The ABCs of Catching Zzzzzzs Presented by T. “Massey” Arrington, RPSGT, MBA Director, Covenant Sleep Centers
The Future is Bright Sleep Center
Definition of Sleep <ul><li>Wakefulness </li></ul><ul><ul><li>Awareness of the environment </li></ul></ul><ul><ul><li>Abil...
<ul><li>Light & deep sleep </li></ul><ul><li>REM (dreaming) and non-REM </li></ul>Sleep Stages
Amount of Sleep <ul><li>Changes with age </li></ul><ul><ul><li>Quantity </li></ul></ul><ul><ul><ul><li>Infant (14-16 hours...
Sleep Deprivation <ul><li>Types of sleep deprivation </li></ul><ul><ul><li>Acute and total sleep loss </li></ul></ul><ul><...
Consequences of Sleep Loss <ul><li>Acute and total sleep loss </li></ul><ul><ul><li>Death </li></ul></ul><ul><ul><ul><li>E...
Consequences of Sleep Loss <ul><li>Chronic partial sleep loss </li></ul><ul><ul><li>Decrease quality of life </li></ul></u...
Sleep Deprivation In Society <ul><li>Americans sleep 1.5 hours less than our ancestors 100 years ago. </li></ul><ul><li>We...
<ul><li>General population </li></ul><ul><ul><li>1 in 15 has moderate to severe OSA  </li></ul></ul><ul><ul><li>T Young 20...
Prevalence of Sleep Apnea   80% 50% 35% 50% Diabetes Obesity All Hypertension Atrial Fibrillation Congestive Heart Failure...
Sleep Apnea <ul><li>Affects about 10% of all adults over 18 </li></ul><ul><li>Over age 65, affects about 25% of adults </l...
Sleep Disordered Breathing <ul><li>The Apnea Cycle: Breathing stops. Blood oxygen level drops.  Waking  briefly occurs to ...
Normal Upper Airway
Snoring
Sleep Apnea
Normal
 
 
 
Consequences of OSA <ul><li>Decrease quality of life </li></ul><ul><ul><ul><li>Fatigue and sleepiness in the day </li></ul...
Symptoms of Sleep-disordered Breathing <ul><li>Symptoms   </li></ul><ul><li>Tired </li></ul><ul><li>Run-down </li></ul><ul...
Lost of Productivity
Snoring Spouse Syndrome (SSS)
 
 
Treatment of OSA <ul><li>Most patients don’t know they have it </li></ul><ul><li>Diagnose by history from patient and fami...
Baseline Arm Therapeutic  Arm  Effect of CPAP on Blood Pressure n = 60 patients Becker et al 2003  Circulation Ineffective...
Oral Appliances <ul><li>Indications </li></ul><ul><ul><li>Snoring </li></ul></ul><ul><ul><li>Sleep Apnea (Mild to moderate...
Oral Appliance: Mechanics
Oral Appliance
Uvulopalatopharyngoplasty  (UPPP)
SRS Basics of Sleep Guide.  Sleep Research Society.  P. 96. 2005.
Genioglossus Advancement
Maxillomandibular  Advancement
Clinical Consequences Sleep Apnea Excessive daytime sleepiness Sleep fragmentation, Hypoxia / Hypercapnia Cardiovascular C...
Diagnostic Process Evaluation/Consult Treatment Plan and Patient  Follow-Up Clinician Referral to Sleep Lab Sleep Study Ti...
Treatment
Darth Vader
Insomnia <ul><li>Insomnia is a disorder </li></ul><ul><li>Typically co-morbid with other diseases </li></ul><ul><li>May be...
Insomnia Causes <ul><li>Stress </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Sleep Disorders </...
Restless Legs and Periodic Limb Movement Disorder <ul><li>PLMD: Repeated leg jerks every 5-90 seconds in sleep </li></ul><...
Others <ul><li>Hypersomnias </li></ul><ul><ul><li>Narcolopsy </li></ul></ul><ul><ul><li>Idiopathic hypersomnia </li></ul><...
Sleep Changes as We Age <ul><li>Sleep architecture changes with age </li></ul><ul><li>Nighttime sleep is more likely to be...
Normal Sleep <ul><li>Non-REM Sleep </li></ul><ul><li>Stage 1, drowsiness </li></ul><ul><li>Stage 2, light sleep </li></ul>...
Other Sleep Changes with Age <ul><li>Less deep sleep, especially men </li></ul><ul><li>Total sleep time increases slightly...
Changes in Sleep Quantity <ul><li>Less melatonin and growth hormone </li></ul><ul><li>Flattening of the temperature cycles...
Changes in Sleep Quality <ul><li>More shallow, fragmented sleep </li></ul><ul><li>More awakenings </li></ul><ul><li>More t...
When To Get Help <ul><li>Some age-related changes mask sleep disorders </li></ul><ul><li>Insomnia or daytime drowsiness is...
Medical Problems Affecting Sleep <ul><li>Arthritis </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Heartburn </li></ul><u...
Pain in Sleep <ul><li>Arthritis pain at night occurs in 30%, 60% over age 50 </li></ul><ul><li>Arthritis patients lose ove...
Menopause and Sleep <ul><li>Hot flashes occur in 75% of women for average of 5 years </li></ul><ul><li>Sharp increase in s...
Owls and Larks <ul><li>Advanced sleep phase syndrome: early bedtime and rise-time </li></ul><ul><li>Delayed sleep phase sy...
Sleep and Dementia <ul><li>Differentiate Alzheimer’s and senile dementia from symptoms of sleep apnea and other sleep diso...
Medications Which Affect Sleep <ul><li>Antidepressants </li></ul><ul><li>Anxiolytics </li></ul><ul><li>Benzodiazepines </l...
Behavioral Treatment:  Sleep Hygiene <ul><li>Regularize sleep / wake schedule </li></ul><ul><li>Avoid stimulants and stimu...
Polysomnography
 
Conclusions <ul><li>Sleeping enough and well is essential to our mental and physical health at any age </li></ul><ul><li>I...
<ul><li>Medical Director  </li></ul><ul><li>Ibrahim Sultan-Ali, MD </li></ul><ul><ul><li>Board Certified: Sleep Disorders ...
Sleep studies at FSSMC <ul><li>New sleep lab opened November 2007 </li></ul>
How to Make an Appointment <ul><li>Call 865.429.8042 to schedule an appointment with Dr. Sultan-Ali </li></ul><ul><li>Visi...
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Sr Ctr Sleep Talk 6202008

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  • Sr Ctr Sleep Talk 6202008

    1. 1. The ABCs of Catching Zzzzzzs Presented by T. “Massey” Arrington, RPSGT, MBA Director, Covenant Sleep Centers
    2. 2. The Future is Bright Sleep Center
    3. 3. Definition of Sleep <ul><li>Wakefulness </li></ul><ul><ul><li>Awareness of the environment </li></ul></ul><ul><ul><li>Ability to respond rapidly to external stimuli </li></ul></ul><ul><li>Sleep </li></ul><ul><ul><li>Sleep is a reversible complex state </li></ul></ul><ul><ul><li>Actively generated by specific neuronal system </li></ul></ul><ul><ul><li>Characteristics: </li></ul></ul><ul><ul><ul><li>Unresponsiveness to the environment. </li></ul></ul></ul><ul><ul><ul><li>Recumbence </li></ul></ul></ul><ul><ul><ul><li>Quiescence </li></ul></ul></ul><ul><ul><ul><li>Closed eyes </li></ul></ul></ul>
    4. 4. <ul><li>Light & deep sleep </li></ul><ul><li>REM (dreaming) and non-REM </li></ul>Sleep Stages
    5. 5. Amount of Sleep <ul><li>Changes with age </li></ul><ul><ul><li>Quantity </li></ul></ul><ul><ul><ul><li>Infant (14-16 hours) </li></ul></ul></ul><ul><ul><ul><li>Young Adults (7-8 hours) </li></ul></ul></ul><ul><ul><ul><li>Elderly (7 hours) </li></ul></ul></ul><ul><ul><li>Quality </li></ul></ul><ul><ul><ul><li>Elderly </li></ul></ul></ul><ul><ul><ul><li>Young </li></ul></ul></ul><ul><li>Sleep accounts one third of our life time </li></ul><ul><ul><li>Sleep is essential for life </li></ul></ul>
    6. 6. Sleep Deprivation <ul><li>Types of sleep deprivation </li></ul><ul><ul><li>Acute and total sleep loss </li></ul></ul><ul><ul><li>Chronic and Partial sleep loss </li></ul></ul><ul><ul><ul><li>Insufficient sleep time </li></ul></ul></ul><ul><ul><ul><li>Fragmented sleep </li></ul></ul></ul>
    7. 7. Consequences of Sleep Loss <ul><li>Acute and total sleep loss </li></ul><ul><ul><li>Death </li></ul></ul><ul><ul><ul><li>Experimental Animal </li></ul></ul></ul><ul><ul><ul><li>Familial Insomnia </li></ul></ul></ul>
    8. 8. Consequences of Sleep Loss <ul><li>Chronic partial sleep loss </li></ul><ul><ul><li>Decrease quality of life </li></ul></ul><ul><ul><ul><li>Decreased concentration and memory </li></ul></ul></ul><ul><ul><ul><li>Fatigue and sleepiness in the day </li></ul></ul></ul><ul><ul><ul><li>Depression and anxiety </li></ul></ul></ul><ul><ul><li>Safety </li></ul></ul><ul><ul><ul><li>Accidents </li></ul></ul></ul><ul><ul><li>Cardiovascular risks: </li></ul></ul><ul><ul><ul><li>Increased diabetes, hypertension, CVD, strokes, and pain </li></ul></ul></ul>
    9. 9. Sleep Deprivation In Society <ul><li>Americans sleep 1.5 hours less than our ancestors 100 years ago. </li></ul><ul><li>We need the same amount as they did. </li></ul><ul><li>Factors: Travel, electric lights, shift work, all night TV and computers </li></ul><ul><li>Misperception that sleep is negotiable…wasted time. Sleeping less is “macho” and desirable. </li></ul>
    10. 10. <ul><li>General population </li></ul><ul><ul><li>1 in 15 has moderate to severe OSA </li></ul></ul><ul><ul><li>T Young 2004 </li></ul></ul><ul><ul><li>9% women and 24% men in the middle-aged working population have OSA </li></ul></ul><ul><ul><li>T Young 1993 </li></ul></ul><ul><li>Type 2 diabetes </li></ul><ul><ul><li>50% of males, 20% females D Einhorn 2005 </li></ul></ul><ul><ul><li>97% of obese diabetics G Foster 2005 </li></ul></ul><ul><ul><li>~85% of patients are not diagnosed T Young 1997 </li></ul></ul>Prevalence of Obstructive Sleep Apnea (OSA)
    11. 11. Prevalence of Sleep Apnea 80% 50% 35% 50% Diabetes Obesity All Hypertension Atrial Fibrillation Congestive Heart Failure Drug-Resistant Hypertension Sjostrom et al, Thorax, 2002 Logan et al, J. Hypertension, 2001 Javaheri et al, Circulation, 1999 O'Keeffe & Patterson, Obes Surgery, 2004 Einhorn et al. Endocrine Prac, 2007 50% Somers et al, Circulation, 2004 77% Coronary Artery Disease 30% 59% Pacemakers Garrigue et al. Circulation 2007 Schafer et al. Cardiology 1999
    12. 12. Sleep Apnea <ul><li>Affects about 10% of all adults over 18 </li></ul><ul><li>Over age 65, affects about 25% of adults </li></ul><ul><li>Risk factor include: </li></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Obesity </li></ul></ul><ul><ul><li>Thyroid disease </li></ul></ul><ul><ul><li>Age </li></ul></ul><ul><ul><li>History of smoking </li></ul></ul>
    13. 13. Sleep Disordered Breathing <ul><li>The Apnea Cycle: Breathing stops. Blood oxygen level drops. Waking briefly occurs to resume breathing. Repeat many times per night. </li></ul><ul><li>Snoring is never normal! </li></ul><ul><li>25% of apnea patients do not snore </li></ul>
    14. 14. Normal Upper Airway
    15. 15. Snoring
    16. 16. Sleep Apnea
    17. 17. Normal
    18. 21. Consequences of OSA <ul><li>Decrease quality of life </li></ul><ul><ul><ul><li>Fatigue and sleepiness in the day </li></ul></ul></ul><ul><ul><ul><li>Decreased concentration and memory </li></ul></ul></ul><ul><ul><ul><li>Depression and anxiety </li></ul></ul></ul><ul><li>Safety </li></ul><ul><ul><li>Accidents </li></ul></ul><ul><li>Cardiovascular risks: </li></ul><ul><ul><ul><li>Increased diabetes, hypertension, CVD, strokes, and pain </li></ul></ul></ul>
    19. 22. Symptoms of Sleep-disordered Breathing <ul><li>Symptoms </li></ul><ul><li>Tired </li></ul><ul><li>Run-down </li></ul><ul><li>No energy </li></ul><ul><li>Fatigued </li></ul><ul><li>Fall asleep when not trying (Sleepiness) </li></ul><ul><li>Snoring </li></ul><ul><li>Witnessed apneas </li></ul><ul><li>Gasping for breath during sleep </li></ul><ul><li>Frequent trips to bathroom at night (Nocturia) </li></ul><ul><li>Mood, memory, or learning problems </li></ul><ul><li>Impotence </li></ul><ul><li>Morning headache </li></ul><ul><li>Dry mouth or dry throat in the morning </li></ul>
    20. 23. Lost of Productivity
    21. 24. Snoring Spouse Syndrome (SSS)
    22. 27. Treatment of OSA <ul><li>Most patients don’t know they have it </li></ul><ul><li>Diagnose by history from patient and family, exam and testing with polysomnogram at accredited sleep center </li></ul><ul><li>Treatment with surgery, oral appliance or CPAP </li></ul><ul><li>Lifestyle changes such as weight loss </li></ul>
    23. 28. Baseline Arm Therapeutic Arm Effect of CPAP on Blood Pressure n = 60 patients Becker et al 2003 Circulation Ineffective therapy- no change in mean blood pressure Effective therapy corresponds to a 10 mm Hg drop in blood pressure
    24. 29. Oral Appliances <ul><li>Indications </li></ul><ul><ul><li>Snoring </li></ul></ul><ul><ul><li>Sleep Apnea (Mild to moderate) </li></ul></ul><ul><li>Side effects </li></ul><ul><ul><li>TMJ discomfort </li></ul></ul><ul><ul><li>Dental misalignment </li></ul></ul><ul><ul><li>Salivation </li></ul></ul>
    25. 30. Oral Appliance: Mechanics
    26. 31. Oral Appliance
    27. 32. Uvulopalatopharyngoplasty (UPPP)
    28. 33. SRS Basics of Sleep Guide. Sleep Research Society. P. 96. 2005.
    29. 34. Genioglossus Advancement
    30. 35. Maxillomandibular Advancement
    31. 36. Clinical Consequences Sleep Apnea Excessive daytime sleepiness Sleep fragmentation, Hypoxia / Hypercapnia Cardiovascular Complications Morbidity Mortality
    32. 37. Diagnostic Process Evaluation/Consult Treatment Plan and Patient Follow-Up Clinician Referral to Sleep Lab Sleep Study Titration Night Therapy Dispensed by Homecare Company Clinician Identifies Sleep Apnea Symptoms in Patient Discuss Results/Treatment Option
    33. 38. Treatment
    34. 39. Darth Vader
    35. 40. Insomnia <ul><li>Insomnia is a disorder </li></ul><ul><li>Typically co-morbid with other diseases </li></ul><ul><li>May be difficulty falling asleep, staying asleep, or waking up earlier than planned </li></ul><ul><li>Transient, short-term, or chronic </li></ul><ul><li>Has many causes: medical, psychological, lifestyle </li></ul><ul><li>The longer it lasts, the harder to treat </li></ul>
    36. 41. Insomnia Causes <ul><li>Stress </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Sleep Disorders </li></ul><ul><li>Caffeine, Nicotine, Drugs </li></ul><ul><li>Irregular schedules </li></ul><ul><li>Circadian rhythm disorders </li></ul><ul><li>Medications </li></ul><ul><li>Pain </li></ul>
    37. 42. Restless Legs and Periodic Limb Movement Disorder <ul><li>PLMD: Repeated leg jerks every 5-90 seconds in sleep </li></ul><ul><li>RLS: Uncomfortable sensations at rest while awake with compulsion to move to relieve this </li></ul><ul><li>Diagnosed by history and PSG </li></ul><ul><li>Treat with dopamine agents, iron, caffeine avoidance </li></ul>
    38. 43. Others <ul><li>Hypersomnias </li></ul><ul><ul><li>Narcolopsy </li></ul></ul><ul><ul><li>Idiopathic hypersomnia </li></ul></ul><ul><li>Circadian rhythm disorders </li></ul><ul><li>Parasomnias </li></ul><ul><ul><li>REM related </li></ul></ul><ul><ul><li>NREM related </li></ul></ul>
    39. 44. Sleep Changes as We Age <ul><li>Sleep architecture changes with age </li></ul><ul><li>Nighttime sleep is more likely to be disturbed, especially late teens and again after age 35. </li></ul><ul><li>Persons 55+ tend to experience more conditions that reduce sleep quality and quantity </li></ul><ul><li>Older people tend to nap more </li></ul>
    40. 45. Normal Sleep <ul><li>Non-REM Sleep </li></ul><ul><li>Stage 1, drowsiness </li></ul><ul><li>Stage 2, light sleep </li></ul><ul><li>Stage 3 and 4, deep sleep (delta or slow wave) </li></ul><ul><li>REM Sleep </li></ul><ul><li>“ dream” sleep </li></ul>
    41. 46. Other Sleep Changes with Age <ul><li>Less deep sleep, especially men </li></ul><ul><li>Total sleep time increases slightly </li></ul><ul><li>Takes longer to fall asleep (13% men and 36% women take >30 minutes after age 45 </li></ul><ul><li>REM sleep is stable </li></ul><ul><ul><li>Men have more passive, inward dreams </li></ul></ul><ul><ul><li>Women have active, outward dreams </li></ul></ul>
    42. 47. Changes in Sleep Quantity <ul><li>Less melatonin and growth hormone </li></ul><ul><li>Flattening of the temperature cycles </li></ul><ul><li>Less exposure to natural light </li></ul><ul><li>Changes in diet </li></ul><ul><li>Less exercise </li></ul><ul><li>Insufficient mental stimulation </li></ul>
    43. 48. Changes in Sleep Quality <ul><li>More shallow, fragmented sleep </li></ul><ul><li>More awakenings </li></ul><ul><li>More trips to the bathroom to void </li></ul><ul><li>However, many healthy people do sleep quite well! </li></ul>
    44. 49. When To Get Help <ul><li>Some age-related changes mask sleep disorders </li></ul><ul><li>Insomnia or daytime drowsiness is never normal or acceptable regardless of age. </li></ul><ul><li>Differentiating the cause of these problems often requires a sleep specialist to determine cause and treatment </li></ul><ul><li>Many people do not seek help…assume poor sleep is inevitable </li></ul>
    45. 50. Medical Problems Affecting Sleep <ul><li>Arthritis </li></ul><ul><li>Osteoporosis </li></ul><ul><li>Heartburn </li></ul><ul><li>Cancer </li></ul><ul><li>Parkinson’s Disease </li></ul><ul><li>Dementia </li></ul><ul><li>Alzheimer’s Disease </li></ul><ul><li>Incontinence </li></ul><ul><li>GERD </li></ul><ul><li>Heart Disease </li></ul><ul><li>COPD </li></ul><ul><li>CHF </li></ul><ul><li>Peripheral Vascular Disease </li></ul>
    46. 51. Pain in Sleep <ul><li>Arthritis pain at night occurs in 30%, 60% over age 50 </li></ul><ul><li>Arthritis patients lose over 20 hours of sleep per month from pain </li></ul><ul><li>Common night pain: back, headaches, muscles, leg cramps, sinuses 44-56% </li></ul>
    47. 52. Menopause and Sleep <ul><li>Hot flashes occur in 75% of women for average of 5 years </li></ul><ul><li>Sharp increase in sleep apnea </li></ul><ul><li>More daytime fatigue and sleepiness </li></ul>
    48. 53. Owls and Larks <ul><li>Advanced sleep phase syndrome: early bedtime and rise-time </li></ul><ul><li>Delayed sleep phase syndrome: late bedtime and rise-time </li></ul><ul><li>Treated with light boxes, medication, and chronotherapy </li></ul>
    49. 54. Sleep and Dementia <ul><li>Differentiate Alzheimer’s and senile dementia from symptoms of sleep apnea and other sleep disorders which affect mood and mentation </li></ul><ul><li>Sleep is affected adversely by degenerative CNS disorders with nocturnal confusion and wandering then daytime sleepiness. </li></ul>
    50. 55. Medications Which Affect Sleep <ul><li>Antidepressants </li></ul><ul><li>Anxiolytics </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>Hypnotics </li></ul><ul><li>Antihypertensives </li></ul><ul><li>Heart meds </li></ul><ul><li>Bronchodilators </li></ul><ul><li>Nicotine </li></ul><ul><li>Caffeine </li></ul><ul><li>Allergy meds </li></ul><ul><li>Prednisone </li></ul><ul><li>Thyroid medications </li></ul><ul><li>Alcohol </li></ul><ul><li>Stimulants </li></ul>
    51. 56. Behavioral Treatment: Sleep Hygiene <ul><li>Regularize sleep / wake schedule </li></ul><ul><li>Avoid stimulants and stimulating behavior </li></ul><ul><li>Establish relaxing bedtime routine </li></ul><ul><li>Provide conducive sleep environment </li></ul><ul><li>Limit daytime naps </li></ul><ul><li>Reduce or eliminate alcohol and caffeine </li></ul><ul><li>Obtain regular exercise </li></ul><ul><li>Avoid clock watching </li></ul>
    52. 57. Polysomnography
    53. 59. Conclusions <ul><li>Sleeping enough and well is essential to our mental and physical health at any age </li></ul><ul><li>It takes more thoughtful effort as adults to be sure we get the sleep we need. </li></ul><ul><li>With current sleep evaluation and treatment, there is help available for anyone needing better sleep! </li></ul><ul><li>SLEEP IS A NECESSITY, NOT A LUXURY…SLEEP WELL! </li></ul>
    54. 60. <ul><li>Medical Director </li></ul><ul><li>Ibrahim Sultan-Ali, MD </li></ul><ul><ul><li>Board Certified: Sleep Disorders & Internal Medicine </li></ul></ul>
    55. 61. Sleep studies at FSSMC <ul><li>New sleep lab opened November 2007 </li></ul>
    56. 62. How to Make an Appointment <ul><li>Call 865.429.8042 to schedule an appointment with Dr. Sultan-Ali </li></ul><ul><li>Visit us online for more information </li></ul><ul><li>www.fssevier.com/fss-sleepcenter </li></ul>

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