intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep...

intervention and treatment:a call for a comprehensive, interdisciplinary approach to treating sleep disorders

emerson m. wickwire, phd, abpp, cbsm

co-director, center for sleep disorders

pulmonary disease and critical care associates

disclosures:

The Sleep Apnea Success Guidebook

HealthMedia- scientific consultant (2009)

what you’ll learn…

I. almost everything you’ll ever need to know about the two most common sleep disorders

II. a whole is greater than the sum of its partsIII. multi-system problems require multi-prong

treatment approaches

essential facts: insomnia

I. definition: what disorder looks like

II. consequences: what disorder does

III. clinical aspects: how to evaluate and treat

sleep onset insomnia

trouble falling asleep

trouble staying asleep

sleep maintenance insomnia

waking too early

early morning awakening

non-restorative sleep

non-restorative sleep

DAYTIME CONSEQUENCE

insomnia symptoms frequently overlap

& complaints may change over time

• fatigue/malaise

• attention, concentration, or memory impairment

• social/vocational dysfunction or poor school performance

• mood disturbance/irritability

• daytime sleepiness

• motivation/energy/initiative reduction

• proneness for errors/accident at work or while driving

• tension headaches/GI symptoms

• concerns or worries about sleep

daytime consequences

epidemiology of the most common sleep disorder

• 30-40% transient

• 10-15% chronic

• clinical practice: >50%

Foley et al, 2004

80

Number of Medical Conditions

0

10

20

30

40

50

60

70

Per

cen

t o

f R

esp

on

den

ts

Rep

ort

ing

an

y In

som

nia

0 1 2 or 3 4

insomnia increases with medical problems

n=1506age 55-84

Taylor et al, 2007

p values are for Odds Ratios adjusted for depression, anxiety, and sleep disorder symptoms.

Heart Disease

Cancer HTN Neuro Pulm Urinary Diabetes Chronic Pain

GI Any medical problem

%

p<.05

p<.05

p<.01p<.01

p<.001p<.001

p<.001

p<.001

medical problems in insomnia

n=772age = 20 to 98

INSOMNIADecreased TST

Increased SOL/WASO

Impaired sleep efficiency

Decreased SWS

PSYCHIATRIC ISSUES

Anxiety

Depression

Insomnogenic drugs

Substance abuse

Altered ACTH and cortisol

Concerns or worries re: sleep

insomnia as a disease of physiologic hyperarousal

Bonnet, 1998; Bonnet & Arand, 1995; Lushington et al., 2000; McClure et al., 2001; Perlis, 2001; Stepanski, 1988

• increased metabolic rate

• increased body temperature

• increased heart rate

• increased catecholamines

• increased high-frequency eeg

hyperarousal: beta eeg

Perlis et al, 2001

hyperarousal: hpa axis

Vgontzas et al, 2001

ACTH elevated from 1400 to 1730 and 2100 to 0030 cortisol elevated from 2100-0030 only

p=.07 p=.04

increased brain metabolism

Nofzinger et al., 2004

Nofzinger et al., 2004

hyperarousal: neuroimaging

attentional systems are active

ARAS: activates/deactivates cortex; alertness

Hypothalamus: sleep & wake

Thalamus: sensory processing; activates/deactivates cortex

Mesial Temporal Cortex: memory; novelty detection

Cingulate: excitatory role in emotions & motivated behavior

Insular cortex: perceptions of disgust & pain

attentional systems are active

ARAS: activates/deactivates cortex; alertnessHypothalamus: sleep & wake

Thalamus: sensory processing; activates/deactivates cortex

Mesial Temporal Cortex: memory; novelty detection

Cingulate: excitatory role in emotions

Insular cortex: perceptions of disgust & pain

• Harvey model

• sleep beliefs & worry

• insomnophobia

• battlemind

• sufferers: cognitive not somatic arousal

cognitive factors in insomnia

Harvey, 2002; Morin et al., 2007; Lichstein & Rosenthal, 1980

how insomnia develops:biobehavioral pathway

PredisposingRisk Factors

Biology/ Hard-wiringPersonality

Temperament

Insomnia

No Insomnia

Spielman, 1987

CompensatoryBehaviors

Spend more time in bed“Try harder” to sleep

Sleep in on weekendsTake naps

Sleep outside bedroomOveruse caffeine/stimulants

Various OTC sleep aids

Obsess/ overfocus on sleep

Insomnia

No Insomnia

EnvironmentalStressor

Medical illnessLoss of loved one

Job transitionCumulative effect


Spielman, 1987

Insomnia

No Insomnia

“Compensatory”Behaviors

Spend more time in bed“Try harder” to sleep

Go to bed earlierSleep in on weekends

Take napsSleep outside bedroom

Overuse caffeine/stimulants

Decrease daytime activityVarious OTC sleep aids

Obsess/ overfocus on sleep



Spielman, 1987

Insomnia

No Insomnia



“Compensatory”Behaviors

Spielman, 1987

Spielman, 1987

ACUTECHRONIC(> 1 mo)

insomnia causes problems

n=1741

insomnia, CVD & mortality

n=1741

n=3430

insomnia worsens quality of life

Leger et al., 2001

n=1053

insomnia precedes depression

n=1053 men

Chang et al., 1997

insomnia post-deployment:#1 symptom & may predict ptsd

n=2249

assessment

ask! (doctors don’t ask & patients don’t tell)

• frequency (>3x/ week)

• intensity (>30m sol/waso, quality)

• duration (>1 mo)

• daytime sequelae

• do you snore?

1. Please rate the SEVERITY of your sleep problem(s).

None Mild Moderate Severe Very Severe

Difficulty falling asleep:

Difficulty staying asleep:

Problem waking up too early:

2. How SATISFIED/dissatisfied are you with your current sleep pattern?

0 1 2 3 4

Very Unsatisfied Very Satisfied

3. To what extent do you consider your sleep problem to INTERFERE with your daily functioning (daytime fatigue, ability to function at work/daily chores, concentration, memory, mood, etc.)?

0 1 2 3 4

Not at all Interfere Interfere Very Much

4. How NOTICEABLE to others do you think your sleeping problem is in terms of impairing the quality of your life?

0 1 2 3 4

Not at all Noticeable Very much Noticeable

5. How WORRIED/distressed are you about your current sleep problem?

0 1 2 3 4

Not at all Worried Very much Worried

clinical screening:insomnia severity index

Bastien et al., 2001

<7 none>7 subthreshold>14 mod severe>21 severe

use CBT-I:

• recommended 1st line treatment

• primary & comorbid insomnias

• adults of all ages & hypnotic users*

combined therapies:

• no benefit over cbt-i alone

• cbt-i aids hypnotic taper

essential facts: insomnia

essential facts: srbd

I. definition: what disorder looks like

II. consequences: what disorder does

III. clinical aspects: how to evaluate and treat

snoring and sleep apnea

noobstruction

hypopneasnoring apnea

Obstructive Sleep Apnea

(OSA)

Upper Airway Resistance Syndrome

(UARS)

noobstruction

hypopneasnoring apnea

AHI (OSA only)<5 none5-14 mild15-29 mod30+ severe

UARSflow-limited breaths

*subtle detection

↓O2

EEG arousal

↓ total sleep

mechanisms of srbd

• anatomical abnormalities

• genetic factors

• collapsibility of upper airway

• weight gain

• behavioral factors

causes of srbd

• EDS, mood disturbance, performance

deficits

• quality of life, libido

• obesity, dm, htn, stroke, cardiovascular

death, overall mortality• enormous societal costs

consequences of srbd

assessment of srbd

out of lab(“at home”)

in lab(gold standard)

treatments for srbd

digeridoo oral appliance

surgery: not first-line treatment

gold standard:positive airway pressure

slide from D Kirsch, MD

• 36 RCTs, N=1718vs control

↓objective & subjective sleepiness quality of life neurocognitive function

vs oral appliance (OA)↓ AHI sleep efficiency minimum O2

Giles, Lasserson, Smith, White, Wright & Cates, 2006

pap works

LESS BAD

eliminates OSA (95+%)

↓ sleepiness

↓ hospitalizations

↓ car accidents↓ HTN (esp nocturnal)↓ pulmonary artery pressures↓ GERD

MORE GOOD

↑ qol↑ cognition↑ glucose control↑ gas exchange↑ heart function in heart

failure pts↓ reduces cardiac

arrhythmias during sleep

srbd in ptsd

• evidence of increased srbd in ptsd

• especially uars

• hypothesis: massive sympathetic burst alters pharyngeal muscle tone

• ↑ increased respiratory effort = EEG

• sleep: 37% of variance in symptoms

a whole is greater than the sum of its parts: insomnia, srbd, or both?

I. secondary insomnia: a myth dismissed

II. frequent co-occurrence

III. hypothesized mechanisms

a myth…

NIH 1983 (that was then)

• insomnia is a symptom (only)

• treat the primary disorder

NIH 2005 (this is now)

• insomnia is a disorder, typically coexisting with other disorders

• treat both conditions

• improvements insomnia can improve other outcomes

a myth… dismissed

NIH 1983 (that was then)

• insomnia is a symptom (only)

• treat the primary disorder

NIH 2005 (this is now)

• insomnia is a disorder, typically coexisting with other disorders

• treat both conditions

• improvements in insomnia can improve other outcomes

• impacts quality of life

• worsens clinical outcomes

• frequently does not remit with

treatment of “primary” condition

comorbid insomnia is a disorder

not just a symptom

• consistency of complaints

• independent course of disorder

• responds to different treatment than comorbid disorder

• responds to same type of treatment across different disorders

Harvey, 2001; Lichstein et al., 2004

insomnia & srbd: research boom

insomnia is common in srbd

insomnia is there (and not just a symptom)

n=105

70% men

M age=53.9±14

insomnia criteria:

ISI>15duration>6 months

PSG SOL or WASO>30m

w/daytime impairment

Smith et al., 2004

39% moderate-severe insomnia(insomnia unrelated to SRBD)

(n=100, 43 men, M age=49±14)

Hagen, Patel, & McCall, 2009; Nguyen et al., 2010; Lichstein et al., 2010

half or more of patients…

61% moderate-severe insomnia (ISI)

(n=166, 138 men, M age=54.8±11.8)49.3% moderate-severe insomnia (ISI)

84% of OSA patients also meet DSM-IV/ ICSD-2 criteria for chronic insomnia

29-43%

40-64.4%

92.7%(15.7 UARS)

90.9%(40.9 UARS)

Wickwire & Collop, 2010

and it works both ways:occult srbd in insomnia

Krakow et al., 2001; Krakow et al., 2002; Krakow et al., 2004

insomnia & srbd in ptsd

(n=44, 37 women, M age=40.9±12.4)

90.9% srbd (50% OSA; 40.9% UARS)

(n=78, 50 women, M age=51.5±13)

95% srbd (41% OSA; 54% UARS)

99% insomnia

(n=187 women, M age=37±11)

89.8% rdc symptoms srbd (confm’d in 21 tested)

↓ sleep (self-report and psg)

↓ neurocognitive function

↓ psychomotor reaction times

↑ sleepiness (self-report and mslt)

↑ psychiatric distress & pain

consequences are additive (1+1=3)

subtle, atypical presentations

• no loud snoring/ normal weight

• older patients

• postmenopausal women

• patients with chronic pain

• ptsd/mTBI?

onset insomnia & srbd severity:inverse relationship

Gold et al., 2007

%

osa patients not always sleepy

N=4653

Luyster, Buysse, & Strollo, 2010

Complex insomnia hypothesis.

Chung K Chest 2003;123:310-313

©2003 by American College of Chest Physicians

Benetó et al., 2009

multi-system problems require multi-prong treatment approaches

I. treatment interactions & combined therapies

II. case study & clinical recommendations

III. a comprehensive practice model

insomnia medications can worsen breathing

• older benzodiazepines bad

1. negatively impact breathing

2. raise arousal threshold

• newer hypnotics minimal impact AHI

• off-label meds may pose risk

untreated insomnia can compromise OSA treatment

only insomnia predicted negative

outcome in oral appliance for osa

Machado et al., 2006

N=188

sleep maintenance insomnia predicts poor cpap adherence

N=232

Wickwire, Smith, Birnbaum, & Collop, 2010

cbt-i #1 surgery #1

surgery #2 cbt-I #2

Guilleminault et al., 2009

combined treatments provide additive benefit

treating both disorders improves outcomes

Krakow et al., 2004, 2006

• in patients with symptoms of insomnia and srbd, nasal strips improved sleep

• treatment of srbd improved outcomes

following cbt-i (8/17 remit 15/17 remit)

• requires additional evaluation

• srbd may be common in patients with treatment-resistant insomnia

refractory insomnia

Guilleminault et al., 2002; Krakow et al., 2006, 2010

screen – insomnia and srbd– poor subjective sleep quality– nonrestorative sleep/ daytime fatigue

antennae up– older adults– postmenopausal women– trauma survivors

treat both conditions, concurrently if possible

clinical recommendations

insomnia– be very careful w/ benzodiazepines and off-label

medications– sleep hygiene not effective in isolation, not effective

in handout– refer to insomnia specialist if available

srbd– appreciate frequent co-morbidity of insomnia– intervene early for cpap adherence– refer to sleep specialist: snoring, obesity, htn, dm,

refractory insomnia

clinical cautions

• self-referred for insomnia study

• ineligible per phone screen (osa)

• discussed treatment options

• initial evaluation scheduled

Wickwire, Schumacher, Baran, Richert, & Roffwarg, 2007

the real-world: case study

• 61 y.o. Caucasian male• lifelong Mississippi resident• normal weight• college degree• US Army veteran• PT VA employee w/shift work• “happily” married 31 years• 2 adult daughters & 2 grandchildren

patient characteristics

• recently diagnosed w/ OSA (AHI=31)• GERD• chronic knee pain• denies past psychiatric treatment• denies history substance abuse• current daily meds: high blood pressure,

GERD, baby aspirin, otc sleep aid prn

medical history

• father had trouble falling asleep– blamed sciatic nerve– slept on sofa

• brother suffers PTSD– experiences sleep problems– takes sleep medication

• wife snores and suffers EDS

relevant family history

↑ SOL– I can’t fall asleep at night (25-year Hx)

– I don’t like to take pills (drug stupor)

OSA– I never dreamed I had apnea… I only started

snoring two years ago… they made a mistake– apnea is obstruction… obese people…– PAP is frustrating, loud, straps too tight, hard

to get adjusted right

what’s on his mind?

• can’t concentrate or read

• can’t stay alert deer hunting

• tired & eyes irritated

• wants to nod off during work

• irritable*

assessing daytime sleepiness

rumination: • grandson’s health, nephew’s safety, involved with family (softball)• thinking about “tomorrow”• previous day: “what someone said, what family goes through”

physical discomfort:• pressure on feet, sensitive to physical, blankets, spouse

bedroom environment:• tempur Pedic bed• TV in bedroom (wife falls asleep with TV)• wife snores; he hears her “rustling” around

assessing sleep onset insomnia

307.42 Primary insomnia

327.23 Obstructive sleep apnea

Plan:

1. CBT for PAP acceptance and adherencewhat, how, why

2. CBT for insomnia

diagnoses & treatment plan

OSA

#2: cbt

insomnia

#1: cpap

the plan: a systematic approach

OSA

mood

insomnia

#2: cbt#1: cpap

• 2 45-minute sessions

• principles of behavioral change

• elicit personalized risks & benefits

• incorporate guided imagery

motivational enhancement

Aloia et al., 2004

develop a pre-sleep routine

typical activity/ arousal level:

Wickwire, Schumacher, & Clarke, 2008

marker

ritual(“greased shoot” to sleep)

sacred sleeping environment

develop a pre-sleep routine

Last meal or snack of day

END DAY ACTIVITIES- Leave work

Change pajamas/ T-shirt

Read 30- minutes (paper, magazine, book)

Relaxation CD

Breathing exercises

Bathroom routine

EARPLUGS

Lights out/ Bed

pre-sleep routine

• self-report: 90-120 m/day, falling asleep with mask on, waking and removing it

• CPAP 30m-300m (mean = 108.5m/ night over 2 week pd)

improved pap adherence

51.8

33.2

20.9

0

10

20

30

40

50

60

Pre Post Follow-up

Minutes

61.5

13.818.6

0

10

20

30

40

50

60

70

Pre Post Follow-up

Minutes

345.2

422.6 439.9

0

50

100

150

200

250

300

350

400

450

500

Pre Post Follow-up

0.75

0.89 0.89

0.65

0.7

0.75

0.8

0.85

0.9

0.95

Pre Post Follow-up

sleep latency

total sleep time

wake aftersleep onset

sleepefficiency

before after

BDI-2 1 (0)

STAI-T 49th % 31st %

ISI 22 16

ESS 10 5

DBAS-10 59.7 51.4

knowledge 4/5 5/5

acceptability 65.7 75.4

quantitative improvement

• definitely not as tired• much less nodding• less drowsy in deer stand• no sleep aid in past 3 months• no TV in bedroom, no late eating• following pre-sleep routine & using

deep breathing exercises

qualitative improvement

silos & 3-month waits

pulmonary(psg)

psychology(cbt)

neurology

psychiatry(meds) surgery

patient hassle & system burden

a better alternative: our model

MDMOD-10in-lab psgat home test

MTF/PCPor specialist

MDPAPoral appliancemedication

PhDinsomniaactigraphyPTSD/mTBI

PhDCBTPAP successIRT

Follow-up Carepap adherence data

HIPAA secure websiteAHLTA friendly data

Treatment

Evaluation

promptscheduling

coordination w/ referring

providers

in conclusion: insomnia & srbd

I. common, bad, & highly treatable

II. frequently co-occur

additive negative effects

III. combined treatments are best

demand comprehensive care

[email protected]

(410) 997-5944 x13

mailto:[email protected]

intervention and treatment: a call for a comprehensive, interdisciplinary approach to treating sleep...

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