Monday, December 31, 2012

Periodontitis linked to obstructive sleep apnea

Periodontitis is inflammation of the ligaments and surrounding structures that support the teeth. Apparently it is associated with increase risk of heart disease. It is related to mouth breathing. Here is a study showing an increased risk of obstructive sleep apnea (OSA) in patients with periodontitis. It's not that surprising since many OSA patients breathe through their mouth at night, and wake up with dry mouth.

Friday, December 28, 2012

Certain sleeping pills may increase risk of pneumonia

Benzodiazepines (BZD) are an older class of medicines that have been used for insomnia - examples include Restoril and Valium. Here is a study that links BZD use to pneumonia in a UK community. I don't have access to the full article, but another review of the article says that researchers think the BZDs may reduce immunity. I was not aware of that - I would think that BZDs could increase pneumonia risk because they may suppress drive to breathe, especially when combined with other sedating medications and alcohol.

Wednesday, December 26, 2012

Obstructive sleep apnea damages cardiovascular system to same extent as diabetes

Obstructive sleep apnea (OSA) has been linked to higher rates of cardiovascular disease. This study looked at a small number of patients with moderate to severe OSA. In particular, they studied their cardiovascular systems using sophisticated imaging equipment, and compared the findings to diabetics without OSA. The results showed that both OSA and diabetes causes a similar amount of damage to the cardiovascular systems

Monday, December 24, 2012

Protected sleep time allows medical trainees to sleep more

In the last few years, the hours worked by medical interns and residents has come under scrutiny. Regulations have been put in place to limit the number of hours worked in an attempt to reduce patient errors. Here is an article about a study showing that if you give medical trainees 5 hour protected time to sleep while on call, they will sleep an extra hour on average. However, the researchers did not measure medical errors, so it's not clear if that extra hour of sleep made any significant difference.

Friday, December 21, 2012

Chronic insomnia and obstructive sleep apnea

Patients with chronic insomnia can have problems falling asleep and staying asleep. For those that wake up at night, it can be difficult to know what wakes them up - after all, they were asleep! I've followed Dr. Krakow's work over the years, and he has a practice and does research over in New Mexico. His work has provided evidence that some "insomnia" patients actually have obstructive sleep apnea (OSA), and that treating the OSA can reduce the insomnia.

Dr. Krakow et al did a study published in the Journal Sleep. He did sleep studies on 20 patients who presented only with insomnia. These patients did not have other symptoms of OSA, although half of them snored. The mean body mass index was <25 and most were tired but not sleepy. The results showed that 11 patients had OSA and another 7 patients had a milder version of OSA called upper airway resistance syndrome. So that means 19/20 patients had some form of sleep disordered breathing. What we don't know is how these patients developed chronic insomnia. But the results help confirm what I see clinically quite often - that insomnia is not just a psychological problem but can be triggered by medical disorders like OSA.

Thursday, December 20, 2012

More sleep may reduce pain

Studies have shown that total and partial sleep deprivation can increase pain sensitivity. Dr. Roehrs et al did a study published in the Journal Sleep, in which they determined whether an extended bedtime would increase alertness and reduce pain threshold in sleepy individuals.

They enrolled 18, healthy, pain free but sleepy patients who most likely were sleep deprived. The patients were randomly selected to either continue their current sleep schedules or to extend their sleep upto 10 hours per night for four nights. The results showed that on average, those with the extended sleep duration had reduced sleepiness and reduced pain sensitivity. The study authors speculate that being sleepy can increase pain sensitivity. They concluded that reversal of mild chronic sleep loss improves pain sensitivity. They think that sleep loss could increase systemic inflammation, which could increase the sensitivity to pain.

I'm not sure what these results mean for clinical practice. In my experience, chronic pain patients have chronic insomnia from various reasons - pain, certain medications for pain, and inadequate sleep hygiene. Sleep deprivation is not usually present and these chronic pain patients couldn't sleep any more. Some chronic pain patients are sleepy during the day, but not from sleep deprivation, but from the pain medications.

Wednesday, December 19, 2012

Non-drug treatment of restless legs syndrome

Restless legs syndrome (RLS) is an uncomfortable sensation in the legs that occurs at rest, more often in the evening, and is relieved temporarily with movement. We don't know what causes RLS, but researchers think it may have something to do with dopamine dysregulation. RLS is often treated with prescription medications. However, sometimes non-medicine treatments can help. This article reviews some of the evidence supporting those non-drug treatments.

Regular exercise has been shown to relieve RLS. Proposed mechanism is an increase in circulation, release of endorphins, and increase in dopamine. More recently, pneumatic compression stockings have shown to be helpful. These are air filled wraps worn around the legs - they repetitively fill and empty the air resulting in a massaging action and can improve circulation. If you don't have a pair of pneumatic compression stockings laying around, regular massage has been shown to be helpful, perhaps by increasing circulation, a counter stimulation action, or generation dopamine. Near-infrared light has been shown to be helpful, possibly by increasing circulation. Acupuncture has not been shown to be effective for RLS when compared to no treatment. Certain vitamins and minerals have been shown to be helpful - vitamin E, vitamin B12, multivitamins with vitamin C, glucosamine, zinc, folic acid, vitamin D, and magnesium made the list.

RLS has been associated with low iron, and sometimes I use iron therapy to help with the symptoms. This often takes months of daily iron intake to increase the levels. I don't recommend people taking iron though unless the level is low, as too much iron is not healthy.

Tuesday, December 18, 2012

Kids do get recommend amounts of sleep

Lots of press about how kids are getting too little sleep. And lots of ink about how too little sleep contributes to childhood obesity. This article discusses new research showing that kids get as much sleep as recommended. Time to focus on the more likely problem of childhood obesity - diet.

Monday, December 17, 2012

More convenient way to do light therapy

Using bright lights to shift circadian rhythms can be helpful for certain sleep disorders. Making the lights portable has been a challenge. Researchers have devised a pair of glasses that uses green light to aid in shifting your circadian rhythm. This article describes the glasses and how they may be used for jet lag and other sleep timing disorders like delayed sleep phase disorder.

Friday, December 14, 2012

Possible chemical identified that causes excessive sleepiness

Patients who can not remain awake but for no known cause are sometimes not responsive to our standard stimulant medications. This is frustrating for the patients, as there has been less research done on this than on more common problems like obstructive sleep apnea and insomnia.

Here is an article about a small study our of Emory. Researchers have isolated a chemical in the cerebrospinal fluid (CSF) of patients with excessive sleepiness, called primary hypersomnia. The CSF chemical acts similar to medicines like Valium. In this study, alertness was improved by giving a medicine that blocks the effect of Valium. These results are interesting, because other studies have not found the same alerting affects of that medicine.

But if researchers can pinpoint the chemical, than novel drug therapies may be helpful in improving the lives of those suffering from primary hypersomnias.

Thursday, December 13, 2012

Older Americans sleep as well as younger Americans

In my training, I was taught that older adults, in general, go to bed early, get up early, and have poorer sleep overall than younger adults. This article discusses new research about the sleep habits of older Americans. Researchers did telephone surveys and found that many of the respondents had sleep schedules and sleep quality similar to those of younger adults.

These results are not actually surprised, as recent studies have shown similar results and Dr. Ancoli-Israel has lectured about this recently. It is true that some sleep disorders are more prevalent as we age, but getting older does not automatically mean you are destined for poor sleep.

Wednesday, December 12, 2012

Music therapy for insomnia

This article discusses a new, non-drug approach to treating insomnia. I don't know much about it, although I have known about it for a few years. I don't understand exactly how it works, either. Apparently, researchers attach electrodes to the scalp of insomnia patients. The electrodes record brain wave activity. A sophisticated software program analyzes the mathematics behind the brain waves and then creates music based on that pattern. The music is then piped in through headphones to the patient. The study showed a significant decrease in insomnia symptoms as reported by study subjects. No sleep studies were done to confirm the effects, and patients knew if they were getting the treatment - two aspects that affect the results. If this new type of therapy proves to be beneficial in larger, controlled, and blinded studies, it may be a good non-drug approach. I am not sure how it would be delivered though - only through major medical centers or through a sleep clinic?

Tuesday, December 11, 2012

Ambien increases risk of falls in hospitalized patients

Here's another article about Ambien and increased fall risk. This study was done at Mayo, where Ambien was associated with a significantly increased risk of falls in hospitalized patients. Mayo has decided not to use Ambien anymore in their hospitalized patients, and instead, use a drug free approach. Details were not given about that approach, and hopefully they will have success. Poor sleep quality during hospitalization can be a challenge, and I am not sure standard behavioral therapies used on an outpatient population would work during an acute hospitalization. More studies will be needed for sure.

Monday, December 10, 2012

Type B natriuretic peptide and obstructive sleep apnea

Obstructive sleep apnea (OSA) has been shown to increase the risk of cardiovascular disease. Type B natriuretic peptide (BNP) is a hormone secreted by the heart when it is stressed. There is conflicting data about the association of OSA and elevated BNP levels, especially in asymptomatic patients, and among women. This study analyzed the association between OSA and BNP in a community-based sample of women. All participants had overnight sleep studies and blood work done the next morning.

The results showed a dose-response relationship between increasing OSA severity and elevated BNP levels, even after adjusting for confounding variables like age, body-mass index, blood pressure, and kidney function. The study authors theorize that during an OSA event, the chest cavity has a reduced pressure, and more blood enters that region. More blood also gets to the heart, stretching the walls a little more. This stresses the heart and BNP is released. Also, OSA can cause low oxygen levels, and this may stress the heart, which would then release more BNP. The authors conclude that BNP could serve as a marker in OSA patients who may be at increased risk for cardiovascular disease.

Friday, December 7, 2012

Weight loss pill helps reduce obstructive sleep apnea severity

Obstructive sleep apnea (OSA) usually gets worse with weight gain, and better with weight loss. A new, combination medication, Phentermine + Topiramate, has been shown to help in weight reduction. This study evaluated the safety and efficacy of Phentermine + Topiramate compared to placebo for treatment of obese patients with moderate to severe OSA that were unwilling or unable to use CPAP. Both groups received a standardized weight reduction counseling program and the study lasted for 28 weeks.

The results showed that the Phentermine + Topiramate treatment showed significant improvements in sleep apnea severity, subjective sleep quality, weight loss, and systolic blood pressure when compared to placebo. Of note, the placebo group also had a reduction in OSA severity and weight reduction, just not as much as the treatment arm. There were no serious adverse events reported, except one case of kidney stones in a patient who already had a history of them. Topiramate typically causes fatigue, but this was not present, probably due to the stimulating effects of the Phentermine.

Phentermine is an appetite suppressant, and was once used in the combination weight loss medication Fen-Phen. The Fen part, or fenfluramine, was taken off the market because it was associated with heart valve damage. Topiramate is an anti-seizure medication, but has been shown to reduce weight through an unknown mechanism. It's not clear from this study if the combination of the two would be better than Phentermine alone. Also, this study was for 7 months, but what would happen when the medications were discontinued? Or would this have to be a life-long treatment?

Thursday, December 6, 2012

Comparing sleep between fibromyalgia and rheumatoid arthritis

Both fibromyalgia (FMS) and rheumatoid arthritis (RA) are chronic pain conditions, can disrupt sleep, and result in subjective daytime sleepiness and fatigue. This article discusses a comparison between the two conditions with regard to objective sleep quality at night and daytime sleepiness in women. Researchers did standard sleep studies and surveyed the patients for their subjective experiences.

The results showed that there was similar nighttime sleep disturbance between those with FMS and RA. The FMS patients reported greater subjective daytime sleepiness and fatigue than those with RA. But the sleep studies showed relatively low daytime sleepiness in FMS and an intermediate amount in the RA patients.

These results support clinical findings - that FMS patients are generally not sleepy, but very fatigued. Fatigue can not be measured like sleepiness. Patients with RA are more sleepy, and this is supported with objective testing. RA patients are also fatigued. The authors of the study concluded that FMS patients have less sleepiness and more fatigue due to hyperarousal. This could be true, but unfortunately it is difficult to treat.

Wednesday, December 5, 2012

Throat muscle paralysis mechanism discovered

Obstructive sleep apnea (OSA) occurs when the throat closes too much during sleep. And when we dream, the throat (as well as other muscles) close the most, as the brain temporarily "paralyzes" our muscles so we don't act out the dreams we are having. This article discusses research showing how the brain paralyzes the throat muscles when we dream, which could lead to OSA. This is exciting (at least to me) and has implications for future medical treatments for OSA.

Tuesday, December 4, 2012

Energy drinks may disrupt sleep in combat troops

Here is article about energy drink consumption by our soldiers. The results showed that those soldiers who consumed more energy drinks also reported less sleep at night and more daytime sleepiness. The article implies that the energy drinks are somehow responsible for the reduced nighttime sleep and daytime sleepiness. That doesn't seem likely to me. More likely is that the soldiers are sleep deprived from other sources, like being in combat! They are tired the next day and reach for the energy drinks to help them make it through the day, not the other way around.

Monday, December 3, 2012

Insomnia medications can increase memory and concentration problems

This article discusses how certain medications used for insomnia can increase mild memory and concentration problems in older people. The medications mentioned were benzodiazepines, like valium and anti-histamines, like benadryl but also the "PM" over the counter sleep aids. The study authors acknowledged that some patients may need these medications despite the risk. But at least for insomnia, non-drug treatments have been shown to improve sleep quality. Talk to your doctor or a sleep physician about how you can improve your sleep, rather than resorting to medications.