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The ABCs of Your ZZZs - Alison S. Kole, MD, MPH, FCCP, Pulmonologist Kerry Kelley, RN, RRT, RPSGT - Montclair Library 3.20.19

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Learn from our Sleep Disorder Center experts about the basics of good sleep and the physical impact of poor sleep. We will also discuss tips for improving sleep and the treatment options for common sleep disorders, such as sleep apnea, restless legs syndrome, and insomnia, among others.

Published in: Health & Medicine
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The ABCs of Your ZZZs - Alison S. Kole, MD, MPH, FCCP, Pulmonologist Kerry Kelley, RN, RRT, RPSGT - Montclair Library 3.20.19

  1. 1. The ABCs of Your ZZZs Presented by: Alison S. Kole, MD, MPH, FCCP Kerry Kelley, RN, RRT, RPSGT
  2. 2. WELCOME!
  3. 3. Registered Polysomnographic Technologist
  4. 4. The Essentials of Sleep • Basics of “Good Sleep” – Sleep Overview • Sleep Requirements – Sleep Deprivation • Sleep Hygiene • Sleep Disorders  Obstructive Sleep Apnea  Restless Legs  REM Behavior Disorder  Insomnia  Narcolepsy
  5. 5. Importance of Healthy Sleep
  6. 6. Importance of Healthy Sleep • AASM and SRS Consensus Statement1  “Adults should sleep 7 or more hours per night on a regular basis to promote optimal health” • Official American Thoracic Society Statement2  “Sleep is an essential biological function with major roles in recovery, energy conservation, and survival”  “It is clear that good-quality sleep is critical for good health and overall quality of life”
  7. 7. The Holy Grail • A Good Night’s Sleep
  8. 8. How Much Sleep is Enough?
  9. 9. Normal Sleep Architecture
  10. 10. Normal Arousals - Awakenings
  11. 11. CDC Declares Sleep Disorders a Public Health Epidemic • In 2014 the Centers for Disease Control described sleep deprivation as so pervasive in the United States that it is considered a public health epidemic. • Research conducted by the CDC indicates that large numbers of Americans experience problems associated with lack of sufficient sleep. For example:  Almost 50 million people reported problems concentrating during the day  24 million people indicated lack of sleep interfered with driving  18 million people reported that sleep deficiency interfered with job performance.
  12. 12. Sleep Disorders Leading Cause of Lost Work Time
  13. 13. As Difficult as it May be to Believe…
  14. 14. Third Pillar of Health • Sleep is the third of the of 4 pillars of health which include nutrition, physical fitness, sleep and stress control. • The estimated cost of lost productivity is 63.2 billion dollars a year! • A primary factor for lost productivity is presenteeism, employees showing up for work but operating at subpar levels due to sleep loss.
  15. 15. Sleep Vs. Technology • The biggest sleep distraction? • 1 in 2 People check their right away if they wake up in the middle of the night • 1 in 4 People don’t silence their phones while sleeping • 1 in 10 People are awoken by their phones at least once a week
  16. 16. Sleep Duration by State
  17. 17. Short Sleep Among Adults New Jersey
  18. 18. Leptin and Ghrelin • Leptin - the appetite suppressor, is the hormone that tells your brain when you're full. • Ghrelin - the appetite increaser, is the hormone released primarily in the stomach to signal hunger to the brain. • Just two nights of restricted sleep were found to significantly impact hormones related to appetite and drive to eat, as well as self-reported hunger.
  19. 19. Sleep Deprivation Getting adequate sleep is not a luxury. It is essential for good health. Sleeping less than 7 hours is associated with:
  20. 20. While it still can’t cure the common cold… Getting enough sleep can help prevent catching a cold
  21. 21. Not getting enough sleep can age you both mentally and physically It’s called beauty sleep for a reason…
  22. 22. Drowsy Driving • National Highway Traffic Safety Administration estimates that at least 100,000 police reported crashes are the direct effect of driver fatigue • Driving after 18 hours without sleep is the equivalent of consuming 2 alcoholic beverages • driving after 24 hours without sleep is the equivalent of consuming 4 alcoholic beverages
  23. 23. Sleep Hygiene • Sleep hygiene - Habits and practices that are conducive to sleeping well on a regular basis.  Ensure an inviting sleep environment  Ensure exposure to light during the day  Limit daytime naps to 20-30 minutes  Exercising improves sleep quality  Avoid stimulants and alcohol prior to bed  Limit foods high in fat and sugar – hydrate  Establish a regular schedule and bedtime routine  Limit screen use for two hours prior to bedtime
  24. 24. Screen Brightness – Blue Light
  25. 25. Night Shift – Night Mode
  26. 26. The Essentials of Sleep Basics of “Good Sleep” – Sleep Overview Sleep Requirements – Sleep Deprivation Sleep Hygiene Sleep Disorders  Obstructive Sleep Apnea  Restless Leg/Periodic Limb Movement Disorder  REM Behavior Disorder  Insomnia  Narcolepsy
  27. 27. Obstructive Sleep Apnea
  28. 28. Airway Anatomy Picture reference: http://stopsnoringrx.com/why-do-we-snore/
  29. 29. Airway During Sleep Picture reference: http://www.dreamstime.com/royalty-free-stock-image-snoring-sleep-apnea-image2780977
  30. 30. Obstructive Sleep Apnea (OSA) • Apnea  Pause in breath for ≥ 10 seconds • Hypopnea  Flow of breath decreases by 30% of baseline for ≥ 10 seconds associated with a fall in oxygen saturation by 4% 3. AASM Scoring Manual Version 2.2, 2015
  31. 31. OSA Video Placeholder for OSA Video
  32. 32. Obstructive Sleep Apnea • Upper airway closes • Increased blood pressure • Increased heart rate • Oxygen level drops Picture reference: http://advan.physiology.org/content/32/3/196
  33. 33. Sleep Apnea Severity Apnea Hypopnea Index (AHI)
  34. 34. • SO WHAT? Health Effects of OSA
  35. 35. Health Effects of OSA
  36. 36. Health Affects of Untreated OSA • Untreated OSA = 2.5x higher risk of accidents • Effective treatment cuts this risk by 70% *Risk of motor vehicle accidents is higher in people with sleep apnea. American Academy of Sleep Medicine Tuesday, March 10, 2015
  37. 37. Risk Factors for OSA • Personal history • Family and ethnic risk • Post menopausal women Picture reference: https://utswim.wordpress.com/tag/pulmona
  38. 38. Options for Diagnosis Home Sleep Testing
  39. 39. Options for Diagnosis Polysomnography
  40. 40. Options for Treatment • CPAP (continuous positive airway pressure) therapy • APAP (auto- positive airway pressure therapy
  41. 41. Sleep Apnea – CPAP
  42. 42. Pre-CPAP and Post-CPAP SAME PATIENT!
  43. 43. Alternative Therapies NONSURGICAL SURGICAL
  44. 44. Preventative Strategies • WEIGHT LOSS  Diet, exercise, weight loss surgery • Avoidance of alcohol • Avoidance of prescription sleep aids • Quit smoking! Picture reference: http://users.rowan.edu/~blondi74/Expert.page.2.html
  45. 45. Willis-Ekbom disease (Restless Leg Syndrome) Diagnostic criteria: • Urge to move (“bugs crawling up the leg”) • Rest induced • Gets better with activity • Evening and nighttime worsening
  46. 46. Causes of Restless Legs Syndrome (RLS) Causes: • Genetics (up to 50%!) • Low iron levels • Chronic diseases • Pregnancy • Kidney failure
  47. 47. Treatment of RLS **AIM TO TREAT THE UNDERLYING CAUSE AASM Guidelines (2012): • Treatment is targeted to increase Dopamine in the brain • Medications for Parkinson's disease pramipexole (Mirapex®), pergolide (Permax®), ropinirole (Requip®), and a combination of carbidopa and Levodopa (Sinemet®). • Alternative medications: gabapentin (Neurontin®), pregabalin (Lyrica®), opiates
  48. 48. Treatment of RLS Dr. Kole’s favorite recommendations: 1. Get your ferritin level checked 2. EXERCISE – regularly! 3. Stretch before bed (restorative yoga) 4. Hydrate well throughout the day 5. Magnesium 6. Tonic water
  49. 49. REM Behavior Disorder
  50. 50. REM Behavior Disorder
  51. 51. Normal REM sleep
  52. 52. REM Behavior Disorder (RBD) • Physically acting out your dreams • Onset can be gradual or sudden • Episodes occasionally or several times a night, latter portion of evening • Noises, such as talking, laughing, shouting, emotional outcries or even cursing • Common movements: kicking, punching, arm flailing or jumping from bed, in response to action-filled or violent dreams, such as being chased or defending yourself from an attack
  53. 53. REM Behavior Disorder (RBD)
  54. 54. RBD Risk Factors • Being male and over 50 years old • Medications: antidepressants (SSRIs, TCAs) • Withdrawal from: alcohol, benzodiazapines • Stress • Co-morbid conditions:  Neurodegenerative disorders, such as Parkinson's disease, multiple system atrophy, stroke or dementia with Lewy bodies  Narcolepsy  Untreated OSA (PseudoRBD)
  55. 55. REM Behavior Disorder Diagnosis • Physical and neurological exam • Talking with your sleeping partner • Nocturnal sleep study (polysomnogram)
  56. 56. REM Behavior Disorder Treatment Physical safeguards – SAFE sleep environment: • barriers on the side of the bed • Move furniture • Padding the floor near the bed • Removing dangerous objects • Separate beds Medications: • Melatonin • Clonazepam (Klonopin)
  57. 57. There are 84 SLEEP DISORDERS WHICH IMPACT 100 MILLION AMERICANS Can anyone guess the most common sleep complaint?
  58. 58. Insomnia • Onset Insomnia - difficulty initiating sleep at the beginning of the night • Maintenance Insomnia – The inability to stay asleep or those who have difficulty returning to sleep or experience early morning awakening. • Comorbid Insomnia - Insomnia that occurs with another condition - such as anxiety and depression. Certain medical conditions can either cause insomnia or make a person uncomfortable at night (pain) which may make it hard to sleep • Further broken down into by duration….  Acute/Primary insomnia – is brief – typically less than a month – tends to be related to life circumstances.  Chronic/Secondary insomnia – effects 3 nights/week for at least 3 months – can have many causes. Inadequate or poor quality sleep
  59. 59. Causes of Primary Insomnia • Significant life stress (job loss or change, death of a loved one, divorce, moving) • Environmental factors like noise, light, or extreme temperatures (hot or cold) that interfere with sleep • Interferences in normal sleep schedule (jet lag or shift work)
  60. 60. Causes of Secondary Insomnia • Conditions that cause chronic (ongoing) pain, such as arthritis and headache disorders • Conditions that effect heart and lungs such as asthma, heart failure, and stoke • Certain medications that delay or disrupt sleep • Caffeine or stimulants • Tobacco or alcohol • An overactive thyroid • Gastrointestinal disorders, such as heartburn • Sleep disorders, such as restless legs syndrome and sleep-related breathing problems • Menopause and hot flashes
  61. 61. The Insomnia Cycle
  62. 62. Treatment of Insomnia • Lifestyle changes • cognitive-behavioral therapy (CBTi) can help relieve the anxiety linked to chronic (ongoing) insomnia. Anxiety tends to prolong insomnia. • Medications, prescription or OTC also can help relieve insomnia and re-establish a regular sleep schedule. • Treat the underlying cause (if possible).
  63. 63. Medications for Insomnia • WEAK recommendations • Short term use • NOT first line treatment • Side effects can be serious
  64. 64. Summit Medical Group CBT Resource Locations throughout Essex, Union, Morris, Warren counties with services that include telepsychiatry
  65. 65. Getting sleepy yet?…
  66. 66. Narcolepsy Type 1: Narcolepsy with cataplexy Type 2: Narcolepsy without cataplexy
  67. 67. Narcolepsy • Hypothalamus produces hypocretins • Neurotransmitters that stimulate neurons in the wake centers of brain • Decreased hypocretins cause narcolepsy http://healthysleep.med.harvard.edu/narcolepsy/what-is-narcolepsy/science-of-narcolepsy
  68. 68. Narcolepsy - Cataplexy video
  69. 69. Narcolepsy • Most patients have inherited a gene that codes for the human leukocyte antigen (HLA) DQB1*06:02 • 25% population has this gene, but only 1% population affected by narcolepsy • A triggering factor that activates the immune system, such as infection with strep • A vulnerable age during which the immune response or some characteristics of the brain make an autoimmune attack on the hypocretin neurons more likely (classically younger age patients) • PSG/MSLT required for diagnosis
  70. 70. Narcolepsy Treatment • Lifestyle and home remedies including: • Sticking to a schedule. Go to sleep and wake up at the same time every day, including weekends. • Taking naps. Schedule short (20 minute) naps at regular intervals during the day. • Avoid nicotine and alcohol. • Get regular exercise.
  71. 71. Narcolepsy Pharmacotherapy
  72. 72. Let’s Connect the Dots Sleep is as important as diet and exercise only easier! Make sleep the foundation of good health
  73. 73. • Set yourself up for optimal sleep by practicing good sleep behaviors • Listen to your bed partner – they offer insight as to nocturnal behavior • Think you have a sleep disorder? Talk to a sleep specialist! Closing Remarks
  74. 74. SMG Sleep Physicians
  75. 75. Recommended Reading • Sleep Smarter: 21 Essential Strategies to Sleep Your Way to A Better Body, Better Health, and Bigger Success, by Shawn Stevenson • The Promise of Sleep, by William Dement • Say Goodnight to Insomnia, by Gregg Jacobs • Goodnight Mind, by Colleen Carney
  76. 76. Thank You! I mustache you a question…

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