clinical tools for managing sleep disorders...clinical tools for managing sleep disorders jason c....

Clinical Tools for Managing Sleep Disorders

Jason C. Ong, Ph.D. Associate Professor

Department of NeurologyCenter for Circadian and Sleep Medicine

Northwestern University Feinberg School of Medicine

Relevant Financial Disclosure(s)

• I have the following financial relationship to disclose:

- Consultant for Headspace

- Consultant for Weight Watchers

- Royalties from the American Psychological Association

• I will not discuss off label use or investigational use in my presentation.

Jason Ong, PhD

The Tired Teen17-year-old male brought in by parents for evaluation and treatment of “depression”

– His grades have become worse over the past year, his teachers have become concerned about him falling asleep in class, and he has few friends, most of whom he met on-line at night.

– During the interview, you observe poor eye contact and flat affect.

He reports difficulty falling asleep and difficulty waking up in the morning.

– He goes to bed at 3am and gets out of bed at 7:30am for school on weekdays and 12:00pm on weekends.

– He thinks that he just needs to fix his sleep and everything else will get better.

Is this a mood disorder or a sleep disorder?

The Sleepless Survivor52-year-old female presents with complaints of anxiety and worsening mood

– She is a cancer survivor and is now in perimenopause– Also has significant weight gain over the past 6 months

She can fall asleep easily but reports difficulty maintaining sleep, which leads to trouble concentrating at work.

– Sleep problems began during breast cancer treatment– Taking Ambien for past year and finds it difficult to sleep without

it but does not want to continue taking it.– Husband complains that her snoring has become louder

Should you help her taper off the ambien? Or refer her for a sleep study?

How does sleep disturbance impact mental and physical health?

• Both insomnia and hypersomnia associated with psychiatric disorders

• Insomnia plus hypersomnia greatest association with psychiatric disorders

• Major Depression had greatest association with sleep disturbance

Insomnia and Medical Conditions

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Sleep Duration & Obesity in the U.S.

Courtesy of Sheila Garland, PhD

Clinical Tools: Assessment of Sleep Disorders

Sleep DisordersClass Disorders Key Symptoms

Insomnia Chronic Insomnia Disorder Difficulty falling or staying asleep

Circadian Rhythm Sleep-Wake Disorders

Delayed Sleep Phase DisorderNon-24 hr Sleep-Wake

Difficulty falling asleep, waking too early, erratic sleep patterns

Sleep-related breathing disorder

Obstructive Sleep Apnea Loud snoring, waking with choking sensation, daytime sleepiness

Hypersomnia Narcolepsy Excessive sleepiness during the day

Parasomnias Sleepwalking, Nightmares Unusual events that occur during sleep

Sleep-related movement disorder

Restless Legs SyndromePeriodic Limb Movement Disorder

Strange sensations in legs, repetitive jerks in feet and legs during sleep

Methods of Assessing SleepSleep Diaries Actigraphy PSG

▪ Prospective self-report of one’s perception of sleep and wake patterns

▪ Provides data on sleep/wake patterns that can be used to evaluate treatment effects

▪ Patient’s perception of sleep ≠ objectively-measured sleep

▪ Watch-like device typically worn on wrist

▪ Assumption: Sleep occurs when there is lack of movement

▪ Objective estimation of sleep/wake pattern

▪ Non-invasive, useful for observing treatment effects over time

▪Gold Standard assessment of sleep

▪Scoring based on physiological signs

▪ Most commonly used to evaluate OSA or PLMD

▪ Does not explain why a patient cannot sleep

Actigraphy

Methods of Assessing SleepSleep Diaries Actigraphy PSG

▪ Prospective self-report of one’s perception of sleep and wake patterns

▪ Provides data on sleep/wake patterns that can be used to evaluate treatment effects

▪ Patient’s perception of sleep ≠ objectively-measured sleep

▪ Watch-like device typically worn on wrist

▪ Assumption: Sleep occurs when there is lack of movement

▪ Objective estimation of sleep/wake pattern

▪ Non-invasive, useful for observing treatment effects over time

▪Gold Standard assessment of sleep

▪Scoring based on physiological signs

▪ Most commonly used to evaluate OSA or PLMD

▪ Does not explain why a patient cannot sleep

Self Report ScalesISI

Insomnia Severity IndexPSQI

Pittsburgh Sleep Quality Index

ESSEpworth Sleepiness Scale

▪7 items with validated cut-off scores

▪Mild, moderate, severe insomnia

▪ Remission, response

▪Easy to score

▪ 19-item scale with 7 components

▪ Total score > 5 “poor sleeper”

▪ Widely used but not easy to score

▪Not a pure measure of insomnia

▪ 8-item scale measuring the propensity to fall asleep in various situations

▪ Total score > 10 “Excessive Daytime Sleepiness”

▪ East to score

▪ State or trait?

Mobile Technology

DEVICE METHOD MODALITY COMMENTS REFERENCES

Oura Wearable (Ring) Multisensor1 No sig differences between PSG in TST, SOL,

WASO, and N1+N2

Ring underestimated N3 and overestimated REM

compared to PSG

Needs more development but results to

distinguish light/deep sleep are promising

de Zambotti et

al. (2017)

Fitbit Wearable (Wrist) Unisensor2 High accuracy in sleep evaluation compared to

Actiwatch 2

Overestimated sleep durations

Overestimated sleep and less sensitive compared

to Actiwatch

Good to supplement qualitative data and

promoting sleep awareness

Lee et al.

(2017)

Dickinson et al.

(2016)

Beddit Non-Wearable (Bed

Pad)

Unisensor3 Accurate SOL compared to PSG

Underestimated WASO, overestimated TST and SE

Could not accurately distinguish stages

Tuominen et al.

(2019)

S+ by ResMed Non-Wearable

(Bedside Table)

Unisensor4 No difference in TST, SE, SOL compared to PSG

Ability to detect stages was better than reported

in literature for actigraphy

Captures movement well for TST

Less accurate than PSG for sleep stages, not likely

to be useful clinically

Zaffaroni et al.

(2017)

Schade et al.

(2019)

24From Gamaldo & Ong, in press

Mobile Technology• Consumer devices tend to overestimate sleep compared

with PSG – Measurement in healthy populations are more accurate

(compared with PSG) than in those with sleep disorders– Not very good at distinguishing wake in the presence of sleep

disturbance

• Not sufficiently validated for clinical assessment at this time– Might offer new ways to connect consumers with health care

providers in monitoring and treating sleep

What can the non-sleep specialist do to assess sleep disorders?

• Ask about sleep disturbances and daytime sleepiness

• Identify key sleep symptoms/signs– Snoring, prolonged bouts of wakefulness, jittery

feelings in the legs, circadian misalignment– Administer a self-report measure

• Do they need a sleep study?– Insomnia: probably not– Everything else: likely

Treatment Planning

• Is there a differential diagnosis to consider?– Sleep disorder vs mood/anxiety disorder– Sleeplessness vs mania/hypomania– Sleepiness vs hyperactivity/cognitive impairment

• If comorbid sleep disorder, which should you treat first?– Can usually do concurrently

Clinical Tools: Treatment of Sleep Disturbances

Cognitive Behavior Therapy for Insomnia (CBT-I)

Summary of CBT-IMulti-component treatment using cognitive and behavioral strategies for reducing symptoms of insomnia

CBT Component Description

Sleep Restriction Restrict time in bed to increase homeostatic pressure for sleep and consolidate sleep

Stimulus Control Re-establish bed/bedroom as stimulus for sleep by not entering until sleepy

Sleep Hygiene Eliminate habits that are counterproductive for sleep

Relaxation

Strategies

Reduce anxiety and physical tension (hyperarousal)

Cognitive Therapy Address maladaptive thoughts and beliefs that interfere with sleep and daytime functioning

Sleep education* Provide rationale, credibility, and understanding about sleep regulation

Sleep Restriction• Background: Increase homeostatic pressure for

sleep, prevent compensation for poor sleep, enhance regularity of sleep/wake

• Treatment Goals:– First, reduce time awake in bed consolidation– THEN, increase sleep opportunity

• Potential side effect: Daytime sleepiness– Important to discuss naps and behaviors to cope with

sleepiness– Contra-indicated for patients with mania, parasomnias, seizure

disorders

Sleep Restriction Instructions1. Sleep Window (TIB) = TST (+ 30 min)

– Should not be less than 5 hours per night.

2. Establish wake time first. Bedtime is the earliest start to the window.

3. Maintain sleep window for at least 7 days and calculate sleep efficiency (SE)

SE = (TST / TIB) x 100

– If SE > 90%, increase sleep window by 15-30 minutes. – If SE < 80%, decrease sleep window by 15-30 minutes.– If SE is 80-90%, keep same sleep window for another week.

What the non-sleep specialist can do

• Introduce key principles – Spending too much time in bed can make the

problem worse– Trying to compensate (e.g., sleeping in) can

make the problem worse– Try to limit time in bed

• These are just “starters”– Doing formal sleep restriction requires follow-up,

monitoring, and adjustments to schedule

Stimulus Control • Background: Based on principles of conditioning

– Efforts to cope with insomnia lead to decreased conditioning of bed and bedroom with sleepiness

• Treatment Goal: Re-establish bed & bedroom as stimulus for sleepiness, thus promoting likelihood of sleep

• Potential side effect: Falls in elderly, those with mobility issues

Stimulus Control Instructions1. Lie down intending to go to sleep only when you are sleepy.

2. Do not use your bed for anything except sleep; that is, do not read, watch television, eat, or worry in bed. Sexual activity is the only exception to this rule. On such occasions, the instructions are to be followed afterward when you intend to go to sleep.

3. If you find yourself unable to fall asleep, get up and go into another room. Stay up as long as you wish and then return to the bedroom to sleep. If you are in bed more than about ten minutes without falling asleep and have not gotten up, you are not following this instruction.

4. If you still cannot fall asleep, repeat rule 3. Do this as often as is necessary throughout the night.

5. Set your alarm and get up at the same time every morning irrespective of how much sleep you got during the night.


• Explain the state of sleepiness

– Sleepiness is the state of being drowsy, very likely to fall asleep (if allowed)

– Not the same as fatigue (lack of energy)

• Only be in bed when sleepy– Avoid going to bed unless you are sleepy– If you wake up in the middle of the night and are

no longer sleepy, it is best to get out of bed

Sleep Hygiene• Background: General guidelines about health

behaviors and environmental factors that might impact sleep.

• Treatment Goal: Eliminate habits that are counterproductive for sleep

• Insufficient evidence to support sleep hygiene as a lone intervention

Sleep Hygiene Instructions1. Do not consume caffeine after 4 PM or within 6 hours before

bedtime.

2. Nicotine is also a stimulant and should be avoided near bedtime and upon night awakenings.

3. Do not drink alcohol 4-6 hours prior to bedtime.

4. Avoid strenuous physical activity within 3-4 hours of bedtime. Regular exercise in the late afternoon may help sleep.

5. Avoid a heavy meal too close to bedtime. However, a light carbohydrate snack before bedtime might help promote sleep. Avoid excessive fluids.

6. Use common sense to make your sleep environment most conducive to sleep. Arrange for a comfortable temperature and minimum levels of sound, light, and noise.


CBT-I ≠ sleep hygiene

Relaxation and Stress Management

• Diaphragmatic breathing– Activates parasympathetic response

• Progressive muscle relaxation

• Guided imagery– Helpful for racing thoughts

• Daytime Stress Management– Scheduled Worry Time

Cognitive Therapy

• Background: Dysfunctional beliefs and attitudes about sleep develop as a reaction to poor sleep, leading to cognitive/emotional arousal and perpetuation of insomnia (Morin, 1993)

• Treatment Goal: Reduce cognitive & emotional hyperarousal by targeting maladaptive cognitions

• Based on Beck’s cognitive therapy for depression– Time consuming– Need specialized training?

Other factors in delivering CBT-I• Interpersonal factors

– Building rapport– Instilling confidence

• Providing education– How does the brain regulate sleep and wakefulness?– Dispelling myths about sleep, insomnia, medications– Learning about sleep rated as most helpful treatment

component in CBT-I (Manber et al., 2004)

• Follow-up is important– Process oriented– Not a “one and done” therapy

Empirical Support for CBT-I

• Meta-analyses on CBT-I: Moderate to large effect sizes – 70-80% of patients benefit from CBT-I– Reduce SOL and WASO by 50%– Increase TST from 6 to 6.5 hrs

• Benefits of CBT-I persists beyond treatment termination– Effects of CBT more durable than medication

Morin et al. (2003). Current Status of Cognitive Behavior Therapy for Insomnia

Remission at post: CBT-I = 35.6% vs control = 17.4%

Can CBT-I help with hypnotic tapering?

• Gradual Tapering + CBT-I vs gradual tapering alone (Baillargeon et al., 2003)– 77% of Combined group were hypnotic-free– 38% of gradual tapering were hypnotic-free– 70% vs. 24% at 12 month follow-up

• Supervised Tapering (10-week) vs CBT-I vs. Combined (Tapering + CBT-I) (Morin et al 2004)– % Drug Free:

• Taper 48% • CBT-I 54.2%• Combined 85.2%

www.behavioralsleep.org49

http://www.behavioralsleep.org/

Imagery Rehearsal Therapy (IRT)

Nightmares• Nightmares are a typical symptom of PTSD

– About 70% of PTSD have recurrent posttraumatic nightmares

– Often persist at clinically significant levels after PTSD treatment

• Nightmares can also have an idiopathic origin– Nightmare disorder (REM-related parasomnia)

• Recurrent nightmares merit treatment

IRT Background• Conceptual Background: Nightmares are like bad habits

– Increase in frequency due to repetition. – It is possible to eliminate nightmares by practicing new dreams

to replace these nightmares.

• IT IS NOT THINKING ABOUT DREAMS!– Using mental imagery activates the parts of our brains that can

replace the nightmares.

• This practice occurs best when:– We are awake, when conditioned arousal is lower, and our

frontal lobes can control arousal and emotion centers– It is self-directed so that voluntary control is involved in the

practice of new dream scenarios.

Delivering IRT1. Choosing a nightmare to practice

2. Write down your new dream by changing it any way you want, so that the new dream is no longer disturbing to you.

3. Dream rehearsal– Try to recreate the vividness of the images using all your senses– This should be different than “thinking” about your dream

4. Practice the new dream– At least twice per day, 3-5 minutes each time– Never rehearse a nightmare!

Other BSM Interventions

Continuous Positive Airway Pressure (CPAP)

CPAP Adherence• High efficacy but limited effectiveness

– Respiratory events are resolved with PAP use– Regular use in only 40-50% of patients

• Average use between 4.5 to 5.6 hours per night

• Barriers to adherence– Discomfort (skin irritation, claustrophobia)– Lack of perceived improvement in daytime functioning– Inconvenient or undesirable appearance– Hard to remember or difficult to use

• Medicare Rule– Regular use of ≥ 4 hours per night for 30 days during first 90 days– If not, must repeat sleep study or CPAP is taken away!

• Reviewed 30 studies consisting of > 2000 participants– Most were treatment naïve at start of study– 3 Intervention categories: Education, Support, Behavior Therapy

• Education: OSA, CPAP delivered by video, groups, phone– Increased CPAP use by 35 min per night

– Increased CPAP use > 4 hours/night from 57% to 70%

• Supportive: Patient provides feedback using telemedicine, internet, home visits– Increased CPAP use by 50 min per night


• Behavior Therapy: MI, self-efficacy– Increased CPAP use by 86 min per night


Light Therapy for CRSWD• Delayed Sleep Phase

– Timing: Immediately upon awakening– Duration: 30 minutes– Intensity: 10,000 Lux

• Advanced Sleep Phase– Timing: Evening (4pm to 8pm?)– Duration: ?– Intensity: ?

• Evidence is less clear for jet-lag, shift work, non-24 hour

Are current treatments satisfactory for addressing psychosocial needs?

Challenges with Current Treatments• Most patients met with sleep doctors/clinics about every 3-6 months

– Generally good for discussing medications & symptoms but insufficient time to discuss psychosocial aspects

“(Sleep Doctor) listens to me but does not provide advice on psychosocial aspects”

• Dissatisfaction with mental health providers

– Most felt their mental health provider did not understand narcolepsy– Reduced rapport and ability to trust therapist

"I get so frustrated because I've spent an hour in therapy explaining what narcolepsy is…”

• Challenges with accessibility– Narcolepsy symptoms create challenges with appointment attendance

“I’ve lost doctors because I couldn’t ever make it…I won’t wake up if I have nobody to call. I’ll turn alarms off.”

CBT-H

• Multicomponent package to address symptom management and quality of life– Adjunct to pharmacological treatment

• Behavioral components are based upon previous empirical evidence– Napping– Sleep hygiene/sleep schedule regulation

• Cognitive component– Emotion-focused coping– Mindfulness and acceptance

PATHPsychosocial Adjunctive Therapy for

Hypersomnia

Optimizing Sleep Health

Are you SATED?

Satisfied

Alert

Timing

Efficiency

Duration

Is your sleep Satisfactory?

Do you feel refreshed?Are you allocating enough time for sleep?

Recommendations:– Make sleep health a priority!– Set aside a regular time for sleep

Are you Alert during waking hours?

Does it take effort to stay awake?Are you falling asleep unintentionally?Do you need to consume caffeine to stay alert?

Recommendations:– Avoid excessive use of stimulants– Avoid excessive napping > 30 minutes– Be aware of sleepiness when operating a motor

vehicle

Is the Timing of sleep right for you?

Does your biological clock line up with your current time zone?

Recommendations:– Pay attention to light exposure patterns– Regularity of sleep/wake behaviors

• Weekday vs weekend

Are you Efficient at sleeping?

Do you spend more than 30 minutes awake while trying to sleep?

Recommendations: – Go to bed only when sleepy.– Avoid lingering in bed if not sleepy.– Consider CBT-I

Are you getting adequate sleep Duration?

Are you getting enough sleep for your age?– Most adults need about 7 to 9 hours of sleep

per day.

Recommendations: Set aside enough time for sleep

– Work on time management and stress management during the daytime

74

Thank You!

clinical tools for managing sleep disorders...clinical tools for managing sleep disorders jason c....

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