54-year-old physician reports that he awakens every morning at 4am no matter what time he goes to sleep. Extremely tired/sleepy mid-afternoon which makes it difficult to work productively. Drinks about five cups of coffee throughout the day to stay awake, but this seems to 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?

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What about Non-caffeine stimulants?

Eg, modafanil (Provigil), methylphenidate

Caffeine

Can you drink coffee and then sleep?

Overuse can lead to restlessness, anxiety, cardiac arrhythmias, gi distress, irritability, etc

How much caffeine in the following products?

133mg 80mg 227mg (per ounce, about 20)

How Much Caffeine?

195mg 260mg 340mg

(Starbucks Featured Dark Roast)

Vivarin

200mg/pill

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What is the half-life of caffeine?

Half-life of caffeine = 3 to 7 hours (in healthy active individuals) Question: If you take 240mg of caffeine at 12noon, how much is still in your body at 10pm?

Answer: 60mg (which is the equivalent of 16oz of Diet Coke)

Assume ½ life = 5hours

Time amount 12noon 240mg 5pm 120mg 10pm 60mg What about another cup of coffee (133mg) at 3pm?

using formula above, that gives another 50mg at 10pm

Total = 60mg+50mg = 110mg

Summary and Key Rule outs

Obstructive sleep apnea
Narcolepsy
Restless leg syndrome
Nocturnal myoclonus
Caffeinism

Outline

Introduction
Epidemiology
Foundational concepts
Diagnosis and assessment of sleep
Treatment

– CBT-I – Pharmacotherapy

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Test Question

62yo woman with sleep maintenance insomnia for the past six months. Self- prescribed trial of Unisom not helpful. No

ther medical or psychiatric morbidities.

Which of the following is true*:

A. Moderate evidence for temazepam
B. Strong evidence for doxepin+suvorexant
C. Sufficient evidence for CBT-I as first line

treatment

D. Moderate evidence that pharmacotherapy

decisions should be independent of CBT-I

*Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2017;13(02):307-349. doi:10.5664/jcsm.6470

Test Question

62yo woman with sleep maintenance insomnia for the past six months. Self- prescribed trial of Unisom not helpful. No

ther medical or psychiatric morbidities.

Which of the following is true*:

A. Moderate evidence for temazepam
B. Strong evidence for doxepin+suvorexant
C. Sufficient evidence for CBT-I as first line

treatment

D. Moderate evidence that pharmacotherapy

decisions should be independent of CBT-I

*Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine. 2017;13(02):307-349. doi:10.5664/jcsm.6470

Nonpharmacologic Treatment Strategies: Sleep Hygiene

Maintain regular bedtime and awakening time1-3
Exercise regularly, but not before bedtime1,2
Avoid naps1,3
Avoid caffeine intake after noon and alcohol

and nicotine in the evening1,2

Make bedroom comfortable: dark, quiet,

not too hot or too cold1,2

If hungry, have only a light snack before bedtime2
1. Lippmann S et al. Insomnia: therapeutic approach. South Med J. 2001;94:866-873.
2. National Heart, Lung, and Blood Institute Working Group on Insomnia. Insomnia: Assessment and Management

in Primary Care. Bethesda, Md: National Heart, Lung, and Blood Institute; September 1998. NIH Publication No. 98- 4088.

3. Kupfer DJ, Reynolds CF. Management of insomnia. N Engl J Med. 1997;336:341-346.

Working Group on Insomnia. 1998. NIH Publication 98-4088.

Minimal evidence for sleep hygiene

Sleep Hygiene is different from stimulus control and sleep restriction “…the direct effects of individual recommendations on sleep remains largely untested in the general population.”

From Irish LA, Kline CE, Gunn HE, Buysse DJ, Hall MH. The Role of Sleep Hygiene in Promoting Public Health: A Review of Empirical Evidence. Sleep Med Rev. 2015;22:23-36. doi:10.1016/j.smrv.2014.10.001

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Sleep Hygiene

If it worked, then the patient probably wouldn’t be coming to see you.

Case conceptualization: Night and Day
Stimulus control/sleep restriction*
Circadian/rhythm education
Pre-sleep ‘wind down’/ Roll bedtime forward by 20-30 mins per

week

Brisk wakeup: overcoming sleep inertia
Unhelpful beliefs about sleep
Worry / rumination
Daytime focus
Strategies for different kinds of sleep disturbance
Attention to: Opportunity to sleep and Light/Dark

CBT-I for Bipolar Disorder: Treatment components

8 sessions, 90min each

Sleep Restriction Therapy Rationale: Aims to limit the person’s time in bed to the estimated average amount of nighttime sleep

Goal 1: Maximize sleep efficiency
Goal 2: Associate the bed with sleep
Goal 3: Build homeostatic pressure

to sleep

Stimulus Control Therapy

Rationale:

Assumes there is a learned

association between wakefulness and the bedroom

To break this association the patient

must not spend excessive time wide awake in the bedroom

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Stimulus Control Therapy

Go to bed only when sleepy
Use the bed only for sleeping and sex – do not

read, watch TV, or eat in bed

If unable to sleep (in 20 mins), move to another
room. Stay up until really sleepy. The goal is to

associate the bed with falling asleep quickly

Repeat tactic immediately above as often as

necessary

Awaken at the same time every morning

regardless of total sleep time

Do not nap

Bootzin RR, Epstein DR. Stimulus Control. In: Lichstein KL, Morin CM, eds. Treatment of late-life

insomnia. Thousand Oaks, Calif: Sage; 2000:167-184.

Books on sleep What about sleep apps? Outline

Introduction
Epidemiology
Foundational concepts
Diagnosis and assessment of sleep
Treatment

– CBT-I – Pharmacotherapy

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Test Question

35yo man with sleep-onset (initial)

insomnia. No h/o substance abuse, nor
ther psych d/o. Currently taking

diphenhydramine, which is not helping. What next?

A. tiagabine
B. zolpidem
C. trazodone
D. melatonin
E. suvorexant

Test Question

35yo man with sleep-onset (initial)

insomnia. No h/o substance abuse, nor
ther psych d/o. Currently taking

diphenhydramine, which is not helping. What next?

A. tiagabine
B. zolpidem
C. trazodone
D. melatonin
E. suvorexant

Classes of hypnotics

Benzodiazepines Heterocyclics Anticonvulsants OTC Unisom

Orexin receptor agonists: suvorexant (Belsomra) Melatonin agonists: ramelteon (Rozerem) BZD receptor agonist: Eszopiclone (Lunesta) Zolpidem (Ambien) Zaleplon (Sonata)

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Test Question

Which of the following agents may be used for both sleep onset insomnia and sleep maintenance insomnia? (more than one may be correct)

A. eszopiclone
B. melatonin
C. ramelteon
D. Suvorexant
E. temazepam
F. trazodone
G. zolpidem

Test Question

Which of the following agents may be used for both sleep onset insomnia and sleep maintenance insomnia? (more than one may be correct)

A. eszopiclone
B. melatonin
C. ramelteon
D. Suvorexant
E. temazepam
F. trazodone
G. zolpidem

Table

Sateia MJ et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults Journal of Clinical Sleep Medicine. 2017;13(02):307-349. doi:10.5664/jcsm.6470

Table (continued)

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Case Vignette

54-year-old physician reports that he awakens every morning at 4am no matter what time he goes to sleep. Extremely tired/sleepy mid-afternoon which makes it difficult to work productively. Doesn’t drink coffee Has good sleep hygiene, even tried CBT-I Has taken zolpidem and zaleplon with variable sucess What medication could you try next?

Best for early morning awakening or

mid-insomnia

Half life of 15 hours
probably best to take only 3-4 nights

per week

1. Krystal AD, Durrence HH, Scharf M, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep. 2010;33(11):1553-1561. 2. Krystal AD, Lankford A, Durrence HH, et al. Efficacy and Safety of Doxepin 3 and 6 mg in a 35-day Sleep Laboratory Trial in Adults with Chronic Primary Insomnia.

Sleep. 2011;34(10):1433-1442. doi:10.5665/SLEEP.1294

Doxepin

Dissolve 10mg in 10cc syringe of

water

Take 2-3mg per night
Complicating factors:

– Long half-life (15 hours) – Tolerance – Decreased sleep debt

Doxepin: how to use

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Doxepin generic 10mg pills, #30 Silenor (doxepin) 3mg pills, #30

$40 $450

Outline

Introduction
Epidemiology
Foundational concepts
Diagnosis and assessment of sleep
Treatment

– CBT-I – Pharmacotherapy

Sleep is God, go worship

Jim Butcher

This Photo by Unknown Author is licensed under CC BY-ND

Bonus material

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Bonus: Light Therapy Light Therapy

Check out the Center for Environmental Therapeutics: www.cet.org

Light boxes Light therapy for MDD

Daily exposure light box for 30

minutes ASAP after awakening, preferably between 7 and 8 am

(Carex Day-Light Classic, emitting 4000-K white light rated at 10000 lux at 35.56 cm from screen to cornea, with a UV filter

Patients used the light box at home

and were given standardized verbal and written instructions.

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Lam RW et al. Efficacy of Bright Light Treatment, Fluoxetine, and the Combination in Patients With Nonseasonal Major Depressive Disorder A Randomized Clinical

Trial. JAMA Psychiatry.

2016;73(1):56-63. doi:10.1001/jamapsychiatr y.2015.2235

A dramatic example of stimulus control: Practice Makes Perfect

Harris J; Lack L; Kemp K; Wright H; Bootzin R. A randomized controlled trial of intensive sleep retraining (ISR): a brief conditioning treatment for chronic insomnia. SLEEP 2012;35(1):49-60.

50 sleep onset trials over a 25-h sleep deprivation period

On day prior sleep restrict to 5 h (to increase homeostatic

sleep drive)

9pm, subject arrives at sleep lab
One treatment trial every 30min until 11pm the following

night (50 trials)

Each trial, pt allowed to fall asleep for 3min, then awoken

and kept awake (reading or DVDs) until next trial

Participants then had a recovery night’s sleep (maximum
f 8 h).