1. The document discusses sleep, sleep disorders like sleep apnea, and how sleep changes with age. It covers the definition of sleep, sleep stages, consequences of sleep deprivation, and prevalence of sleep disorders. 2. Treatment options for sleep apnea are discussed, including CPAP, oral appliances, and surgery. Diagnosis involves a sleep study. 3. Sleep changes as people age, with less deep sleep and more nighttime awakenings. Medical conditions can also affect older adults' sleep. Seeking help from a sleep specialist is recommended for persistent sleep issues.

1. The ABCs of Catching Zzzzzzs Presented by T. “Massey” Arrington, RPSGT, MBA Director, Covenant Sleep Centers

2. The Future is Bright Sleep Center

3. Definition of Sleep Wakefulness Awareness of the environment Ability to respond rapidly to external stimuli Sleep Sleep is a reversible complex state Actively generated by specific neuronal system Characteristics: Unresponsiveness to the environment. Recumbence Quiescence Closed eyes

4. Light & deep sleep REM (dreaming) and non-REM Sleep Stages

5. Amount of Sleep Changes with age Quantity Infant (14-16 hours) Young Adults (7-8 hours) Elderly (7 hours) Quality Elderly Young Sleep accounts one third of our life time Sleep is essential for life

6. Sleep Deprivation Types of sleep deprivation Acute and total sleep loss Chronic and Partial sleep loss Insufficient sleep time Fragmented sleep

7. Consequences of Sleep Loss Acute and total sleep loss Death Experimental Animal Familial Insomnia

8. Consequences of Sleep Loss Chronic partial sleep loss Decrease quality of life Decreased concentration and memory Fatigue and sleepiness in the day Depression and anxiety Safety Accidents Cardiovascular risks: Increased diabetes, hypertension, CVD, strokes, and pain

9. Sleep Deprivation In Society Americans sleep 1.5 hours less than our ancestors 100 years ago. We need the same amount as they did. Factors: Travel, electric lights, shift work, all night TV and computers Misperception that sleep is negotiable…wasted time. Sleeping less is “macho” and desirable.

10. General population 1 in 15 has moderate to severe OSA T Young 2004 9% women and 24% men in the middle-aged working population have OSA T Young 1993 Type 2 diabetes 50% of males, 20% females D Einhorn 2005 97% of obese diabetics G Foster 2005 ~85% of patients are not diagnosed T Young 1997 Prevalence of Obstructive Sleep Apnea (OSA)

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. Sleep Apnea Affects about 10% of all adults over 18 Over age 65, affects about 25% of adults Risk factor include: Family history Obesity Thyroid disease Age History of smoking

13. Sleep Disordered Breathing The Apnea Cycle: Breathing stops. Blood oxygen level drops. Waking briefly occurs to resume breathing. Repeat many times per night. Snoring is never normal! 25% of apnea patients do not snore

14. Normal Upper Airway

15. Snoring

16. Sleep Apnea

17. Normal

21. Consequences of OSA Decrease quality of life Fatigue and sleepiness in the day Decreased concentration and memory Depression and anxiety Safety Accidents Cardiovascular risks: Increased diabetes, hypertension, CVD, strokes, and pain

22. Symptoms of Sleep-disordered Breathing Symptoms Tired Run-down No energy Fatigued Fall asleep when not trying (Sleepiness) Snoring Witnessed apneas Gasping for breath during sleep Frequent trips to bathroom at night (Nocturia) Mood, memory, or learning problems Impotence Morning headache Dry mouth or dry throat in the morning

23. Lost of Productivity

24. Snoring Spouse Syndrome (SSS)

27. Treatment of OSA Most patients don’t know they have it Diagnose by history from patient and family, exam and testing with polysomnogram at accredited sleep center Treatment with surgery, oral appliance or CPAP Lifestyle changes such as weight loss

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

29. Oral Appliances Indications Snoring Sleep Apnea (Mild to moderate) Side effects TMJ discomfort Dental misalignment Salivation

30. Oral Appliance: Mechanics

31. Oral Appliance

32. Uvulopalatopharyngoplasty (UPPP)

33. SRS Basics of Sleep Guide. Sleep Research Society. P. 96. 2005.

34. Genioglossus Advancement

35. Maxillomandibular Advancement

36. Clinical Consequences Sleep Apnea Excessive daytime sleepiness Sleep fragmentation, Hypoxia / Hypercapnia Cardiovascular Complications Morbidity Mortality

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

38. Treatment

39. Darth Vader

40. Insomnia Insomnia is a disorder Typically co-morbid with other diseases May be difficulty falling asleep, staying asleep, or waking up earlier than planned Transient, short-term, or chronic Has many causes: medical, psychological, lifestyle The longer it lasts, the harder to treat

41. Insomnia Causes Stress Depression Anxiety Sleep Disorders Caffeine, Nicotine, Drugs Irregular schedules Circadian rhythm disorders Medications Pain

42. Restless Legs and Periodic Limb Movement Disorder PLMD: Repeated leg jerks every 5-90 seconds in sleep RLS: Uncomfortable sensations at rest while awake with compulsion to move to relieve this Diagnosed by history and PSG Treat with dopamine agents, iron, caffeine avoidance

43. Others Hypersomnias Narcolopsy Idiopathic hypersomnia Circadian rhythm disorders Parasomnias REM related NREM related

44. Sleep Changes as We Age Sleep architecture changes with age Nighttime sleep is more likely to be disturbed, especially late teens and again after age 35. Persons 55+ tend to experience more conditions that reduce sleep quality and quantity Older people tend to nap more

45. Normal Sleep Non-REM Sleep Stage 1, drowsiness Stage 2, light sleep Stage 3 and 4, deep sleep (delta or slow wave) REM Sleep “ dream” sleep

46. Other Sleep Changes with Age Less deep sleep, especially men Total sleep time increases slightly Takes longer to fall asleep (13% men and 36% women take >30 minutes after age 45 REM sleep is stable Men have more passive, inward dreams Women have active, outward dreams

47. Changes in Sleep Quantity Less melatonin and growth hormone Flattening of the temperature cycles Less exposure to natural light Changes in diet Less exercise Insufficient mental stimulation

48. Changes in Sleep Quality More shallow, fragmented sleep More awakenings More trips to the bathroom to void However, many healthy people do sleep quite well!

49. When To Get Help Some age-related changes mask sleep disorders Insomnia or daytime drowsiness is never normal or acceptable regardless of age. Differentiating the cause of these problems often requires a sleep specialist to determine cause and treatment Many people do not seek help…assume poor sleep is inevitable

50. Medical Problems Affecting Sleep Arthritis Osteoporosis Heartburn Cancer Parkinson’s Disease Dementia Alzheimer’s Disease Incontinence GERD Heart Disease COPD CHF Peripheral Vascular Disease

51. Pain in Sleep Arthritis pain at night occurs in 30%, 60% over age 50 Arthritis patients lose over 20 hours of sleep per month from pain Common night pain: back, headaches, muscles, leg cramps, sinuses 44-56%

52. Menopause and Sleep Hot flashes occur in 75% of women for average of 5 years Sharp increase in sleep apnea More daytime fatigue and sleepiness

53. Owls and Larks Advanced sleep phase syndrome: early bedtime and rise-time Delayed sleep phase syndrome: late bedtime and rise-time Treated with light boxes, medication, and chronotherapy

54. Sleep and Dementia Differentiate Alzheimer’s and senile dementia from symptoms of sleep apnea and other sleep disorders which affect mood and mentation Sleep is affected adversely by degenerative CNS disorders with nocturnal confusion and wandering then daytime sleepiness.

55. Medications Which Affect Sleep Antidepressants Anxiolytics Benzodiazepines Hypnotics Antihypertensives Heart meds Bronchodilators Nicotine Caffeine Allergy meds Prednisone Thyroid medications Alcohol Stimulants

56. Behavioral Treatment: Sleep Hygiene Regularize sleep / wake schedule Avoid stimulants and stimulating behavior Establish relaxing bedtime routine Provide conducive sleep environment Limit daytime naps Reduce or eliminate alcohol and caffeine Obtain regular exercise Avoid clock watching

57. Polysomnography

59. Conclusions Sleeping enough and well is essential to our mental and physical health at any age It takes more thoughtful effort as adults to be sure we get the sleep we need. With current sleep evaluation and treatment, there is help available for anyone needing better sleep! SLEEP IS A NECESSITY, NOT A LUXURY…SLEEP WELL!

60. Medical Director Ibrahim Sultan-Ali, MD Board Certified: Sleep Disorders & Internal Medicine

61. Sleep studies at FSSMC New sleep lab opened November 2007

62. How to Make an Appointment Call 865.429.8042 to schedule an appointment with Dr. Sultan-Ali Visit us online for more information www.fssevier.com/fss-sleepcenter