1 SLEEP DISORDERS IN ASBESTOS-RELATED DISEASES Asbestos pleural diseases ie benign asbestos pleural plaques, diffuse pleural thickening, benign asbestos pleurisy, benign asbestos pleural effusions and asbestosis as well as the more common asbestos-related malignancies ie lung cancer and mesothelioma all have a significant impact on the function of sufferers during the day. However, we spend approximately one-third of our life asleep. There is very little in the literature regarding the impact of asbestos diseases in all its varied forms on sleep. Sleep disorders are also common in the community and by middle age, sleep apnoea and periodic leg movement disorder is found in increasing frequency particular as patient s age and gain weight. Other conditions such as insomnia are also extremely common. BENIGN ASBESTOS DISEASES I have recently conducted a study of approximately 300 patients at the Wesley Hospital, most in middle age and older, presenting with asbestos-related diseases referred either by their general practitioner or for medico-legal assessment. About onethird had obstructive apnoea. Although this is a common condition, asbestos diseases may precipitate the obstructive sleep apnoea by causing weight gain as a result of reduced physical activity, exertional dyspnoea and chest pain. Other comorbidities often follow with weight gain including diabetes mellitus type 2, hypertension, ischaemic heart disease and cerebrovascular disease as well as back pain and musculoskeletal problems. In my experience of over 20 years of seeing patients with asbestos diseases and also in my capacity of a sleep physician, I frequently diagnose sleep apnoea in patients with asbestos disease which has either occurred a result of weight gain or been aggravated by significant weight gain. This is also compounded in the subgroup of patients with significant asbestos pleural pain who require drugs such as gabapentin and Lyrica and tricyclic and other antidepressants, all of which may have a significant impact on weight gain. Although the majority of patients with asbestos diseases and obstructive sleep apnoea can be treated with standard CPAP pumps. Autotitrating devices which cost roughly around $2,000 and fixed pressure pumps are approximately half this cost.
2 There is another subgroup of patients who have significant restrictive lung disease and who require more sophisticated CPAP pumps which are called bi-level pumps (Bi-PAP for short) and which range from $4,000 to $6,000. The more restrictive lung function present, the more difficult it is to inflate the chest and to overcome the sleep apnoea. Some patients also require entrained oxygen due to resting low oxygen saturations which are aggravated by sleep. In the normal individual, lying supine ie on one's back, causes the diaphragm to elevate and this is accentuated by gravitational effect on abdominal contents. In patients who are obese, this problem is accentuated and in those with coexisting restrictive defects from asbestos pleural disease and asbestosis as well as mesothelioma and lung cancer find that this problem is even worse, to the extent that the resting oxygen saturation may be well below normal even while they are awake. During sleep the skeletal muscles and diaphragm maintain respiration and control oxygen saturation in the blood. However, during REM sleep the skeletal muscles become atonic ie floppy and the only muscle which maintains respiration is the diaphragm. In patients with impaired diaphragmatic function ie due to eventration or those with a paralysed hemidiaphragm ie after surgery or idiopathic, find themselves at increasing disadvantage during REM sleep particularly in the supine position and even worse so in the presence of obesity or significant restrictive lung pathology. Many of such patients require CPAP at night even in the absence of significant obstructive sleep apnoea and a subgroup require Bi-PAP. The diaphragm can be likened to both a piston and a bellows and by its contraction, the abdominal contents are pushed down and the chest cavity made larger causing an indrawing of air. However, in patients who have significant diaphragmatic pleural plaques, diffuse pleural thickening and/or asbestosis combined with obesity, this function is impaired leading to reduced oxygen saturations at rest and particularly in the supine position and even worse so during sleep and with elevated carbon dioxide levels in the blood which can be monitored by transcutaneous CO2 monitoring during a sleep study.
3 There is also a subgroup of patients with diffuse asbestos pleural thickening who have severe pleural thickening in the apices of the lungs as well as in the costovertebral gutters. The reason for this is unclear and this occurs in a minority of patients. In my experience these patients are those who often require bi-level respiratory support at night due to the severe decrease in lung and chest wall compliance ie making the chest wall and lungs stiffer and therefore more difficult to inflate. Obstructive sleep apnoea is not restricted to men and more commonly occurs in postmenopausal women and also in those who are overweight. MESOTHELIOMA Patients with mesothelioma always have reduced lung and chest wall compliance as a result of growth of the tumour and this therefore may precipitate or aggravate coexisting obstructive sleep apnoea and the medications used to control pain ie narcotics may precipitate or aggravate coexisting central sleep apnoea and lead to a worsening of control of obstructive sleep apnoea. Although most patients eventually lose weight because of tumour, a subgroup of patients will have significant weight gain eg from corticosteroids administered at the time of chemotherapy and some patients also require antidepressants and have weight gain as a result of these drugs. Insomnia due to concerns about the future, interruption of sleep from pain, constipation and general dysthymia all may have a significant impact on the quality of life and also sleep. This may also have a significant impact on the spouse with whom the patient sleeps. As the mesothelioma worsens, patients may frequently develop worsening insomnia, a sense of alienation, frustration and have numerous side-effects from a whole range of medications required during the treatment process and including effects of chemotherapy.
4 PERIODIC LEG MOVEMENT DISORDER This condition is a form of restless legs which occurs during sleep causing phasic contraction of the feet and sometimes the arms for reasons incompletely understood but probably due to some form of nervous irritation of the lower spinal nerves and aggravated by the presence of renal dysfunction and iron-deficiency anaemia. The condition becomes increasingly more common in the elderly and each contraction of the feet and sometimes arms can produce arousals which lead to excessive daytime somnolence similar to that of sleep apnoea. I find this condition increasingly common in older patients and coincidentally in those with asbestos diseases but are not caused by the latter. Treatment of this usually consists either of clonazepam (Rivotril) at night, anti-parkinsonian drugs such as Sinemet and more recently other drugs such as Repreve and more recently Sifrol. This condition also commonly accompanies obstructive sleep apnoea and sometimes can be ameliorated by treating the latter. REM-BEHAVIOUR DISORDER This a condition which is found more commonly in older males and is characterised by acting out of violent dreams with the affected subject sometimes inadvertently hitting or even punching the sleeping partner or objects by the bedside. Although this is not caused by obstructive sleep apnoea or asbestos diseases, it occurs in a small proportion of patients in this age group ie middle-aged to elderly. It may be induced or aggravated by emotional stress e.g. with regards asbestos diseases. INSOMNIA Many patients with asbestos disease develop insomnia, difficulty with sleep onset ie initial insomnia, poor sleep maintenance or middle insomnia and thirdly, early-morning wakening. The latter two are more common in depression and the first is more common in patients with anxiety. However, there is an overlap in all these conditions. In my experience, patients with asbestos diseases often are perturbed by the diagnosis of asbestos diseases and are fearful of their future particularly having read medico-legal reports, with fears also with regard the possibility of their developing mesothelioma or lung cancer, concerns about their spouse and family, their financial affairs, their ability to
5 continue work for those who are still employed and compounded by the stress of medico-legal proceedings, having medico-legal reports done by specialists (ie expert witnesses) and concerns about court appearances and the costs thereof. There is a significant subgroup of patients who develop very significant anxiety, adjustment disorders and also overt depression which require treatment by psychiatrists as well as sleep physicians. However, as many of the medications used for treating depression lead to weight gain, this often compounds pre-existing problems in control of sleep apnoea as well as the problems that obesity causes by reducing respiratory function via a worsening restrictive defect. Indeed the most common cause of a restrictive defect in my experience in Queensland is obesity. CHEST PAIN In a recent study of mine, approximately 40% to 50% of patients had significant asbestos pleural pain from asbestos pleural plaques. In a subgroup of patients this led to significant disability, the need for them to see pain specialists and in some cases also to have psychiatric support. A significant subgroup of such patients require drugs such as Lyrica and gabapentin for the control of the neuropathic pain, which frequently causes weight gain which therefore compounds obstructive sleep apnoea. In addition, some patients also require narcotics for control of pain and this has a deleterious effect on sleep apnoea by causing significant depression of ventilatory drive during sleep and therefore predisposing to central sleep apnoea and aggravating coexisting obstructive sleep apnoea. Asbestos diseases therefore have a significant interaction with sleep disorders and this dimension needs to be more widely recognised by general practitioners, the expert witnesses and the legal fraternity. In my experience, few medical reports outline the effects of asbestos diseases on sleep or the interaction between common sleep pathologies and asbestos-related diseases. Professor Roger K. A. Allen Faculty of Health Sciences and Medicine Bond University, Gold Coast, QLD 4229
Asbestos Related Diseases Asbestosis Mesothelioma Lung Cancer Pleural Disease Asbestosis and Mesothelioma (LUNG CANCER) Support Group 1800 017 758 www.amsg.com.au ii Helping you and your family through
What is Mesothelioma? Mesothelioma is a rare type of cancer that develops in the mesothelial cells found in one s body. These cells form membranous linings that surround and protect the body s organs and
8 David The respiratory system Baldwin Introduction Respiratory medicine comprises a large part of every day clinical practice for two reasons: respiratory conditions are common accounting for more than
THe Rich PiCtuRE Other cancers 1,100,000 Around 340,000 getting cancer for the first time Lung 72,000 Colorectal 290,000 Breast 691,000 Prostate 330,000 2.5m Living with cancer 66% aged 65+ Around 163,000
Cycling & Health What s the evidence? Nick Cavill & Dr Adrian Davis Public health advisors to Cycling England CONTENTS ForEwOrd 5 Executive Summary 7 Introduction 9 1. A Brief History 11-12 2. THE IMPORTANCE
American Thoracic Society Documents An Official American Thoracic Society/European Respiratory Society Statement: Key Concepts and Advances in Pulmonary Rehabilitation Martijn A. Spruit, Sally J. Singh,
Veterans Affairs Canada MEDICAL GUIDELINES INDEX OF MEDICAL GUIDELINES ALCOHOL DEPENDENCY ALZHEIMER'S DISEASE ARTERIOSCLEROSIS ASBESTOSIS BRAIN AND SKULL TRAUMA CANCER - CARCINOMA OF LARYNX CANCER - MALIGNANT
Let s Get Physical The impact of physical activity on wellbeing Mental Health Awareness Week 2013 Contents 04 Introduction 08 What is Wellbeing? 10 What is Physical Activity? 14 What impact does physical
Trial Management Group Page 1 of 142 ISRCTN54285094 GRADED EXERCISE THERAPY Information for Participants Bavinton J, Dyer N, White PD On behalf of the PACE trial management group FINAL TRIAL VERSION: (MREC
Introduction Surgery for Malignant Pleural Mesothelioma Treatment for Malignant Pleural Mesothelioma (MPM) may involve surgery, chemotherapy and radiotherapy or a combination of these. This booklet has
A Student s Guide to Considering Medication for Depression or Anxiety Real answers to your most important questions!! University!of!Missouri Kansas!City! Counseling!&!Testing!Center! 4825!Troost,!Suite!206!
Asbestos and Mesothelioma a briefing document for the Metropolitan Police Prepared by Professor John Cherrie, Heriot Watt University, Edinburgh, UK. Introduction The purpose of this document is to provide
No health without public mental health the case for action Royal College of Psychiatrists Position statement PS4/2010 No health without public mental health The case for action Position Statement PS4/2010
81 Mesothelioma JASCAP JEET ASSOCIATION FOR SUPPORT TO CANCER PATIENTS MUMBAI, INDIA Macmillan Cancer Support, .This publication is based on [Understanding Mesothelioma May 2013 7th. edition] published
Health Effects HEALTH EFFECTS Asbestos can kill you. You must take extra precautions when you work with asbestos. Just because you do not notice any problems while you are working with asbestos, it still
Ministry of Defence Synopsis of Causation Mesothelioma Author: Dr David Jenkins, Medical Author, Medical Text, Edinburgh Validator: Professor Mark Britton, St Peter s Hospital, Chertsey, Surrey September
Clinical guidelines and procedures for the use of methadone in the maintenance of opioid dependence Clinical Guidelines and Procedures for the Use of Methadone in the Maintenance Treatment of Opioid Dependence
Asbestos Exposure and Psychic Injury-A Review of 48 Claims Irwin N. Perr, MD, JD Asbestos exposure has been a common occupational risk resulting in much litigation. Where pulmonary dysfunction has been
New Zealand Acute Low Back Pain Guide INCORPORATING THE GUIDE TO ASSESSING PSYCHOSOCIAL YELLOW FLAGS IN ACUTE LOW BACK PAIN ll october 2004 edition Prepared by ll ACC P O Box 242, Wellington, New Zealand
Lung disease in Australia Leanne M Poulos Patricia K Correll Brett G Toelle Helen K Reddel Guy B Marks Woolcock Institute of Medical Research, University of Sydney, NSW Prepared for Lung Foundation Australia
CANCER FACTS N a t i o n a l C a n c e r I n s t i t u t e N a t i o n a l I n s t i t u t e s o f H e a l t h D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s Mesothelioma: Questions
XX HEALTHY PEOPLE LIBRARY PROJECT American Association for the Advancement of Science High Blood Pressure The Science Inside XX High Blood Pressure: The Science Inside HEALTHY PEOPLE LIBRARY PROJECT American
Florida Brief Intervention and Treatment for Elders (BRITE) Initial Training Manual Revised July 2009 An SBIRT Project funded by The US Substance Abuse and Mental Health Services Administration (SAMHSA)
Asbestos Diseases Uncovered Your complete download & keep guide to asbestos-related diseases. Their symptoms, causes and potential compensation payable Contents What is Asbestos? What diseases are caused