#184 Update in Sleep Medicine: LIVE from CHEST 2019!

November 25, 2019 | By Cyrus Askin

Catch up on sleep medicine insights with Christine Won MD, MSc!

Score some great insights and clinical pearls from Dr. Christine Won on the incredibly important topic of sleep medicine during this live recording at CHEST! On this episode we’ll tackle why we sleep, how to treat insomnia, the “Z-drugs” and more! ACP members can claim CME-MOC credit at https://www.acponline.org/curbsiders (CME goes live at 0900 ET on the episode’s release date).

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Credits

• Written and Produced by: Cyrus Askin MD, Matthew Watto MD, FACP 
• Cover Art: Kate Grant MBChB DipGUMed
• Hosts: Stuart Brigham MD; Matthew Watto MD, FACP; Paul Williams MD, FACP   
• Editor: Matthew Watto MD, FACP; Emi Okamoto MD
• Guest: Christine Won, MD MSc

Sponsor

Time Stamps

• 00:00 Intro, disclaimer, guest bio
• 06:10 Guest one-liner
• 10:15 Picks of the Week*: Become Your Child’s Sleep Coach (book) by Lynelle Schneeberg; Sleep in Art: How artists portrayed sleep and dreams in the last 7000 years (book) by Meir Kryger; The Toxic Avenger (film); Ballistyx Jump Rope; Weird Al – The Essentials
• 12:28 Case of Mr. S. Andman; Why we sleep
• 16:04 Spiel on how sleep affects health, testosterone
• 21:05 How much sleep do we need; Teens an sleep
• 28:05 Spiel to patients self medicating with sedatives; CBT for insomnia (CBTI) including online CBTI
• 32:10 Sleep hygiene, naps
• 34:10 Z drugs
• 39:17 How sleep apnea differs in women
• 41:52 Sleep trackers (wearables); Blue blockers and screens
• 45:00 Audience questions: Alarm clocks; Cultural sleep issues;  Shift work; Melatonin; 5-hydroxytryptophan
• 55:45 Outro

Sleep Medicine Pearls

• Sleep is important! Sleep seems to be critical for memory formation and to clear certain neurotoxins, but we don’t know for certain.
• Poor sleep doesn’t just make you feel tired the next day. Poor sleep may lead to or exacerbate medical comorbidities such as hypertension, heart disease and obesity.
• Say “No”  to diphenhydramine (and other such drugs)! Sedating drugs (i.e. antihistamines) are not the answer! The Z-drugs can be used sparingly, for short periods of time, as an adjunct to cognitive behavioral therapy for insomnia (CBTI). 
• Sleep hygiene is good, but probably not enough. Sleep hygiene (i.e. avoiding screen time around bedtime, relaxation exercises before sleep) are helpful adjuncts to CBTI but in-and-of-itself, sleep hygiene isn’t enough to treat insomnia.
• OSA in women is different than in men: Women are less likely to be screened for sleep apnea and more likely to have REM-predominant sleep apnea which may be linked to a greater incidence of cardiovascular disease than non-REM-predominant sleep apnea.

Sleep Medicine In-depth Show Notes

Why we sleep?

Many theories, no certain answer

• Evolutionarily beneficial from a conservation-of-energy standpoint & to keep us out of harm’s way in the dark
• Restorative Theory: We build up toxins during wakefulness and we need time for those to be cleared (i.e. during sleep)
  • Ex: Increased tau protein which may be extracted during sleep
• Brain Plasticity Theory: Memories are consolidated during sleep and “unnecessary” neuronal connections are “pruned” (see Feld, et. al.)

Sleep and Medical Comorbidities:

Poor sleep has been associated with:

• Cardiovascular disease (see Tobaldini, et. al.)
  • Among those with more severe insomnia studied, incident risk hypertension was 3.8x higher (Penn State Cohort study, Fernandez-Mendoza et al.) and heart failure risk was 4.5 x higher (Norwegian Study, Laugsand et al.)
  • May be confounded by undiagnosed OSA
• Weight gain, obesity, metabolic disease 
• Sleep deprivation (particularly when sleep onset is dysfunctional) is associated with low testosterone (see Wittert)
  • Also can be confounded by OSA/obesity
• Poor sleep & common cold-like symptoms?
  • Theory: Poor sleep may be associated with immune dysregulation and immunosuppression 
  • Patients sleeping less were 4-5x more likely to develop symptoms when infected with rhinovirus (see Prather, et. al.) 

How long should we be sleeping?

• American Academic of Sleep Medicine & Sleep Research Society recommendations:
  • Adults ≥ 7 hours of sleep per night
  • Children and adolescents need much more sleep time
    • Often 10+ hours recommended
    • Adolescents often become “phase shift delayed”, meaning they want to sleep and wake later,  and also suffer from “social jetlag”, where during the weekends they shift their schedule to social life which must re-shift during the week
  • Remember, sleep is a bell curve – some people may be fine at 6 or 7 hours, others need more to be at peak performance
• Can you catch up on sleep?
  • You can “bank” on sleep – prophylactic napping can help before planned sleep deprivation 
  • To some extent, you can catch up on sleep that has been missed, though to some extent (chronic sleep debt) you cannot “pay it back”

Treatment options:

•  CBTI (cognitive behavioral therapy for insomnia) is a first-line therapy for chronic insomnia
  • Some online resources available, like: ShutI now called “Somryst,” Sleepio , VA Sleep Coach app
• Antihistamines may be appealing to a lot of patients, but anticholinergics have a lot of dangerous side effects – especially in older patients
• Discourage their use / do not recommend

So what exactly is “Sleep Hygiene”?

• Basic, proper sleep promoting behaviors:
  • Avoid screen time around bedtime 
  • Dim lighting is best, though reducing blue lighting can help (Tosini et al)
  • Bedtime routine
  • Relaxation exercises prior to sleep
  • Avoid caffeine and physical activity right before sleep
  • Minimize/avoid naps (exception of prophylactic naps as below)
• Dr. Won:  Sleep hygiene alone is insufficient to treat insomnia, consider using with CBTI
• Prophylactic naps
  • Can be useful in preparation for certain activities, or to mitigate sleep debt
  • Keep them short – 20 to 40 minutes
  • Anything longer can lead to sleep inertia and grogginess which can interfere with night time sleep

The Pharmacology of Sleep: the “Z-Drugs”

• The “Z-Drugs” are the non-benzodiazepine hypnotics. Examples are  zolpidem, eszopiclone, and zaleplon
  • Generally recommended up to 7 days
• Dr. Won: Okay to use for short-term / acute insomnia 
• Can be used as an adjunct or a bridge in-addition to CBTI
• Parasomnias such as sleepwalking, sleep driving, sleep eating are important side effects to be aware of
• Zolpidem: female drug metabolism differs from that of men with respect to this agent and can result in unexpectedly high drug levels after 8 hours leading to daytime impairment (see Farkas et. al.) 
  • This disparity is still being evaluated (see Greenblatt et. al.)
• CBTI can help get patients off of sleep medications such as zolpidem

Wait so… sleep apnea in women is different than in men?!

• We currently use the AHI to diagnose sleep apnea in all comers, however, this is probably not the most important thing in all patients! (For more, listen to Episode 123 on Sleep Apnea)
• Sleep apnea in women: More likely to have REM-predominant OSA
  • May mean that women are at greater risk for cardiovascular disease as there is a specific link between REM-predominant OSA and heart disease(for more, see Acosta-Castro et. al.) 
  • May be useful to look specifically at the REM-AHI, not just the AHI 

Thoughts on Shift Work:

• Has been shown to be associated with more cardiovascular disease and cancer
• Ask patients: Are there other options? If not…
  • Suggest that patient’s keep a regular sleep schedule during their days off
  • Use blackout shades, simulate dark light whenever possible during daytime sleep periods
  • Try to do critical tasks earlier in the shift
  • Moderate caffeine use is helpful
  • Try to take little (15-20 minute) naps when possible

To melatonin or not to melatonin:

• Melatonin is an organically produced hormone that regulates the circadian rhythm
• Used for treatment of circadian rhythm disorders 
• 0.5mg (or less) is probably all that is needed to impact the circadian rhythm (i.e. to improve entrainment)(Carter, 2012)
• Can be attempted for insomnia, but patient needs to take regularly at the same time every time
  • Again, this may correct insomnia due to delayed sleep-wake cycle and can help reset a patient to the “normal” circadian cycle
• Melatonin is not a sedative that will acutely help someone fall asleep 
  • Although the placebo effect may enable its use in such a capacity

Goal

Listeners will gain a broad overview of sleep medicine the purpose of sleep, its implications for promoting health and preventing disease, tips for improving sleep quality, plus answers to the most common sleep questions from patients.

Learning objectives

After listening to this episode, you should be able to…

1. Explain the theories behind why we sleep and recognize the link between sleep, overall health, and various comorbid conditions
2. Counsel patients about sleep and recall tips to improve their own sleep
3. Answer common questions about over the counter supplements and prescription medications used in sleep medicine
4. Discuss approaches to therapy for insomnia, specifically the role of prescription medications in conjunction with cognitive behavioral therapy and sleep hygiene

Links*

1. Become Your Child’s Sleep Coach, Lynelle Schneeberg, book recommendation from Dr. Won
2. Sleep in Art: How artists portrayed sleep and dreams in the last 7000 years, by Meir Kryger, book recommendation from Dr. Won
3. The Toxic Avenger– Paul’s move pick-of-the-week, by way of Stuart 
4. Jump Ropes – Matt’s pick-of-the-week, by way of Stuart
5. Weird Al – The Essentials – Matt’s actual pick-of-the-week, by way of himself
6. My Pillow – Stuart’s pick-of-the-week, which you cannot have, because it’s literally his very own pillow!
7. AASM (Sleep) Guidelines: https://aasm.org/clinical-resources/practice-standards/practice-guidelines/
8. Topical Article from CHEST: The Impact of Sleep and Circadian Disorders on Physician Burnout
9. CBTI Resources: ShutI now called “Somryst,” Sleepio , VA Sleep Coach App

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on my Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

References

1. Feld GB, Born J. Sculpting memory during sleep: concurrent consolidation and forgetting. Curr Opin Neurobiol. 2017;44:20-27.
2. Tobaldini E, Costantino G, Solbiati M, et al. Sleep, sleep deprivation, autonomic nervous system and cardiovascular diseases. Neurosci Biobehav Rev. 2017;74(Pt B):321-329.
3. Fernandez-Mendoza et al. Insomnia with objective short sleep duration and incident hypertension: the Penn State Cohort. Hypertension. 2012. 
4. Laugsand LE et al. Insomnia and the risk of incident heart failure: a population study. Eur Heart J. 2014.
5. Wittert G. The relationship between sleep disorders and testosterone. Curr Opin Endocrinol Diabetes Obes. 2014;21(3):239-43.
6. Prather AA, Janicki-deverts D, Hall MH, Cohen S. Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015;38(9):1353-9.
7. Consensus Conference Panel et al. Recommended amount of sleep for a healthy adult: a joint consensus from AASM and SRS. Sleep. 2015.
8. Farkas RH, Unger EF, Temple R. Zolpidem and driving impairment–identifying persons at risk. N Engl J Med. 2013;369(8):689-91.
9. Tosini et al. Effects of blue light on circadian system and eye physiology. Mol vis. 2016.
10. Greenblatt DJ, Harmatz JS, Roth T. Zolpidem and Gender: Are Women Really At Risk?. J Clin Psychopharmacol. 2019;39(3):189-199.
11. Acosta-castro P, Hirotsu C, Marti-soler H, et al. REM-associated sleep apnoea: prevalence and clinical significance in the HypnoLaus cohort. Eur Respir J. 2018;52(2)

Disclosures

Dr. Won reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Won, M, Williams PN, Brigham SK, Askin C, Okamoto E, Watto MF. “#184 Update in Sleep Medicine: LIVE from CHEST 2019!”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list November 25, 2019.