Sunday, December 26, 2010

Anatomy vs. Physiology

There is an article in the December edition of the Journal of Clinical Sleep Medicine about the clinical usefulness of the way many sleep clinicians grade the crowding of the back of a patient's mouth. It's called the Mallampati score and is based on the way Anesthesiologists judge how easy someone might be to intubate.

The Mallampati grade is done by looking at the space in the back of the mouth with the mouth open and tongue out. In this case, it is done when the patient does not say "Ahhhh." I use a modified Mallampati grade like this...

The higher the grade, the more crowded the back of the throat. In general, the higher the grade, the more likely there will also be snoring and/or obstructive sleep apnea (OSA). It's nice to have a physical feature that corresponds to risk of OSA because symptoms alone are not able to predict if OSA is present. In fact, this article quotes some interesting stats from another study - in patients without OSA, 56% snore, 67% report choking while asleep, 35% have witnessed apneas, and 68% report waking unrefreshed - all symptoms usually seen in OSA.

The study done in this edition of the Journal of Clinical Sleep Medicine attempted to determine if a higher Mallampati grade ruled in severe OSA or if a lower Mallampati grade ruled out any OSA. The results showed that Mallampati grade is significantly associated with sleep apnea severity. However, the Mallampati grade only explained 1.7% of the variability of the severity of the OSA. In other words a high Mallampati grade alone can not be used to rule in severe OSA and a low Mallampati grade can not rule out OSA.

This makes sense to me, as anatomy, or the degree of crowding in the back of the mouth is only part of the reason OSA occurs. In some patients, their throat has a predisposition to collapse during sleep, no matter how crowded their throat is. It's analogous to body builders.

You might think that someone who wins body building competition would be strong. However, they are not power lifters, as body builders focus more on the visual appearance, rather than the strength of their muscles. By the way, the movie Predator is one of Arnold's best. Yes, Terminator is good too.

Monday, December 20, 2010

Sleep Symptoms and Metabolic Syndrome

An article in the December issue of the Sleep Journal has received media attention, so I thought I would summarize it here.

Metabolic syndrome is defined as having three or more of the following: elevated blood glucose, increased waist circumference, high blood pressure, increased triglycerides, and low HDL (the good cholesterol). It is estimated that 20% of us have the metabolic syndrome.

The authors of this study assessed over 800 people ages 45 to 74 over a three year period to see if they developed the metabolic syndrome and if it was associated with any sleep symptoms. They used a subjective questionnaire to assess insomnia symptoms, loud snoring, gasping at night, and/or nighttime choking. Sleep duration was not assessed. Almost 300 of the study participants volunteered to have a home sleep study (Resmed's ApneaLink) at the end of the three years.

Over the three year span of time, 14% developed the metabolic syndrome. The sleep symptoms that were statistically related to metabolic syndrome were difficulty falling asleep, unrefreshing sleep, loud snoring, and elevated score on the ApneaLink home sleep study. There was no interaction with race of gender. Loud snoring was most predictive, more than doubling the risk of developing metabolic syndrome. As expected, insomnia syndrome did not raise the risk of metabolic syndrome.

The study authors were not able to tell if the patients who claimed loud snoring also had the elevated sleep apnea severity as measured by the ApneaLink. This would have been helpful because the authors concluded that loud snoring by itself is a risk factor in developing metabolic syndrome. I'm not convinced that loud snoring without sleep apnea is physically dangerous to patients.

It was interesting that difficulty staying asleep did not significantly raise the metabolic syndrome risk, but difficulty falling asleep did. This goes against my clinical experience of how many sleep apnea patients sleep - most fall asleep easily, but just can not stay asleep. The authors suggested that the difficulty falling asleep could be due to emotional and/or physiologic hyperarousal, which could be due to increase nervous system activity and elevated cortisol levels. These have been linked to insulin resistance and the metabolic syndrome.

For me, the conclusion from this study is that you should seek a sleep evaluation from your doctor if you have loud snoring and/or difficulty falling asleep.

Monday, December 13, 2010

Snoring and Obstructive Sleep Apnea

In the October (yes, I am behind) edition of the Journal of Clinical Sleep Medicine, there is an article about how snoring correlates with the severity of obstructive sleep apnea (OSA). Snoring occurs in 25% of women and 45% of men, and is the most common symptom of OSA. Snoring is considered a "cosmetic" issue and is not associated with other illnesses like high blood pressure, cardiovascular disease, stroke, or metabolic syndrome, the way OSA is.

This study was the first one to use an objective measurement of snoring intensity in a large (>1600) group of patients to determine the relationship between OSA and snoring loudness. They measued snoring during a sleep study with a digital sound meter. In this study, there were more males than females. Men were older, heavier, and had larger neck circumferences than women.

The results showed that men had louder snoring than women (big surprise, huh?), and this was consistent across all sleep stages, body positions, and weight. Snoring was louder among those that were heavier, had larger neck sizes, and when sleeping on the back, regardless of gender. Snoring was more common in non-dream (NREM) than dream (REM) sleep. As expected, snoring got louder as the OSA got more severe. I've told patients about this observation in my clinical practice, and now there is objective proof.

Monday, December 6, 2010

Geneitc Link and Sleep Disorders

There is an article in the October 26th issue of Neurology where researchers studied normal sleep and sleep-deprivation, and determined if participants had a certain gene variant (DQB1*0602). Patients with that gene variant were sleepier and more fatigued while sleep-deprived or even while fully rested. These individuals also woke up more often at night and spent less time in deep sleep than those without the gene variant. However, there was no difference on tests of memory and attention, or in their ability to resist sleep during the day.

The authors explained that their findings mean there might be a genetic biomarker to predict how people will respond to sleep deprivation. This has significant health consequences and affects millions around the world. It may be particularly important in those work night shift, travel frequently across multiple time zones, or just don't sleep enough due to multiple work and family obligations.

This gene variant has already been implicated in narcolepsy, a sleep disorder characterized by excessive sleepiness, despite adequate amounts of sleep at night.

Friday, November 26, 2010

Power Naps at Work

I loved the show Seinfeld. In the episode called "The Nap", George has a carpenter make some adjustments on his desk at work so that he can take secret naps and not be caught by his boss (George Steinbrenner at the time).



There is an article about napping at work from US News and World Report. Apparently, more companies are allowing employees to nap at work, usually on their work break. Employers say it increases the nappers well-being and their mood.

One employee keeps a "nap mat" in her office. Perhaps it looks like this?



Some companies offer reclining chairs and "renewal rooms." Another company offers a cot in a Zen-like room with smoothing earth tones or a beach-themed room inside an "energy pod." Finally, some companies will pay for their employees to go to a company that charges for naps - customers can take power naps in private rooms with aromatherapy, music, or nature sounds.

The article also mentions keeping the naps brief to avoid post-nap grogginess. I suggest to people that if they need to nap, keep it less than 30 minutes (by using an alarm) and take the nap before 3 pm to avoid making it tough to fall asleep that night.

Saturday, November 20, 2010

Sleep Duration and Stroke Risk

A study was presented at the American Heart Association meeting where almost 70,000 female nurses were asked how long they slept on average over a 20 year span of time. The researchers than recorded which women had a stroke and analyzed if a certain number of hours of sleep increased the risk of stroke relative to the baseline average of seven hours per night.

The researchers found that women who slept 10 or more hours had a 63% increase risk of stroke. Those women that slept less than 7 or 8-9 hours per night had an insignificant increase in stroke risk. Of note, the researchers adjusted the risk for other factors like alcohol intake, fruit and vegetable consumption, physical activity, and smoking status. Body mass index and the presence of diabetes and high blood pressure were recorded as potential influential factors.

The researchers were unable to determine any underlying biological mechanism that could cause the increased risk of stroke in longer sleepers.

I wonder if some of the women have untreated sleep apnea, which can cause longer sleep durations, in an attempt to get more rest. Untreated sleep apnea does increase the risk of stroke.

Longer sleep durations could mean that these women have brains that function differently or are structurally different, and perhaps those differences could account for the increased stroke risk.

Wednesday, November 10, 2010

Foods that promote sleep?

There is an article on Foxnews health about five foods that supposedly promote sleep. My immediate reaction to such a title is skepticism, as such "treatments" for insomnia rarely provide any lasting relief.

The first food is cottage cheese. The author says it helps sleep because it is a source of tryptophan, the same sleep-inducing amino acid in turkey. Unfortunately, consuming tryptophan is not likely to help most people who are struggling to sleep.

The next food mentioned is oatmeal. The author states that oatmeal is a slow-digesting carbohydrate that promotes serotonin release, the "feel good" neurotransmitter. He then says that serotonin is the sleep hormone - factually inaccurate on two counts - serotonin is not a hormone, it's a neurotransmitter, and many other neurotransmitters are thought to affect sleep.

Next is peanuts or peanut butter, which is a source of niacin. The author claims that niacin can promote serotonin - see above comment regarding oatmeal.

Warm milk is next and the author claims it has tryptophan - see cottage cheese. Also, the calcium in milk can help with melatonin production, so milk will help with sleep! If only it was that easy.

Finally, the author recommends grapes, which supposedly are the only food that contains melatonin. In my opinion, melatonin production is not the problem with most insomniacs.

Eating these foods most likely will not help chronic insomniacs. It could help someone who is just recently suffering from mild difficulty sleeping. This effect most likely would be due to a placebo response.

Relying on things external to our own body, whether it is food, pills, a special blanket, or whatever, probably won't work in the long term and can set up someone to become psychologically dependent on that thing to sleep. In other words, over time, the thing used to help sleep might be paired enough times with actual sleep so that if the thing is not available, the person will not be able to sleep.

Insomnia usually responds better to behavioral therapy, rather than relying on gimmicks like certain foods or other external things.

Tuesday, November 2, 2010

CPAP and Facial Structure

In young children, who are still growing, using CPAP can alter the way their face grows because of the pressure of the mask on their face every night. Therefore, using CPAP in young children can be challenging.

In adults, their faces are done growing, so using CPAP shouldn't alter their facial structure...or so we thought.

A study was done in Japan on Japanese adults with obstructive sleep apnea who used CPAP. There were 46 patients who used CPAP with a nasal mask (one that fits over the nose like this) for at least 4 hours per day for at least five days a week for between 25 and 46 months. Facial structure was measured with special x-rays.

The researchers concluded that there was a statistically significant change in the upper jaw of these CPAP using patients. Specifically, the change was a slight pushing in of the front teeth and upper jaw. None of the patients noticed any of the changes in their face or jaw. It was only seen on the special x-rays. Also, there was no clinical significance (like difficulty eating) with the facial changes. Finally, this is a small study and from the report, I can't tell if the masks were all the same brand or how tight they were. These are important variables that affect the significance of these findings.

I think the spokesperson, Harry L. Legan, for the American Association for Orthodontics sums up what's going on with this study. Dr. Legan says "the sharp sleep doctor will consider having the patient evaluated by an orthodontist to see if they should wear an intraoral device to prevent untoward movements of the teeth while using nCPAP."

In other words, despite having no clinical significance or asthetic change from using CPAP, the orthodontists want us sleep doctors to have our patients see them for an oral appliance. That's what it boils down to. Orthodontists can't knock CPAP for it's far superior efficacy, so they have to drum up some very minor facial changes as the reason to use an oral appliance instead. I'm not buying it. I'll stick with what works - CPAP.

Monday, October 25, 2010

Sleep Apnea Treatment, Stroke Recovery, and Cardiovascular Events

In the September 16th edition of the European Respiratory Journal, there was a study done to assess the benefits of early CPAP treatment on funtional outcome, quality of life, and rates of new cardiovascular events and mortality in patients who suffered their first stroke.

In this study, 325 patients were randomized to CPAP treatment or a control group that did not receive CPAP. 90.5% of the CPAP group had improvements in neurological assessments in one month, which was significantly greater than the 56.3% that showed improvement in the control group. Beyond one month though, results between the two groups did not differ significantly.

Cardiovascular mortality rates did not differ significantly between the two groups. However, the average time from the stroke to the first cardiovascular event was significantly longer in the CPAP group (15 months) than in controls (8 months). This implies that CPAP might help delay the onset of new cardiovascular events in a patient population already at high risk for cardiovascular disease.

Wednesday, October 20, 2010

Sleeping Pills and Death Risk

In the September issue of the Canadian Journal of Psychiatry, a study was performed to assess the mortality risk associated with sleeping pills and anti-anxiety medications. The study involved over 14,000 people aged 18 to 102 who participated in the National Population Health Survey in Canada between 1994 and 2007. Every two years, participants were asked if they used sleeping pills or anti-anxiety medications in the past month.

The overall mortality rate for the entire population was 11.55%. In respondents who took sleeping pills or anti-anxiety pills, the rate was 15.56%. In respondents who said they did not take sleeping pills or anti-anxiety medications, the mortality rate was 10.52%.

After controlling for other factors like alcohol and tobacco use, physical health, physical activity level, and the presence of depression, the mortality rate was still slightly higher in those participants who reported they took sleeping pills or anti-anxiety medications.

The study authors proposed different explanations. Benzodiazepines like Valium could impair reaction time, coordination, alertness, and memory, which then could lead to falls and other accidents. Benzodiazepines could also depress the respiratory system, which could aggravate sleep-related breathing disorders.

Limitations of the study include the fact that medication use was assessed using only two questions. There was no control for the presence of anxiety disorders, whereas the study did control for depression. Also, self-reported data like this survey can introduce a number of biases.

The authors recommend that physicians consider alternative, non-pharmacological treatment of insomnia and anxiety, like cognitive-behavioral therapy, a form of psychotherapy.

Saturday, October 9, 2010

Obstructive Sleep Apnea and Coronary Artery Disease

In 2005, a study was undertaken to to address the impact of continuous positive airway pressure (CPAP) on patients who had undergone revascularization for coronary artery disease (CAD) and who had documented obstructive sleep apnea (OSA). The study is still ongoing, and researchers have found that the prevalence of OSA is 64% in the CAD population. Hypertension, or high blood pressure, is 58% and obesity is 28% prevalent in CAD.

Patients with CAD and OSA were older, more obese, more often male gender, and had higher incidence of hypertension, diabetes, and atrial fibrillation than those patients with CAD but not OSA.

Interestingly, the risk of CAD was the same in patients with OSA, regardless of their level of sleepiness. And the only difference in the comorbidities of sleepy versus non-sleepy OSA patients was obesity, which was more common in the sleepy OSA patients.

The researchers also studied CPAP compliance. At one year of follow-up, 70% of sleepy OSA patients with CAD were still using their CPAP compared to 60% of non-sleepy OSA patients. This makes sense, as more symptomatic OSA patients are more likely to keep using their CPAP.

The study will conclude in 2012 and the researchers are hoping to prove that treatment of OSA with CPAP will offer patients a non-pharmacologic intervention to reduce the risk of cardiovascular disease.

Monday, October 4, 2010

Older Women and Sleep Apnea Symptoms

There is a summary from Reuters of an article in the September 3rd online paper in the European Respiratory Journal Express. The study authors examined 379 women and 262 men with obstructive sleep apnea (OSA) ages 65 to 70 years old. Specifically, it looked at the different symptoms of OSA in older men versus women.

In this study, more men had severe OSA than women. Men also had a greater body mass index. The women were less likely to report snoring, apnea, or sleepiness, and more likely to be anxious and depressed, and be taking antidepressants and anti-anxiety medications.

This goes along with my clinical experience. Women (not just older women) report less snoring and apneas than men. It could be because they don't snore as much or as loud. Also, their husbands are sometimes less in tune to their wives sleep problems. Since patients rely on bed partners to note snoring or apneas, some women might never realize they are doing that in their sleep. All they know is that they might not sleep well or feel tired or sleepy in the daytime.

Finally, the study authors said older women with OSA were a greater hypertensive (high blood pressure) risk than men, and therefore may have greater cardiovascular mortality and morbidity. This would emphasize the need for early diagnosis to prevent cardiovascular risk. This is true to a point. When a patient reaches a certain age, treating OSA just to prevent cardiovascular disease becomes a "numbers" game. In other words, treating asymptomatic OSA in an 85 year old (male or female) is less likely to prolong life than in a 55 year old, since the 85 year old has already lived longer than the average US lifespan. However, often I suggest treatment in the older patients to improve quality of life, even in those who do not endorse overwhelming symptoms.

Monday, September 27, 2010

Sleep Duration and Adolescents' Fat and Carb Intake

Another article in the September edition of the Journal Sleep is about how short sleep durations can change the dietary habits of adolescents. The authors begin by pointing out the lack of data quantifying sleep duration and caloric intake. There is an association between sleep loss and obesity, especially in adults. The question is if it's due to increased caloric intake, decreased physical activity, or the same diet, but just altered metabolism.

The researchers measured sleep times in older adolescents with a watch-like device called actigraphy, which can measure sleep at home. They did this during the weekdays only, as weekend sleep times were too variable. They asked the adolescents to recall what food they had eaten, the portions, the percent of fat and carbohydrate, and snacking. They defined short sleepers as getting less than 8 hours of sleep, which is one hour less than the recommended 9 hours per night for adolescents.

The results showed that the average sleep time was 7.55 +/- 1.14 hours and 34% slept at least 8 hours per night. The median caloric intake was 1917 calories, 51% carbs, and 35% fat. If an adolescent slept <8 hours per night, they tended to be obese rather than non-obese. Also, if the adolescent slept <8 hours per night, they had a 2.7% increase in fat consumption and a 3.7% decrease in carbohydrate consumption than those that slept >8 hours.

Those that slept <8 hours / night had a 2.1 fold increase in the odds of eating a high-calorie snack. For each 1 hour increase in sleep duration, the odds of a high-calorie snack decreased by 21%. This was most prominent in girls.

The authors acknowledge the small differences in fat and carb intake, but point out that small increases tend to accumulate and could increase obesity rate.

As I've said in another post, childhood obesity is not caused by short sleep duration. In my opinion, people who sleep less and are obese have extra weight because they have more wake time to eat. Obestity is caused by increased consumption of high-calorie foods rich in salt, sugar, and fat. The food tastes good, so kids eat it, and eat lots of it. They also don't exercise much, as our society is so sendentary. And thinking that if you get an extra hour of sleep, you can magically shed extra weight without serious dietary change is unrealistic.

Friday, September 17, 2010

Insomnia, Sleep Duration, and Mortality

In the September edition of the Sleep Journal, there is an article about the association of insomnia, sleep duration, and insomnia. The authors followed adult men and women to assess death rates. The study participants were assessed with a comprehensive sleep history and physical exam and one night in the sleep laboratory. Insomnia was defined subjectively as an insomnia complaint that lasted for one year. Sleep duration was defined as short if it lasted less than 6 hours per patient's report.

The results showed that in men, the mortality rate was increased for insomniacs with short sleep duration and this was independent of age, race, obesity, alcohol consumption, smoking, obstructive sleep apnea, or depression. The effect was not mitigated by the presence of high blood pressure or diabetes.

There was no increased mortality in women, whether or not they were short sleepers or had insomnia. Also, the association with sleep duration was only for the subjective report, and not based on the duration of sleep measured objectively in the sleep lab.

This study purports to be the first one to link insomnia with mortality. However, the average follow up was 14 years in the men, meaning their sleep study was done at a time when only airflow was routinely monitored. This means that nasal pressure transducers were not used, and therefore sleep apnea could have been present in these men. Sleep apnea is more prevalent in men which could explain why the mortality rate was increased for men and not women.

I'll concede that some patients with insomnia can have a revved up nervous system, referred to as hyperarousal. This, theoretically, could increase cardiovascular disease. But the results of this study do not prove that insomnia by itself increases mortality. Objective monitoring of sleep duration at home over extended periods of time will help answer this question more completely.

Tuesday, September 14, 2010

Zeo and Insomnia

I've had a few patients with insomnia try the Zeo. I've even tried it myself. For those unfamiliar, the Zeo is an EEG monitor worn around the head like a headband while trying to sleep. The device will analyze EEG patterns and display your sleep stages for you to review.

I found the headband comfortable enough and the report interesting. I can see where the Zeo could be helpful in some patients. For example, I've had some tell me how their sleep stages changed in response to medication adjustments I made. Some slept deeper or had less dream sleep. I could also see the Zeo help people understand that they might be sleeping more or better than they think they are, as all of us have an imperfect perception of our sleep duration.

The Zeo could also cause more focus on getting the "gold standard" eight hours of sleep per night. I could see some insomniacs becoming more anxious because the Zeo only confirms that they are not sleeping as well or as long as they think they should.

I could see the Zeo being an important tool for diagnosing other sleep disorders in the home as well, especially sleep apnea. A Zeo along with a portable device to measure breathing would be helpful. The entire area of ambulatory monitoring is very exciting to me, as it opens up the possibility of measuring sleep over multiple nights in a patients home environment.

Friday, September 10, 2010

Sleep duration and obesity in children

There was an article by NPR about a recent study published in the Archives of Pediatric and Adolescent Medicine. The researchers surveyed 2000 children about their sleep duration and measured the children's weight over a five year period.

The researchers concluded that children who slept greater than 10 hours per night were less obese than those that slept less than 10 hours per night. Napping during the daytime did not help, implying that nighttime sleep duration is the more important factor. The effect was most prominent in infants and toddlers. The authors of the study hypothesized that children who do not get enough sleep would be too tired to exercise. Also, certain hormones that control appetite can be affected by sleep duration, but this has only been proven in adults.

The article author at NPR lead off the story by stating that in infants and pre-schoolers, a good and long nights sleep may be just as important as diet and physical activity with regards to obesity! This is highly misleading, in my opinion. It takes the focus off the real problem with childhood obesity, which is their poor diet. If it only were that easy - just get more sleep and your overweight child will be thin again. The problem with this study is that it is dependent on parents' report of sleep duration, which is frought with uncertainty. Also, it could be argued that parents who let their children stay up late probably also let them eat too much junk food. I wish the authors of the study had surveyed caloric intake along with sleep duration in these children.

Don't get me wrong. Sleep is very important to kids' physical, emotional, and cognitive development. And too little sleep could play a small role in weight regulation. But lets focus on the real problem with childhood obesity rather than on these minor issues.

Thursday, September 2, 2010

How Do You Expect Me To Sleep With All That?

When I ask a patient to undergo a sleep study, I explain to them what is involved so that they can prepare properly. Most of my patients don't mind spending one or two nights away from home. In fact, it's like going to a motel for the night. But I explain that I need to monitor their sleep with multiple wires - on their scalp, face, neck, chest, abdomen, finger, and legs. I imagine some patients immediately think of Pinhead from the movie Hellraiser.



I explain that the sleep study uses no needles, and there will be no pain or blood involved in the process. I let them know that all of the wires are put on with glue, tape, or velcro. I find it helpful to show them a picture of a patient that has the wires placed, so that they can visualize the process.



When patients see the picture, most of them ask, "How do you expect me to sleep with all of those wires on me?" I tell them that almost everyone sleeps on the sleep study. And it's not crucial that I get 8 hours of solid sleep to be able to make a diagnosis. I ask the patient to just do their best - and they usually do.

Tuesday, August 31, 2010

Sleep and Your Local Paper

There was an article in today's local paper about the importance of sleep and the usual list of tips for dealing with sleep issues - mainly insomnia. The tips are the standard good sleep hygiene practices advocated by the sleep community and regurgitated by every newspaper and magazine that deals with health topics. Most people I meet have heard of these proper sleep practices, but rarely does anyone practice them on a regular basis. Since many of those people I meet are my patients, we usually spend some time discussing the importance of good sleep habits.

One word of caution - studies do not support sleep hygiene measures as stand alone therapy for the treatment of chronic insomnia. However, that does not mean they should be ignored. On the contrary, they should be part of a more comprehensive treatment treatment program.

For a list of good sleep habits, click on the link to the American Academy of Sleep Medicine's Sleep Education page.

Wednesday, August 25, 2010

Sleep and Noise Makers

A common question I get is if it's healthy to sleep with background noise. Some people feel like they sleep better if there is a background noise to break up the silence.

I explain that some noise can help certain people sleep better. In fact, my family and I all use the Sleep Sound Generator, which generates a soothing white noise. Here is a picture of the unit...



Not all noises are created equal. Constant white noise is better than the changing tones of a television or radio. Before we got the Sleep Sound Generators, we used a CD put on continuous replay that played white noise, like that heard on analog radios in between stations. However, the CD players were unreliable, and the white noise CD lasted only about an hour. When the CD finished playing, the volume would die down over a few seconds until the CD began playing again. This on-off-on again would sometimes wake one of us up. The Sleep Sound Generator plays the same volume of white noise continuously all night long. Now, I miss it if I stay in a hotel and don't have my white noise.

Tuesday, August 17, 2010

Sleep Duration and Cardiovascular Risk Factors

There is an article in the August edition of the Journal of Clinical Sleep Medicine on napping, nighttime sleep, and cardiovascular risk factors in mid-life adults.

The authors measured sleep quantities over 10 nights with a combination of at-home and in-lab testing. They found that adults who nap more often had less nighttime sleep - this makes sense, as your body only needs so much sleep per 24 hour period. The authors also noted that adults who nap more had greater self-reported daytime sleepiness, fatigue, and bodily pain. This makes sense, too, as people who are more tired or in pain might nap more. These results support practicing good sleep hygiene in those patients with insomnia, because eliminating napping can improve nighttime sleep quantity and quality. I tell patients that napping in the daytime will usually take sleep away from them at night.

Finally, the authors noted that adults who napped more frequently had larger waist lines and a bigger body-mass index (BMI). Blood pressure level was not affected by the amount of napping. Therefore, in this study, napping was associated with an increase in some of the cardiovascular risk factors (BMI and waist circumference), but not blood pressure.

Thursday, August 12, 2010

The Delicate Balance of Sleep Duration

Discussing the optimal amount of sleep someone should get each night can be challenging, and the conversation differs based on the problem the patient presents to me with. In those who tend to get too little sleep, they usually report excessive daytime sleepiness or fatigue. I explain that the amount of sleep someone needs can not be altered and that the patient should get as much sleep as needed to feel rested. Sleep deprivation, whether voluntary or from a sleep disorder, can affect mental and physical health.

On the other hand, for patients with primary insomnia, focusing too much on sleep duration or attempts get the coveted 8 hours per night often fuels the insomnia. Most insomniacs are not as sleep-deprived as they think. Plus, the behavioral treatments I use will produce a temporary sleep-deprived state. I use that built up sleep pressure to overcome patients' insomnia.

In other words, the message to my patients about sleep duration can be contradictory at times. Getting too little sleep can be dangerous, even in the short term. But for some with insomnia, focusing on the perceived consequences of insomnia often make the insomnia worse. For these patients, putting less emphasis on sleep and sleep duration can actually help them sleep better.

Sunday, August 8, 2010

FDA Warns Against Quinine for Nocturnal Leg Cramps

The FDA recently issued a second warning against treating nocturnal leg cramps with a quinine product called Qualaquin (quinine sulfate). Using Qualaquin for leg cramps is "off-label" as it is only approved for uncomplicated Malaria infection - a very different disorder than nocturnal leg cramps.

The FDA has been getting reports of bleeding dirorders from Qualaquin use. One of the bleeding disorders has been linked to severe kidney disease.

Nocturnal or night-time leg cramps can be a real sleep destroyer. This disorder is more common in older individuals and can produce very painful muscle cramps, usually in the calves. It can wake someone from sleep, contributing to insomnia. Doctors and patients have used quinine for decades until the past few years, when the FDA warned against its use due to irregular heart beat. Now, there appears to be another reason to be more careful when using quinine for leg cramps.

In some cases, leg cramps that wake people from sleep are due to electrolyte and/or mineral deficiencies, like magnesium or potassium. Replacing those that are deficient can often reduce or eliminate the night-time leg cramps. A simple blood test can help your doctor determine if your electrolyte or mineral levels are too low, and possibly contributing to night-time leg cramps.

Thursday, August 5, 2010

Sleep Duration and Cardiovascular Disease

The August edition of the journal Sleep has an article about the association of sleep duration and cardiovascular disease. It was based on a survey of over 30,000 Americans. The results showed that cardiovascular disease was more common in people who reported that they slept less than or greater than seven hours per night. These results were independent of age, sex, race, ethnicity, smoking, alcohol use, body mass index, physical activity, diabetes, high blood pressure, and depression.

The authors of the study did not determine the reason why sleep duration could affect cardiovascular disease, but they provided some theories. Hormonal and metabolic changes can occur in people who sleep less than seven hours, and these changes could impact cardiovascular health. People who sleep longer than seven hours could be sleeping that long due to an underlying sleep disorder, such as obstructive sleep apnea (OSA). OSA can impact cardiovascular health in a negative way.

Getting seven hours of sleep each night may not prevent you from having a heart attack, but getting the right amount of sleep can be an important part of overall good health.

Monday, August 2, 2010

Weight Loss Surgery in Adolescents

I saw a review of an article published in the Journal of Pediatrics about how weight-loss surgery works to reduce weight in adolescents.

According to the review, the success rate of lifestyle changes and medications in achieving long-standing weight reduction is modest at best. Weight-loss surgery is gaining acceptance as an effective treatment in obese adolescents.

Weight-loss surgery significantly improved obesity-related illnesses like type 2 diabetes, high cholesterol, and high blood pressure. There was no mention of sleep apnea in the review, but that can also improve significantly with weight loss after surgery.

I frequently evaluate adult patients in order to treat any significant obstructive sleep apnea that might make weight-loss surgery more risky. This is exciting news that perhaps adolescents will also have another treatment option in the battle against obesity.

Friday, July 30, 2010

Children and Insomnia

There is a review from Medscape about an article that's coming out in the August edition of Sleep Medicine. The authors performed a nation-wide survey of child and adolescent psychiatrists about their patients with insomnia. Apparently, upto one-third of patients receiving psychiatric care have insomnia. At least one-fourth of those with insomnia receive either prescription or over-the-counter medications for their sleeping difficulty.

However, those surveyed expressed concerns about the side effects and lack of proof that medications for insomnia work. I guess this is why only one-fourth of their patients with insomnia received medications.

It's my opinion that medications are not a good long term strategy for children and adults that struggle with insomnia. Even if these medications have few side effects and are not physically addictive, patients can still develop psychological dependence to the medication. The patients often begin to believe they must have a pill to sleep, instead of using their body's own sleep drive and circadian rhythm to help them sleep.

Treating insomnia in children is very challenging and obviously common. Parents must be educated because the work really falls on their shoulders. The child can not be expected to do it alone. When dealing with adolescents, however, they need to become willing participants in their own insomnia treatment. Non-medication treatments for insomnia often work well in both children and adolescents, and it can be rewarding to see family dynamics improve once the child is sleeping better.

Monday, July 26, 2010

Insomnia and Women

I saw an article in Current Psychiatry about insomnia across women's life stages. It was a nice review of how menstruation, pregnancy, and menopause can change sleep. I'll point out some of the highlights.

Compared to men, women have a 1.3 to 1.8-fold greater risk of developing insomnia. The reasons vary, but include hormonal changes, a greater chance of developing mood and anxiety disorders, and other factors like being single, separated, or widowed.

Sleep complaints are common in Premenstrual Syndrome (PMS) and Premenstrual Dysphoric Disorder (PMDD).

Of course, any woman who has been pregnant will tell you how difficult it can be to sleep as the baby grows. Usually, sleep worsens as women approach the delivery date. Difficulty breathing is a common complaint, as the baby pushes up on the diaphragm, which then compresses the lungs. Obstructive sleep apnea can also become an issue during pregnancy, usually associated with weight gain. Pregnancy can also bring on Restless Legs Syndrome, possibly related to temporary iron deficiency.

Finally, post-menopausal women can have sleeping difficulties due to hot flashes at night. Also, they are at increased risk of obstructive sleep apnea as their female hormone levels diminish.

Tuesday, July 20, 2010

Chronic insomnia increases mortality?

I saw a review from Medscape about a poster presented at the annual SLEEP meeting in San Antonio last month. In this study, researchers analyzed patients from the Wisconsin Sleep Cohort. The patients were mailed surveys about insomnia symptoms - difficulty starting or staying asleep, for example. After adjusting for other factors that could be contributing to death (age, BMI, chronic conditions, e.g.), the researchers concluded that there was an approximately 2-fold increase risk for all-cause mortality in chronic insomnia patients.

The problem with this study is in the way the researches determined if someone has insomnia, and what type of insomnia they might have. Insomnia is difficult to diagnose off of a mailed survey. Although I did not read the poster because I did not attend this meeting, the review of the poster mentions nothing about whether the patients in this study might have had a coexistent sleep-related breathing disorder. Not all insomnia symptoms are due to primary insomnia - many times, insomnia is due to undiagnosed obstructive sleep apnea, a condition known to increase mortality if left untreated.

This study is misleading in that it implies that patients with primary chronic insomnia have an increased risk of dying. Insomnia is a serious disorder, but it is not life threatening and has not been linked to other physical diseases based on research studies where primary insomnia was diagnosed by an experienced sleep clinician.

Thursday, July 15, 2010

Aliens, Darth Vader, and Hannibal Lecter





What do these three have in common? They either had a mask (Darth Vader and Hannibal) or had young that attached to a human host's face (Aliens). What does this have to do with sleep? Everything, as these are the three most common comparisons to CPAP masks.

There are dozens of masks available for CPAP, several manufactures, but only a handful of styles. In my practice, I use mainly Resmed and Fisher Paykel masks. A pillows style fits into the nostrils like thick oxygen prongs, such as Resmed's Swift FX. This mask is the least bulky and does not block the vision while being worn. Nasal masks like Resmed's Activa fit over the nose. Because most of these have a T-piece that touches the forehead, vision can be blocked somewhat while the mask is on. Full-face masks cover the nose and mouth, such as Fisher Paykel's Forma. This style tends to be the bulkiest and can be difficult to get an air-tight seal.

All masks work with the same CPAP devices, meaning no special or extra equipment is necessary if a patient wants to change mask brands or styles. Mask choice depends on multiple factors, many of which are patient preference. Working with a knowledgeable person to find the most appropriate mask can help determine whether a patient uses CPAP enough to benefit.

Monday, July 12, 2010

Not Your Parents CPAP

Many of my patients have heard of or know someone who uses CPAP. When I discuss this treatment option for obstructive sleep apnea, the most common question is if the CPAP flow generator is loud. They've heard that the fan inside the CPAP can be loud.

It is true that older models of CPAP were louder. But modern CPAP units are whisper quiet. And they have many comfort features. Most can ramp up the pressure from the lowest to the prescribed pressure over an amount of time chosen by the patient. I always prescribe a heated humidifier with CPAP to ease the dryness. The size of CPAPs has gradually decreased over time, meaning they fit easier on a nightstand or in your luggage.

My two favorite CPAPs currently are the S9 from Resmed and the System One from Respironics. Both of these offer a pressure relief feature that can make breathing out more comfortable. Plus, the data recorded from these devices gives me a wealth of information about a patient's breathing while they are asleep. I can download this data from the CPAP and go over it with the patient in my office during follow ups. Most patients appreciate this information, as they are unaware of how they might (or might not) be breathing when they sleep.

Friday, July 9, 2010

Sleep and Headaches

Although I did not go this year, I saw that the American Headache Society Annual Scientific meeting recently occurred. I received an update from Medscape about the importance of screening for sleep disorders in chronic headache sufferers. This goes along with my clinical experience treating patients with sleep disorders.

There is an association between sleep and headaches, but it's not been entirely worked out. Headaches can disrupt sleep, and sleep disorders can worsen headaches. A common referral I get is waking up with headaches, which sometimes can be from a sleep-related breathing disorder like obstructive sleep apnea. Migraine headache patients seem especially vulnerable to disorders that break up sleep.

Most headache physicians know the importance of adequate sleep in treating patients with chronic headaches. Hopefully, the recent Headache meeting will remind headache specialists to consider sleep disorders as they attempt to manage their headache patients.

Wednesday, July 7, 2010

The Other Sleep Apnea?

When patients ask me about sleep apnea, most often they are referring to obstructive sleep apnea, characterized by repetitive throat collapse while asleep. There is another type of sleep apnea, central sleep apnea, where a person will stop breathing, but the throat remains open.

Central sleep apnea occurs when a person breathes too slowly or not deep enough. It can occur in the setting of brain, heart, or lung diseases. In heart failure, central sleep apnea can be a problem, and not all cardiologists are aware of it.

The symptoms of central sleep apnea can be similar to those seen in obstructive sleep apnea, such as restless sleep, daytime sleepiness or extreme fatigue, and unusual breathing patterns while asleep (usually observed by a bed partner).

Although central sleep apnea gets less attention than the more common obstructive sleep apnea, both deserve to be treated since both conditions can increase mortality rates. However, the treatment for each sleep apnea type can be different, making it important to figure out the exact type of sleep apnea that is affecting the patient.

Saturday, July 3, 2010

Sleep Disorders and Parkinson's Disease

Medscape has an article from the Movement Disorders Society 14th International Congress on Parkinson's Disease and Movement Disorders. In the article, it describes research linking falling out of bed while asleep and Parkinson's Disease.

I see this occur in my practice too, and I'll explain what is happening. Normally, our bodies are temporarily paralyzed in dream sleep, so that we don't act out our dreams while asleep. In patients with Parkinson's or Parkinson's-like disorders, that dream paralysis mechanism doesn't always work so well. If this occurs, patients can act out their dreams, with screaming, arms waving, or even attempting to get out of bed. Since patients are responding to their dreams, they often fall right after getting out of bed, sometimes injuring themselves. This problem is referred to as REM sleep behavior disorder.

This might sound ironic, as Parkinson's disease patient's have difficulty moving while awake, but could be moving too much while asleep. Sometimes, this can lead to daytime sleepiness. Unfortunately, Parkinson's disease itself and the medications used to treat Parkinson's disease can lead to daytime sleepiness.

Just to complicate matters more, REM sleep behavior disorder can be worsened by untreated obstructive sleep apnea. Certain medications can worsen the movements in dream sleep as well. So, if a patient is moving too much in their sleep, the exact cause can be difficult to figure out.

Fortunately, REM sleep behavior disorder is usually treatable with medications and making the bedroom environment as safe as possible when the patient sleeps.

Thursday, July 1, 2010

Exercise and Insomnia

People with chronic insomnia do not necessarily respond to a single treatment type. In an article in the June 2010 edition of the Journal of Clinical Sleep Medicine, the authors studied the effect of exercise on chronic insomniacs that were healthy otherwise and did not exercise regularly. They found that moderate intensity aerobic exercise decreased anxiety and improved sleep quality, when studied in the sleep lab and when they asked the participants. There was no significant improvement in anxiety or sleep quality with high intensity aerobic exercise or moderate intensity resistance exercise (weight training).

Before you go out and hit the running trail, some caution is advised. This study was small and only measured participants' response after one session of exercise. Also, the moderate intensity aerobic exercise group had the most severe insomnia to begin with - and therefore had the most to gain with the exercise session.

Exercise can be an important part of healthy sleep. Exercise too close to bedtime can disrupt sleep, especially in the beginning of the night. You might struggle more if you go for a run at 10 pm, then grab a shower, and hit the sheets by 11 pm. You'll probably need more wind-down time - perhaps 4-6 hours after exercise, before trying to sleep.

Wednesday, June 30, 2010

CPAP Versus Positional Therapy for Sleep Apnea

I just finished another article in the June 2010 issue of the Journal of Clinical Sleep Medicine. It was a study about patients with mild to moderate positional obstructive sleep apnea (OSA) - in this case, the patients only had OSA on their backs, and not on their sides.

I see this type of OSA less often. It usually is in patients who have a normal body weight or only mildly overweight. However, OSA is often worse when patients sleep on their back, but they usually have it on their sides as well. Those patients were not the focus of this study.

CPAP was tested against a device worn at night to keep people on their sides - the Zzoma . The authors found that the Zzoma was just as effective as CPAP in treating position-dependent mild to moderate OSA. This is good news, as sometimes patients with this type of OSA do not want or do not tolerate CPAP. I usually tell patients with this type of OSA to use a wall of pillows to keep them off of their back when they sleep. Some of these patients also respond better to an oral appliance worn at night. Now, they have another option.

Monday, June 28, 2010

Sleep Apnea, Sexual Health, and CPAP Treatment

I did not plan for my first post to be out sex, but this was the first article in the June 2010 issue of the Journal of Clinical Sleep Medicine (JCSM), entitled “Outcome of CPAP Treatment on Intimate and Sexual Relationships in Men with Obstructive Sleep Apnea.”


To begin with, the authors explain that 30% to 68% of men with obstructive sleep apnea (OSA) suf­fer from some level of sexual dysfunction. Loss of interest in sex has been associated with the number of apneas and how low a patient’s oxygen level goes when asleep. They warn us that CPAP treatment has not definitively been shown to improve sexual function.


The authors designed the study to look at OSA patients’ perceptions of their intimate and sexual relationships, the as­sociation with daytime sleepiness, and degree of impairment compared to normal values, and to document if there was any improvement with CPAP treatment.


They studied 123 men, with most of the patients being middle-aged, obese, and with severe sleep apnea. The patients rated their intimate and sexual relationships with a questionnaire that asked about sexual desire, ability to become sexually aroused, and ability to have an orgasm.


The results showed that men with OSA have worse intimate and sexual relationships and this is related to daytime sleepiness. Following treatment with CPAP, intimate and sexual functioning improved, with the most severe amount of OSA showing the largest improvement. This im­provement was related to improvement in daytime sleepiness.


Why would men with OSA have worse intimate and sexual relationships? Being tired may mean men are less interested and have more difficulty with sexual activity. OSA can affect certain hormones like testosterone, which could then impact sexual interest and performance. Finally, low oxygen levels have been associated with impotence. The authors also point out that, although regular CPAP use did improve sexual functioning, 43% of those OSA patients using CPAP for 3 months did not improve to a level seen in men who do not have OSA at all.