Learn from our Sleep Disorder Center experts about the basics of good sleep and the physical impact of poor sleep. We will also discuss tips for improving sleep and the treatment options for common sleep disorders, such as sleep apnea, restless legs syndrome, and insomnia, among others.

1. The ABCs of Your ZZZs
Presented by:
Alison S. Kole, MD, MPH, FCCP
Kerry Kelley, RN, RRT, RPSGT

2. WELCOME!

3. Registered Polysomnographic Technologist

4. The Essentials of Sleep
• Basics of “Good Sleep” – Sleep Overview
• Sleep Requirements – Sleep Deprivation
• Sleep Hygiene
• Sleep Disorders
 Obstructive Sleep Apnea
 Restless Legs
 REM Behavior Disorder
 Insomnia
 Narcolepsy

5. Importance of Healthy Sleep

6. Importance of Healthy Sleep
• AASM and SRS Consensus Statement1
 “Adults should sleep 7 or more hours per night on a
regular basis to promote optimal health”
• Official American Thoracic Society Statement2
 “Sleep is an essential biological function with major roles
in recovery, energy conservation, and survival”
 “It is clear that good-quality sleep is critical for good
health and overall quality of life”

8. The Holy Grail
• A Good Night’s Sleep

9. How Much Sleep is Enough?

10. Normal Sleep Architecture

11. Normal Arousals - Awakenings

12. CDC Declares Sleep Disorders a
Public Health Epidemic
• In 2014 the Centers for Disease Control described
sleep deprivation as so pervasive in the United States
that it is considered a public health epidemic.
• Research conducted by the CDC indicates that large
numbers of Americans experience problems associated
with lack of sufficient sleep. For example:
 Almost 50 million people reported problems
concentrating during the day
 24 million people indicated lack of sleep interfered with
driving
 18 million people reported that sleep deficiency
interfered with job performance.

13. Sleep Disorders Leading Cause
of Lost Work Time

14. As Difficult as it May be to
Believe…

15. Third Pillar of Health
• Sleep is the third of the of 4 pillars of health which include
nutrition, physical fitness, sleep and stress control.
• The estimated cost of lost productivity is 63.2 billion dollars a
year!
• A primary factor for lost productivity is presenteeism, employees
showing up for work but operating at subpar levels due to sleep
loss.

16. Sleep Vs. Technology
• The biggest sleep distraction?
• 1 in 2 People check their right away if they wake up
in the middle of the night
• 1 in 4 People don’t silence their phones while
sleeping
• 1 in 10 People are awoken by their phones at least
once a week

17. Sleep Duration by State

18. Short Sleep Among Adults
New Jersey

19. Leptin and Ghrelin
• Leptin - the appetite
suppressor, is the
hormone that tells
your brain when you're full.
• Ghrelin - the appetite
increaser, is the hormone
released primarily in the
stomach to signal hunger to
the brain.
• Just two nights of restricted
sleep were found to
significantly impact
hormones related to
appetite and drive to eat, as
well as self-reported
hunger.

20. Sleep Deprivation
Getting adequate sleep is not a luxury.
It is essential for good health.
Sleeping less than 7 hours is associated with:

21. While it still can’t cure the common
cold…
Getting enough sleep can help prevent
catching a cold

22. Not getting enough sleep can age you both mentally
and physically
It’s called beauty sleep for a reason…

23. Drowsy Driving
• National Highway Traffic Safety
Administration estimates that at
least 100,000 police reported
crashes are the direct effect of
driver fatigue
• Driving after 18 hours without
sleep is the equivalent of
consuming 2 alcoholic
beverages
• driving after 24 hours without
sleep is the equivalent of
consuming 4 alcoholic
beverages

24. Sleep Hygiene
• Sleep hygiene - Habits and practices that are conducive to
sleeping well on a regular basis.
 Ensure an inviting sleep environment
 Ensure exposure to light during the day
 Limit daytime naps to 20-30 minutes
 Exercising improves sleep quality
 Avoid stimulants and alcohol prior to bed
 Limit foods high in fat and sugar – hydrate
 Establish a regular schedule and bedtime routine
 Limit screen use for two hours prior to bedtime

25. Screen Brightness – Blue Light

26. Night Shift – Night Mode

27. The Essentials of Sleep
Basics of “Good Sleep” – Sleep Overview
Sleep Requirements – Sleep Deprivation
Sleep Hygiene
Sleep Disorders
 Obstructive Sleep Apnea
 Restless Leg/Periodic Limb Movement Disorder
 REM Behavior Disorder
 Insomnia
 Narcolepsy

28. Obstructive Sleep Apnea

29. Airway Anatomy
Picture reference: http://stopsnoringrx.com/why-do-we-snore/

30. Airway During Sleep
Picture reference: http://www.dreamstime.com/royalty-free-stock-image-snoring-sleep-apnea-image2780977

31. Obstructive Sleep Apnea (OSA)
• Apnea
 Pause in breath for ≥ 10 seconds
• Hypopnea
 Flow of breath decreases by 30% of baseline
for ≥ 10 seconds associated with a fall in
oxygen saturation by 4%
3. AASM Scoring Manual Version 2.2, 2015

32. OSA Video
Placeholder for OSA Video

33. Obstructive Sleep Apnea
• Upper airway
closes
• Increased
blood
pressure
• Increased
heart rate
• Oxygen level
drops
Picture reference: http://advan.physiology.org/content/32/3/196

34. Sleep Apnea Severity
Apnea Hypopnea Index (AHI)

35. • SO WHAT?
Health Effects of OSA

37. Health Effects of OSA

38. Health Affects of Untreated OSA
• Untreated OSA =
2.5x higher risk of
accidents
• Effective treatment
cuts this risk by
70%
*Risk of motor vehicle accidents is higher in people with sleep apnea. American Academy of Sleep Medicine
Tuesday, March 10, 2015

39. Risk Factors for OSA
• Personal history
• Family and ethnic risk
• Post menopausal women
Picture reference: https://utswim.wordpress.com/tag/pulmona

40. Options for Diagnosis
Home Sleep Testing

41. Options for Diagnosis
Polysomnography

42. Options for Treatment
• CPAP (continuous
positive airway
pressure) therapy
• APAP (auto-
positive airway
pressure therapy

43. Sleep Apnea – CPAP

44. Pre-CPAP and Post-CPAP
SAME PATIENT!

45. Alternative Therapies
NONSURGICAL SURGICAL

46. Preventative Strategies
• WEIGHT LOSS
 Diet, exercise, weight loss surgery
• Avoidance of alcohol
• Avoidance of prescription sleep aids
• Quit smoking!
Picture reference: http://users.rowan.edu/~blondi74/Expert.page.2.html

47. Willis-Ekbom disease
(Restless Leg Syndrome)
Diagnostic criteria:
• Urge to move (“bugs crawling up the leg”)
• Rest induced
• Gets better with activity
• Evening and nighttime worsening

48. Causes of Restless Legs Syndrome (RLS)
Causes:
• Genetics (up to 50%!)
• Low iron levels
• Chronic diseases
• Pregnancy
• Kidney failure

50. Treatment of RLS
**AIM TO TREAT THE UNDERLYING CAUSE
AASM Guidelines (2012):
• Treatment is targeted to increase Dopamine in the
brain
• Medications for Parkinson's disease
pramipexole (Mirapex®), pergolide (Permax®), ropinirole
(Requip®), and a combination of carbidopa and Levodopa
(Sinemet®).
• Alternative medications:
gabapentin (Neurontin®), pregabalin (Lyrica®), opiates

51. Treatment of RLS
Dr. Kole’s favorite recommendations:
1. Get your ferritin level checked
2. EXERCISE – regularly!
3. Stretch before bed (restorative
yoga)
4. Hydrate well throughout
the day
5. Magnesium
6. Tonic water

52. REM Behavior Disorder

53. REM Behavior Disorder

54. Normal REM sleep

55. REM Behavior Disorder (RBD)
• Physically acting out your dreams
• Onset can be gradual or sudden
• Episodes occasionally or several times a night, latter
portion of evening
• Noises, such as talking, laughing, shouting, emotional
outcries or even cursing
• Common movements: kicking, punching, arm flailing or
jumping from bed, in response to action-filled or violent
dreams, such as being chased or defending yourself from
an attack

56. REM Behavior Disorder (RBD)

57. RBD Risk Factors
• Being male and over 50 years old
• Medications: antidepressants (SSRIs, TCAs)
• Withdrawal from: alcohol, benzodiazapines
• Stress
• Co-morbid conditions:
 Neurodegenerative disorders, such as
Parkinson's disease, multiple system atrophy,
stroke or dementia with Lewy bodies
 Narcolepsy
 Untreated OSA (PseudoRBD)

58. REM Behavior Disorder Diagnosis
• Physical and neurological
exam
• Talking with your sleeping
partner
• Nocturnal sleep study
(polysomnogram)

59. REM Behavior Disorder Treatment
Physical safeguards – SAFE
sleep environment:
• barriers on the side of the
bed
• Move furniture
• Padding the floor near the
bed
• Removing dangerous
objects
• Separate beds
Medications:
• Melatonin
• Clonazepam
(Klonopin)

60. There are 84 SLEEP DISORDERS
WHICH IMPACT
100 MILLION AMERICANS
Can anyone guess the
most common sleep
complaint?

62. Insomnia
• Onset Insomnia - difficulty initiating sleep at the beginning of the night
• Maintenance Insomnia – The inability to stay asleep or those who
have difficulty returning to sleep or experience early morning
awakening.
• Comorbid Insomnia - Insomnia that occurs with another condition -
such as anxiety and depression. Certain medical conditions can either
cause insomnia or make a person uncomfortable at night (pain) which
may make it hard to sleep
• Further broken down into by duration….
 Acute/Primary insomnia – is brief – typically less than a month –
tends to be related to life circumstances.
 Chronic/Secondary insomnia – effects 3 nights/week for at least
3 months – can have many causes.
Inadequate or poor quality sleep

63. Causes of Primary Insomnia
• Significant life stress (job loss or change, death of a loved one,
divorce, moving)
• Environmental factors like noise, light, or extreme temperatures
(hot or cold) that interfere with sleep
• Interferences in normal sleep schedule (jet lag or shift work)

64. Causes of Secondary Insomnia
• Conditions that cause chronic (ongoing) pain, such as
arthritis and headache disorders
• Conditions that effect heart and lungs such as asthma,
heart failure, and stoke
• Certain medications that delay or disrupt sleep
• Caffeine or stimulants
• Tobacco or alcohol
• An overactive thyroid
• Gastrointestinal disorders, such as heartburn
• Sleep disorders, such as restless legs syndrome and
sleep-related breathing problems
• Menopause and hot flashes

65. The Insomnia Cycle

66. Treatment of Insomnia
• Lifestyle changes
• cognitive-behavioral therapy (CBTi) can help relieve
the anxiety linked to chronic (ongoing) insomnia. Anxiety
tends to prolong insomnia.
• Medications, prescription or OTC also can help relieve
insomnia and re-establish a regular sleep schedule.
• Treat the underlying cause (if possible).

67. Medications for Insomnia
• WEAK
recommendations
• Short term use
• NOT first line
treatment
• Side effects can be
serious

68. Summit Medical Group
CBT Resource
Locations throughout Essex, Union, Morris, Warren counties with
services that include telepsychiatry

69. Getting sleepy yet?…

70. Narcolepsy
Type 1: Narcolepsy
with cataplexy
Type 2: Narcolepsy
without cataplexy

71. Narcolepsy
• Hypothalamus produces
hypocretins
• Neurotransmitters that
stimulate neurons in the
wake centers of brain
• Decreased hypocretins
cause narcolepsy
http://healthysleep.med.harvard.edu/narcolepsy/what-is-narcolepsy/science-of-narcolepsy

72. Narcolepsy - Cataplexy video

73. Narcolepsy
• Most patients have inherited a gene that codes for the human
leukocyte antigen (HLA) DQB1*06:02
• 25% population has this gene, but only 1% population affected by
narcolepsy
• A triggering factor that activates the immune system, such as
infection with strep
• A vulnerable age during which the immune response or some
characteristics of the brain make an autoimmune attack on the
hypocretin neurons more likely (classically younger age patients)
• PSG/MSLT required for diagnosis

74. Narcolepsy Treatment
• Lifestyle and home remedies including:
• Sticking to a schedule. Go to sleep and
wake up at the same time every day, including
weekends.
• Taking naps. Schedule short (20 minute)
naps at regular intervals during the day.
• Avoid nicotine and alcohol.
• Get regular exercise.

75. Narcolepsy Pharmacotherapy

76. Let’s Connect the Dots
Sleep is as important as diet and exercise
only easier!
Make sleep the foundation of good health

77. • Set yourself up for
optimal sleep by
practicing good sleep
behaviors
• Listen to your bed
partner – they offer
insight as to nocturnal
behavior
• Think you have a
sleep disorder? Talk to
a sleep specialist!
Closing Remarks

78. SMG Sleep Physicians

79. Recommended Reading
• Sleep Smarter: 21 Essential
Strategies to Sleep Your Way
to A Better Body, Better Health,
and Bigger Success, by Shawn
Stevenson
• The Promise of Sleep, by
William Dement
• Say Goodnight to Insomnia, by
Gregg Jacobs
• Goodnight Mind, by Colleen
Carney

80. Thank You!
I mustache you a question…