Sleep Disorders 101
“Why can't I sleep like I used to”
Beth A. Malow, M.D., M.S.
Professor of Neurology and Pediatrics
Burry Chair in Cognitive Childhood Development
Director, Sleep Disorders Division
Have you met Ruth and John?
 Ruth is a 67-year-old retired nurse. Presents with
difficulty falling asleep and early morning wakings
for last month. She has neuropathy. Also admits to
having anxiety about her husband John’s heart
condition and his loud snoring at night.
 John is a 70-year-old retired engineer. He falls asleep
easily but snores loudly all night, and is very sleepy
during the day. His sleepiness interferes with Ruth and
his participating in social activities.
 How can we help Ruth and John sleep better at night
and enjoy life more?
Teasing out the Root Causes
(first step in treatment)
“Medical”
“Biological”
“Environmental/Behavioral”
Disclaimer: This is simplistic. Anxiety can be both “medical”
and “biological.” Relaxation techniques at night used to
relieve anxiety work on the biological, medical or
environmental/behavioral aspects of insomnia
Hyperarousal Theory of InsomniaNeuroendocrine
Cortisol
Primary hormonal product of the
hypothalamic-pituitary-adrenocortical
(HPA) axis
Mediates basal metabolic and stressrelated processes
Cortisol typically reaches its lowest
levels in the evening. Dysregulation of
the cortisol rhythm, with blunting of the
expected fall in cortisol in the evening,
has been observed in insomnia
Vgontzas et al., J Clin Endo Metab,
2001)
“Environmental” and “Behavioral” Causes of
Insomnia
Perpetuating Factors
Conditioning
Substance Abuse
Poor Sleep Hygiene
Insomnia
Predisposing Factors
Personality
Circadian Rhythm
Age
3-P model of Spielmann
Precipitating Factors
Situational
Medical/Psychiatric
Medication-related
Why
not
simply
prescribe
“Biological” Causes of Insomnia
hypnotics?
1. Behavioral sleep approaches work, in
many cases better than medications!
2. They help other aspects of your patients’
lives (e.g., stress reduction)
3. Medications have side effects as well as
implications on public health
The challenge is how to deliver behavioral
treatments in ways that are both effective
and cost-efficient
Evidence
for Behavioral
Treatment
“Biological”
Causes of Insomnia
of Insomnia
Krypke DF, BMJ Open 2013
10529 patients and 23676
matched controls (12 classes
of comorbidity)
Non-Pharmacological Treatment of
Insomnia
 Stimulus control (use bedroom only for sleep)
 Sleep restriction (and related tactic of delaying
bedtime)
 Relaxation techniques
 Sleep hygiene: avoiding caffeine, alcohol, iPad use
at night. Physical exercise.
 Cognitive therapy: identifying and changing stressful
and distorted sleep cognitions that exacerbate
insomnia by elevate psychophysiologic arousal
Evidence
for Behavioral
Treatment
“Biological”
Causes of Insomnia
of Insomnia
63 young and middle-aged adults with chronic sleep-onset insomnia
randomized to CBT, zolpidem (10 mg 30 minutes before bedtime).
Sleep diaries and home sleep monitoring showed significant
improvements in CBT groups.
Jacobs, Arc Intern Med, 2004
Treatment of InsomniaMindfulness and Other Techniques
Mindfulness (being in the
here and now,
and acceptance of what is)
www.franticworld.com
Tapering Hypnotics
1- Implement a behavioral sleep medicine plan
2- Choose 1 day of the week (Saturday often a good choice)
to cut sleep aid in half.
3- One week later, choose a 2nd day of the week (Tues,
Wed, or Thurs) to cut sleep aid in half.
4- Each week, add another day of the week to take half of
sleep aid.
5- When down to half of a pill every night, start the process
again by discontinuing sleep aid one night a week until it is
completely stopped
Back to Ruth
 Started on gabapentin 100 mg at bedtime for sleep.
Titrated up to 200 mg.
 Eliminated caffeine after noon, limited alcohol use to
weekends. Started running in the mornings before
work.
 Ruth is sleeping a little better, but there is a missing
piece to consider.
John
 70 year old man with coronary artery disease, who had
a heart attack last year. He snores heavily and often
stops breathing, especially on his back.
 He falls asleep right away and sleeps 8 hours, unaware
that he is restless and stopping breathing in his sleep.
He is sleepy during the day and feels like he hasn’t had
a refreshing night’s sleep. He wakes up with a dry
mouth and sore throat.
Cardiovascular complications
•
•
•
•
•
•
Hypertension (High blood pressure)
Atherosclerosis (Hardening of arteries)
Heart attacks
Heart failure
Heart rhythm problems
Stroke
Other complications of OSA
DAY






excessive sleepiness
afternoon drowsiness
memory loss
impaired concentration
irritability
headaches
NIGHT
 snoring and snorting
 observed apneas
 choking or gasping
arousals unexplained
tachycardia
 restless sleep
 sweating during sleep
 nocturia
 bruxism
 nocturnal acid reflux
Screening Tools: STOP-BANG
STOP (yes/no)
BANG (yes/no)
Snore
Tired
Obstruction
Pressure
BMI > 30
Age > 50
Neck > 17"/16"
Gender: Male
> 3 “yes” answers suggests high risk of sleep
apnea
Vanderbilt Sleep Disorders CenterNashville (Marriott Hotel)
Established in 2003
 Accredited multidisciplinary
10 bed lab, 7 nights a week
(neurology, pulmonary, pediatrics)
Vanderbilt Sleep Disorders CenterFranklin (Hyatt Place Hotel)
Opened Oct 08
Accredited
multidisciplinary
6 bed lab, 7 nights a
week (neurology,
pulmonary, pediatrics)
EEG Patterns of Sleep Stages
A negative test does not exclude clinically
significant sleep apnea.
The Evolution of CPAP
Treatments for Sleep Apnea
• Weight Loss & Exercise
• Continuous Positive Airway Pressure Therapy
• Mandibular repositioning device
• Surgery
ORAL APPLIANCE
Happy Endings: Ruth and John
 John was diagnosed with sleep apnea and treated
with continuous positive airway pressure.
 Ruth is sleeping more soundly at night, and is not
awoken by John’s snoring. The CPAP provides a
level of white noise that is soothing.
 Both Ruth and John are feeling much more alert
during the day, and are able to spend more time
on activities they enjoy.
 In fact, things are so much better that they are
planning a trip to Paris this summer.
Jet Lag Disorder
Complaint of insomnia or daytime sleepiness,
accompanied by a reduction in total sleep time,
associated with transmeridian jet travel across at
least 2 time zones.
Impairment of daytime function, general malaise, or
somatic symptoms (GI disturbance), within 1-2 days
after travel.
An individual’s innate circadian preference may
confer a greater or lesser ability to adjust
Estimated that it takes one day per time zone for
circadian rhythms to adjust to the local time
Traveling the World without Jet Lag
Eastman CI, Burgess HJ.
Sleep Med Clin. Sleep Med
Clinics 2009 4(2):241-255.
Traveling from Nashville to Paris
(West to East)
Eastman CI, Burgess HJ.
Sleep Med Clin. Sleep Med
Clinics 2009 4(2):241-255.
Summary
Sleep disorders are very common
They are also highly treatable
Improving sleep can improve a person’s
functioning during the day and quality of
life