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Melanie Cole (Host): Expert insights is an ongoing medical education podcast. The Carle Division of Continuing Education designates that each episode of this enduring material is worth a maximum of 0.25 AMA PRA category 1 credit. To collect credit, please click on the link and complete the episode’s post test.

It’s been studied that the cumulative effects of sleep loss and sleep disorders represent an underrecognized public health problem and have been associated with a wide range of negative health consequences. My guest today is Dr. Charles Davies. He’s a sleep medicine specialist and the program lead in sleep medicine at Carle Foundation Hospital. Dr. Davies, let’s start with sleep disorders. Who notices them? A loved one? Are there symptoms you would notice in yourself? Speak about some of the comorbidities that would go along with a lack of sleep.

Dr. Charles Davies (Guest): Yes Melanie, well certainly as you suggest, it is often a loved one who is noticing symptoms to begin with. For example, snoring or even if the person stops breathing or has pauses in their breathing or snorts with those pauses during sleep and then the person themselves may experience daytime sleepiness, may have difficulty with concentration and attention and they may have increased headaches, especially in the morning and we know that these kinds of symptoms are signs that the person may have obstructive sleep apnea and so it is very important to have that evaluated. Certainly untreated obstructive sleep apnea, which you mentioned as well at the outset, it’s actually estimated that there may be about 23 million people in the country who have undiagnosed obstructive sleep apnea and the risks are numerous. We know that there’s a three fold increased risk of hypertension for obstructive sleep apnea. If it’s moderate or severe we know that there are three times as many fatal heart attacks and strokes associated with untreated obstructive sleep apnea. Certainly because of the excessive daytime sleepiness, there’s an increased risk of motor vehicle accidents.

Melanie: Wow so as we talk about, and we will get into sleep apnea, but there are also other disorders. So if somebody comes to you and they’re discussing their symptoms that you’ve mentioned, daytime sleepiness, how is the assessment? An evaluation done, speak about some of the clinical practice guidelines for recognizing sleep disorders.

Dr. Davies: Well when a patient comes to my office, and it’s always nice to have the loved one as well to provide further history, I will certainly ask about snoring, if it’s every night, how loud it is, and the apneas again. I’ll also ask if the person is waking up short of breath, gasping, or choking or even if they are feeling very sweaty overnight, that’s another sign of obstructive sleep apnea because when you’re airway blocks off, you’re basically fighting to breathe, and that is a danger signal, kind of like the fight or flight response. So your blood pressure is going to spike up, you may sweat and your heart rate may increase as well. So we obtain some of that history and then I will go ahead and do a physical exam, which will include height, weight, so we can then calculate the body mass index. We certainly know that there is a strong association between elevated blood mass index and obstructive sleep apnea. I will also measure the neck circumference, larger neck circumference again associated with obstructive sleep apnea. I will look in the airway to see whether the airway is crowded or narrow. It turns out that people can have obstructive sleep apnea without an elevated body mass index and that’s often because they have a narrow airway and that could be inherited. We know that obstructive sleep apnea can be run in families.

Melanie: How are they categorized, the various sleep disorders? Because there’s apnea, people have heard about insomnia, there’s circadian rhythm disorders. How do you classify these once you’ve sort of determined what’s going on?

Dr. Davies: Well we would also get a very detailed history of the person’s sleep routine, what time they usually go to bed, how long it roughly takes them to fall asleep, whether they awaken overnight, what causes them to awaken, whether it’s for example they were short of breath or they had to get up to go to the bathroom many times a night and sleep quickly or does it take them quite a while, if they are awake for a while are they having difficulties with not being able to shut their mind off, and what kinds of things they do when they can’t sleep and then certainly what time they get up for the day. So by getting that very detailed indication of their sleep routine, we can then decide if the person has for example, insomnia, meaning it’s taking them more than half an hour to fall asleep most nights and if they’re awake for more than a half an hour overnight. We can also check on whether they are having any other kids of symptoms that might prevent them from sleeping. For example, restless legs syndrome which is a condition involving uncomfortable urges to move the legs at night while they’re awake and so that may keep people awake. So we could either be looking at somebody with obstructive sleep apnea or sleep disruptions and poor sleep due to insomnia or sleep disturbance due to restless legs syndrome.

Melanie: As you mention some of these sleep hygiene things, as far as falling asleep or white light or various distractions that people go through, what do you want other physicians to discuss with their patients about the things that they need to do or try first before they would start on any sort of treatments?

Dr. Davies: That is a very important topic and yes the first line strategy or treatment is to optimize the person’s sleep hygiene. So for example, we always instruct people to get up out of bed if they have difficulty falling asleep. We try to have them not looking at the clock in bed. Just use their internal clock. If they’ve rolled over more than a couple, three times, if they’re having a lot of thoughts that they can’t get out of their mind that are keeping them awake, then they should definitely get up out of bed and engage in some kind of relaxing activity. For example, listening to quiet music or reading an actual book not using a device because any kind of lighted device activates a circuit that goes from the retina to the master clock in the brain and that light will then reset the clock and keep the person awake, so we try to have people avoid using any kind of lighted device, phone, computer, iPod, TV and certainly just engage in some relaxing activities out of the bed until they feel tired, then go back to bed. If they’re having difficulty getting things out of their mind, then sometimes writing down a to do list before bed could help clear their mind. Also journaling, that type of thing can also help as well.

Melanie: So that would be a good first line treatment for physicians to discuss with their patients. When it comes to the treatments whether it’s CPAP or medication intervention, what do you want other physicians to know about choosing those and adherence for their patients and discussing adherence and compliance?

Dr. Davies: So in the case of obstructive sleep apnea, CPAP, continuous positive airway pressure, is still the best recognized treatment for obstructive sleep apnea and we always stress that it is very important to use the CPAP machine essentially whenever they are sleeping as that will eliminate those risks. We know that when somebody is using the CPAP whenever they sleep, they are basically eliminating the additional risk from the obstructive sleep apnea for things like high blood pressure, heart attacks, and strokes. So that is extremely important. In the case of insomnia, first of course the sleep hygiene as I mentioned, if that’s not helping, then the first – the next thing would be to refer a person for cognitive behavioral therapy for insomnia with a sleep psychologist, and that actually has been shown to be more effective and longer lasting than sleeping pills, for example or any kinds of sleeping aids that would be taken. Then in the case of restless leg syndrome, actually we first take a look at iron levels and that includes checking ferritin and iron studies. Even if those iron stores, which are blood tests, are low normal, that can then be associated with restless leg syndrome. So example if the ferritin is below 75 ng/mL or the iron transferrin saturation is below 20%, we would recommend supplemental iron as a first line therapy and then of course checking iron levels every three months while the person is taking the supplemental iron.

Melanie: Such good advice Dr. Davies and for other providers, wrap it up what you’d like them to know about recognizing sleep disorders and the importance of recognizing these disorders so that they can get going on treatment because of all those comorbidities that can go along with sleep disorders.

Dr. Davies: Thank you, the important thing first is to ask the questions. First make sure to ask people if they are having any of those kids of symptoms such as snoring, waking up short of breath, having unrefreshing sleep, being sleepy during the daytime, and again of course having the loved one there is an additional bonus. So that is extremely important to simply ask the questions first and then proceed accordingly, and if there are signs or symptoms suggesting increased risk of obstructive sleep apnea, certainly it would be appropriate to refer the person to the sleep clinic for evaluation at which time then a diagnostic study can be ordered.

Melanie: Thank you so much Dr. Davies for coming on and sharing your expertise today on sleep disorders and for other physicians what you wanted them to know about the importance of recognizing sleep disorders in their patients. You’re listening to expert insights with Carle Foundation Hospital. For a listing of Carle providers and to view Carle sponsored educational activities, please visit carleconnect.com, that’s carleconnect.com. We hope the information gained will be applicable to your work and life. This is Melanie Cole, thanks for listening.