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.