Other Sleep Problems That May Occur with RLS

Transcription

1 Other Sleep Problems That May Occur with RLS Clete A. Kushida, M.D., Ph.D., RPSGT Associate Professor, Stanford University Medical Center Acting Medical Director, Stanford Sleep Disorders Clinic Director, Stanford Center for Human Sleep Research

2 Overview The Need for Sleep Sleep in a Nutshell Periodic Limb Movements Insomnia Associated with RLS

3

4 Challenger Disaster Why did the Space Shuttle Challenger explode? Sleep Deprived NASA Managers made an erroneous decision to launch.

5 Nighttime Catastrophes Attributed to Human Error Bhopal Chemical Plant Chernobyl Atomic Power Station Three Mile Island Atomic Power Station Peach Bottom Atomic Power Station Rancho Seco Atomic Power Station Davis-Besse Atomic Power Station

6 Daytime Sleepiness 70% of a group of train drivers reported they dozed off while driving a train. 82% of oil refinery shift workers stated they suffered from lack of sleep. Physicians during on-call nights slept an average of 2.8 hours.

7 Societal Costs of Sleepiness Sleepiness accounts for approximately 10% of fatal car accidents, however, it interacts with the other two major causes of accidents: alcohol (18%) and inattention (15%)

8

9 Prevalence of Sleepiness It is estimated that at least 36% of the population suffers from sleep loss, including: One-third of young adults secondary to chronic partial sleep deprivation 7% of adults secondary to sleep disorders 2% of adults secondary to shift work

10 Daytime Sleepiness One-third of adults sleep < 6.5 hours during the workweek 1 Approximately one-third of normal adults fall asleep in 5 minutes 2 1 NSF 2000 Omnibus Sleep in America Poll. 2 Levine et al., 1988, Bonnet et al., 1991

11 Daytime Sleepiness When total sleep times in normal young adults are reduced hours for one night, decreases of up to one-third are found in objective alertness. 1 1 Rosenthal et al., 1993; Bonnet et al., 1995

12 The Need for Sleep Sleep in a Nutshell Periodic Limb Movements Insomnia Associated with RLS

13 Sleep Staging NREM Sleep Stage N1 Stage N2 Stage N3 REM Sleep

14 EEG Patterns of Wakefulness and Sleep W N1 N2 N3 REM

15 Sleep Stage - Ontogeny Mahowald M, Sleep Academic Award Program, NHLBI and AASM

16 Sleep histogram - Ontogeny Mahowald M, Sleep Academic Award Program, NHLBI and AASM

17 Total Sleep Requirement Mahowald M, Sleep Academic Award Program, NHLBI and AASM

18 The Need for Sleep Sleep in a Nutshell Periodic Limb Movements Insomnia Associated with RLS

19 PLMD Characteristics PLMD is a disorder characterized by periodic episodes of repetitive and highly stereotyped limb movements that occur during sleep (PLMS, periodic limb movements during sleep). It is estimated that 80.2% of patients with RLS have PLMS.

20 RLS vs. PLMD RLS PLMD Diagnosis Presenting Sleep Complaint Patient or Bedpartner Awareness History Insomnia Yes Sleep study Insomnia or excessive sleepiness No

21 PLMS SleepMultiMedia, Sleep Multimedia, Inc., Scarsdale, NY

22 Diagnostic Criteria of PLMS A clinical sleep disturbance or a complaint of daytime fatigue Repetitive highly stereotyped limb muscle movements, which in the leg are characterized by big toe extension in combination with partial flexion of the ankle, knee, and sometimes hip Polysomnographic criteria No evidence of a medical or psychiatric disorder that can account for the primary complaint Other sleep disorders do not account for symptoms

23 PLMS Polysomnographic Criteria Leg Movement: A 0.5 to 10 second burst of leg activity with an amplitude above baseline Periodic Limb Movement Sequence: Four or more leg movements separated by more than 5 and less than 90 seconds Sleep Disturbance Associated with PLMS: Arousal onset following leg movement onset by no more than 3 seconds PLM or Myoclonus Index: PLMS per hr (> 15) of sleep

24 Differential Diagnosis for PLMS Sleep starts (hypnic jerks) Leg movements associated with other sleep disorders Movements associated with nocturnal epileptic seizures and myoclonic epilepsy Waking myoclonus associated with dementia

25 Conditions Associated with PLMS Sleep Disorders: OSAS, narcolepsy, RBD Neurologic Disorders: ALS, HD, Isaac s Syndrome, MS, myelopathies, spinal cord lesions, startle disease, Stiff-man Syndrome Medical Disorders: COPD, fibrositis syndrome, impotence, leukemia, uremia Exogenous Chemicals: levodopa, lithium, tricyclic antidepressants

26 Severity Criteria for PLMS Mild: Mild insomnia or mild sleepiness. Typically associated with a PLM index 15 but < 25. Moderate: Moderate insomnia or moderate sleepiness as defined above. Typically associated with a PLM index 25 but < 50. Severe: Severe insomnia or severe sleepiness. Typically associated with a PLM index 50 or PLM-arousal index > 25.

27 Complications of PLMS Severe insomnia Excessive sleepiness Disruption of bedpartner s sleep Symptoms during wakefulness Anxiety and depression

28 The Need for Sleep Sleep in a Nutshell Periodic Limb Movements Insomnia Associated with RLS

29 Demographic Features of Insomnia Up to 47% of American adults may suffer from insomnia 12% of all adults experience difficulty sleeping on a frequent basis

30 Causes of Insomnia POOR POOR SLEEP SLEEP HYGIENE Alcohol Alcohol Caffeine Nicotine Sleep Sleep schedule PRIMARY SLEEP SLEEP DISORDERS RLS, RLS, PLMS PLMS Sleep Sleep Apnea Apnea PSYCHIATRIC CONDITIONS Anxiety Depression INSOMNIA MEDICATIONS Beta Beta blockers Bronchodilators CNS CNS stimulants Corticosteroids Decongestants MEDICAL CONDITIONS Chronic lung lung disease Heart Heart failure failure Neurological disorders Pain Pain disorders Acute Acute Stressors Bereavement Relocation Marriage // Divorce CIRCADIAN RHYTHM DISORDERS Advanced // delayed sleep sleep phase phase Irregular sleep sleep // wake wake schedule

31 RLS Video clip

32 Insomnia Symptoms Inability to fall asleep when desired Conditioned arousal to the bedroom environment or sleep-related activities Increased somatized tension at bedtime

33 General Insomnia Criteria Difficulty initiating or maintaining sleep or Waking up too early or sleep that is chronically nonrestorative or poor in quality Above sleep difficulty occurs despite adequate opportunity and circumstances for sleep ICSD-2

34 Common Types of Insomnia Psychophysiological Insomnia A disorder of somatized tension and learned sleep-preventing associations that result in a complaint of insomnia and associated decreased functioning during wakefulness Idiopathic Insomnia A lifelong inability to obtain adequate sleep that is presumably due to an abnormality of the neurological control of the sleep-wake system

35 Treatment Behavioral techniques are used first Relaxation, stress management, and stimulus control techniques may be beneficial An occasional mild hypnotic may be used on an infrequent basis Psychologic or psychiatric counseling may be useful

36 Temporal and Stimulus Control Techniques Expected 52% improvement after one year Standardize awakening time Avoid daytime naps Turn off the light immediately upon retiring Avoid reading, watching television, eating or working in bed 20 - minute rule

37 Circadian Sleep Disorders Phototherapy Bright light in the morning can phase advance sleep onset Bright light in the evening can phase delay sleep onset Light intensity recommended at 2,000 lux for minutes Morning light should be administered immediately after waking up

38 Key Points Diagnosis, not complaint, should determine treatment and medication use. Hypnotic drugs do little to directly enhance sleep. The major benefit is to reduce arousal, therefore allowing sleep to occur. Ware JC, Sleep Academic Award Program, NHLBI and AASM

39 Cognitive Effects of Diphenhydramine in Older Hospitalized Patients Delirium Symptoms CAM Criteria CAM Criteria/MMSE Decline * Relative risk (RR) of potential adverse outcomes associated with diphenhydramine (DH) use Inattention Disorganized Speech Altered Consciousness Disorientation Memory Impairment * * n=426 * Abnormal Psychomotor Altered Sleep/Wake Cycle RR CAM=Confusion Assessment Method. MMSE=Mini-Mental State Examination. DH-exposed DH-nonexposed *P<0.05. * * Agostini JV, et al Arch Intern Med. 2001;161:

40 Antidepressants Trazodone is the most commonly prescribed medication for the treatment of insomnia in the US 1 In the short-term, trazodone is sedating and can improve some sleep parameters. 2 Doxepin has beneficial effects on sleep for up to 4 weeks for individuals with insomnia 3 Data on other antidepressants in individuals with chronic insomnia are lacking 4 1. Walsh JK. Sleep. 2004;27: Saletu-Zyhlarz GM, et al. Neuropsychobiology. 2001;44: Hajak G, et al. J Clin Psychiatry. 2001;62: NIH State of the Science Conference Statement. Sleep. 2005;28:

41 Benzodiazepines Effective in short-term insomnia management Adverse events Rebound insomnia Residual daytime sedation Impaired cognitive function Motor incoordination Dependence NIH State of the Science Conference Statement. Sleep. 2005;28:

42 Benzodiazepine Receptor Agonists Frequency and severity of adverse effects are much lower in the newer benzodiazepine receptor agonists In the short term, tolerance and abuse of the benzodiazepine receptor agonists are not major problems in the general population with chronic insomnia Long-term use needs further study NIH State of the Science Conference Statement. Sleep. 2005;28:

43 Benzodiazepine Receptor Agonists Agonist Usual Dose (mg) Time to Peak Plasma Concentration (hours) Half-life (hours) Active Metabolite Eszopiclone No Zaleplon No Zolpidem No Zolpidem Extended Release No

44 New Agents Agent Mechanism of Action Receptor Impact of Receptor Binding Profile Ramelteon* Activates melatonin (MT) receptors MT 1 MT 2 No measurable affinity for other receptors including ω, opiate, and dopamine receptors; ion channels; or transporters Indiplon Nonbenzodiazepine, GABA A receptor potentiator, α 1 subunit selective GABA A High specificity limits adverse events Gaboxadol Specific, nonselective GABA A receptor agonist GABA A Sedation, euphoria, dizziness, blurred vision, and nausea * Ramelteon recently approved by the FDA. Not approved by the FDA. Kato K, et al. Neuropharmacology. 2005;48: Sullivan SK, et al. J Pharmacol Exp Ther. 2004;311: Huckle R. Curr Opin Investig Drugs. 2004;5:

45 Potential Adverse Events Anterograde amnesia Masking of untreated problem Daytime sedation Rebound insomnia & anxiety Disinhibition Tolerance and dependence Distortion of normal sleep Cognitive and psychomotor impairment Ware JC, Sleep Academic Award Program, NHLBI and AASM

46 DO Maintain regular bedtimes and awakenings Optimize your sleep amounts Use bright light in the morning Create a comfortable, quiet, dark, and tempcontrolled bedroom environment Establish a regular pattern of relaxing behaviors within an hour before bedtime Exercise on a regular basis

47 DON T Take a nap Eat or drink heavily before bedtime Lie awake for long periods of time Allow disturbances (e.g., phones, pets, family) Read or watch television in bed (unless these activities definitely make you drowsy Use alcohol, caffeine, or nicotine