Help Your Patients Get a Better Night’s Sleep

By: Linda Harder

Photography By: Tracey Brown

Sleep. It’s a third of our life, and many of us will spend 25 to 30 ‘years’ of it sleeping.  Not getting quality sleep or sufficient sleep is correlated with unhealthy habits and even disease. Yet until recently, sleep did not get the respect and attention that diet and exercise have had as a cornerstone of health. 

Ira Weinstein, M.D., medical director of Anne Arundel Medical Center’s Sleep Disorders Center, says, “There has to be a reason we sleep a third of our lives. Without sleep, many of our systems don’t work and muscles can’t repair themselves. It’s common for sleep to be interrupted before you get sick, and studies increasingly find a correlation between sleep issues and diseases such as prostate and breast cancer, or dementias. It’s logical that sleep would be a marker of disease because sleep deprivation affects memory and other brain functions.”

He adds, “I think of sleep as equally important to health as diet and exercise. My advice to referring physicians is to ask about the patient’s sleep habits during the history and physical. Many sleep disorders start when the patient experiences a personal issue such as divorce or job loss, but become habitual. Psychological issues, including stress, are significant causes.”

Sleep Apnea

Of all the causes that bring patients to a sleep specialist or center, the most prevalent is obstructive sleep apnea – even as some 70 to 80% of those with this disorder go undiagnosed. The disorder is characterized by repetitive cessation of breathing or shallow breathing during sleep that lasts 10 seconds or more. Entailing repeated arousals from sleep and a fall in blood oxygen levels, it can result from large tonsils or tongue, excess fat in the upper airway, blocked nasal passages or anatomical issues in the jaw or airway.

Jason Marx, M.D., chief of Pulmonary, Critical Care, and Sleep Medicine at University of Maryland St. Joseph Medical Center, says, “About half of those who snore have sleep apnea; the only way to diagnose it is through a polysomnogram (sleep study). If the patient snores and has one other risk factor, or has daytime sleepiness, he or she is a candidate for a polysomnogram.”

Insurers are driving more patients to unattended home sleep studies, rather than being evaluated overnight in a sleep center. Our sleep specialists note that home studies are appropriate for some patients, but not those with comorbid conditions or other disorders.

Dr. Marx notes, “The big story is the transition from inpatient labs to home sleep studies, and some sleep labs are closing as a result. It’s not necessarily bad medicine, but it’s a new paradigm.”

Who is not appropriate for a home sleep study? Anita Naik, D.O., medical director of the Sleep Disorders Center, Harford Memorial Hospital and Northern Maryland Sleep Center, answers, “Those with significant co-morbid conditions such as severe CVA, CHF, or lung disease, or those with suspected parasomnias. By contrast, a home study can be adequate for those with a high pre-test probability of sleep apnea, such as those with significant obesity, snoring or witnessed apneas.” 

Home sleep studies that are diagnostic for obstructive sleep apnea can be followed by a formal lab-based CPAP titration or the patient maybe set up with an automatic CPAP device.  These devices are about 80 to 90% effective. They are not effective at detecting and treating central sleep apnea, and are not indicated for patients with co-morbid diseases that could require additional therapies such as bi-level therapy or supplemental oxygen.

“CPAP remains the gold standard for treatment, but oral appliances are improving and weight loss is crucial,” Dr. Marx remarks. “If a patient declines CPAP or cannot tolerate CPAP and wishes to try an oral appliance, make sure the patient is referred to a dentist who specializes in these appliances. A newer option is nasal resistance plugs, but I think the jury is still out on their effectiveness. Also, insurance coverage for some of these alternative treatments could be an issue.”

Document Co-morbid Conditions

When ordering a lab-based sleep study, it is important for primary care physicians to document co-morbid diseases or a suspicion of other sleep disorders. A board-certified sleep doctor should always interpret the test to assure accuracy.

Dr. Marx notes, “Sleep specialists can be called on to interpret the sleep study and, if appropriate, consult as well. It’s the primary care physician’s discretion whether they or we manage the patient. If you’re having trouble getting what you think the patient needs, contact a sleep specialist. We can work with the patient and insurer to select the appropriate diagnostic approach and treatment.”

Increased Anesthesia Risk

Physicians should also be aware that anesthetics, including conscious sedation used in procedures such as a colonoscopy, make sleep apnea worse. “It’s like a stress test for sleep apnea,” Dr. Marx cautions. “Post-op patients are at higher risk for several days after their procedure. It’s important to indicate on your pre-op notes if a patient has or is at risk for sleep apnea.”

Insomnia

Insomnia can be challenging to treat and typically requires both a medical and a psychological/behavioral approach.  Dr. Naik recommends that the latter approach be tried first. “Good sleep hygiene is the first step.”  Her list of recommendations for good sleep hygiene include:

·         Avoid caffeine (including energy drinks) and alcohol after 3 pm. As a depressant, alcohol helps people fall asleep but then disrupts sleep

·         Avoid smoking, as nicotine is a stimulant

·         Exercise regularly but not close to bedtime

·         Don’t go to bed stuffed or starving – instead, have a light snack

·         Avoid napping

·         Don’t spend more than 20 minutes wide-awake in bed

·         20 minutes before sleep, avoid light exposure from smart phones or any backlit device

·         Don’t fall asleep to the television

Dr. Weinstein says, “Many cases of insomnia start with a personal problem like a divorce, but then become habitual. Physicians should ask about sleep as part of the history and physical. Review their medications to make sure they aren’t causing problems, and ask about alcohol and family issues.”

When good sleep hygiene alone does not impact insomnia, Dr. Naik is a proponent of cognitive behavioral therapy, with or without medications. “I try to empower the patient,” she says. “They can use tapes or CDs, progressive relaxation techniques, and so on. If a single approach doesn’t work, try a combination. We often refer patients to specialists in sleep cognitive behavioral therapy. If anxiety or depression is suspected, seeing a psychiatrist or psychologist may be helpful.”

Studies have not demonstrated a consistent benefit from melatonin supplements for insomnia but it may help jet lag or circadian rhythm disturbances. Valerian root and acupuncture have shown some promise in very small, early studies, but more research is needed.

Medications can be very effective, including extended-release versions such as Ambien CR (zolpidem). Dr. Naik notes, “Melatonin agonists such as Rozerem (ramelteon) are useful for many patients and have limited side effects. Sedative-hypnotics such as Lunesta (eszopiclone) and Sonata (zaleplon) can be effective but should be approached with caution because they still have habit-forming tendencies.”

Restless Leg Syndrome and PLM

Another common sleep disorder is restless leg syndrome (RLS), accompanied in about 80% of patients by periodic limb movement disorder (PLM).  RLS affects from 1% to 7% of the population and is more prevalent in those 50 and older.

RLS is characterized by painful dysesthesias such as crawling, creeping and/or burning sensations in the legs. “It usually happens in the evening and when sedentary,” says Pavel Klein, M.D., director, Mid-Atlantic Epilepsy & Sleep Center, LLC. “The sensations are relieved by movement but it often keeps patients from falling asleep. PLM typically occurs once asleep in the first third of the night.  A sleep study can evaluate for PLM and help determine the cause.

“The primary cause in younger patients is a family history,” he explains. “Iron deficiencies, renal impairment, peripheral neuropathy or Parkinson’s are other possible causes in the older patient population, e.g. in those over the age of 50.  If there is no identifiable cause, treat symptomatically.  The most common medications are the dopamine agonists like Mirapex and Requip, which increase dopamine transmission between the neurons.”

For patients who do require treatment, the next step may involve anti-seizure medications such as Gabapentin (neurontin) or Lyrica (pregabalin), and for those who don’t respond to this therapy, narcotics may be a last resort.

Dr. Naik notes, “Recent data suggests that those with PLM alone should not usually be put on benzodiazepines unless they are injuring their partner or significantly disrupting their sleep continuity.”

Circadian Rhythm Disturbances

Night owls, or those with circadian rhythm disturbances, have sleep schedules out of synch with societal norms. Dr. Klein comments, “Delayed Sleep Phase Syndrome, where the person falls asleep at 2 or 3 am, is more common than Advanced Sleep, where they fall asleep too early in the evening. It commonly starts in adolescents and manifests itself in poor academic performance or being habitually late for school or work in the morning. Primary care physicians should be attuned to this problem because, while common, it’s often overlooked. Symptoms include having difficulty falling asleep at 10 or 11 pm, feeling most awake in the late evening, and feeling extremely sleepy or groggy, especially in the morning. It’s common for patients to sleep through their alarm five to six times.”

The treatment is not highly technical, but may be hard to implement except during a long vacation period.  “We train the brain through regular exposures to bright light,” notes Dr. Klein. “When the patient naturally wakes up, say at 1 pm, they sit in front of a light box with 10,000 LUX for 30 minutes for three to four days. Then we continue the light box therapy while having them get up a half hour earlier every three to four days until they return to a more normal waking time. If done correctly, the treatment is about 80% effective.”

Sleep is so critical to well being that sleep disruption, not incontinence or memory issues, is the reason many caregivers finally refer loved ones with dementia to a residential facility. Dr. Weinstein concludes, “The deal breaker is often when the person with dementia gets up at night and has their sense of day and night disrupted. It becomes intolerable for the caretaker to get up at night/worry about them.” 

Jason Marx, MD, chief of Pulmonary, Critical Care, and Sleep Medicine, University of Maryland St. Joseph Medical Center

Ira Weinstein, M.D., FCCP, Annapolis Asthma, Pulmonary and Sleep Specialists and medical director of Anne Arundel Medical Center’s Sleep Disorders Center

Pavel Klein, M.D., director, Mid-Atlantic Epilepsy & Sleep Center, LLC

Anita Naik, D.O., medical director, Sleep Disorders Center, Harford Memorial Hospital and Northern Maryland Sleep Center


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One Comment

  1. Varija RamakrishnanNo Gravatar
    Posted July 28, 2013 at 10:57 am | Permalink

    Knowledgeable, but funny, as are many of your pages. I read through the past entries over the
    past week, and I must say I think I’m smitten.

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