American College of Physicians: Internal Medicine — Doctors for Adults ®

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Sleep disorder rise is wake-up call for internists

From the November/December ACP Observer, copyright 2007 by the American College of Physicians.

By Jessica Berthold

In addition to chronic sleepiness, a patient of Robert Vorona, MD, associate professor of internal medicine in Eastern Virginia Medical School’s sleep medicine division, had one classic symptom of narcolepsy: whenever he laughed hard, his legs would buckle and he'd fall to the floor. So the doctor was relieved when the patient reported that this bothersome symptom, called cataplexy, was infrequent ... until he heard the reason why.

"He told me he didn't experience much cataplexy because he didn't leave his house much. The only way he could control it was to not place himself in situations that might cause his legs to give out," Dr. Vorona said.

Sleep disorders can wreck a person's quality of life, yet they often go undetected by busy internists who have dozens of other conditions to screen for during short routine visits. Recent findings confirm that sleep disorders are widespread among the U.S. population, however, and the physical harm they may cause merits asking about sleep habits during physical exams, experts said.

"Sleep problems are under-recognized in the primary care world," said Maha Alattar, MD, a Chapel Hill, N.C. neurologist and lead author of a recent study showing a high prevalence of sleep disorders in primary care patients. "I understand there are limitations in regards to the time a physician can spend with a patient, but sleep problems need to be addressed and treated because they are strongly linked to many systemic diseases.”

Sleep and Disease

More than a third of adults who visit primary care practices have trouble sleeping, Dr. Alattar's study in the July/August issue of the Journal of the American Board of Family Medicine found. Of the 2,000 adults surveyed at five primary care practices in North Carolina, 34% reported they woke up at least three times a night, 14% had symptoms of sleep apnea, 28% had symptoms of restless legs syndrome at least weekly, 37% dozed off at least once a week during daily activities and 33% snored loudly at least once a week.

Meanwhile, evidence of a link between sleep disorders and physical illness continues to grow. In the last few years, studies have found a correlation between obstructive sleep apnea and cardiovascular disease, stroke and death. Insufficient or poor quality sleep has also been associated with lower immune function, increased appetite that may lead to obesity, lower insulin sensitivity and reduced glucose tolerance.

In many cases, however, the link between sleep disorders and disease has yet to be established as causal. Associating sleep duration or apnea with insulin resistance isn't the same as saying lack of sleep causes diabetes, noted David White, MD, director of the sleep disorders program at Brigham and Women’s Hospital, Harvard Medical School.

"Until someone does an intervention study and shows that increasing sleep directly lowers weight or helps diabetes, one can't endorse it," Dr. White said.

The most robust evidence about obstructive sleep apnea is that it causes hypertension, experts said. A meta-analysis of 16 randomized clinical trials in the August 2007 Hypertension found that treating sleep apnea patients with continuous positive airway pressure (CPAP) for at least two weeks lowered their blood pressure compared with apnea patients in a control group.

Given the links between sleep disorders and other diseases, internists should be aware of new and existing treatments they can either offer directly or refer to sleep specialists to obtain, experts said.

Behavioral treatment

Lifestyle is often to blame for sleep troubles. A Sept.1, 2007 study in Sleep found that people who work long hours will sacrifice sleep in order to engage in leisure or other activities. Amount of time spent working is the biggest factor in how much sleep people get, followed by travel time, the study found.

"Over the years there have been more people complaining of sleepiness and insomnia due to the ubiquitous nature of this 24-hour lifestyle we all engage in," said R. Robert Auger, MD, assistant professor in psychiatry and medicine at the Mayo Clinic Sleep Disorders Center in Rochester, M.N.

Experts say good sleep hygiene includes going to bed and waking up at the same time; using the bedroom only for sleep and sex; avoiding alcohol, caffeine, tobacco and heavy meals at night; leaving time to wind down before going to sleep (which includes staying away from stimulation like television or computer games); and sleeping in a room that is a comfortable temperature and sufficiently dark.

”Cognitive behavioral therapies which include optimizing sleep hygiene techniques have been shown to be first line techniques for chronic insomnia, and appear to be at least as effective as medications,” Dr. Vorona said.

Indeed, a meta-analysis of insomnia treatment options in the 2002 (Vol. 159) American Journal of Psychiatry found that pharmacologic and non-pharmacologic treatments were equally effective in treating insomnia for a two- to four-week period. Patients also got to sleep slightly faster with non-drug treatment, the study found.

Several studies also back the effectiveness of cognitive-behavioral and relaxation therapies as helping insomnia for up to two years. The latter involves treatments such as meditation, hypnosis, biofeedback, and tensing and relaxing different muscle groups. The former involves learning techniques to help change one's false beliefs and attitudes about sleep.

It can be difficult to find a psychologist to do these therapies however, or to have the treatment covered by insurance, experts said.

For patients with obstructive sleep apnea, the main behavioral recommendations are weight loss, sleeping on one's side and avoiding alcohol three to four hours before bedtime. Behavioral treatments for narcolepsy patients include maintaining a consistent sleep schedule, taking 10- to 30-minute naps once or twice a day, and reducing consumption of alcohol and carbohydrates. Patients should also be helped to organize their lives around their symptoms, including avoiding activities that could be dangerous, experts said.

"Behavioral techniques are more time-consuming, for both the patient and the physician. It's easier to say 'Can't sleep? Here's a pill,'" Dr. White said. "The thing is, if you get your patients going on pills, they are probably going to take them the rest of their lives. That's not terrible, but if they can fix things behaviorally, it's probably better."

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Treating sleepless nights: new drugs and devices provide options

Insomnia: A substantial change in drug treatment of chronic insomnia came from the FDA's approval in 2005 of three hypnotics for long-term use. Zolpidem tartrate (Ambien), eszopiclone (Lunesta) and ramelteon (rozerem) were approved following a clinical trial that found eszopiclone effective and safe for six months of use. Prior to this study, "The standard was that you shouldn't be on them more than a couple weeks," said Dr. White.

Still, no research has directly compared the effectiveness of these drugs with other medications that are sometimes used for chronic insomnia, like benzodiazepines and antidepressants, according to an overview of treatment options for insomnia in the Aug. 15, 2007 American Family Physician.

The article recommends that over-the-counter drugs containing antihistamines like doxylamine shouldn't be used for chronic insomnia (insomnia lasting more than 30 days) because they aren't very effective and can reduce sleep quality. As well, benzodiazepines and most other hypnotics should be used only for about two weeks, as they can have side effects and withdrawal symptoms. Sedating antidepressants like trazodone should be used only in patients with comorbid depression, it said.

Restless Legs Syndrome (RLS): Ropinirole (Requip) and Primapexole (Mirapex) are the only drugs approved by the FDA specifically to treat moderate- to-severe RLS, though other dopamine agonists are often used, and research in the last two to three years has backed their efficacy, Dr. White said.

Physicians sometimes use benzodiazepines for patients with milder symptoms, whereas opioids are used for those with pain, and anticonvulsants for those with strong "creepy-crawly" leg sensations. All have a risk of side or withdrawal effects, according to the National Institute of Neurological Disorders and Stroke, a unit of the National Institutes of Health.

Narcolepsy: Modafinil (Provigil) is a preferred drug for sleepiness because it tends to be gentler than stimulants like methylphenidate (Ritalin) and dextroamphetamine (Dexedrine), and has fewer side effects, said Lewis Kline, ACP Member, director of the Center for Sleep Disorders at Western Pennsylvania Hospital in Pittsburgh. For cataplexy, venlafaxine (Effexor) or sodium oxybate (Xyrem) are common.

Sleep apnea: Continuous positive airway pressure (CPAP) machines are the standard treatment for moderate to severe sleep apnea, with studies showing they reduce patients' sleepiness and blood pressure, and improve their quality of life. The machines have gotten less cumbersome in recent years, with the masks fitting more comfortably and less likely to leak, said Thomas Mulrooney, ACP Member, who treats patients at the Minnesota Sleep Institute. "Initially, the machine was bulky and noisy. It looked like a Rube Goldberg apparatus," he said. "But now they are smaller and quieter, and the problems with it have diminished greatly."

Alternatives to CPAP are automatic PAP (APAP), which titrates air pressure as a patient's sleep levels and positions shift throughout the night, and bilevel PAP, which uses a lower level of air pressure for exhalation than inhalation. A 2007 article in Chest (Vol. 132) found that these alternatives didn't result in greater adherence to treatment in unselected patients than CPAP, but they may help on the individual patient level. A second Chest study (Vol. 131) found that sleep apnea indexes were reduced regardless of treatment with CPAP or APAP, but only CPAP patients saw a reduction in blood pressure.

It's standard practice to diagnose obstructive sleep apnea and determine CPAP levels with polysomnography during an overnight stay in a sleep lab. But a February 6, 2007 study in the Annals of Internal Medicine suggests this may not be necessary. In patients with a 90% probability of having sleep apnea, it found no advantage to doing the overnight lab test before CPAP, compared to starting with APAP at home for a week, then switching to CPAP. After three months, apnea and quality of life scores improved about equally, while treatment adherence was actually better for the group that started treatment at home.

Still, nearly a third of patients dislike CPAP enough to stop using it by the end of their first year, Dr. Kline said. For these patients, dental devices that clip to the teeth and gently move the jaw forward to open up the airway are reasonable alternatives, he said. The only drawback is that the device can shift one's teeth and alter bite.

"These devices have been around since the 1990s, but the design has gotten a lot better. Insurance is starting to pay for them, so they've become more popularized," said Dr. Kline.

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Two questionnaires help add sleep screening to busy visits

Internists need only ask a single open-ended question, such as "How do you feel about your sleep?" during a patient's yearly physical examination to open the door to discovering a sleep disorder, experts said.

"It's what a good internist does all day. If a patient complains of shortness of breath, the internist needs to determine if the problem is anemia, or a neuromuscular disorder, or heart failure or asthma," Dr. Vorona said. "Likewise, you start off generically asking about sleep and get specific thereafter."

There's no single questionnaire that serves as a catch-all for sleep problems, experts said, but internists can use specific questionnaires once they suspect certain conditions. The Epworth Sleepiness Scale is a simple measure that can help target the severity of daytime sleepiness, while the Berlin Questionnaire helps categorize a patient's risk for sleep apnea.

"It's important for internists to be aware of sleep disorders because so many of the symptoms they hear every day, or the medical problems they treat, are linked to sleep disorders," Dr. Vorona said. "It has to be in the differential diagnosis."

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Web resources

The College's Physicians' Information and Education Resource (PIER) has diagnostic and treatment tips.

The Epworth Sleepiness Scale has patients rate the severity of their sleepiness during different daily activities.

The Berlin Questionnaire helps categorize a patient's risk for sleep apnea.

The American Academy of Sleep Medicine has a map of sleep centers by state.

American Academy of Sleep Medicine

National Sleep Foundation

National Center on Sleep Disorders Research (NIH)

National Institute of Neurological Disorders and Stroke

American Sleep Apnea Association

Restless Legs Syndrome Foundation

American Insomnia Association

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