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).
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.)
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”
CBTI (cognitive behavioral therapy for insomnia) is a first-line therapy for chronic insomnia
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
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.
After listening to this episode, you should be able to…
Explain the theories behind why we sleep and recognize the link between sleep, overall health, and various comorbid conditions
Counsel patients about sleep and recall tips to improve their own sleep
Answer common questions about over the counter supplements and prescription medications used in sleep medicine
Discuss approaches to therapy for insomnia, specifically the role of prescription medications in conjunction with cognitive behavioral therapy and sleep hygiene
*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.
Feld GB, Born J. Sculpting memory during sleep: concurrent consolidation and forgetting. Curr Opin Neurobiol. 2017;44:20-27.
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.
Fernandez-Mendoza et al. Insomnia with objective short sleep duration and incident hypertension: the Penn State Cohort. Hypertension. 2012.
Laugsand LE et al. Insomnia and the risk of incident heart failure: a population study. Eur Heart J. 2014.
Wittert G. The relationship between sleep disorders and testosterone. Curr Opin Endocrinol Diabetes Obes. 2014;21(3):239-43.
Prather AA, Janicki-deverts D, Hall MH, Cohen S. Behaviorally Assessed Sleep and Susceptibility to the Common Cold. Sleep. 2015;38(9):1353-9.
Consensus Conference Panel et al. Recommended amount of sleep for a healthy adult: a joint consensus from AASM and SRS. Sleep. 2015.
Farkas RH, Unger EF, Temple R. Zolpidem and driving impairment–identifying persons at risk. N Engl J Med. 2013;369(8):689-91.
Tosini et al. Effects of blue light on circadian system and eye physiology. Mol vis. 2016.
Greenblatt DJ, Harmatz JS, Roth T. Zolpidem and Gender: Are Women Really At Risk?. J Clin Psychopharmacol. 2019;39(3):189-199.
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)
Dr. Won reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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.
Dormir la siesta - could this not be an indirect cultural way of controlling diabetes via lowering cortisol?