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BHC Restorative Sleep


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Poor sleep is a hallmark symptom of ME/CFS and FM. Not getting a good night’s sleep can worsen symptoms. Dive into the mechanics of good sleep with Dr. Bateman and learn why sleep disturbances occur and how to implement strategies that improve them.

Published in: Health & Medicine
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BHC Restorative Sleep

  1. 1. SLEEP DISTURBANCES ME/CFS and FM Lucinda Bateman MD Bateman Horne Center 2018
  2. 2. General Principles of Supportive Management: • 1) Address all other conditions (complete a good medical work-up) • i.e. anemia, thyroid, diabetes, sleep apnea, low Vit B12 • 2) “Pace” to prevent symptom escalation (Preventive activity management. Reduce overload) • 3) Address the major aspects of illness • PAIN: reduce severe pain • SLEEP: achieve restorative sleep • MENTAL HEALTH: insight and support • FITNESS: engage in restorative exercise PAIN SLEEP MENTAL HEALTH FITNESS
  3. 3. Alternate "new" Fibromyalgia Criteria (ACR 2010) 1) Widespread PAIN index (WPI) (0-19 points—see next slide) 7+ or 3-6 2) Symptom Score (SS): 0=none, 1=mild, 2=mod, 3=severe Chronic fatigue (0-3) Unrefreshing sleep (0-3) Cognitive complaints (0-3) Multisystem complaints (0-3) Max SS = 12 5+ and 9+ FM FM > 3 months in duration and without other apparent explanation Wolf F, et al. The American College of Rheumatology Preliminary Diagnostic Criteria for Fibromyalgia and Measurement of Symptom Severity. Arthritis Care & Research. Vol. 62, No. 5, May 2010, pp 600–610
  4. 4. ME/CFS Clinical Diagnostic Criteria: These CORE 4-5 criteria are required for diagnosis, must be moderate-severe, frequent in occurrence (present >50% of time) and not otherwise explained by another condition. 1) Impaired function related to exhaustion/fatigue/fatigability (physical and cognitive) 2) PEM: post exertional malaise (illness relapse or worsening after activity) 3) Unrefreshing sleep 4) A. Cognitive impairment and/or B. Orthostatic intolerance/autonomic dysfunction Other common features of illness include: ---Pain: including significant overlap with FM as currently defined ---Immune or infection manifestations (allergy, inflammation, etc) ---Neuroendocrine dysregulation (brain regulation of hormones)
  5. 5. Unrefreshing sleep • Sleep disturbances are common • Included in all CFS ME/CFS, ME and FM case definitions or symptom criteria • Present in >90% of all diagnosed • Sleep abnormal in: • Quality (light, restless, interrupted, heavy) • Duration/timing (delayed, prolonged, irregular)
  6. 6. Central Sensitivity disturbs sleep • Pain amplification/hyperalgesia (FM): pain disrupts sleep* • Sensory amplification in ME/CFS/FM: • Noise. Bright light. Temperature. • Central “overload” PEM disturbs unravels normal sleep • Tired but wired • Too exhausted to sleep • “oversignaling” *Modofsky 2008
  7. 7. “Unrefreshing sleep” is the most consistently reported symptom of ME/CFS This includes sleeping too much or too little, trouble falling asleep, light sleep and frequent awakenings, trouble getting back to sleep, early morning awakening, trouble waking up after finally getting to sleep, need for naps and irregular sleep cycles. pwMECFS spend more time in bed and have less quality sleep* *Morris 1993
  8. 8. 300 Dutch CFS patients* (those with primary sleep disorders excluded) Four types of sleep presentation (1 PSG): • sleep time REM (catch up sleep?) • REM (drugged sleep?) • #arousals/hour (disrupted sleep?) • sleep REM (insomnia?) *Gotts 2013
  9. 9. Observing/Monitoring sleep • Polysomnography---$$$ and good for some observations. “Sleep lab artifact” can be high and is often ignored. • Home sleep study---new • Pulsoximetry overnight---only records oxygen levels • You should monitor your own sleep! • Fitbit or other self monitoring devices • Ouraring (
  10. 10. Polysomnography (PSG) • PSG reveals Primary Sleep Disorders • PSG non-diagnostic in ME/CFS/FM* but… • Increased alpha (dozing, light sleep) • Decreased delta (slow wave, deep sleep) • Fragmentation • Delayed onset *Cunnington 2011, Togo 2008, Neu 2009, Manu 1994, Jackson 2012
  11. 11.
  12. 12. Primary Sleep Disorders • Central sleep apnea • Obstructive sleep apnea • Movement disorders (RLS, PLMD) • Narcolepsy Cause severe sleep disruption, somnolence, fatigue and other symptoms. Primary sleep disorders are illnesses commonly seen in ME/CFS/FM patients*. *LeBon 2000
  13. 13. Hypnograms (diagram of sleep stages) two examples of ‘”normal” sleep cycles or stages Graphic representations of sleep stages recorded EEG during polysomnography EEG leads
  14. 14. OSA (obstructive sleep apnea) hypnogram---on and off CPAP
  15. 15. Somnolence may be more treatable • Sleep deprivation (all causes) • Medications • Illness (neurologic, endocrine, inflammation) ESS (Epworth Sleepiness Scale) helps identify sleepiness vs fatigue sleepy tired Primary sleep disorders cause somnolence
  16. 16. Polysomnography (PSG) • You can read your own hypnogram if you have undergone PSG. But it represents only one night and might not represent your sleep stages at home. • Many people sleep lightly, with more disturbances or discomfort during PSG compared to sleeping at home. • This is “sleep study artifact” • The best way to study sleep is to record many nights
  17. 17. FitBit or equivalent monitoring devices • Records hours of “sleep” • Documents the number of disruptions • Not very good at identifying what causes the disruptions • Only estimates sleep stages
  18. 18. Oura Ring
  19. 19. Activity. Sleep. Readiness
  20. 20. Investigate and improve your own sleep • "Unrefreshing sleep" may come from sleep that is abnormal and not restorative • Dysregulated sleep is insidiously destructive over time. • Use every healthy method possible to achieve "restorative sleep" • Develop skills in relaxation and understand medications
  21. 21. Develop better communication about sleep •SLEEP 0 1 2 3 4 5 6 7 8 9 10 •MOOD 0 1 2 3 4 5 6 7 8 9 10 •PAIN 0 1 2 3 4 5 6 7 8 9 10 •HEADACHE 0 1 2 3 4 5 6 7 8 9 10 •FATIGUE 0 1 2 3 4 5 6 7 8 9 10 •FUNCTION 0 1 2 3 4 5 6 7 8 9 10 ☺ ☹
  22. 22. Sleep disruptions are varied 0123 Can’t go to sleep 0123 Restless sleep 0123 Wake up too early 0123 Can’t go back to sleep 0123 Need too much sleep 0123 Need to take naps 0123 Unrefreshing sleep 0123 Restless legs 0123 Leg cramps 0123 Myoclonic jerks (involuntary jerking of limbs) 0123 Snoring 0123 Stop breathing during sleep 28 0= none 1= infrequent 2= moderate severity or frequency 3= severe or frequent
  23. 23. 32 Address reversible sleep disturbances: • Reduce caffeine, alcohol, decongestants, stimulants • Avoid ACTIVATING the brain before bed (bright screens included) • Learn and become skilled in deep relaxation techniques. • Treat Restless Legs Syndrome (RLS), myoclonus and Periodic Limb Movement Disorder (PLMD). • Treat Obstructive Sleep Apnea (OSA). • Address Central Sleep Apnea. • Reduce medications that cause CNS depression
  24. 24. Additional Recommendations: • Improve sleep hygiene (routine timing, environment). • Identify medications that might adversely impact sleep • Daytime activity. Get physically tired---but not exhausted, “wound up” or relapsing (PEM). • Be wary of long or late naps. • Minimize sedating drugs during the day. • Aim at all the CAUSES of sleep disruption vs just being “drugged” to sleep • Simplify use of medications and use them skillfully • Sleep onset? ...wind down, establish cycles, short acting drugs, earlier dosing of longer acting sedating medications • Light sleep and frequent awakening? …reduce interruptions, low dose longer acting meds • Early morning awakening? …med rebound or withdrawal? Too much sleep? Depression?
  25. 25. Don't give up because achieving restorative sleep is a constant battle. More restorative sleep improves fatigue, cognition, pain and mood.
  26. 26. 35 Drugs used for sleep disturbances: Longer acting sleep “sustainer” examples used off-label for sleep: *TCA: amitriptyline (10-20 mg), doxepin (5-20 mg) Other antidepressants: trazodone 25-100 mg, mirtazapine 7.5-15 mg *Anticonvulsants: gabapentin 300-1200 mg, topiramate 25-100 mg Benzodiazepines: clonazepam, lorazepam 0.5-1 mg, temazepam 15-30 mg Neuroleptics: quetiapine 12.5-50 mg, olanzapine 2.5-5 mg These longer acting drugs may cause “hangover” symptoms the next morning if dosed too high or taken too late in the evening. Choose a sleep medication based on comorbid conditions and the nature of the sleep disturbances. *additional benefits for pain
  27. 27. 36 Drugs used for sleep disturbances: Sleep “initiators” or hypnotics FDA approved for insomnia, not specifically for FM or ME/CFS zolpidem 5-10 mg (approx 4 hours, CR 6 hours) zaleplon 5-10 mg (approx 2 hour duration) eszopiclone 1, 2 or 3 mg (approx 6 hour duration) benzodiazepines, ex: triazolam 0.125-0.25 mg (tolerance/habituation) • Chronic use discouraged, and thus problematic for chronic insomnia • Tolerance or dependence typically develops. • Better for sleep initiation than to sustain sleep all night. • Better for PRN use rather than nightly use *may prove different than other sleep agents
  28. 28. 37 Drugs used for sleep disturbances: Belsomra/suvorexant. An orexin receptor antagonist (suppresses wakefulness) May prove different than other sleep agents No generic available so cost is higher. *