Treatments for Adults
I am commonly asked what I feel about a certain treatment. Melatonin, Dental Devices, and new medications. My answer is always “what are you treating”. As discussed in my Sleep 101 Series, treating sleep begins with establishing a diagnosis. Disrupted sleep is a symptom, and once we find what the cause(s) are then we can move forward with treatments.
OSA
Some mild forms of sleep apnea may be position dependent. When laying on your back (supine position) there is increased airway collapse from gravity. Positional sleeping, that is sleeping on your side, may be helpful. They sell fancy items on the internet, snore shirts, positional devices, and even a shirt with pocket on the back that you put a tennis ball in. All of these are with the goal of keeping you on your side. Frankly, I advise to get a body pillow. Using a body pillow allows your shoulders to align with your spine, hips, and knees to prevent the back pain that frequently keeps someone to turning on there back.
Weight loss is a potential curative treatment of sleep apnea. And I have seen sleep apneas go from severe to cured with weight loss. The Catch 22 is if you have OSA, the body is in a stress state. Such pro-inflammatory state does make it difficult to lose weight. I am not saying that CPAP melts body fat. However attempting weight loss with an untreated OSA is an uphill challange.
Oral appliance outcomes do have efficacy in reducing snoring and sleepiness. And they have been shown to be better tolerated then CPAP in some studies. They have a role of which the success is higher in the Mild to Moderate OSA range and in supine-dependent OSA. And compliance of oral appliance therapy in some notable studies has been found to be better then that of CPAP. But I get back to my original question, “what are you treating”? You don’t know if the snoring is Primary Snoring or a Mild, Moderate, Severe, or even Complex OSA without a sleep study for diagnosis.
Nasal EPAP (Expiratory Positive Airway Pressure) is a treatment for obstructive sleep apnea (OSA). Nasal EPAP utilizes the user’s own breathing to create positive airway pressure to prevent obstructed breathing. In a series of published articles, nasal EPAP has been shown to provide statistically significant reductions in symtoms associated with sleep apnea with high patient acceptance and engagement.
CPAP (Continuous Positive Airway Pressure) is the gold standard treatment for OSA. But as I have pointed out it is not the only treatment for OSA.
Generally when CPAP is initiated we conduct another type of sleep study. A CPAP Titration is a study where a PSG (Polysomnogram) is conducted and different pressures of pressure are given. The goal is to eliminate upper airway respiratory disturbances, resulting in restoration of better sleep. The positive pressure essentially splints the airway open. In some cases of severe OSA we can see frequent oxygen desaturations with a “saw tooth” pattern as well as frequent arousals to wake and sleep fragmentation. We also see a much higher occurrence snoring on the microphone and respiratory disturbance events. Commonly as CPAP pressure is increased, the respiratory disturbance events and oxygen desaturations are reduced.
I usually explain to my patients why I give a Sleep Study and a CPAP Titration. For example, you just don’t start someone on cholesterol medication without checking cholesterol. First you check a cholesterol level. Then you start the med, if there is a problem. Then you routinely check cholesterol while you adjust the dose. Likewise, first you need to do a sleep study to see if someone even has OSA. Then you need to bring them to the sleep lab to give different pressures of CPAP. Too low will not help open the airway. Too much will not open the airway further, but will cause problems with tolerance. Also, CPAP is not the only treatment. Different degrees of sleep apnea can be treated with other measures.
RLS
RLS (Restless legs syndrome) is a clinical diagnosis based on symptoms from the clinical history. PLMD (Periodic Limb Movement Disorder) is diagnosis that needs objective findings on a PSG (Polysomnogram) in addition to clinical symptoms of sleepiness or cognitive disturbances and/or night symptoms of disrupted sleep. RLS (Restless Legs Syndrome) is found in about 6% of children, 3% in people 18 to 29, 10% in people 30 to 79, and 19% in those aged 80 or older. Note: a diagnosis can lag behind symptom by 15-35 years. Polysomnography shows repetitive movements that are 0.5 – 5 seconds in duration and are separated by 5 to 90 seconds. Some studies have also shown that 75% of patients with PLMD have ADHD symptoms. At times the leg movements can be frequent or forceful enough that it results in arousals and disruption of sleep.
Potential underlying causes such as iron deficiency, renal disease, peripheral neuropathy, diabetes should be investigated by your primary care physician before treating the symptoms of such.
There are some FDA approved treatments for RLS, there are no FDA approved treatments for PLMD, but there are commonly used treatments for both. Parkinson medications involving dopamine, anticonvulsant drugs, opiods have all been shown to help. Even some treatments such as muscle relxants and hypnotics have been used to help both symptoms.
Excessive Sleepiness
A patient may tell you then never sleep, but objective information shows normal sleep time. There could be a paradoxical insomnia or a narcolepsy. Or a patient may say they are getting to bed in time, when in-fact they may have very poor pattern of sleep wake times. Visually impaired people may not have the same ability to assimilate environmental cues of the circadian system and can intrinsically run on a non-24 hour internal clock. Autistic patients likewise have been found to have problems with melatonin secretion. Falling asleep and/or feelings of sleepiness are normal and physiologic. However to have such symptoms of EDS (Excessive Daytime Sleepiness) when one is trying to maintain vigilance and function, in the absence of self induced sleep deprivation is not normal.
I explain Narcolepsy mostly as a mismatch between awake and asleep states. Most specifically between REM sleep and wake. Such symptoms may include EDS and Cataplexy (loss of muscle tone). This is a function of muscle atonia, similar to a lack of muscle tension or a type of temporary paralysis, that is normally seen in REM but happens during the day. A patient will be awake, they know they are awake, but there body feels paralyzed. Hallucinations can be seen while awakening and are described as vivid dream like images. Just as there can be REM states during wake, there can be abrupt wake states during sleep and this can result in complaint of insomnia. Treatment of the Cataplexy is different then the treatment of EDS. Treatment of Cataplexy is generally with a REM suppressing medication (as cataplexy is REM atonia during wakefulness). Generally, antidepressants are REM suppressing. Sodium Oxybate can be used in treatment of Cataplexy as well as EDS.
MSLT (Multiple Sleep Latency Test) is an objective measurement of sleepiness. Remember, in the normal sleep study, REM normally does not come until after about 90-120 minutes. So if when one is given 20 minutes to sleep and they fall into REM, that is sudden. Two SOREMPs (Sudden Onset REM Periods) are needed to make diagnosis of narcolepsy, in setting of a negative PSG (Polysomnogram) on the night prior to. Mean age of Narcolepsy symptoms is 15-20 years of age. However, that is the largest peak. The second largest peak is between 10-14 years of age. So to call it “Pediatric Narcolepsy” is a misnomer. Narcolepsy is Pediatric.
Where as Narcolepsy has intrusion of REM sleep in wake, KLS (Klein Levin Syndrome) differs in intrusion of SWS (Slow-Wave Sleep). Also, narcolepsy symptoms are persistent, where KLS is cyclical.
Pharmacologic treatments for excessive daytime sleepiness may include alerting medications such as stimulants of the dextroamphetamine or methylphenidate classes. Other FDA approved treatments include Provigil or Nuvigil.
Non-Pharmacologic approaches in hypersomnia management include avoid sedating meals, avoid sedating medications, do not drive when tired, etc… Caffeine use with moderation is appropriate. I advise against large size, over-caffeinated beverages like Monster and other drinks toutes as “Energy Drinks”.
Caffeine content in commonly found in common drinks, food or OTC medications:
Excedrin Migraine (1 tab) = 65 mg
Cola or soft drink (12 oz) = 35-72 mg
Coffee (8 oz) – 102-200 mg
Decaf coffee (8 oz) – 3-12 mg
Starbucks Brewed Coffee (16 oz) – 320 mg
Red Bull (8.3 oz) – 80 mg
Monster (16 oz) – 160 mg
5-Hour Energy (2 oz) – 138 mg
Hershey Chocolate bar (1.5 oz) or Hot Cocoa (8 oz) – 3-13 mg
Insomnia cures. Insomnia escape. <Video Link>
Parenting and sleep. <Video Link>
