Obstructive Sleep Apnea and Other Causes of Excessive Daytime Sleepiness

1. Obstructive Sleep Apnea and Other Causes of Excessive Daytime Sleepiness

2. Patient Scenario #1 A 45 year old man sought treatment of his snoring, which had been present for many years. His wife slept in another room because the snoring “shook the walls”. The patient reports excessive sleepiness (Epworth sleepiness scale score 18/24. Normal is 10 or less), morning headaches and problems concentrating at work. He admits to drinking more than five cups of coffee daily. There was no history of recent weight gain or alcohol use.

3. The Physical Examination • Height: 5 feet 10 inches • Weight: 190 pounds; Blood Pressure: 150/90 • Neck 18 inch circumference • HEENT: long, edematous uvula, dependent palate (low lying) • Chest: clear • Cardiac: normal • Extremities: no edema

4. What is The Next Step? Sleep Apnea is the most common cause of excessive daytime sleepiness and snoring, but there are many other disorders that must be carefully considered.

5. Sleep Apnea Syndromes Upper airway resistance syndromes Narcolepsy Periodic leg (limb)movements in sleep Restless leg Syndrome Circadian Sleep Disorders Insomnia Withdrawal from Stimulants Drug dependence/Abuse Medication side effects Idiopathic Hypersomnia Brain tumors Parasomnias History Self-rating scale of Sleepiness Sleep-wake diary Polysomnography Evaluating Causes of Excessive Daytime Sleepiness (EDS) Disorders Evaluation All Cases Selected Cases • MSLT • Drug Screen

6. Epworth Sleepiness Scale:Measures average sleep propensity (chance of dozing) over 8 common situations that almost everyone encounters. 3= High chance of dozing; 2=moderate; 1=slight; 0=never

7. Stanford Sleepiness Scale:Measures subjective feelings of sleepiness

8. Obstructive Sleep Apnea (O.S.A) • OSA is a common disorder occurring in 4% of men and 2% of women. • During sleep, closure of the upper airway results in cessation or diminished airflow despite continued respiratory effort. The termination of the apneic event is associated with a brief awakening. • These arousals result in sleep fragmentation which reduces the amount of slow wave and REM sleep and causes varying degrees of daytime sleepiness.

9. Risk Factors for Sleep Disordered Breathing • Excess body weight • Large neck circumference • Male gender • Ethnicity • Age • Menopause • Anatomy of airway=soft and hard palate.

10. Indicators for a Polysomnography (PSG) • Suspicion of disorders that disturb sleep like sleep apnea, periodic limb disorder, REM behavior disorder • EDS • Obesity • Insomnia with daytime sleepiness • Nocturnal behavioral disorders

11. Polysomnography Multiple physiologic parameters are measured and compared with the established norms. • Electrocardiography (EKG) • Electroencephalography (EEG) • Electro-oculography (EOG) • Electromyography (EMG) • Pulse Oximetry • Respiration: -Effort (chest and abdominal movements) -Airflow Snore sensor/microphone • Heat sensors measure airflow by detecting temperature changes in inspired and expired air *Sleep conditions in the laboratory should be as close to the patients baseline sleep as possible.

12. Human Sleep Architecture • Wake • NREM sleep • Stages 1 and 2 (light sleep) • Stages 3 and 4 (deep sleep) • REM sleep • *Recognition of certain characteristic EEG patterns is essential for staging sleep

13. Electroencephalographic Lead Placement • Central • Occipital • Mastoid • *More electrodes can be added if nocturnal seizure is in the differential

14. Monitoring Eye Movements Standard : 2 eye channels • Detecting horizontal/vertical eye movements • Determining various stages of sleep

15. Electromyography (EMG) • Diagnosis of Periodic Limb Movements(PLMS) • Chin movement • Diagnosis of certain sleep stages

16. Monitoring Respiration During Sleep • Apnea – cessation of airflow at the nose and mouth for 10 seconds or longer • Central Apnea – an absence of inspiratory effort • Obstructive Apnea – absence of airflow despite persistent respiratory effort • Mixed Apnea – initially no inspiratory effort…then terminates as an obstructive event • Hypopnea – reduction in airflow by 30% from baseline for > 10 seconds with > 4 % drop in oxygen saturation (controversial) • Respiratory Effort Related Arousals(RERAs) – an event not meeting the above criteria, yet produces an arousal from sleep.

17. Important Sleep Parameters on PSG • Sleep stages (percentage) • Sleep efficiency • Apnea Hypopnea index (AHI), Respiratory Disturbance Index (RDI), paradoxical respiration; desaturations and cardiac arrhythmias

18. Sleep Hypnogram

19. Diagnosis of OSA The Apnea + Hypopnea Index (AHI) a.k.a Respiratory Disturbance Index (RDI) = The Number of Apneas + hypopneas Per Hours of Sleep

20. Treatment of OSA • Obesity- Diet and behavior modification • Positional Therapy -non-supine sleep (pillow, etc.) -raise the head of the bed • Nasal CPAP, BiPAP, Auto CPAP • Oral appliances • Soft tissue surgery or UPPP (Uvulopalatopharyngoplasty) • Skeletal surgery • Tracheotomy

21. Significance of Sleep Disordered Breathing • Risk factor for stroke • Risk factor for cardiac arrhythmias • Risk factor for CAD and M.I. • Risk factor for pulmonary hypertension and right heart dysfunction • Cause of hypertension

22. Patient Scenario #2 A 40 year old man was referred because his wife complained that he kicked in his sleep and constantly disturbed her. The patient remembered awakening several times each night, but never noticed any discomfort at those times. He admitted that at bedtime he did have an irresistible urge to move his legs and he described a feeling of “pins and needles.” However this delayed his sleep only rarely. His Epworth Sleepiness Scale was 15/24 (sleepy). PSG shows: Periodic leg movements in sleep (PLMS) – 20% of these events were associated with arousals.

23. Periodic Leg Movement in Sleep (PLMS) PLMS are repetitive, stereotypic dorsiflexion movements of the toes, ankles, knees and thighs that recur at regular intervals. They occur most commonly in stages 1 and 2 but can occur less commonly in other stages. Patients are rarely aware of the leg movements themselves and complaints are usually from bed partners.

24. Periodic Leg Movement Disorder PLMD This is a syndrome of leg movements + symptoms (ie. insomnia or excessive daytime sleepiness. This is a polysomnographic diagnosis; but, it is often incorrectly used interchangeably with Restless Leg Syndrome. International Classification of Sleep Disorders Criteria for PLMS Severity

25. Restless Leg Syndrome (RLS) Characterized by abnormal and uncomfortable sensations in the limbs that compel the person to move to relieve the sensation and these movements are exacerbated by rest. The symptoms occur primarily in the evening or at night.

26. Unpleasant limb sensations: desire to move the limbs usually associated with paresthesias/dysesthesias (abnormal/unpleasant sensations) Motor restlessness: patient is compelled to move Symptoms precipitated by rest and relieved by activity: symptoms are worse or exclusively present at rest (i.e., sitting or lying with at least partial and temporary relief by activity Symptoms worse in the evening or at night Sleep disturbance and consequences: difficulty initiating or maintaining sleep; less commonly, excessive daytime sleepiness Involuntary movements during wake or sleep (PLMS) Normal neurologic exam in primary RLS; in secondary forms, possible evidence of neuropathy Clinical course: onset any age, usually chronic and progressive, remissions may occur, can be exacerbated by or exclusively during pregnancy Family history: sometimes present; suggestive of autosomal dominant pattern International RLS Study Group Criteria for Diagnosis of RLS Primary Features Associated Features

27. PSG : Quasi-periodic movements of the legs during wakefulness with a prolonged sleep latency. After sleep, PLMs are noted in 70 –90% of Patients PLMs RLS

28. Differential Diagnosis of RLS • Neuropathy • Claudication • Painful toes and moving leg syndrome (lumbrosacral radiculopathy) • Neuroleptic akathesia

29. Causes and associations of PLMs • Any cause of RLS • Withdrawal of anti-convulsant, barbiturates, hypnotics • Associated with narcolepsy, OSA, CPAP titration Causes of RLS/PLMD Primary RLS • Secondary RLS • Fe deficiency anemia • ESRD • Pregnancy • Medications • -caffeine • -TCA’s • Cause unknown • ? If there’s an abnormality in Fe (iron) transport into the CNS or a defect in the use of Fe as it relates to dopaminergic neurons. -SSRI’s -Dopamine blockers

30. Treatment options for RLS/ PLMs • Nonpharmacologic-avoid etoh, caffeine, do light stretching, exercise, warm baths • Dopaminergic agents (ie, Sinemet) -Treats PLMs and improves sleep quality • Dopamine agonists • Benzodiazepines • Narcotics (usually reserved for severe cases)

31. Patient Scenario #3 A 30 year old woman was evaluated for excessive daytime sleepiness of 5 year duration. There was no history of snoring or observed apnea. The patient recalled having difficulty holding her head up when she laughed or was embarrassed. The patient’s husband reported that sometimes she kicked the covers at night. Rarely, the patient felt she could not move for a while as she was falling asleep at night.

32. Narcolepsy is related to abnormal regulation of REM sleep and inappropriate intrusion of REM sleep physiology into wakefulness. 1998 Hypocretin/orexin (2 peptides) secreted by the hypothalamus and other brain areas. 2 major pathways: -hypothalamus cortex -hypothalamus Brain stem -locus ceruleus- NE secreting neurons important in maintaining wakefulness 7 of 9 patients with narcolepsy had low orexin levels in their CSF. Other studies have shown an absence of orexin-secreting neurons in the hypothalamus Antigen DQB1* 0602 is the most sensitive marker for narcolepsy across all ethnic groups

33. Narcolepsy is a Neurological Disorder Characterized by: Pathognomonic Can be followed years later by the other SX’s

34. Narcolepsy • Prevalence of disorder is .03 - .05% in the general population • Adolescence is the common age of onset • Second peak at about 40 years of age • (5% of cases start after age 50)

35. Head Trauma Stroke MS Neurodegenerative Disorders Brain tumors CNS infections Secondary Narcolepsy PSG Findings: Short REM Latency (low sleep efficiency) Sleep fragmentation; reduced slow wave sleep; +/- PLMs

36. Indications for a Multiple Sleep Latency Test (MSLT) • Unexplained hypersomnolence (sleepiness); sleep apnea and other disorders. • Narcolepsy: to confirm diagnosis and determine the severity before stimulant therapy. • Insomnia with daytime sleepiness. • Circadian rhythm disorders

37. Consists of 4-5 naps at 2 hour intervals conducted in the daytime commencing 1.5-3 hours after waking from the PSG. A mean sleep latency of <5 minutes and 2 or more naps with REM sleep. MSLT Scoring and Interpretation Testing

38. Tx of Daytime Sleepiness Stimulants are working to increase the availability of NE/DA Largest doses should be given 1 – 2 hours before the periods of maximum sleepiness methylphenidate dextroamphetamine selegiline modafinil Tx of Cataplexy/Hallucinations TCA’s Venlafaxine (Effexor) Tegretol GHB (Xyrem) Treatment of Narcolepsy • Sleep hygiene • Optimizing the amount of sleep • If able, regularly schedule naps during the day (if restorative)

39. Insomnia Patient Scenario #4 A 30 year old Female is referred for complaints of inability to sleep for more than 10 years. The patient reports it usually takes her 2 to 3 hours to fall asleep after going to bed. She also finds herself awakening 3 to 4 times during the night. She reports that it takes at least 30 minutes to fall back asleep after each awakening. Alcohol and over the counter medications sometimes helped. During the day, fatigue, but not definite sleepiness was noted. Her husband denied that she snores, kicks, or jerks during sleep.

40. Sleep onset insomnia Insomnia Sleep maintenance insomnia Early morning awakening Non-restorative sleep

41. Psychophysiological Acute (adjustment sleep disorder) Chronic Idiopathic Sleep state misperception Sleep disorders (sleep apnea, PLMD, RLS) Psychiatric disorder(depression, panic attacks) Inadequate sleep hygiene Environmental sleep disorder Drugs (nicotine, ethanol, caffeine) Medical conditions/medications Fibromyalgia and chronic pain syndromes COPD and other respiratory disorders Medications (beta blockers, theophylline) Circadian disorders Delayed sleep phase syndrome Advance sleep phase syndrome Shift work or jet lag syndrome Common Causes of Insomnia Primary Insomnia Secondary Insomnia

42. Nature and Duration of problem Sleep habits Time in bed, lights out, sleep onset, wake time Bedroom environment Timing and duration of naps Changes on weekends Effects of a new sleep environment (vacation) Medication/beverage history Symptoms of depression. History of leg jerks, restless leg syndrome, snoring, apnea Insomnia History

43. Diagnosis of the cause of Insomnia based on: • Careful History • Review of Patient’s sleep diary • PSG: Typically normal and may not be beneficial unless there’s a suspicion of another underlying sleep disorder • Or • Insomnia is severe and doesn’t respond to empiric therapy.

44. Treatments for Insomnia • Optimize sleep hygiene • Behavioral techniques relaxation therapy stimulus control therapy Sleep restriction therapy Cognitive behavioral treatment • Combined behavioral and pharmacological treatment Benzodiazepines BZ receptor agonists (ie ambien, sonata) • Sedating anti-depressants

45. Patient Scenario #4A -Same as previous patient. She averages 4 hours/night of sleep with EDS -On weekends able to sleep in and get 7 to 8 hours of sleep and awake feeling refreshed.

46. Sleep Disorders Associated with Alterations in Circadian Rhythm • Delayed sleep phase syndrome • Advance sleep phase syndrome • Time zone change (jet lag) syndrome • Shift work sleep disorder • Irregular sleep wake pattern • Non-24-hour sleep –wake disorder

47. Circadian rhythms are generated by an internal pacemaker in the suprachiasmatic nucleus (SCN) of the hypothalamus • The main role of the SCN is to synchronize bodily functions with the light – dark cycle.

48. Diagnosis: History Sleep Diary Treatment: Chronotherapy (progressive phase delay) Bright light therapy Melatonin Short-acting hypnotics

49. Parasomnias: A motor, verbal, or experiential phenomenon that occurs during sleep and is often undesirable

50. Differential Diagnosis of Unusual Behavior Associated With Sleep Diagnosis Usual Sleep Stage Normal Sleep Phenomena Sleep starts (hypnic jerks) Sleep onset Nightmares (REM anxiety attacks) REM>>NREM Parasomnias Sleep walking (somnabulism) NREM Sleep terrors NREM Confusional arousal NREM Sleep talking (somniloquy) NREM and REM REM behavior disorder REM Parasomnia overlap disorder NREM and REM Bruxism NREM (stage 2) Enuresis NREM and REM (random)