The Sleepy Pilot
Steven I. Altchuler, Ph.D., M.D.
Mayo Clinic
Rochester MN
Learning Objectives
• By the end of this hour, you will:
• Know the differential diagnosis for
excessive sleepiness in airmen
• Know how to do the initial
assessment for excessive
sleepiness in airmen
• Be aware of the treatment options
Reality Check
• I will be discussing the science
• Changing some of the things that
cause sleepiness is often difficult
• Habits
• Work requirements
Outline
• Overview
• Problems and Treatment
• Circadian rhythm sleep disorders
• Sleep hygiene
• Periodic limb movement disorder
• Sleep apnea
• Assessment
Tiredness
• Main Entry: tire
Pronunciation: 'tIr
Function: verb
Inflected Form(s): tired; tir·ing
Etymology: Middle English tyren,
from Old English tEorian, tyrian
intransitive senses : to become
weary
transitive senses
1 : to exhaust or greatly decrease
the physical strength of : FATIGUE
Tiredness
• When someone complains of being
tired, are they:
Tiredness
• When someone complains of being
tired, are they:
• Sleepy?
Tiredness
• When someone complains of being
tired, are they:
• Sleepy?
• Fatigued?
• We’re dealing with somnolence
Broad Categories
• Not enough sleep
• Sleep is at the wrong time
• Sleep they obtain is not restorative
Normal Sleep
• Circadian rhythm
• Good sleep hygiene
Circadian rhythm
• More than 24 hours
• Effects multiple body systems
Zeitgebers
• Main Entry: zeit·ge·ber
Pronunciation: 'tsIt-"gA-b&r, 'zItFunction: noun
Etymology: German, from Zeit time +
Geber giver
: an environmental agent or event
(as the occurrence of light or dark)
that provides the stimulus setting or
resetting a biological clock of an
organism
Photic
Melanopsincontaining retinal
ganglion cells
Non-Photic
Activity
Eating
Drugs
Lewy AJ. Dialogues Clin Neurosci 2003;5:399-413
Basic Overview of
Sleep/Wake Regulation
• Homeostatic sleep drive:
• Process driven by time from and duration of last
sleep period
• Linear and cumulative—one gets progressively
more tired with each passing hour
• Circadian rhythm:
• Process driven by the biological clock in the
hypothalamus and synchronized to the time of day
• Cyclical—periods of maximal sleepiness and
maximal wakefulness oscillate each day
Interaction of Circadian Rhythm
and Sleep Drive
Wake
Sleepiness
Increases
Sleep
The temporal interaction between the
homeostatic sleep drive and the circadian
pacemaker regulates the timing and
quality of sleep
Decreases
6 AM
Noon
6 PM
Time
Midnight
Interaction of Circadian Rhythm
and Sleep Drive
Wake
Increases
Sleep
Sleepiness
Homeostatic
sleep drive
increases linearly
through the day,
then falls during
the night
Decreases
6 AM
Noon
6 PM
Time
Midnight
Interaction of Circadian Rhythm
and Sleep Drive
Wake
Homeostatic sleep drive will Sleep
continue to increase until
quenched by sleep
Sleepiness
Increases
Decreases
6 AM
Noon
6 PM
Time
Midnight
Interaction of Circadian Rhythm
and Sleep Drive
Wake
Increases
Sleep
Sleepiness
Circadian drive to wakefulness
varies rhythmically with peaks
in the late morning and early
evening and troughs in the mid
afternoon and middle of the
night
Decreases
6 AM
Noon
6 PM
Time
Midnight
“Jet Lag”
Treatment of Circadian Rhythm
Sleep Disorders
Adequate Duration
• Sleep needs change as we mature
• As we mature, while we may need
slightly less sleep, we are less able
to tolerate sleep deprivation
Age and Total Sleep Time
Total sleep time
650
600
550
Minutes
500
450
400
350
300
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
Age
Ohayon M et al. SLEEP in press
100
Naps
• Best if less than 30 minutes or
greater than 90 minutes
• Otherwise, creates “sleep inertia”
• Best time: 14:00 – 17:00, 02:00 –
05:00
Effective Sleep
Environment
• Dark and quiet
• Ear plugs
• Eye shades
Other Interrupters
Good Sleep Hygiene
• Winding down time
• Exercise, but not too late
Reinforce Circadian Rhythm
• Phototherapy: 10,000 lux for _ hour
• At sunrise, will reset your rhythm
• At sunset, will help you stay up later
• So, traveling to the east, bright light
on arising
• Traveling to the west, bright light
near sunset
Intrinsic Disorders of Sleep
• There are disorders of sleep that
interfere with the quality of sleep
• Restless legs syndrome
Intrinsic Disorders of Sleep
• There are disorders of sleep that
interfere with the quality of sleep
• Restless legs syndrome
• Periodic limb movement disorder
Intrinsic Disorders of Sleep
• There are disorders of sleep that
interfere with the quality of sleep
• Restless legs syndrome
• Periodic limb movement disorder
• Obstructive sleep apnea
Periodic Limb Movement Disorder
and Restless Legs Syndrome
• Description
• Etiology
• Idiopathic
• Aggravated by low ferritin ( < 50
mcg/L)
Treatment
• Iron supplementation
• This is OFF-LABEL
• Ferrous fumarate 200 mg +
ascorbic acid 125 mg (to improve
absorption), up to three times a
day
• Exercise
• Hot baths
Pharmacologic
These are off-label
• Carbidopa/levodopa
• Pramipexole
• Gabapentin
• Silber MH, Ehrenberg BL, Allen RP, et al.
An algorithm for the management of
restless legs syndrome.[erratum appears
in Mayo Clin Proc. 2004 Oct;79(10):1341].
Mayo Clinic Proceedings. Jul
2004;79(7):916-922.
Periodic limb movement disorder
Requires FAA Decision
• Submit all pertinent medical
information and current status
report. Include sleep study with a
polysomnogram, use of medications
and titration study results along with
a statement regarding Restless Leg
Syndrome.
Obstructive Sleep Apnea
Assessment
• Oximetry
• Screening only
• Polysomnogram
Normal Oximetry
Abnormal Oximetry
Polysomnogram
Polysomnogram
Polysomnogram
CPAP Titration
Treatment
• CPAP
Treatment
• CPAP
• UPPP (uvulopalatopharyngoplasty)
Treatment
• CPAP
• UPPP
• Mandibular advancement
Treatment
• CPAP
• UPPP
• Mandibular advancement
• Oral appliance
Treatment
• CPAP
• UPPP
• Mandibular advancement
• Oral appliance
• Tracheostomy
FAA Initial Special Issuance
• FAA Decision
• Submit all pertinent medical
information and current status
report. Include sleep study with a
polysonogram, use of medications
and titration study results
AME-Assisted Special Issuance (AASI) for
Sleep Apnea for Reissuance
• Include in status report: A current
report (performed within last 90 days)
from the treating physician that
references the present treatment,
whether this has eliminated any
symptoms and with specific
comments regarding daytime
sleepiness. If there is any question
about response or compliance with
treatment, then a MWT will be
required
Defer
• Defer if:
·There is any question concerning
the adequacy of therapy
· The applicant appears to be noncompliant with therapy
· The MWT demonstrates sleep
deficiency
· The applicant has developed some
associated illness, such as rightsided heart failure
Assessment of Alertness
• Maintenance of Wakefulness Test
Other Causes of Sleepiness
• Medicines
• Narcolepsy
• Idiopathic CNS hypersomnolence
Difficulty for Airmen
• Can be treated, not cured
• Treatment requires CNS-active
medications
Diagnosis
Multiple Sleep Latency Test
Sleepy MSLT
Sleep History
• Time to bed and awaken (may need
to use UTC)
Be Suspicious!
Sleep History
• Time to bed and awaken (may need
to use UTC)
• Actigraphy
Normal Actigraphy
Abnormal Actigraphy
Sleep History
• Time to bed and awaken (may need
to use UTC)
• Actigraphy
• Bedtime routine
• How do they relax
Sleep History
• Time to bed and awaken (may need
to use UTC)
• Actigraphy
• Bedtime routine
• How do they relax
• Oximetry for screening
PSG and CPAP trial if indicated
• Observed apneas
• Profoundly loud snoring
• Abnormal oximetry
• Clinical suspicion
• Want to treat snoring
Multiple Sleep Latency Test
• To assess for narcolepsy and
idiopathic CNS hypersomnia
Maintenance of Wakefulness Test
• To assess if treatment is working