Sleep medicine specialist Rochelle Zak, MD, delivers a rousing update on what’s known about sleep’s stages and physiological payoffs, followed by her guide to assessing and treating insomnia – by far the main sleep issue seen in primary care. Learn what to do with a patient’s Fitbit data; how to discuss “sleep hygiene”; how CBT for insomnia works; and uses and caveats for the range of drugs used to help patients snooze. Bonus: Tips on understanding and addressing sleep apnea.
um First off I want to thank you. It was a great deal of fun making this lecture and um what I did when preparing it was actually talked to my 25 year old son who has a degree in engineering physics and his friends as well as reflect on what's the patient population from you whom I see. And so I'm sort of extrapolating. So yeah, I'll talk about sleep apnea, but not for a long time because that's actually probably much less of what you see then. Um some of the other issues. And so I will talk about top sleep issues. But I do wanna address aps and naps because that's what these kids ask about. Um. Oops, okay. Just when we said we did a whole trial. Yes. Okay. Um so I have no disclosures. I'm going to at various points in time. Talk about a little bit of physiology. So you know what I'm talking about? Non rem and rem and then I want to talk about the wearables because they all come in and they want to show me there are a data and their Fitbit data etcetera. Um And what are what's helpful from it and what are the limitations. And then I want to start with insomnia because that's the number 12 and three diagnosis that we end up seeing um to really explain to a lot of the behavioral treatments what they're doing now. And there's some very nice summaries in the literature then you can't do a sleep talk and not talk about sleep apnea, but that's probably not a lot of what you see. And of course, um as dr kim alluded to, I can talk about restless leg syndrome for hours, so luckily there's a 45 minute limit on this talk, so I'll get to what we can get to. And if you have further questions please ask cause I can wax eloquent forever on RLS. Okay. Um so the first thing um is to understand that how we define different types of sleep we got grossly and you probably will run this anyway by divided into non I'm sorry, let me just go back. This is a sleep hypno graph. It is a graphical representation of sleep changes throughout the night. This would be the beginning of the night, the end of the night. These are the different sleep stages, wake rem and then three stages of non rem sleep. So sleep is grossly divided into rem and non rem. And within non rem we divided into drowsy light sleep, and deep sleep. And depth of sleep is defined by how hard is it for me to wake you up? How loud a bell do I need to rent? How painful is stimulus do I need to impose to get you to wake up? And you can see that non rem and rem leapfrog throughout the night. But the other thing that's important is where they occur. So, Rem starts out the first rem episode is very short and it's your last room episodes. That's actually your longest this person was woken up, it probably would have extended about 40 minutes to an hour at this point. And you see that as you leapfrog throughout the night, the amount of deep sleep goes away. And in fact most deep sleep is during the 1st 3rd of the night. Now why am I showing you this partly because I will continue to talk about non rem and rem sleep and partly to address the question that these kids want to know about, which is should I nap or what what's advised for naps and you will end whether or not you basically need the amount of sleep you need to feel refreshed and you needed over a 24 hour period. So in the siesta culture people are going to nap in the american culture and american culture people tend less to nap except now that work actually goes into the evening and late into the night napping can be helpful. So if you need a daytime nap to get what you need to be to feel refreshed. We recommend that daytime naps be limited to 20 to 20 minutes is the technical, I often tell people 30. Now why do we have that limit? The reason is that if you look here when you start awake and you go through it takes a while before you get into deep sleep. As I mentioned, deep sleep is very hard to wake people up from and when they wake up from deep sleep they feel as if they have never slept and you'll um for um they always talk about the intern who's paged in the middle of the night and has no memory of having even answered the beeping the beeper or what they said. That's because they were awakened out of deep sleep. They were groggy and they have no memory for and when you wake up at a deep sleep you actually feel worse than before you went to sleep. And that's why we stayed a limited to 20 minutes with the hope that people will not enter depth deep sleep. I often say to go to 30 okay. They will always, people always ask why do we sleep well? Um There are multiple reasons we know about immunity because of the original studies from the seventies I think it was um where they put rodents on a disk in the middle of the water. Thing of water and the disk would start spinning and if the road didn't run he was gonna hear it would fall into the water and they kept running and they died of sepsis. So we know that severe sleep deprivation affects immunity, metabolic homeostasis. When you go to sleep at night the temperature drops, your metabolism decreases. You know you go from and then you change from the sympathetic to the parasympathetic nervous system from the fight and flight system to the rest and digest. This actually is just important to understand baseline and it actually comes up when we talk about apps which is that the when you actually watch people enter sleep you will see as they go from sympathetic to parasympathetic that the pulse starts to slow the blood pressure actually goes down. And so one of the problems with obstructive sleep apnea is forget even the fallen oxygen. But when you have sleep apnea you have frequent intermittent arousal. That's how you end up um as ending a respiratory event. And with each of these arouse als you end up going back from parasympathetic to sympathetic I. E. You get a burst of sympathetic activity with an acute increase in pulse and increases blood pressure. Now why else do we sleep memory consolidation? And the interesting thing about that is we is that we have now learned that every single sleep stages important. There isn't anyone that you can afford to to not have. And so you sort of divide. There are all sorts of types of memory and I know that there's some phds anxieties and they probably know this so much better than I but just grossly if you sort of think about procedural memory which is how you do something learning to play an instrument memorizing physical types of behaviors as opposed to declarative memory which is backs light sleep. We need for procedural memory. This was a lot of the work that Matthew walker did when he was doing various snap studies on cal students. Um deep sleep is fascinating. We had no idea deep sleep is playing a role in memory. So as I told you deep sleep hard to wake people up from, it turns out you need that to have to for a declarative memory. So we learned a few things are happening in deep sleep. Um This is um these are data out of italy Tony, I think it was two to find it. Um Pruning is the term they use and the idea is that while you're awake you are having experiences and they're getting encoded in various neurologic networks while you're awake and you don't want to run out of room and so you have to prune back, get rid of the ones that aren't impossible to allow for storage the next day, literally deep sleep is defrauding the hard drive. And we also now know about glimpse, the brain does not have lymphatic channels that has glimpse thematic channels which wash away bad things, waste products and these tend to be more open during sleep. Real sleep. We've known for a long time that was necessary for memory. So that's much less um revolutionary. And you need it for both. You need it for declarative and procedural but here's the thing, how did one of the measures of antidepressants was, how well did they suppress from sleep? And so people can be an antidepressant. We know that you can suppress rem sleep to some degree and not have an effect on memory. So we know you need room from memory. Um But the we don't totally understand this because we do know that with rem suppression you can improve mood and not necessarily have an adverse effect on memory. So there you go. Um Now I want to start talking about apps and in order to understand the limitations, you have to understand what how we have defined sleep and what we look at in the sleep lab. So this shows you what a person who's in a full policy som diagram which we can hardly ever get paid for anymore. Um But we we do a modified E. E. G. And we actually do 6 to 8 channels depending how you look at it. We do frontal central occipital. We put I channels here because that's how we define rapid eye movement. Sleep, right eye movements. And we also pick up E. G. Here actually which is why I said it's between six and eight channels then so and then we do chin tone because in rem sleep the chin tone drops. We also are able to measure respiration with bands across the chest and stomach a measured nasal airflow that sits in the nose pulse ox. And we actually there are leg leads here that will monitor leg kicking. Um And we actually I'm sorry let me just go back for a second. We also have video. I love having a video because one of the limitations with home sleep tests is that this is back. This is side what's this? I can see this on the video. I can see a head turn and that can be the difference between diagnosing positional sleep apnea and not. But I'm going to get off my soapbox now. So this is what an epic iii 30 seconds of a full policy. Full full policy under graham. Looks like these are the data we look at when we do policy ethnography. So here are the 60 E. G. Leads plus the two islands which also clearly are showing new E. G. Your chin tone your uh it's your E. K. G. Um you know your rhythm strip one like the other lake snore channel. This is um airflow. It's actually this is actually pressure. It's the pressure transducer which is a very sensitive measure of air flow. This is actually nasal thermometer. It's actually measuring temperature. But it's another version of airflow. The thoracic movement, abdominal movement and the pulse ox. Okay now let's get to the apps now that you know with the gold standard is you'll be able to understand where we get the limitations. How do you evaluate apps? It's a little complicated because they have proprietary algorithms. So when people are doing studies on them you know you only have access to so much um there are different outputs. So with respect to sleep. Sometimes there's just a sleep score. Others are trying to show you percentages of different stages of sleep. What are they actually looking at for the most part they are doing that. They have an accelerometer. Iii it's it's tracking movement the way an old actor graph would they tend to be tri axial. Which is nice. And that means three different you know axis your X. Y. And Z. But don't really ask me what that means. But it's basically a sensitive measure of movement. But interestingly they now add heart rate and heart rate variability. Why do we care? We care? Because as I mentioned you transition from the sympathetic to the parasympathetic ie there is an increasing parasympathetic drive during sleep And in rem sleep they fight with each other since the sympathetic starts to come into this and rest and pulse rate gets very regular. So this is helping these algorithms to understand whether or not whether or not it's measuring sleep awake and what stage. Some of them will have a pulse ox there are there. And so when I'm talking about these you're talking about the ordering. Um the Fitbit um the Apple watch. They're mostly doing motion and cardiac activity. The the heart rate the inter beat interval. And um sometimes there's pulse ox data added in. Unfortunately there are very few with E E. G. Now this is really interesting. Um I don't know how much how familiar you are with um the um the abyss and um the said line But in anesthesia now they're using these strips to monitor frontally E. G. To gauge depth of anesthesia. And I have been extremely lucky in one of my anesthesia colleagues has asked me to actually look at the raw data for her. And it's good you can really see brain waves and you could score sleep and that's what dream was doing. It actually was frontal and it had when occipital they they know they used to market to the consumer but they don't anymore. They can be used for research studies but they sort of pulled out of the consumer market which actually is really the best. Um Well if you really want to know sleep you really need an E. E. G. Because this is what happens with these. Um Despite really similar to the data from an actor graph actually the aura and the Fitbit are very sensitive for sleep. And so that's good. They're gonna pick up sleep. They sort of over call it um meaning and well let me just I'm sorry that's down here. Um But they're not as great about sleep stages the aura which will which produces a beautiful little hypno graham. Similar to what I showed you actually overestimates rent and underestimates deep sleep. And when they when it was actually done 121 comparing epic by epic with. And what I showed you the type of data. I showed you there was only 50-65%% agreement. Um my only experiences that I did have a patient who was coming in for an in lab, but I told them just wear your aura ring, let's see. And it actually did correlate with Rem. But um but that's my one anecdote. Um it's the larger study showed only 50-60% agreement. And one other problem is the ring has to know if you're going to sleep or not, and I don't remember how it does that actually, I don't know how it does that, but in some studies, if it didn't figure out that you were going to sleep, but when score it right now, it's a poor, it's poor for detecting wake, so it underestimates week. So what this means and what this means is that if somebody comes in and says my Fitbit, my aura, my apple watch is telling me that I have a lot of wake during the night. That's probably accurate because it's gonna underestimate it, but it will, it will. So if you have decreased sleep, this may be an indication of poor sleep. Um But it's not 100% accurate. It is definitely an accurate vis a vis sleep stages. Because patients get really worried, am I getting enough deep sleep or whatever. Um And it is somewhat surprisingly similar in the numbers tactic, graffiti. Um But the real thing is people need to not focus on a number and not focus on this, you really need to focus on how you feel, How are you functioning? You need the amount of sleep you need to stay awake. Um So that's kind of the story on these there they where they will probably end up being the most useful is in terms of gauging efficacy to insomnia treatment. And I'm going to show you um and I'm gonna, when I discuss how people do sleep restriction etcetera there, I think it can be useful, but for people who either don't have safe complaints that are just curious. It may not be a completely accurate and it's not helpful to focus on this number. People get overly focused on them, but it will end up I think being a useful aid, particularly with the insomnia when patients are having insomnia. Um snoring, they're pretty good, they're kind of um and it's a nice clinical screen. There's something called the zoom function, I think snore lab has it that will allow because remember when they use these, they're going to use them the entire night that allow you to sort of zoom into areas where your snoring if you want to play it back. Um Not totally accurate because you don't know who's snoring. Um One of the funniest talks I heard and I can't remember who it was, but it was if I'm not mistaken, an irish sleep researcher who's who's happiest moment was when he showed that the british bulldog was the animal model for sleep apnea. So I don't know how many of you have friends who have bulldogs or pugs, but the dogs with the smashed in face faces, they're gonna snore. So it could be a false positive if somebody else's snoring in the room. If the patients facing away from the smartphone, it can be a false negative but they can be a nice screen. But pretty much if somebody just complains about your snoring, that's actually good enough for me because the reality is um number one, I kind of don't mind doing unnecessary sleep studies and that I'd rather make sure we find people than not. The other is that in particular. Um Although women can snore as loudly as men, they tend not to snore as often. And so you know I've seen people with wicked apnea who just come in with occasional snoring, mild snoring. Um But it's unusual to have absolutely no snoring. Um It can happen but I don't care as much about how loud it is. I care more that they have snoring and and that their sleep is un refreshing so the snow wraps are helpful But again it's not as necessary in terms of sleep. It's kind of interesting. There's a very old one. They're actually these mattress sensors, they go under the the sheet. These have been around for a long time. Used most they use sometimes in the European studies. I don't know why they don't have much acceptability here. Um they actually are able to measure respiration and body movements. They're very sensitive but they do have a 20% false positive rate, particularly for miles. There also contact list devices and they're trying to pick up changes in snoring essentially. And are you seeing crescendo and that kind of thing? Um again you can have a false positive. Um and then there's some that are pulse ox again, microphone accelerometers fairly sensitive and a false positive rate. Although is that, you know, again it can be a nice screen and then you can send someone in, okay, this is what we deal with all the time right among ourselves among our patients. And um so in order to understand that you need to understand why and how we sleep. So the process of sleep, we talked about, we primarily talk about process um S and C. And then there's also process A which is attention. So we're gonna start with process, the process is the circadian drive for sleep. It's the biological clock. It gates when it's easy to fall asleep and it's hard to fall asleep. The biological clock opens twice. So the so the gate the gate it's gonna open right before sleep. This is when you have a huge drive for um this is the drive for sleep. So it's going to open and then and then it's going to close so you stay awake and then it's gonna open again right around the siesta time. Okay that's process. See process S stands for sleep because sleep researchers aren't very creative. Um And it's the home a static drive for sleep. It says that the longer you're awake the greater the rise of of the psalms regions which are these circulating chemicals that will promote sleep. The major one is a dentist seen, the longer you wait, the more dentist in you produce it will make you sleepier and caffeine is an anti dentist in drug that's hard caffeine promotes alertness and when you sleep a dentist in falls. I put this here because it's important to see that tumor necrosis factor I. L. One they also go rise and fall throughout the day. They tend not to be major modulators of sleep unless you're sick. And this is why you're sleepy during while you're sick. You get a lot of the a lot of TNF alpha and interleukin one. And then finally we have process a which is where attention which means that um all of these can be overridden if you are bored. Um Okay the new guy is direction, you may have heard about this and we'll talk about with the with the doors, the dual orexin receptor antagonists. Um reckson is there is um the major the major modulator we sort of like to think of slip that the original description was that its sleep is regulated by a flip flop switch. You'll see that all over that. Either you're awake or you're asleep. They talk about a flip flop switch and then they actually um uh this this the illustration is a teeter totter but fine they mix their metaphors um But a rex in it that's coming out the lateral hypothalamus is controlling it all. So when a rexon starts being reduced by the hypothalamus it positively stimulates the areas of the brain. This is the the tube, romana, mary, the tubarao, mammal larry nuclei in the hypothalamus, the dorsal and these are in the brain stem to to start putting out your wake promoting chemicals which tend to be norepinephrine, serotonin and actually dopamine and then they inhibit the sleep promoting and then when the director when it stops being promoted, then you end up having the um you have the sleep, the sleep promoting areas of the brain starting to put out the more inhibitory neurotransmitters of Gava and gallon in. But again a Wrexham plays a role in in supporting and maintaining wakefulness. Okay, so now that you have that sort of, his background will start talking about insomnia um they're basically, when you talk about insomnia you talk about behavioral treatments and pharmacologic treatments, right? And I'm going to talk a bit about both of those. Um This is a I was actually looked trying to find something else and I stumbled on this lovely patient summary that came out of the CSF. Um Andrew crystal is a psychiatrist who specializes in sleep and most of the not most many of the drug. Um The drug therapy for the drug studies for insomnia will have his name on it. He's an expert on that Liza Ash book um is a neurologist who also specializes in sleep and she's actually doing most of her work on um circadian rhythm disorders and eric prather. I'm going to refer to him later. He is a neuropsychologist who specializes in behavioral aspects of insomnia. This is just a really nice summary for patients. So I don't mean this to be self promoting, but it's a really nice link. So when you get the slides you can access it for patients. Um I just thought it was really well done. Um behavioral treatments don't bother to look at this and then because it's kind of annoying actually when you know how the sausage is made. But this reference um has this, this is such a great table. Um And so what what we asked them to do when they did this task force is to clearly spell out each of the types of behavioral treatments. So really this is just one of the best summaries I've ever seen. So the mainstay of treatment, the number 12 and three um treatment for chronic insomnia is going to be cognitive behavioral therapy for insomnia. CBT i it is a multi component form of behavioral therapy that is designed to decrease anxiety about sleep. Um align the biological clock aligned. The circadian home aesthetic processes for sleep, which is going to be done through stimulus control and sleep restriction. Um to to um provide relaxation techniques, which I realized I actually don't go over in this talk, but I'll give you some references and also to deal with habits. Ie sleep hygiene. Um It was you know, just sort of an interesting, we're dealing a lot with nomenclature these days and that isn't right. You don't want to say that somebody is a narcoleptic, someone is a patient with narcolepsy. We have more patient centered. Um Language. Well when sleep hygiene came out and you talk about patients having inadequate sleep hygiene literally patients would say, but I shower and like you really have to realize, I don't even know who came up with that. I actually should find out, not, not a great, not a great term. But um it does talk about sleep methods anyway. CBT I is usually done over 6 to 8 weekly sessions by people who are trained in it. So they now talk about brief BTS, brief therapies for insomnia. You'll also see them abbreviate. BBT. Very similar. And then what this does is break down the individual components that actually are part of CBT. I and we're really going to talk about these in detail. Um I actually should um you know what I am going to explain how the sausage is made for a second. We said look at this, we suggest that clinicians not use sleep hygiene as a single component therapy for the treatment of chronic insomnia. This one statement became debate hotly debated within the sleep community. This is where you have to really read when you look at these, you really have to read the details. Single component. What they're trying to say is that um don't just tell them not to drink coffee at night and not follow up. What they're worried about is that you'll go through sleep hygiene and never see the patient again. They are not saying that sleep hygiene doesn't work. It's very effective. It's part of CBT I they're just saying don't just do that, make sure you're not missing something, make sure you follow up. So sometimes you have to be very careful and read things extremely carefully. So its recommendation is against single component sleep hygiene. It doesn't mean not to do, it means don't do just that. Okay, I can now get off. I got a lot of soapboxes, sorry about that because sleep hygiene is really really really really really, really important. Um and they didn't mean when they wrote this paper, they did not mean to say it's not what they meant to say is there's more there. Okay. So obviously it has to be quiet. People are pretty good about that here exercise. People are really attuned to that. Um They don't tend to drink as much caffeine. Um younger people sometimes they do um alcoholic. What we do do say is to avoid caffeine after noon time to allow for to have lives to go through. One of the things I sometimes see is people drink caffeine at three o'clock at night. They say they don't have any trouble falling asleep, but they end up having trouble maintaining sleep. Some metabolism can vary and sometimes that can crop up later alcohol. What people don't realize is that alcohol is a soporific effect, but it has a paradoxical arousal effect when it wears off. So again we say don't drink it near bedtime, nicotine. And the real problem is this right? It's screens, screens, screens, screens. Um Okay, so there are probably two aspects with the problem with screens. As I mentioned, the, I talked about the circadian um theory, the biological clock. The biological clock is um Gates was easy to fall asleep and hard to fall asleep. What opens the gate what opens the gate is the rise of melatonin. Melatonin is best to be thought of as the hormone of darkness, it rises when things get dark. It does not go up if you have light, you can suppress melatonin by light. Guess what? It's blue light specifically. So there aren't a ton of data on um specifically on um screens and their effects on melatonin. Um There's one article that shows that if they use screens before and it shifts it a little bit later, but there are data suggesting that if you decrease the exposure to blue light you do improve sleep. So either putting the screen in the night mode or you vex goggles. Let me just show you what they look like. Okay um a couple of hours before bedtime can improve sleep. In this study it increased total sleep time and sleep and improves the quality after It did. Um it decreased sleep latency but it wasn't statistically significant and we do know that the night mode will decrease blue light by about 93%. Here's another um study that restricted phone use before bedtime. Um In college students with sleep complaints and they did much better but it's probably light is probably not the entire story. This was actually a frank RC team done out of out of Brigham Young and they divided its large for sleep. 168 students will just laugh but hey we think that's large actually. The sleep apnea studies are now large. Um But they essentially at 50 to 60 students in each group. And the three groups were no phone phone in night mode phone not in night mode. And they were just said go home, you know it was done in their dorm rooms are at home. And what was interesting was overall they didn't see a difference but when they looked at students who were getting at least seven hours of sleep um They saw that the no phone group did much better and the reason they, but the two phone conditions didn't differ. And so when you are on your phone, are you passive or are you active? Usually people are on their their on face. Well I guess they're not nothing on on facebook. They're on instagram. Um And there are there on websites and basically going back and forth is increasing adrenaline. It's adrenaline, it's increasing dopamine, it's increasing the hormones of alertness. So just going back and forth, even forgetting any type of melatonin suppression is going to have a deleterious effect on sleep. They think that they didn't and so that's what they were sort of proposing in this study was that it wasn't a function of light. It was a function of using an interactive screen. They think they did not see a difference in those who got less than eight hours than seven hours of sleep because everybody was relatively sleep deprived. And this everything um went out in the wash. So it's just when I counsel people about using their screens. I say look yes I know using in the night road that's great. But there is also a role of of being interactive that's actually stimulating to wakefulness. Can you just go on the can and just get a can you know use a Kindle or something and read or try to do something that is passive not active. Okay. One of the main so that's the sleep hygiene. One of the main stains of CBT i is also stimulus control. This is to align the biological clock as well as to increase the home, a static drive for sleep. And probably the number 12 and three recommendation is a consistent wake time. So you're getting light exposure when the biological clock melatonin secreted you open it, you see light up the gate closes And the biological clock is 24 hours and 15 minutes in periodicity and we pull it back every time we see morning light. Wait Times seven days a week, avoid naps, avoiding naps is so that you don't have a fallen in dentistry and you have a good dentist. Whenever you sleep, the density levels fall. You have a good level of a dentist in when you go to sleep at night. It's also to break the subconscious association the bed with wakefulness and we tell people don't lie awake in bed for long periods of time. Use the bed only for sleep and sex and involves sleep restriction. Where you actually sometimes will try to restrict their time in bed. Um to to sleep deprived them a bit to build up the sleep pressure. The other thing that happens is if people start to have trouble sleeping, they think, oh if I spend more time in bed I'll get more sleep, that's not what happens. What happens is you end up getting more wake so you'll end up and they think, oh I'm only getting six hours, I better spend eight hours in bed. And what they do is they get two hours of sleep, two hours of wakefulness than another four hours and having that wakeful that sustained wakeful period ends up in the morning feeling as if you have less refreshing sleep then if you had six straight hours of identical um E. G. Confirmed sleep. So really how you feel in the morning is a combination not only of how you slept at night but also of your experience of your wake during night. And then they also will go over relaxation techniques. So my approach to insomnia is identified problems with sleep habits, substances irregular sleep and wake time. Personal screen use absence of wind down period and then I do a lot of referral to CBT. I um I'm not officially trained in it. I know a lot about it. Um I do aspects of it but it's really best when it's done by somebody who can see the patient every single week and make incremental changes. These are just some good references because sometimes people like mind over mood, organ night minds sometimes just reading that and people get enough help to deal with the with the active mind. Um which is so so common and particularly in this group of people medications. Um There was a clinical practice guideline for medications for insomnia that was published actually. Um long before the CBT. I. This is a much older publication. Um They basically make their recommendations for difficulty initiating sleep maintaining sleep or both. Um and so I just want to kind of review for you a little bit about the pharmacology of these types of medications. Um the Benzo receptor agonists. These are the Z drugs zolpidem, zappa clone Xalapa on. They are not Gaba agonists. They actually enhance the effect of existing Gaba now because they are not full Gaba agonists. They actually do not have an anxiety allergic effect. And so I remember my when zolpidem first came out and I was a fellow and I was so smart, I had this patient who was on, I can't even remember what Benzo was at the time. I'm going to switch her over the zolpidem. This is a great drug and ayan master underlying anxiety disorder. So they are not full Gaba agonist. They're actually not Gaba agonists at all. But um they only have a hypnotic effect. Um one of the they are intended for short term use. And this is the problem is people start using them and then they don't want to go off them. They can be very helpful for things such as grief. Um you know, loss of a job acute acute um aspects of insomnia that are that I'm acute insomnia. Yes. Um one of the side effects of them is this complex sleep behavior. You'll see it described as sleepwalking. It's not sleepwalking. Um people are they're just they're partly sedated. They're not sedated enough that they're staying in bed but they're too sedated to know what they're doing. It is dose related occurs 30 minutes after taking the med and it can occur in people who have never had it years into therapy and it's more common at higher doses etc. Um And so those are the it's not clear if they are associated with dementia or not. Um The data sort of various experts disagree on this. Um Sorry about that I about the doorbell, the new guy on the block are the Dora's the dual orexin receptor antagonists. Um These are these are aimed at at turning the switch off. Okay they inhibited Wrexham. So and there are two erects um um receptors. The um I didn't even put super reckson up here. That was the first one. Bell Samra. Um It turns out the dose at which it was recommended isn't that effective which is why it's been replaced by limbo Brexit david go. Um And it's not that Belson wasn't that effective. It actually just got put out at too low a dose. Um The new one coming out as Dorito rex and I can't remember what his name is going to be. They tend to be pretty well tolerated. There are studies of these actually in the um in an older age group um their liver metabolized. They do not cause respiratory suppression. Um And in theory that um so rex it it is the absence of Iraq's um that is the underlying path of physiology of narcolepsy. So in theory these could induce narcoleptic type symptoms. They tend not to in most cases but there are reports of cataplexy in patients who have been taking them but it tends it's pretty rare. Um The other new guy on the block or the anti history, they quote anti histamines. Let me explain what I mean by that. These are older drugs that when given at a very low dose are just specifically an anti histamine. One of the knocks against Benadryl is that, yes it's an anti histamine but it also has other side effects. Um It's not it's a dirty drug when you take doxy pin which some of you may be too young to remember was originally marketed as an anti it is it's an antidepressant if you use it at very low doses. It is a pure anti history and that's its only side effect. They do say to watch for anti Colin ergic side effects. But it's basically unheard of at this extremely low dose silent or is the brand name. It is outrageously expensive. So when we try to give it we actually there's actually a dock slip in um a liquid oxygen pin and so we will do that and say get a dropper and you do 3 to 6 mg. What it does is it actually it's recommended for difficulty maintaining sleep and people actually wake up during the night that they just roll over and go back to sleep. So they feel a whole lot better because again the experience of your sleep is a combination of how much sleep and wake you had during the night. Um The other sort of newer newer type of drug or the melatonin receptor agonists not room lT on it. There are two melatonin receptors um M one receptors actually block a Wrexham release and can promote sleepiness. Um And the M. Two are what are used for biological clock shifting which is primarily what I tend to use melatonin for. Um These will improve sleep latency a bit less less effective on wake after sleep onset. Um And they also metabolized um in the liver. Um traZODone. traZODone is a very old drug. Guess how good the sleep the studies are that tell you whether or not it works. They're pretty awful studies. And so the the clinical practice guideline did not endorse the use of traZODone. In fact they endorsed they recommended against it. Yeah the data are lousy the data are lousy studies. It's old stuff. Um But there's a lot of clinical experience with it. Um It works for you the serotonin ergic and alpha um and northern ergic systems mirror to supine again um This also very low doses is when 2 to 4 mg has a pure anti histamine effect. Um Although some people do gain weight and then of course um like prototyping can be used particularly when there's a co morbid psychiatric disorder. So the real question. So what we tend to do is I tend to go behavioral um sleep is not in the pill. There are instances where patients don't do well with behavioral and they do need some limited pharmacologic. And the question is what about the two together? And the reality is it's probably very effective. Um And so there are they they are working on actually developing recommendations for this. Um It is likely very effective to give both a med and C. B. T. I. And then as the patient goes through CBT I tapering off the med. Um The only downside with it is patients may not realize how effective the CBT. I. Is being. Um And I. Um But it can't but together you can actually taper more effectively. The other thing to know is that when you are doing a taper to warn patients that they may have a poor night's sleep for a couple of nights at the at the inflection point when they decrease. And in fact actually um actually dr mason will actually suggest to people that they buy these medications scales and use a razor and slowly just keep decreasing the amount. Um I forgot to put in a slide and mention there there are good data that show that in the long run people do better with CBT. I long term in terms of maintaining good sleep than if they are put on a medication. Um And then of course there are the M. S. Um marijuana the data we have. So it's hard to study marijuana. Prior to legalization you had to get. It was very difficult. There aren't there aren't a lot of data but from colorado there was a study looking at CBD and remember you have THC CBD, CBN, you have vaping, you have edibles, you got a whole bunch out there and CBD tends to have more of an anxiety politic effect. Um And this case series noted that 66% improved their sleep in 25% worse in their sleep. Um Usually people have tried it on their own and either help them or it didn't neither they had side effects or they didn't. Um Melatonin as I mentioned, there are two receptors, one that modulates the biological clock and one that induces sleep. The take home point is that melatonin is a very short half life. And that's again why Rome lt on is better for sleep. Melatonin receptor agonists because it's better for sleep onset rather than sleep maintenance. Um So it'll decrease some melatonin will decrease sleep latency but less of effect on total sleep time and sleep maintenance. Typical doses are 1 to 5 mg But really physiologically 0.1 mg is physiologic. Um So I often will tell people try just a half a milligram a couple hours before bedtime. So you get this nice um secretion. There are now there are now the extended release formulations so those actually may be better for maintaining sleep. But what's important is you need to make because it's not regulated by the FDA. You don't know what you're getting. So make sure people are gonna try melatonin that they use. One that says it's USP verified and some good ones are natural and sundown. Okay now let's talk about sleep apnea. Um You'll often see if you refer to a sleep specialist and say oh the patient had a melon party for this is what we're looking at. What we're looking at is when the patient opens their mouth. Can I see to the back? Okay? It's a gross approximation. This was really designed for the ear, nose and throat. Doctor for intubation and we kind of took it over. Um But melon potty for means you're gonna have a big tongue or a very low hanging soft palate. Why do we care? All right, This is now walk like this. So here this is it's a sagittal section. This way this is the soft powder in your villa. Here's the tongue that the air goes in through the nose or in through the mouth to get down to the trachea. Here. Here you can have airflow here you can't, okay now we tend to associate with obesity but it's not all about obesity. So here's this is a career. This is um a um ah a not so subtle axl this is an axle section uh an axle M. R. M. R. I. So here's your tongue, here's your spinal cord. This is the airway. This is somebody who's obese but does not have absolute bath nia. This person is obese and does it's the size of the airway and a lot of that is modulated through the tongue. Okay. Okay. That's very important because not everybody who has sleep apnea is obese. This is actually a before and after photo of the same person before before um the mandibular advancement um and reconstruction and after this person is going to have sleep apnea. Because if um let me just go back, notice the tongue is attached to the lower jaw. What happens if your retro graphic, where is it going to be your base of your tongue back here? So you'll see it in obese and you'll see people who have either small jaws which is going to push the tongue back or frank retro Matthew. Okay. Um So what happened? Why is it sleep happening? Not wake apnea. If you think of the back of the throat is being made out of balloons like material, it has to be actively kept open. You enter sleep, the muscles relax. It's gonna get smaller and um it doesn't matter if the obstruction is complete which is an apnea or partial which is a hypothermia. Your body is designed to breathe and your lungs literally are going to wake you up to go to breathe. They'll have increased respiratory effort and there's a feedback loop from the pulmonary stretch receptors to the brain that will literally wake patients up to breathe there, wait for just a few seconds too short to form a memory, but long enough to get weight, muscle tone, the back of throat opens up, you get one breath in and immediately returned to sleep. So they end up breathing at the expense of sleep continuity. So what do I, what do we look for in the history? Obviously um snoring snoring is just vibration of the soft palate and uvula for turbulent airflow. Most people have sleep apnea. Will snore, but not everybody who snores has sleep apnea. So if it's loud, heard through the door, if it's been going, how long has the bed partner been in another room? We don't see this as often because people come in sooner. Um however, even mild snoring at times because how disturbing snoring is, is relative. There are now snore as, as I said, there are snore apps that can actually look at decibels, usually loud snoring is around 50 decibels um has has anyone noticed apnea as gas, mere choking and sleep on refreshing sleep. Um night sweats generally seen with more significant sleep apnea, daytime sleepiness. We usually are seeing patients more with un refreshing sleep rather than frank daytime sleepiness. Sleep apnea is getting diagnosed so much earlier. Now we still sometimes see daytime sleepiness. It's less common and then knocked urea. And what's interesting is that the reason patients have knocked urea. Um is that as I mentioned with each of the intermittent arouse als you go from asleep to an awake state. You go from parasympathetic to sympathetic nervous system and literally the body starts to produce atrial natural genetic factor literally producing um nature's own diuretics. So the knocked urea is not simply a function of sleep fragmentation. It is also a function of the production, natural actor nat natural Nate. Real natural atrial natural heretic factor. Forget it. Um Okay so um however people can store and have insufficient sleep. Not everything is sleep apnea. The differential includes sleep will be more refreshing if patients with sleep apnea it's never refreshing because the sleep is too fragmented. I shouldn't say never. Some patients do but generally um refreshing sleep if patients snore and they always wake up and they feel fine and they're alert. That is often the story of snoring an insufficient quantity of sleep. And these patients are likely to be alert in the morning. Get sleepier in the day and often feel fine on the weekend when they get their catch up sleep but also it could be snoring in inadequate sleep hygiene, irregular sleep wake schedule all this other stuff. Um Some people like to use the stop bang score again. This was developed by E. M. T. S. It sort of gives you a like what's the likelihood that a higher likelihood of having sleep apnea. High likelihood. If you score five out of eight and you get one point for each of loud snoring, tired. You can read these observed apnea. Z. P. Is pressure. I. E. Hypertension. Um elevated a high B. M. I. Age greater than 50. Next size it's a this sort of is a poor little For um for obesity where it's depositing it here um and gender, it being more being almost twice as prevalent in men as in women it's a 15-30% prevalence in men. 10-15% prevalence in women. Now I am um showing you the definition of respiratory events. Not because you really need to know this but I want you to understand why the home sleep tests are not as good as the in labs. What the limitations are um they're fine for most patients but there are limitations. And the only way you can understand that is you need to understand our respiratory, how we, how we score and how we score. Also, by the way we're not even sure if we're doing the right thing. First off respiratory vince last 10 10 seconds. Don't worry about that. Apnea apnea absent breath. No airflow. I popped nap hypothermia, decreased airflow, decreased airflow with something. Either an arousal or specified oxygen fall depending on whether using american Academy of Sleep Medicine criteria or Medicare criteria. Fine then you get into this part respiratory effort related arousal is and this is where we have issues with the home sleep test depending on the technology. This is there is no decrease in airflow. Okay. None. There's just an increase in resistance and that can be enough to trigger an arousal. You may have heard of upper airway resistance syndrome. That's based on more rare is the japanese and hypotheses. And these patients can present with one refreshing sleep but without daytime sleepiness usually although they can. Um But and this is what we see in a younger population you you've fallen into here with age. So I always say cardiovascular issues primarily hypertension. When you treat it, hypertension gets better. Treatment for the others. Not as clear. Um These are the home sleep tests. Uh This measures respiratory flow. It can underestimate OS a this is the watch pat. It's actually measuring um vascular tone and pulse also oxygen. And it can complete the lake movements that we see with RLS with um with respiratory events. Um Maybe I should. This is what the this is what this is a type three. These are the output. Um And treatment CPAP I love doing positional aids oral appliance. Let me briefly explain bongo. This is a nasal expert, partial nasal exploratory valve. It sits in the nose. It looks like bongo drums. There are holes with flaps on top with when you breathe in you get full inhalation. When you exhale the flaps go down partially blocking airflow. That means more air goes and then goes out. It's a modified form of path, but it's packed with expiration. We tell people breathe in and out of your mouth for comfort, bypassing it. Your mouth will close Self. Pay only $200 for starter kit, $100 every few months for replacements. And again, my apologies. I really did go through this. I guess I was just talking so much more quickly when I did it at home. So tell me some questions. Let me ask that. And then I have a ton of slides on RLS and anybody who wants to talk about it. I love talking about RLS. Mm hmm.